Hyperkalemic emergency department patients intubated with rocuronium or succinylcholine: Retrospective study of clinical outcomes

Abstract

Study objective: Emergency department (ED) clinicians often avoid succinylcholine due to concerns about potassium elevation leading to adverse events, though clinical evidence beyond case reports is limited. Rocuronium is a non-depolarizing paralytic that does not affect potassium levels. Therefore, it is perceived as safer despite causing longer paralysis than succinylcholine. This study aimed to compare adverse clinical outcomes in patients with pre-existing hyperkalemia who received either succinylcholine or rocuronium during rapid sequence intubation (RSI) in the ED.

Methods: We conducted a retrospective cohort study of all ED patients aged ≥18 years presenting between October 2015 and July 2024 with initial serum potassium >5.5 mmol/L who underwent RSI with either rocuronium or succinylcholine. Data included demographics, medical history, lab values, medication administration, hospital course, and chart-reviewed details of adverse events. The primary outcome was death within 24 hours of RSI. The secondary outcome was cardiac arrest within 1 hour of RSI.

Results: 434 patients were included in analysis: 310 were paralyzed with rocuronium and 124 with succinylcholine. There was no significant difference in 24-hour mortality (rocuronium 10.0%, succinylcholine 10.5%, p=0.989). Cardiac arrest within 1 hour occurred in 7 cases (1.6% overall). 6 cases were in the rocuronium group (1.9%) and 1 in the succinylcholine group (0.8%, p=0.758). None of these arrests were fatal. Regression analysis showed no association between paralytic choice and 24-hour mortality (OR 0.911, 95% CI 0.414-2.00). Among succinylcholine cases, potassium level was not associated with increased 24-hour mortality (OR 1.311, 95% CI 0.359-4.780).

Conclusion: We found no statistically significant difference in clinical adverse events between succinylcholine and rocuronium in hyperkalemic ED patients. While limited by its retrospective design, this study questions the presumed clinical importance of potassium levels in paralytic selection for RSI.