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INTRODUCTION The goal of rapid sequence intubation is to secure the patients airway smoothly and quickly, minimizing the chances of regurgitation and aspiration of gastric contents. Traditionally succinylcholine chloride has been the neuromuscular blocking drug of choice for use in rapid sequence intubation because of its rapid onset of action and profound relaxation. Succinylcholine chloride remains unsurpassed in providing ideal intubating conditions. However the use of succinylcholine chloride is associated with many side effects like muscle pain, bradycardia, hyperkalaemia and rise in intragastric and intraocular pressure. Rocuronium bromide is the only drug currently available which has the rapidity of onset of action like succinylcholine chloride. Hence the present study was undertaken to compare rocuronium bromide with succinylcholine chloride for use during rapid sequence intubation in adult patients METHODOLOGY The study population consisted of 90 patients aged between 18-60 years posted for various elective surgeries requiring general anaesthesia at Sri Venkateswara Medical College, Tirupati study population was randomly divided into 2 groups with 30 patients in each sub group. 1. Group I: Intubated with succinylcholine chloride 1 mg kg-1 (n = 30) 2. Group II: Intubated with rocuronium bromide 0.9 mg kg-1 (n = 30) Intubating conditions were assessed at 60 seconds based on the scale adopted by Toni Magorian et al. 1993. The haemodynamic parameters in the present study were compared using p-value obtained from student t-test. RESULTS It was noted that succinylcholine chloride 1 mg kg-1 body weight produced excellent intubating conditions in all patients. Rocuronium bromide 0.9 mg kg-1 body weight produced excellent intubating conditions in 96.67% of patients, which was comparable to that of succinylcholine chloride. INTERPETATION AND CONCLUSION Thus, from the present study, it is clear that succinylcholine chloride is the drug of choice for rapid sequence intubation. Rocuronium bromide is a safe alternative to succinylcholine chloride in conditions where succinylcholine chloride is contraindicated and in whom there no anticipated difficult airway. [ABSTRACT FROM AUTHOR]

RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research. [ABSTRACT FROM AUTHOR]

Objectives: To compare the quality of intubating conditions and hemodynamic responses to the administration of Rocuronium Bromide and Succinyl Choline during general anesthesia. Methods: This was a comparative study conducted at the anesthesiology department of a tertiary care medical college. Sixty patients undergoing various surgeries under general anesthesia were included in this study based on predefined inclusion and exclusion criteria. Patients were divided into Group S (receiving succinylcholine) and Group R (receiving rocuronium). In all patients, the quality of intubating conditions was assessed. Excellent or good conditions were considered to be acceptable intubating conditions, whereas fair and poor conditions were considered unacceptable. Results: Mean age, weight, gender distribution, and ASA grades were comparable in both groups. The overall quality of intubation was found to be better in group S than in group R, and the difference was statistically significant (P=0.004). The duration of action was significantly longer in group R than in group S (P

Introduction: Succinylcholine is a muscle relaxant of choice for paediatric intubation due to its fast onset and ultrashort duration of action but it is associated with unwanted sideeffects. Rocuronium bromide can be used alternatively to avoid those unwanted side-effects because of its fast onset and intermediate duration of action. Aim: To compare two doses of rocuronium bromide with succinylcholine in terms of intubating conditions, duration of action, haemodynamic variations, and complications to get a better alternative dose of rocuronium bromide in children undergoing elective surgeries. Materials and Methods: The present randomised, doubleblinded clinical trial study was conducted in the Department of Anaesthesiology, Jawaharlal Nehru Medical College (JNMC), Sawangi, Wardha, Maharashtra, India from January 2021 to October 2022. Ninety American Society of Anaesthesiology (ASA) Grade-I-II children of both sexes of 1-10 years age, undergoing elective surgery were equally divided into three groups. Group-R9 (n=30) and Group-R12 (n=30) received rocuronium bromide 0.9 mg/kg and 1.2 mg/kg, respectively while Group-S (n=30) received succinylcholine 1.5 mg/kg. Comparative evaluation of intubating conditions was done around 60 seconds in all three groups and duration of action, haemodynamic variations, and complications were noted. All data were entered in a microsoft excel sheet and results were expressed as percentages, mean Standard Deviation (SD), chi-square test, and Analysis of Variance (ANOVA) test where the difference was considered statistically significant if the p-value <0.05 by using the software Statistical Package for the Social Sciences version 11.0 (SPSS version 11.0). Results: Rocuronium bromide 1.2 mg/kg and succinylcholine 1.5 mg/kg provided excellent intubating conditions in 96.7% children and good intubating conditions in 3.3% children in both groups while rocuronium bromide 0.9 mg/kg provided excellent intubation conditions in 83.3% of children and good intubating conditions in 16.7% of children There was a significant difference present in intubation scores between three groups (p=0.01). The duration of action was longer with rocuronium bromide 1.2 mg/kg (38.93±4.323 min) as compared to rocuronium bromide 0.9 mg/kg (26.07±2.791 min) while it was shortest with succinylcholine 1.5 mg/kg (6.00±1.74 min). Adverse effects like fasciculations were only found in children (n=30) receiving succinylcholine (p=0.01) but not in rocuronium bromide groups. Conclusion: Rocuronium bromide 1.2 mg/kg gives the same intubating conditions as succinylcholine 1.5 mg/kg with good haemodynamic stability and no side-effects but the duration of action was longer with rocuronium bromide 1.2 mg/kg as compared to rocuronium bromide 0.9 mg/kg. So, to avoid unwanted sideeffects of succinylcholine in children, rocuronium bromide 1.2 mg/kg can be used as an alternative to succinylcholine 1.5 mg/kg in children undergoing elective surgeries where early return of spontaneous recovery is not needed. [ABSTRACT FROM AUTHOR]

Background: Suxamethonium, a depolarizing neuromuscular agent, was introduced in 1952 and since then has been used for tracheal intubation. It was favoured for its rapid onset and ultra-short duration of action but has numerous side effects, especially cardiovascular. So agents with low potency and shorter duration of action were developed, and in 1995, Rocuronium was introduced, which is a non-depolarizing agent and has the fastest onset of action. Aim and objective: The aim of the study was to compare the intubating conditions at 60 seconds after giving Rocuronium 0.6 mg/kg and Suxamethonium 1 mg/kg intravenously. Methods: In this clinical trial, a total of 60 patients were enrolled. Patients were divided into groups A and B. Group A received Rocuronium 0.6 mg/kg intravenously, and Group B received suxamethonium 1 mg/kg, and all were intubated after 1 minute. Intubation conditions were noted and scored according to a modification of the Kreig et al.,. method. Results: It was observed that intubation conditions were excellent in both groups; there was tachycardia associated with the Rocuronium group, and blood pressure was higher in the Suxamethonium group. Conclusion: Rocuronium can be acceptable for intubation instead of Suxamethonium, except in conditions anticipating difficult intubation. [ABSTRACT FROM AUTHOR]

Background and aims Cisatracurium has many advantages over other nondepolarizing muscle relaxants; however, for rapid intubation, rocuronium is the preferred drug in lieu of succinylcholine. The aim of this study was to compare the onset time and intubating conditions at 90 s using 0.3 mg/kg cisatracurium (6x ED95) versus 1.2 mg/kg rocuronium (4x ED95). Material and methods The study was conducted at a tertiary care hospital as a randomized double-blind prospective study after obtaining the ethical committee clearance. A total of 60 patients were randomly assigned to receive 1.2 mg/kg rocuronium (4x ED95) or 0.3 mg/kg cisatracurium (6x ED95) after premedication with fentanyl-midazolam and induction with propofol-sevoflurane. Laryngoscopy and intubation were done at 90 s. Primary outcomes assessed were laryngoscopy and intubation conditions and onset times. The Student t test was used to compare prospective, repeated measures. χ² test was used to test the significance of difference for qualitative variables. Results The onset of action of the muscle relaxant was predicted by measuring train-of-four ratio and was found to be significantly longer in the cisatracurium group (149.50 ±25.064 s) than in the rocuronium group (101±s) (P<0.05). Although the intubating conditions were better in the rocuronium group, cisatracurium also provided good to excellent intubation conditions at 90 s. Conclusion Cisatracurium can be used to intubate the trachea at 90 s at a dose of 0.3 mg/kg in patients premedicated with fentanyl-midazolam and induced with propofol-sevoflurane, while maintaining hemodynamic stability, without increasing the incidence of adverse effects. [ABSTRACT FROM AUTHOR]

Endotracheal tube (ETT) cuff leaks can be encountered in the operating room with variable consequences ranging from a mere annoying bubbling sound to life-threatening respiratory compromise requiring immediate intervention. This scenario becomes more challenging if there is a difficult airway with limited mouth opening and oromaxillofacial surgery where nasal intubation is required with a north pole tube. ETT replacement can expose the patient to airway loss or life-threatening hypoxemia during the ETT exchange. There are no recommended guidelines on how to deal with an ETT cuff leak and no published step-by-step safe management strategy. With the lack of defined protocols and guidelines to manage intraoperative cuff leaks, the presence of mind and ability to make critical decisions by the anesthesiologist cannot be overemphasized. We present a case report of a 40-year-old patient weighing 70 kg diagnosed with carcinoma retromolar trigone posted for wide local excision and posterior segmental mandibulectomy. On airway examination, he had a limited mouth opening of <1 cm, with both nostrils of equal and adequate size. As mask ventilation was not difficult after induction of general anesthesia, we did fiberoptic-guided right nasal intubation with North Pole tube. We were unable to inflate the cuff of ETT and there was a significant leak. Here, we discuss how we exchanged the ETT in this difficult airway scenario. [ABSTRACT FROM AUTHOR]

BackgroundInpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA.MethodsRetrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution.Results29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups.ConclusionPatients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.

• Postneuromuscular blockade sedation and analgesia differ for patients intubated with succinylcholine or rocuronium. • Intubation with rocuronium was associated with a longer time to administration of sedation. • Intubation with rocuronium was also associated with a decreased weight-adjusted dose of fentanyl. Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P <.001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation. [ABSTRACT FROM AUTHOR]

Introduction: Magnesium Sulphate (MgSO4) pre-administration is effective in reducing Succinylcholine (Sch) induced fasciculations due to its effect at presynaptic end plate. Magnesium competes with calcium at the pre-synaptic end plate of neuromuscular junction and inhibits the release of acetylcholine (Ach) from the motor nerve terminal and to a lesser extent, decreases the sensitivity of the postjunctional membrane and reduces the excitability of the muscle fibre. Aim: To evaluate three doses of MgSO4 in reducing the incidence and severity of fasciculations and correlate with the serum magnesium levels. Materials and Methods: This prospective, randomised clinical trial was at Vijayanagar Institute of Medical Sciences (VIMS), Ballari, India. Ninety consenting adult patients aged 20-50 years scheduled for elective surgeries with endotracheal intubation under general anaesthesia were randomly allocated to three groups-Group 1, Group 2 and Group 3, to receive Injection (Inj.) MgSO4 20 mg/kg, 30 mg/kg and 40 mg/kg, respectively, before induction. Induction with Inj. propofol (2 mg/kg) was followed by administration of Inj. Sch (1.5 mg/kg). The main outcome parameters were the incidence of fasciculations and grading of the severity. Haemodynamic responses from the basal levels and after intubation, and adverse effects to the study drugs were noted. Chi-square test was used to find the significance of study parameters on categorical scale among the groups. Probability values at <0.05 were considered as significant. Results: The incidence of fasciculations was 90%, 53.4% and 43.4% in groups 1, 2 & 3, respectively. Greater number of patients had grade 3 fasciculations in group 1 (20%), compared to group 2 and group 3 (3.4% and nil) respectively. The fall in blood pressure after MgSO4 was comparable among the three groups. Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) increased by 23.5% and 18.5%, 7.9% and 4.1% and 2.8% and 2.7% in groups 1, 2 and 3, respectively at one minute. The SBP and DBP at 3rd and 5th minute stayed at statistically significant greater levels in group 1 as compared to groups 2 and 3, but were similar in groups 2 and 3 overall. The Heart Rate (HR) changes followed similar trend in all 3 groups. Incidence of feeling of warmth was highest in group three as compared to other groups. Conclusion: MgSO4 at 40 mg/kg can be the optimal dose to suppress Sch-induced fasciculations, with better attenuation of intubation associated haemodynamic changes. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to evaluate first attempt intubation failure rate, its associated factors, and its related complications in out-of-hospital emergency setting, when emergency physicians perform standardized airway management using rapid sequence intubation in adult patients. Material and methods: The present study was a substudy of the Succinylcholine versus Rocuronium for out-of-hospital Emergency Intubation (CURASMUR) Trial, which compared Succinylcholine and Rocuronium used for Rapid sequence intubation. First attempt Intubation failure rate and early intubation related complications were recorded. We used multivariable logistic regression analysis to determine first intubation failure associated factors. Results: A total of 1230 patients were included with mean age of 55.9 +/- 19 years. First attempt intubation failure was recorded in 285 (23.2%) patients. The occurrence of a first attempt intubation failure was independently associated with history of ear, nose, and throat neoplasia (OR 2.20, CI 95% 1.06–4.60). Early intubation related complications were more frequent in case of first attempt intubation failure: 80 of 285 (28.4%) in patients with first attempt intubation failure and 185 of 945 (19.6%) in patients with successful first attempt intubation [OR 1.44; CI 95%, 1.11–1.87]. Conclusion: Based on a large multicenter study on out-of-hospital tracheal intubation of adult patients, we found that first attempt intubation failure rate was high and that history of ear, nose, and throat (ENT) neoplasia was an independent associated factor. Failure in first intubation attempt was associated with significantly more intubation related complications. [ABSTRACT FROM AUTHOR]

Background: Succinylcholine has been the main neuromuscular blocking agent for the endotracheal intubation in rapid sequence induction with some adverse effects. This study was conducted to find a better alternate drug with minimal adverse effects and easy for intubations. Thus, our study aimed to compare the onset time, duration of action, intubating condition and hemodynamic effect of rocuronium bromide at the dose of 0.8 mg/kg and Succinylcholine at the dose of 1.5 mg/kg. Materials and methods: A double blinded randomized control study was conducted among 60 patients undergoing surgery each groups having 30 patients, Duration of action, Hemodynamic parameters, and intubating conditions were assessed after administering drugs in each group. Appropriate statistical tests were applied P value < 0.05 was considered to be significant Results: The mean of onset of action of succinylcholine is significantly shorter than that of rocuronium (48.07 ± 4.04 Vs 74.4 ± 9.1); and duration of action succinylcholine is significantly shorter than that of the rocuronium (3.85 ± 0.33 Vs 44.4 ± 4.7). Both the drugs significantly elevated mean Heart rate, Systolic Blood Pressure, Diastolic Blood pressure, MAP from intubation to subsequent intervals. Conclusion: The rocuronium bromide (0.8 mg/kg) has longer duration of action and slower onset of action than succinylcholine (1.5 mg/kg) with excellent intubating condition and minimal alteration in hemodynamic profile. Hence rocuronium bromide (0.8 mg/kg) can be used as an alternative to Succinylcholine (1.5 mg/kg) in selected situations. [ABSTRACT FROM AUTHOR]

Background: Succinylcholine is a depolarizing agent used for rapid sequence intubation (RIS). While the agent is the most widely used drug of choice in most emergency departments (EDs), the adverse effect profile is lengthy compared to nondepolarizing paralytic agents included rocuronium and vecuronium. Objectives: Our objective in this analysis is to detect potential safety signals and differences in safety related outcomes between patients that received succinylcholine compared to those that received rocuronium or vecuronium when undergoing RSI. Specifically, we asked whether there was a difference in all-cause mortality, whether succinylcholine was used in patient later found to have contraindications to the medication, as well as differences in the rates of rescue airway or difficult airway algorithms utilized. Methods: We utilize two clinical cases as a framework to review adverse events among ED patients undergoing RSI when using succinylcholine compared to nondepolarizing agents over a 7 years’ period at our institution as part of a quality review project. The review is retrospective and does not allow us to link adverse events specifically with drug but, instead, considers aggregate level event frequency. Results: From January 31, 2013, to January 31, 2018, there were 36,059 intubations with paralytics in the ED (75.39% with succinylcholine and 24.61% with rocuronium or vecuronium). There was no evidence of death or associated adverse events in 98.49% of patients. Of 36,059 intubations, 14 patients expired, representing 0.039% of all RSI encounters. There were 39/100,000 total deaths during RSI events. There was a higher rate of mortality in the combined vecuronium/rocuronium group (90/100,000) compared to the sample of patients intubated with succinylcholine (22/100,000). Conclusions: While the succinylcholine adverse effect profile is concerning, data from our institution does not support removal of the agent as an available option for RSI as the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents. Patient level data will be needed in future work to further understand why the all-cause mortality rate was higher in the group receiving rocuronium or vecuronium and whether those patients had increased risk of mortality from underlying disease at time of presentation.

Background: Rapid-onset paralytic agents are recommended to achieve muscle relaxation and facilitate tracheal intubation during rapid sequence induction in patients at risk of pulmonary aspiration of gastric contents. However, opioids are frequently used in this setting. The study's objective is to demonstrate the non-inferiority of remifentanil compared to rapid-onset paralytic agents, in association with an hypnotic drug, for tracheal intubation in patients undergoing  procedure under general anesthesia and at risk of pulmonary aspiration of gastric contents.Methods: The REMICRUSH (Remifentanil for Rapid Sequence Induction of Anaesthesia) study is a multicenter, single-blinded, non-inferiority randomized controlled trial comparing remifentanil (3 to 4 μg/kg) with rapid-onset paralytic agents (succinylcholine or rocuronium 1 mg/kg) for rapid sequence induction in 1150 adult surgical patients requiring tracheal intubation during general anesthesia. Enrolment started in October 2019 in 15 French anesthesia units. The expected date of the final follow-up is October 2021. The primary outcome is the proportion of successful tracheal intubation without major complications. A non-inferiority margin of 7% was chosen. Analyses of the intent-to-treat and per-protocol populations are planned.Discussion: The REMICRUSH trial protocol has been approved by the ethics committee of The Comité de Protection des Personnes Sud-Ouest et Outre-Mer II and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals. The REMICRUSH trial is the first randomized controlled trial powered to investigate whether remifentanil with hypnotics is non-inferior to rapid-onset paralytic agents with hypnotic in rapid sequence induction of anesthesia for full stomach patients considering successful tracheal intubation without major complication.Trial Registration: ClinicalTrials.gov NCT03960801. Registered on May 23, 2019. [ABSTRACT FROM AUTHOR]

BACKGROUND: Data are limited regarding current practice and outcomes for emergency department airway management in status asthmaticus. This paper describes the foremost methods and outcomes of airway management in patients in the emergency department who required intubation for status asthmaticus. METHODS: We analyzed all intubations with a primary indication of asthma over a 3-y period (January 1, 2016 to December 31, 2018) using the National Emergency Airway Registry (NEAR), a 25-center, prospective, observational registry of emergency department intubations. We report the incidence of intubations for asthma, methods and medications used, devices used, peri-intubation adverse events, and intubation success and failures using univariate descriptive statistics and cluster-adjusted incidence with 95% CI. RESULTS: A total of 19,071 encounters were recorded during the study period, with 14,517 patients intubated for medical indications. Of those, 173 (1.2%, 95% CI 0.9-1.6) were intubated for asthma. The first-attempt success rate was 90.8% (95% CI 81.9-95.5), and overall intubation success was 100%. Compared to the medical registry as a whole, patients with asthma were more likely to undergo rapid-sequence intubation (96.5% [95% CI 92.9-98.3] vs 80.8% [95% CI 75.1-82.5]), preoxygenation with bi-level positive airway pressure (BPAP) (62.9% [95% CI 49.6-74.6] vs 13.5% (95% CI 10.4-16.9]), and induction with ketamine (51.8% [95% CI 30.6-71.4] vs 11.6% [95% CI 7.6-16.8]). The adverse event rate in the patients with asthma was 12.14% (95% CI 8.1-17.9) compared to 11.93% (95% CI 9.79-14.12) in the medical registry. CONCLUSIONS: Status asthmaticus accounted for about 1% of emergent medical intubations. The majority of patients were intubated using rapid-sequence intubation after preoxygenation with BPAP and induction with ketamine, with the latter 2 practices being much more common for emergent intubations for status asthmaticus than for other medical indications. [ABSTRACT FROM AUTHOR]

Background: Succinylcholine is a depolarizing agent used for rapid sequence intubation (RIS). While the agent is the most widely used drug of choice in most emergency departments (EDs), the adverse effect profile is lengthy compared to nondepolarizing paralytic agents included rocuronium and vecuronium. Objectives: Our objective in this analysis is to detect potential safety signals and differences in safety related outcomes between patients that received succinylcholine compared to those that received rocuronium or vecuronium when undergoing RSI. Specifically, we asked whether there was a difference in all-cause mortality, whether succinylcholine was used in patient later found to have contraindications to the medication, as well as differences in the rates of rescue airway or difficult airway algorithms utilized. Methods: We utilize two clinical cases as a framework to review adverse events among ED patients undergoing RSI when using succinylcholine compared to nondepolarizing agents over a 7 years' period at our institution as part of a quality review project. The review is retrospective and does not allow us to link adverse events specifically with drug but, instead, considers aggregate level event frequency. Results: From January 31, 2013, to January 31, 2018, there were 36,059 intubations with paralytics in the ED (75.39% with succinylcholine and 24.61% with rocuronium or vecuronium). There was no evidence of death or associated adverse events in 98.49% of patients. Of 36,059 intubations, 14 patients expired, representing 0.039% of all RSI encounters. There were 39/100,000 total deaths during RSI events. There was a higher rate of mortality in the combined vecuronium/rocuronium group (90/100,000) compared to the sample of patients intubated with succinylcholine (22/100,000). Conclusions: While the succinylcholine adverse effect profile is concerning, data from our institution does not support removal of the agent as an available option for RSI as the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents. Patient level data will be needed in future work to further understand why the all-cause mortality rate was higher in the group receiving rocuronium or vecuronium and whether those patients had increased risk of mortality from underlying disease at time of presentation. [ABSTRACT FROM AUTHOR]

Objectives: To compare endotracheal intubating conditions in rapid sequence induction using Suxamethonium and Rocuronium. Study Design: Randomized Controlled Trial. Setting: Allied Hospital Faisalabad. Period: From 02-07-2015 to 01-07-2016. Material & Methods: After taking approval from hospital ethical committee, cases of emergency surgery fulfilling the inclusion criteria were enrolled and informed consent was taken after explaining all the procedure to the patient. All the patients were randomly divided into 2 groups by using computer generated random number table. Both groups were induced with thiopentone sodium 5mg/kg, analgesia was given with nalbuphine 0.1mg/kg. Group A was given Suxamethonium in a dose of 1 mg/kg body weight after induction agent. Group B was given 0.6 mg/kg Rocuronium after induction. Intubation was performed after 60 sec in both groups with cricoid pressure. Anesthesia was maintained with O2/N2O in a ratio of 50:50 and isoflurane (0.6-1.0%) in both groups. Anesthesia was stopped at the end of surgery in all the patients. Results: Mean age of the patients was 40.49+11.47 and 43.43+12.88 years, 51.43% and 45.71% were male while 48.57% and 54.29% were females, Comparison of intubation conditions was recorded as 97.14% excellent and 2.86% good in patients received suxamethonium and 82.86% and 17.14% in Rocuronium Group had good conditions. Conclusion: It was found that Suxamethonium is significantly better when compared to Rocuronium for endotracheal intubation conditions in rapid sequence induction. [ABSTRACT FROM AUTHOR]

Objectives: To compare the frequency of excellent intubation condition with Succinylcholine and rocuronium for rapid sequence induction in patients undergoing surgery under general anesthesia. Design: Randomized control trial. Place and duration of study: Department of anesthesiology and pain medicine, Combined Military Hospital Malir Cantt Karachi from 25th June to 10th August 2019. Methodology: In this randomized control trial, a non-probability consecutive sampling technique was used. Anesthesia was given through a standard approach. Then patients were randomly divided into two equal groups. In group A, succinylcholine (1mg/Kg) was given while in group B, rocuronium (1mg/Kg) was given. Laryngoscopy was attempted after 60 seconds. Intubating conditions were labeled as excellent, good, poor, and impossible. All the data was collected in two groups, the data was entered and analyzed on SPSS version 21. Results: The mean age of the patients was 40.11±9.49 years. The male to female ratio of the patients was 0.7:1. The study results showed the excellent intubation conditions were noted in 11 from group A and 9 from group B, good intubation condition was noted in 29 from group A and 25 from group B, poor conditions were noted in 17 from group A and 16 from group B and the impossible intubation conditions were noted in 13 from group A and 20 from group B. Statistically insignificant difference was found between the study groups with intubation conditions i.e. p-value=0.570. Conclusion: It has been proved in our study that both the succinylcholine and rocuronium are statically equally effective in terms of excellent intubation conditions in the management of rapid sequence induction in patients undergoing surgery under general anesthesia. [ABSTRACT FROM AUTHOR]

The skill to assess and manage the pediatric airway is essential. Correlating anatomic considerations with the need for escalating airway management is critical to optimize each child's outcome. [ABSTRACT FROM AUTHOR]

Background: Succinylcholine is the most common muscle relaxant but its side effects resulted in researches for a drug as alternative. The aim of present study was to compare the effects of succinylcholine and remifentanil on intubating conditions in elective cesarean section. Methods: Patients undergoing elective cesarean (n = 200) were enrolled in a double-blinded clinical trial study in Ali Ibne Abitaleb hospital, Zahedan, Iran. Patients were divided in 2 groups of control, received succinylcholine (1.5 mg/kg), and case, received remifentanil (1 µg/kg). Statistical analysis was performed using Fischer’s exact and chi-square tests via SPSS software at the significant level of P < 0.050. Findings: In the succinylcholine group, 92 patients (92%) and in the rhymifentanil group, 76 patients (76%) had good intubation (P < 0.050). Apgar score of 1st minute was less than 7 in 2 (2%) and 14 (14%) newborns in succinylcholine and rhymifentanil groups, respectively (P < 0.050). In case group, Apgar score of 5th minute was seen in 6 newborns (6%), while there was not any case in control group. Conclusion: Our results suggest that with respect to the effect of remifentanil on Apgar, it could be used only in contraindications of succinylcholine in suitable conditions of monitoring and effective resuscitation of neonates.

Background: Tracheal intubation is closely associated with increases in intraocular pressure (IOP); however, the effects of double-lumen tube (DLT) intubation on IOP have not been validated. Systemic hypertension (HTN) is another factor that may increase IOP. In this study, we observed differences in IOP increases between DLT and singlelumen tube (SLT) intubation, and evaluated the influence of underlying HTN during rapid sequence induction. Methods: Sixty-eight patients were allocated into one of the following group: SLT/without HTN (n = 17), SLT/HTN (n = 17), DLT/without HTN (n = 17), and DLT/HTN (n = 17). An SLT was inserted for orthopedic or gynecological surgery, and a DLT was inserted for lung surgery after rapid sequence induction using succinylcholine. IOP was measured before anesthetic induction and until 10 min after intubation using a handheld tonometer (Tono-Pen AVIA®). Results: In the DLT/without HTN and DLT/HTN groups, the maximum increases in IOPs after tracheal intubation were 7.9 and 12.2 mmHg, respectively, compared to baseline. In the SLT/without HTN and SLT/HTN groups, the maximum increases were 5.0 and 4.9 mmHg, respectively, compared to baseline. In comparisons between patients with and without underlying HTN, the values of IOPs were comparable. Conclusions: Tracheal intubation with a DLT is associated with more increases in IOPs than with an SLT in rapid sequence induction. Well-controlled underlying hypertension did not increase IOP during tracheal intubation. [ABSTRACT FROM AUTHOR]

The use of neuromuscular blocking agents (NMBAs) in acute care settings during intubation is vitally important. The NMBAs increase first pass success rates significantly while protecting patients from gastric aspiration, tracheal injury, and death. During emergent intubations, succinylcholine and rocuronium are commonly used, but each comes with specific risks and individualized interventions. First pass success can be increased by ensuring correct dosing for overweight patients and employing the use of video laryngoscope. For planned, nonemergent intubations with sustained paralysis, the chosen NMBA can be individualized to fit the patient's needs. This includes dosages based on upregulation or downregulation of acetylcholine as well as speed of administration to prevent histamine release. Nurses must provide specific care when managing the treatment in high-risk patient populations (coronary artery disease, hyperkalemia, renal failure, liver failure, and traumatic brain injuries) who may receive certain types of NMBAs. Finally, because of the wide range of adverse effects with these drugs, close assessments are essential to prevent complications. [ABSTRACT FROM AUTHOR]

Objectives: To compare efficacy in term of intubating condition between rocuronium and succinylcholine for rapid sequence induction in cesarean section Methodology: This randomized controlled trial was conducted at anesthesia department of our hospital at Nawabshah from January to December 2016. A total of 124 full term patients with Mallampati I & II and American Society of Anesthesiologists (ASA) physical status class I and II were randomly allocated into two groups. Group A (62 patients), was treated with succinylcholine chloride and Group B (62 patients) received rocuronium bromide for intubation. Intubating conditions were assessed by jaw relaxation, movement of vocal cords and bucking. Efficacy was labeled as ‘Yes’ when score 8 and 9 (excellent) otherwise ‘No’ if score was less than 8 “good and poor”. Blood pressure, heart rate, and SpO2 were monitored. Results: - The average age of the patients was 32.37 ± 1.98 y. Overall rate of excellent intubating conditions at one min was observed in 103 (83.1%) patients, good in 17 (13.7%) and poor in 4 (3.2%). The frequency of clinically acceptable intubating conditions (i.e. excellent) was 87.1% in group A and 79.03% in group B which is not statistically significant. Conclusion: Rocuronium can be safely used for rapid sequence induction in caesarean sections and the intubating conditions are similar to those of succinylcholine. [ABSTRACT FROM AUTHOR]

Malignant hyperthermia (MH) is a life-threatening hypermetabolic state that can occur following induction with depolarizing neuromuscular blockade and volatile anesthesia gases. Because succinylcholine is a common choice for prehospital and emergency department inductions, it is important for staff to be able to recognize and effectively treat an MH crisis. This case study highlights a 20-year-old male trauma patient who presented to a Level I trauma center and was intubated for declining mental status. He developed suspected MH following his anesthetic induction with succinylcholine. The following outlines the case, clinical identification of MH, and treatment. [ABSTRACT FROM AUTHOR]

The article presents a case study of a patient suffering from respiratory arrest following computed tomogrphy (CT) guided selective cervical nerve root injection. Topics discussed include CT guided cervical nerve root injection, and complications like spinal cord or brain infarction and death, vascular penetration with vessel injury or intravascular injection of local anaesthetic and steroid.

The process of airway management has evolved considerably to include rapid sequence intubation (RSI), the use of various procedures, and sophisticated devices designed to assist in the placement of an endotracheal tube. This article summarizes the basic concepts of airway management, the technique of RSI, and post-intubation management in trauma patients. [ABSTRACT FROM AUTHOR]