Rapid sequence induction with rocuronium - a challenge to the gold standard

In the previous issue of Critical Care, Marsch and colleagues [1] report the results of a trial that compares the use of rocuronium and succinylcholine for rapid sequence induction (RSI) in the intensive care unit (ICU). Given the importance of high-quality airway management in the critically ill, for whom time is of the essence and the consequences of failed intubation are at their most serious [2], this challenge to the gold standard is contentious.RSI is an anesthesia induction technique designed to facilitate rapid tracheal intubation in patients at high risk for pulmonary aspiration. Succinylcholine has been a mainstay of RSI for more than 50 years, primarily because of the drug's rapid onset time. This property facilitates that fundamental axiom of RSI, which is that the time from induction of anesthesia to endotracheal intubation with a cuffed endotracheal tube, the airway's period of vulnerability to aspiration risk, should be as short as possible.The concept of RSI evolved after the introduction of succinylcholine in 1951 and the description of cricoid pressure in 1961 [3]. The traditional components of the technique as outlined in the original description [4] include oxygen administration, injection of a predetermined dose of thiopental immediately followed by succinylcholine, application of cricoid pressure, and avoidance of positive pressure ventilation before tracheal intubation with a cuffed endotracheal tube [4]. Currently, RSI is the standard of care for anesthesia induction in patients with an increased risk for gastric aspiration. However, in practice, there is considerable variation and not a little controversy regarding some elements of the technique [5].For more than 30 years, questions over succinylcholine use in RSI have been raised [6]. Succinylcholine possesses the fastest onset (45 seconds) and produces the shortest period of muscle relaxation (6 to 10 minutes) compared with all other agents. However, it is a 'pharmacologically dirty and da