Tran Diem T T, Newton Ethan K, Mount Victoria A H, Lee Jacques S, Wells George A, Perry Jeffrey J
Division of Cardiac Anesthesiology, Department of Anesthesia, The University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada, K1Y 4W7.
Cochrane Database Syst Rev. 2015 Oct 29;2015(10):CD002788. doi: 10.1002/14651858.CD002788.pub3.
Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015.
To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation.
In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.
We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg.
Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model.
The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.
AUTHORS' CONCLUSIONS: Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.
在紧急情况下或择期手术时，患者常需要快速顺序诱导（RSI）气管插管技术，以防止误吸、颅内压升高或便于插管。传统上，琥珀酰胆碱因其起效快、作用时间短，一直是最常用于此目的的肌肉松弛剂；不幸的是，它可能有严重的副作用。罗库溴铵已被建议作为琥珀酰胆碱插管的替代药物。这是我们Cochrane系统评价的更新版，该评价首次发表于2003年，随后在2008年和现在的2015年进行了更新。
确定在RSI插管期间，罗库溴铵产生的插管条件是否与琥珀酰胆碱相当。
在我们最初的评价中，我们检索了所有数据库至2000年3月，随后更新至2007年6月。此次最新更新包括检索Cochrane对照试验中心注册库（CENTRAL；2015年第2期）、MEDLINE（1966年至2015年2月第2周）和EMBASE（1988年至2015年2月14日），以查找与罗库溴铵和琥珀酰胆碱使用相关的随机对照试验（RCT）或对照临床试验（CCT）。我们纳入了外语期刊，并手工检索了已识别研究的参考文献以获取更多引用文献。
我们纳入了任何报告在任何年龄组或临床环境中比较罗库溴铵和琥珀酰胆碱用于RSI或改良RSI时插管条件的RCT或CCT。罗库溴铵的剂量至少为0.6mg/kg，琥珀酰胆碱的剂量至少为1mg/kg。
两位作者（EN和DT）独立提取数据，并为“偏倚风险”表评估方法学质量。我们在Review Manager 5中使用风险比（RR）和随机效应模型合并结果。
上一次更新（2008年）识别出53项潜在研究，纳入37项进行荟萃分析。在此次最新更新中，我们又识别出13项研究，纳入11项，总结了50项试验的结果，包括4151名参与者。总体而言，在实现极佳插管条件方面，琥珀酰胆碱优于罗库溴铵：RR 0.86（95%置信区间（CI）0.81至0.92；n = 4151），在临床可接受的插管条件方面也是如此（RR 0.97，95%CI 0.95至0.99；n = 3992，48项试验）。试验中检测偏倚的高发生率以及显著的异质性为这些结论提供了中等质量的证据，这些结论与上一次更新一致。当使用硫喷妥钠作为诱导剂时，琥珀酰胆碱更有可能产生极佳的插管条件：RR 0.81（95%CI：0.73至0.88；n = 2302，28项试验）。在上一次更新中，我们得出结论，丙泊酚是与琥珀酰胆碱联用的更佳诱导剂。未报告严重不良事件的发生率。当将琥珀酰胆碱与1.2mg/kg罗库溴铵进行比较时，我们发现插管条件无统计学差异；然而，琥珀酰胆碱在临床上更具优势，因为其作用持续时间更短。
在实现极佳和临床可接受的插管条件方面，琥珀酰胆碱产生的插管条件优于罗库溴铵。
