Rapid sequence induction

The use of rocuronium 0.6 mg.kg−1 for rapid sequence induction (RSI) should be discouraged despite the apparently good intubating conditions described by Lowry et al. (Anaesthesia 1999; 54: 247–52). The apparent advantages of rocuronium for RSI are its rapid onset and cardiovascular stability. Certainly, this dose will give rapid paralysis. There will, however, be a correspondingly long duration of action of up to 70 min [1]. This is not desirable when performing a rapid sequence induction in an emergency case. Suxamethonium has two advantages over other neuromuscular blocking agents when used for RSI. First, it produces rapid paralysis allowing the airway to be secured quickly and safely. Secondly, its short duration of action means that respiratory effort should return in approximately 5 min in over 95% of patients. This is of great importance should there be a failed intubation. If there is a desire to avoid suxamethonium for RSI then high-dose opioids such as alfentanil (20–60 μg.kg−1), plus or minus lignocaine 1 mg.kg−1, in association with propofol may be preferable to rocuronium 0.6 mg.kg−1 [2–4]. In the event of difficulties, the opioid can be reversed rapidly with naloxone if necessary. As trainees, some of whom are quite junior, perform many of the rapid sequence inductions, a technique that maximises patient safety in the event of an unexpected failed intubation should be encouraged. At present this is either the traditional thiopentone/suxamethonium- or a propofol/alfentanil-based regimen.