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A 41-year-old female with acute cholecystitis presents to the operating room (OR) for laparoscopic cholecystectomy. The patient’s medical history is significant for type II diabetes, gastroesophageal reflux disease, obesity (BMI 52 kg·m−2) and obstructive sleep apnea (OSA) with no surgical history. She has been using a continuous positive airway pressure machine regularly for the past 3 years and her serum glucose levels have been well controlled (A1C 6.5%). When asked, she endorsed symptoms of free reflux, waking her up in the night 3 to 4 times a week. She is on pantoprazole 40 mg PO once daily and has no allergies. She is alert and in no distress but has had multiple episodes of vomiting in the past 24 hours. Her last meal was over 24 hours ago. A focused cardiovascular and respiratory exam were unremarkable, and her vitals were all within normal limits. An airway exam was completed and showed a Mallampati class III, good mouth opening (>5 cm), good thyromental distance (6 cm), good mandibular protrusion, and normal neck extension. There were no missing, loose, or protruding teeth.

Given her history of free reflux and vomiting, you decide to proceed with a rapid sequence intubation (RSI) and intubation. After appropriate patient positioning and denitrogenation, you induce the patient. On direct laryngoscopy, a grade 3b view is obtained where you are unable to secure the airway. After another two unsuccessful attempts with a styletted smaller ETT followed by video-laryngoscopy, you declare a failed airway and decide to wake the patient up.

How Will Your Choice of Neuromuscular Blocking Agent for the RSI Impact This Decision?

The ideal muscle relaxant to facilitate intubation in a situation requiring an RSI should have a rapid onset, a short duration of action, and be immediately reversible. The two most commonly used neuromuscular blocking agents for rapid sequence inductions are the nondepolarizing neuromuscular blocking agent rocuronium and the depolarizing neuromuscular blocking agent succinylcholine. Succinylcholine was the agent of choice when no contraindications exist, given its short duration of action of 5 to 8 minutes and its rapid onset of drug effect (<60 seconds). The side effects of succinylcholine include fasciculations, hyperkalemia, bradycardia, increased intraocular pressure, and malignant hyperthermia (MH). Rocuronium has been commonly used given that at larger doses (1-1.2 mg·kg−1) a similar onset time to succinylcholine can be achieved (1 minute), but the major drawback to the use of rocuronium for RSI in the context of a potentially difficult airway is its long duration of action compared with succinylcholine. This has changed with the advent of sugammadex which at adequate doses can reverse rocuronium-induced profound neuromuscular blockade in 2.7 minutes. Normal healthy individuals theoretically have 8 minutes of apneic reserve; however, in critically ill, morbidly obese, pediatric, or pregnant patients that reserve is significantly reduced increasing their risk of hypoxemia prior to the return of spontaneous breathing.


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