Rocuronium vs succinylcholine in the traumatically injured brain: a prospective, pilot study

Lauren Stambolic, PharmD1; Marc McDowell, PharmD, BCPS1; Sabrin Jaber, PharmD2; Brook Walsh, PharmD3: Ellen Omi, MD1;

Robert Mokszycki, PharmD, BCPS4

Authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

Determine the effect of succinylcholine vs rocuronium on in-hospital mortality when administered to TBI patients during RSI. 1. TBI-related Emergency Department Visits, Hospitalizations, and Deaths (EDHDs). Centers for disease control and

prevention. https://www.cdc.gov/traumaticbraininjury/data/tbi-edhd.html. Published March 29, 2019. Accessed November 6, 2019. 2. Boucher BA, Wood G. Chapter 42. Acute Management of the Brain Injury Patient. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e New York, NY: McGraw-Hill; 2014. http://accesspharmacy.mhmedical.com.proxy.cc.uic.edu/content.aspx?bookid=689&sectionid=45310492. Accessed November 11, 2019.3. Carney N, Totten A, O'Reilly, et al. Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition. Brain Trauma Foundation. 2016.4. James E. Cottrell; Succinylcholine and Intracranial Pressure. Anesthesiology 2018;129(6):1159-1162. doi: https://doi.org/10.1097/ALN.0000000000002429.5.Asad Patanwala, et al. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy. 2016.

• In 2014, there were approximately 2.9 million emergency department (ED) visits due to traumatic brain injury (TBI).1

• In TBI patients, the severity of brain injury is commonly assessed using the Glasgow Coma Scale (GCS) with a score of 9-12 considered moderate and 3-8 considered severe.2

• Patients presenting with TBI often require rapid sequence intubation (RSI) to protect their airway.• Common paralytics for RSI are succinylcholine and

rocuronium due to their rapid onset of action and relatively short duration. • Currently, there are no recommendations in the Brain

Trauma Foundation Guidelines on agents of choice for RSI in patients with severe TBI.3

• Animal models have demonstrated an increase in intracranial pressure with the administration of succinylcholine, which has led to concern when administered to TBI patients.4

• Recent retrospective data has suggested an increase in mortality associated with the administration of succinylcholine in TBI patients compared to rocuronium.5

• Presentation to ED with TBI• Administration of either

succinylcholine or rocuronium for RSI• Age > 18 years of age

• Pregnancy•More than one paralytic

agent administered• Paralytic agent other than

succinylcholine or rocuronium administered• Surgical airway placed• Cardiac arrest prior to

intubation• Intubation prior to ED arrival

Author Contact Information: Lauren.Stambolic@advocatehealth.com

Prospective, observational cohort

Primary Outcome: Incidence of in-hospital mortality Secondary Outcomes: In-hospital and intensive care unit (ICU) length of stay (LOS)

Demographics Rocuronium (n=15)

Succinylcholine (n=29) P value

Age (years), mean 51.1 45.1 0.35

Sex (male), n (%) 12 (80) 26 (89.7) 0.39

Body mass index, mean 27.8 28.9 0.77

Home anticoagulant use, n (%) 1 (6.7) 5 (17.2) 0.33

Home antiplatelet use, n (%) 3 (20) 3 (6.9%) 0.32

Initial GCS, mean 5.9 6.4 0.63

Minor, n (%) 0 (0) 2 (6.9)

0.87Moderate, n (%) 4 (26.7) 7 (24.1)

Severe, n (%) 11 (73.3) 20 (69)

Hyperosmotic therapy, n (%)

8 (53) 23 (80) -

Seizure prophylaxis, n (%)

10 (65) 21 (72) -

Outcomes Rocuronium (n=15)

Succinylcholine (n=29) P value

In-hospital mortality, n (%)

5 (33.3) 9 (31) 0.88

In-hospital survival, n (%)

Discharge home 5 (33.3) 9 (31) 0.36

Transfer to rehab 5 (33.3) 8 (27.6) 0.69

Transfer to long term care

0 6 (31) 0.06

Length of stay, days

In-hospital 7.7 +/- 7.3 15.8 +/- 13.1 0.03ICU 4.9 +/- 6.3 8.6 +/- 6.3 0.07

Inclusion Criteria Exclusion Criteria

• Based on the limited data collected, there was no difference found in-hospital mortality or ICU LOS when, but anincrease in in-hospital LOS in the succinylcholine cohort.• These results are inconclusive due to low patient

enrollment.• Patient enrollment ongoing.

1Advocate Christ Medical Center; 2Stanford University Medical Center; 3Little Company of Mary Hospital; 4University of Massachusetts