Written by Aaron Lacy
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In this retrospective, database-propensity-matched study, children in the ED who underwent rapid sequence intubation (RSI) with succinylcholine had a lower rate of death compared to rocuronium.
Sux ≠ Sucks and Roc ≠ Rocks
In case you haven’t heard, pediatric airways are a big deal. While extensively researched in the adult population (with more work ongoing), it has yet to be delineated which neuromuscular blocker (NMB; e.g., succinylcholine or rocuronium) is best in the pediatric population. This retrospective, propensity-matched study used a large healthcare database (TriNetX) to compare outcomes in children who underwent RSI in the ED. When comparing 706 propensity-matched patients in each group, patients who were administered succinylcholine compared to rocuronium as their NMB for RSI had a lower rate of death: 5.7% vs. 8.9%, RR 0.65 (95%CI 0.43–0.93). There were no significant differences in other outcomes of interest, such as PTSD (2.6% vs. 3.7%, RR: 0.71, 95%CI 0.32–1.68), or malignant hyperthermia (0 vs. 1 instances). PTSD has not been studied in children undergoing RSI with a NMB, and it was chosen as an outcome of interest given work showing that rocuronium in adults is associated with higher risk of awareness with paralysis, which portends PTSD.
Subgroup analysis found that the overall lowest mortality combination of induction agent and NMB was etomidate and succinylcholine (7%), followed by ketamine and succinylcholine (8.2%), etomidate and rocuronium (8.6%), and finally ketamine and rocuronium (16.4%).
How will this change my practice?
It feels as if clinicians are very loyal to either one induction agent or one NMB, and they stick to the combo they are comfortable with. I try to take individual patient factors and the clinical scenario into consideration for my pharmacologic choices during RSI, but with recent evidence I do find myself reaching more and more for the combination of etomidate and succinylcholine. In kids (barring contraindication to sux), etomidate and sux will almost certainly be my standard.
Source
Succinylcholine Versus Rocuronium for Pediatric Rapid Sequence Intubation in the Emergency Department. Pediatr Emerg Care. 2026 Mar 1;42(3):203-208. doi: 10.1097/PEC.0000000000003532. Epub 2026 Jan 6. PMID: 41489184.
