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Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room

David Caro, MD
Section Editor
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The first task of any clinician managing an acutely unstable patient is to secure the airway. In most circumstances, emergency clinicians use rapid sequence intubation (RSI) when active airway management is required. RSI incorporates neuromuscular blocking agents (NMBA) and rapidly acting sedative (ie, induction) medications to create optimal intubating conditions.

This topic review will discuss the basic clinical pharmacology and selection of NMBAs for use in RSI outside the operating room. The practice of RSI and other medications used as part of RSI are discussed elsewhere, as are other aspects of airway management both inside and outside the operating room. (See "Rapid sequence intubation for adults outside the operating room" and "Induction agents for rapid sequence intubation in adults outside the operating room" and "Pretreatment medications for rapid sequence intubation in adults outside the operating room" and "Basic airway management in adults" and "Rapid sequence induction and intubation (RSII) for anesthesia".)


Rapid sequence intubation (RSI) is the standard of care in emergency airway management for intubations not anticipated to be difficult [1-4]. RSI involves the use of a sedative and a neuromuscular blocking agent (NMBA) to render a patient rapidly unconscious and flaccid in order to facilitate emergent endotracheal intubation, mitigate unwanted physiologic responses to laryngoscopy and intubation, and minimize the risk of aspiration. Multiple prospective observational studies confirm the excellent success rate of RSI using the combination of a sedative and a NMBA in the emergency department (ED) [2-4]. (See "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach".)

NMBAs are integral to the performance of RSI. Multiple randomized trials and observational studies demonstrate that the use of NMBAs improves success rates for emergency endotracheal intubation and reduces the risk of complications [1,5-10]. One prospective trial performed in a prehospital air medical setting and using a crossover design found the use of NMBAs improved the view of the larynx by a full grade in most patients when performing direct laryngoscopy [6].

In RSI, a NMBA is given in conjunction with a sedative agent. Patients undergoing RSI may be fully aware of their environment and painful stimuli, but unable to respond [11,12]. If such patients are not adequately sedated, potentially adverse physiologic responses to airway manipulation can occur, including tachycardia, hypertension, and elevated intracranial pressure (ICP) [13]. Sedative use prevents or minimizes these effects, and may also improve the laryngoscopic view obtained after neuromuscular paralysis [14,15]. (See "Induction agents for rapid sequence intubation in adults outside the operating room".)

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Literature review current through: Sep 2017. | This topic last updated: Jun 22, 2017.
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  1. Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999; 17:141.
  2. Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
  3. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325.
  4. Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999; 6:31.
  5. Cicala R, Westbrook L. An alternative method of paralysis for rapid-sequence induction. Anesthesiology 1988; 69:983.
  6. Bozeman WP, Kleiner DM, Huggett V. A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care 2006; 10:8.
  7. Ma OJ, Atchley RB, Hatley T, et al. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Am J Emerg Med 1998; 16:125.
  8. Vijayakumar E, Bosscher H, Renzi FP, et al. The use of neuromuscular blocking agents in the emergency department to facilitate tracheal intubation in the trauma patient: help or hindrance? J Crit Care 1998; 13:1.
  9. Wilcox SR, Bittner EA, Elmer J, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 2012; 40:1808.
  10. Lundstrøm LH, Duez CH, Nørskov AK, et al. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. Cochrane Database Syst Rev 2017; 5:CD009237.
  11. Topulos GP, Lansing RW, Banzett RB. The experience of complete neuromuscular blockade in awake humans. J Clin Anesth 1993; 5:369.
  12. Wagner BK, Zavotsky KE, Sweeney JB, et al. Patient recall of therapeutic paralysis in a surgical critical care unit. Pharmacotherapy 1998; 18:358.
  13. Sivilotti ML, Ducharme J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med 1998; 31:313.
  14. El-Orbany MI, Wafai Y, Joseph NJ, Salem MR. Does the choice of intravenous induction drug affect intubation conditions after a fast-onset neuromuscular blocker? J Clin Anesth 2003; 15:9.
  15. Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med 2003; 10:612.
  16. Caro DA, Andescavage S, Akhlaghi M, et al. Pupillary response to light is preserved in the majority of patients undergoing rapid sequence intubation. Ann Emerg Med 2011; 57:234.
  17. Walls RM. Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF (Eds), Lippincott Williams & Wilkins, Philadelphia 2012.
  18. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151.
  19. Tran DT, Newton EK, Mount VA, et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015; :CD002788.
  20. Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438.
  21. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483.
  22. Levitan R. Safety of succinylcholine in myasthenia gravis. Ann Emerg Med 2005; 45:225.
  23. Boehm JJ, Dutton DM, Poust RI. Shelf life of unrefrigerated succinylcholine chloride injection. Am J Hosp Pharm 1984; 41:300.
  24. Gronert GA. Cardiac arrest after succinylcholine: mortality greater with rhabdomyolysis than receptor upregulation. Anesthesiology 2001; 94:523.
  25. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006; 104:158.
  26. Miller R. Miller's Anesthesia, 6th, Elsevier Churchill Livingstone, Philadelphia 2005.
  27. Kolb ME, Horne ML, Martz R. Dantrolene in human malignant hyperthermia. Anesthesiology 1982; 56:254.
  28. Magee DA, Gallagher EG. "Self-taming" of suxamethonium and serum potassium concentration. Br J Anaesth 1984; 56:977.
  29. Zink BJ, Snyder HS, Raccio-Robak N. Lack of a hyperkalemic response in emergency department patients receiving succinylcholine. Acad Emerg Med 1995; 2:974.
  30. Raman SK, San WM. Fasciculations, myalgia and biochemical changes following succinylcholine with atracurium and lidocaine pretreatment. Can J Anaesth 1997; 44:498.
  31. Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anesth Analg 2000; 91:237.
  32. Carroll JB. Increased incidence of masseter spasm in children with strabismus anesthetized with halothane and succinylcholine. Anesthesiology 1987; 67:559.
  33. Sims C. Masseter spasm after suxamethonium in children. Br J Hosp Med 1992; 47:139.
  34. Bauer SJ, Orio K, Adams BD. Succinylcholine induced masseter spasm during rapid sequence intubation may require a surgical airway: case report. Emerg Med J 2005; 22:456.
  35. Gill M, Graeme K, Guenterberg K. Masseter spasm after succinylcholine administration. J Emerg Med 2005; 29:167.
  36. Rosenberg H, Fletcher JE. Masseter muscle rigidity and malignant hyperthermia susceptibility. Anesth Analg 1986; 65:161.
  37. Harvey SC, Roland P, Bailey MK, et al. A randomized, double-blind comparison of rocuronium, d-tubocurarine, and "mini-dose" succinylcholine for preventing succinylcholine-induced muscle fasciculations. Anesth Analg 1998; 87:719.
  38. Larach MG, Rosenberg H, Gronert GA, Allen GC. Hyperkalemic cardiac arrest during anesthesia in infants and children with occult myopathies. Clin Pediatr (Phila) 1997; 36:9.
  39. Yasuda I, Hirano T, Amaha K, et al. Chronotropic effects of succinylcholine and succinylmonocholine on the sinoatrial node. Anesthesiology 1982; 57:289.
  40. Vachon CA, Warner DO, Bacon DR. Succinylcholine and the open globe. Tracing the teaching. Anesthesiology 2003; 99:220.
  41. Chidiac EJ, Raiskin AO. Succinylcholine and the open eye. Ophthalmol Clin North Am 2006; 19:279.
  42. Ishigaki S, Masui K, Kazama T. Saline Flush After Rocuronium Bolus Reduces Onset Time and Prolongs Duration of Effect: A Randomized Clinical Trial. Anesth Analg 2016; 122:706.
  43. Perry JJ, Lee J, Wells G. Are intubation conditions using rocuronium equivalent to those using succinylcholine? Acad Emerg Med 2002; 9:813.
  44. Nava-Ocampo AA, Velázquez-Armenta Y, Moyao-García D, Salmerón J. Meta-analysis of the differences in the time to onset of action between rocuronium and vecuronium. Clin Exp Pharmacol Physiol 2006; 33:125.
  45. Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med 2011; 18:10.
  46. Na HS, Hwang JW, Park SH, et al. Drug-administration sequence of target-controlled propofol and remifentanil influences the onset of rocuronium. A double-blind, randomized trial. Acta Anaesthesiol Scand 2012; 56:558.
  47. Hans GA, Bosenge B, Bonhomme VL, et al. Intravenous magnesium re-establishes neuromuscular block after spontaneous recovery from an intubating dose of rocuronium: a randomised controlled trial. Eur J Anaesthesiol 2012; 29:95.
  48. Czarnetzki C, Lysakowski C, Elia N, Tramèr MR. Intravenous lidocaine has no impact on rocuronium-induced neuromuscular block. Randomised study. Acta Anaesthesiol Scand 2012; 56:474.
  49. Baumgarten RK, Carter CE, Reynolds WJ, et al. Priming with nondepolarizing relaxants for rapid tracheal intubation: a double-blind evaluation. Can J Anaesth 1988; 35:5.
  50. Sparr HJ, Vermeyen KM, Beaufort AM, et al. Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex in a randomized multicenter study: efficacy, safety, and pharmacokinetics. Anesthesiology 2007; 106:935.
  51. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg 2007; 104:575.
  52. Plaud B, Meretoja O, Hofmockel R, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology 2009; 110:284.
  53. Sørensen MK, Bretlau C, Gätke MR, et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth 2012; 108:682.
  54. Van Gestel L, Cammu G. Is the effect of sugammadex always rapid in onset? Acta Anaesthesiol Belg 2013; 64:41.
  55. Lee C, Jahr JS, Candiotti KA, et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology 2009; 110:1020.
  56. Gaszynski T, Szewczyk T, Gaszynski W. Randomized comparison of sugammadex and neostigmine for reversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia. Br J Anaesth 2012; 108:236.
  57. Geldner G, Niskanen M, Laurila P, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67:991.
  58. Pongrácz A, Szatmári S, Nemes R, et al. Reversal of neuromuscular blockade with sugammadex at the reappearance of four twitches to train-of-four stimulation. Anesthesiology 2013; 119:36.
  59. Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology 2008; 109:816.
  60. Abrishami A, Ho J, Wong J, et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Database Syst Rev 2009; :CD007362.
  61. Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core Evid 2013; 8:57.
  62. Stourac P, Adamus M, Seidlova D, et al. Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation. Anesth Analg 2016; 122:1536.
  63. Won YJ, Lim BG, Lee DK, et al. Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4678.
  64. Loupec T, Frasca D, Rousseau N, et al. Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients. Anaesthesia 2016; 71:265.
  65. Tsur A, Kalansky A. Hypersensitivity associated with sugammadex administration: a systematic review. Anaesthesia 2014; 69:1251.
  66. Blichfeldt-Lauridsen L, Hansen BD. Anesthesia and myasthenia gravis. Acta Anaesthesiol Scand 2012; 56:17.
  67. Martyn JA, White DA, Gronert GA, et al. Up-and-down regulation of skeletal muscle acetylcholine receptors. Effects on neuromuscular blockers. Anesthesiology 1992; 76:822.
  68. Eisenkraft JB, Book WJ, Mann SM, et al. Resistance to succinylcholine in myasthenia gravis: a dose-response study. Anesthesiology 1988; 69:760.
  69. Baraka A. Suxamethonium block in the myasthenic patient. Correlation with plasma cholinesterase. Anaesthesia 1992; 47:217.
  70. Wainwright AP, Brodrick PM. Suxamethonium in myasthenia gravis. Anaesthesia 1987; 42:950.
  71. Dillon FX. Anesthesia issues in the perioperative management of myasthenia gravis. Semin Neurol 2004; 24:83.
  72. Itoh H, Shibata K, Nitta S. Difference in sensitivity to vecuronium between patients with ocular and generalized myasthenia gravis. Br J Anaesth 2001; 87:885.
  73. Chan KH, Yang MW, Huang MH, et al. A comparison between vecuronium and atracurium in myasthenia gravis. Acta Anaesthesiol Scand 1993; 37:679.
  74. Nilsson E, Meretoja OA. Vecuronium dose-response and maintenance requirements in patients with myasthenia gravis. Anesthesiology 1990; 73:28.
  75. Eisenkraft JB, Book WJ, Papatestas AE. Sensitivity to vecuronium in myasthenia gravis: a dose-response study. Can J Anaesth 1990; 37:301.
  76. Baraka A, Taha S, Yazbeck V, Rizkallah P. Vecuronium block in the myasthenic patient. Influence of anticholinesterase therapy. Anaesthesia 1993; 48:588.
  77. Baraka A, Haroun-Bizri S, Kawas N, et al. Rocuronium in the myasthenic patient. Anaesthesia 1995; 50:1007.
  78. Eisenkraft JB, Papatestas AE, Kahn CH, et al. Predicting the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology 1986; 65:79.
  79. Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology 1980; 53:26.
  80. Tagawa T, Sakuraba S, Okuda M. Rapid sequence intubation using Pentax-AWS without muscle relaxants in patients with myasthenia gravis. Acta Anaesthesiol Taiwan 2009; 47:154.
  81. Narimatsu E, Munemura Y, Kawamata M, et al. Tracheal intubation without neuromuscular relaxants for thymectomy in myasthenic patients. J Med 2003; 34:47.
  82. el-Dawlatly AA, Ashour MH. Anaesthesia for thymectomy in myasthenia gravis: a non-muscle-relaxant technique. Anaesth Intensive Care 1994; 22:458.
  83. Shaw I, Trueger NS, Pirotte MJ. What Is the Time to Muscle Relaxation After Intramuscular Administration of Neuromuscular Blockers? Ann Emerg Med 2015; 66:390.