405 - Rocuronium versus Succinylcholine Use in Pediatric Emergency Department Intubations and Adverse Airway Outcomes: A National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) Study

Publication Number: 4397.405

Yevgeniy Liverant, Goryeb Children's Hospital, Florham Park, NJ, United States; Christina Melchionne Miseo, Morristown Medical Center, Morristown, NJ, United States; Yasmin H. Soliman, The Warren Alpert Medical School of Brown University, Providence, RI, United States; Joshua Nagler, Boston Children's Hospital, Boston, MA, United States; Alexander Bracey, Albany Medical College, Albany, NY, United States; Robyn Wing, The Warren Alpert Medical School of Brown University, Wrentham, MA, United States; Akira Nishisaki, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Kelsey A.. Miller, Harvard Medical School, Boston, MA, United States; Monica Prieto, Childrens Hospital of Philadelphia, Swarthmore, PA, United States; Benjamin T. Kerrey, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Emily Greenwald, Duke University School of Medicine, Durham, NC, United States; John Rutledge, Atlantic Health System, Morristown, NJ, United States

Background: Rocuronium and succinylcholine are the most commonly used neuromuscular-blocking agents (NMBAs) for tracheal intubation (TI) in Pediatric Emergency Departments (PEDs). It remains unclear whether either agent is associated with improved TI outcomes.

Objective: We sought to determine whether adverse airway outcomes (AAOs) were more common and first attempt success (FAS) less common with rocuronium versus succinylcholine for TI in the PED.

Design/Methods: We performed a retrospective review of pediatric TIs performed in PEDs contributing to the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM). We used NEAR4PEM operational definitions for all variables and outcomes of interest. We included all patients undergoing TI in the PED from 1/1/2020 to 12/31/24 who received rocuronium or succinylcholine before intubation. The main outcomes were AAOs and FAS, compared between patients who received rocuronium versus succinylcholine and adjusted for covariates known to be associated with both outcomes.

Results: During the 60-month study period, 1895 TI were performed with either rocuronium (1726 TI, 91.1%) or succinylcholine (169 TI, 8.9%; Table 1). There was a significant difference in the incidence of AAO (rocuronium [22.8%] vs. succinylcholine [16.0%], p = 0.04) but not in FAS (rocuronium [75.9%] vs. succinylcholine [77.5%], p = 0.64) in TIs performed with rocuronium versus succinylcholine (Table 2). After adjusting for our defined covariates, there was no statistically significant difference in the odds of AAO or FAS for rocuronium versus succinylcholine (Table 3). In contrast, both infancy and difficult airway risk factors were associated with a higher odds of AAO and lower odds of FAS. VL was associated with lower odds of AAO and higher odds of FAS.

Conclusion(s): We found no significant difference in AAOs or FAS with use of rocuronium versus succinylcholine. In the absence of specific contraindications, the choice of NMBA may reasonably be guided by institutional protocols or provider preference without adversely affecting patient outcomes.

Table 1: Patient and Procedural Characteristics


Table 2: Univariate Analysis of TI Outcomes by NMBA Selection
1. AAO: oxygen desaturation (SpO2 < 80%), mainstem bronchial intubation, esophageal intubation (immediate recognition), esophageal intubation (delayed recognition), hypotension requiring intervention, emesis with aspiration, emesis without aspiration, cardiac arrest (survived), cardiac arrest (died), dysrhythmia (including bradycardia), dental/lip trauma, pain/agitation requiring additional medication and delaying procedure, epistaxis, direct airway injury, hypertension requiring intervention, laryngospasm, pneumothorax/pneumomediastinum, malignant hyperthermia, or medication error

Table 3: Regression Analysis of TI Outcomes by NMBA Selection