Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION: In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to suc-cinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities.EVIDENCE ACQUISITION: A systematic review of the literature concerning neuromuscular blockade for airway emer-gencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Develop-ment, and Evaluation (GRADE) system was used to assess the certainty of evidence.EVIDENCE SYNTHESIS: The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as strong evidence to provide recommendations for the posed questions.CONCLUSIONS: The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Automated summary

This study aims to evaluate the clinical utility, patient safety, and financial implications of using rocuronium and sugammadex instead of succinylcholine and dantrolene in class B surgical facilities. The results show that both succinylcholine and rocuronium-sugammadex provide adequate treatment for airway emergencies and rapid spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.