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Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 9 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 27

Rocuronium vs Succinylcholine: Emergency Airway Management of the COVID-19 Patient
Ryan Shores, DNP, CRNA*
Katherine Fowler, DNP, CRNA*
John McDonough, EdD, Dr. (habil) NSA, CRNA, APRN*
Amy Suralis, DNP, CRNA*
Denise Schindele, BA, CCRN, RNA*^
Tilmann Müller-Wolff, MA, BSc, RNA, CCRN*^
Affiliation:
*University of North Florida
^Klinikum Ludwigsburg, Germany

Funding/Conflict of Interest Disclosure: 
None

KEYWORDS: COVID-19, Airway management; Rapid sequence induction; Rocuronium; Succinylcholine

Abstract
Severe acute respiratory syndrome-coronavirus-2 (SARS CoV-2) infection leading to the COVID-19 pandemic has 
created a new paradigm and challenge for airway management. Anesthesia providers perform tracheal intubation in a 
variety of settings where the best possible approach and plan for tracheal intubation is determined including patient 
anatomy, pathophysiology and urgency.  SARS CoV-2 is a highly contagious RNA virus that has caused widespread 
infections, severe respiratory disease, and deaths.  The purpose of this article is to describe current international 
standards of COVID-19 airway management, review the multi-system pathophysiology of COVID-19 patients, as 
well as evidence-based pharmacologic options available for intubating COVID-19 patients.  This review supports 
rapid sequence induction with minimal airway manipulation using rocuronium 1.2-1.5 mg/kg with an option of 
sugammadex (16 mg/kg) reversal as a safer and superior choice to succinylcholine.

AEJ



INTRODUCTION
Severe acute respiratory syndrome-coronavirus-2 (SARS 
CoV-2) infection leading to the COVID-19 pandemic has 
created a new paradigm and challenge for airway management. 
Anesthesia providers perform tracheal intubation routinely 
in a variety of settings where the best possible approach and 
plan for tracheal intubation is determined including patient 
anatomy, pathophysiology and urgency.   SARS CoV-2 is a highly 
contagious RNA virus that has caused widespread infections, 
severe respiratory disease, and deaths.1  A study conducted in 
Lombardy, Italy revealed that 88% of COVID-19 patients who 
were critically ill needed mechanical ventilation.14 In Italy, March 
2020 up to 15% of all COVID-19 infected individuals were 
active healthcare staff.4 Alternative and safer airway management 
techniques must be used.  In order to protect and prevent more 
healthcare providers from becoming infected with COVID 
patients needing airway management have been preferentially 
intubated, initiating full ventilator support and then placed in the 
prone position for twelve hours per day to improve oxygenation 
and alveolar recruitment.4-6  
The American Association of Nurse Anesthetists (AANA), 
American Society of Anesthesiologists (ASA), and Anesthesia 
Patient Safety Foundation (APSF) suggest using rapid sequence 
induction (RSI)  for endotracheal intubation in COVID-19 
patients.7, 8  The RSI technique for COVID-19 patients includes 
a sedative-hypnotic and rapid-acting muscle relaxant.  Some 
practitioners recommend the use of ketamine 1-2 mg/kg to 
enhance bronchodilation.7 Muscle relaxation during RSI can 
be achieved with succinylcholine or rocuronium.  Choice of 
drug for muscle relaxation during RSI is multifactorial in 
COVID patients.  Obviously a drug with a rapid onset is 
desired after full preoxygenation and denitrogination.7,8  The 
other primary consideration is the ability to reverse and/or 
recover from muscle relaxation in the event tracheal intubation 
is unsuccessful.  Succinylcholine is rapidly metabolized by 
plasma pseudocholinesterase and does not need a reversal 
agent.9  Rocuronium has a longer duration of action.  Without 
reversal, an RSI intubating dose (1.2 mg/kg) would result in 
extended paralysis.10  The reversal agent sugammadex, specific 
for rocuronium and vecuronium, can provide rapid recovery of 
muscle relaxation even with larger doses of rocuronium.11  This 
article will discuss existing evidence supporting the merits of 
a pharmacologic plan utilizing rocuronium with sugammadex 
reversal in lieu of succinylcholine when providing endotracheal 
intubation in the COVID-19 patient population. 
REVIEW OF LITERATURE
CINAHL, PubMed, and Cochrane Database of Systematic 
Reviews were searched using key words, rapid sequence induction, 
COVID, SARS-CoV-2, rocuronium, succinylcholine, sugammadex, 
and airway management.  Inclusion criteria included prospective 
and retrospective articles that evaluated rocuronium and 
succinylcholine for onset times and/or recovery.  Additional 
relevant literature included recent data analyses, monographs, case 
analyses, and guidelines specific to COVID.

SARS-CoV-2 Pathophysiology and Respiratory Compromise
SARS CoV-2 emerged in press headlines December 2019 
due to the aggressive pneumonia outbreak in Wuhan, China.1   
This pneumonia progressed to severe adult respiratory distress 
syndrome (ARDS) and was highly communicable.  By March 
11, 2020 the virus had spread to over 100 countries.  The World 
Health Organization (WHO) declared SARS CoV-2 a pandemic 
and named the disease COVID-19.1  
The SARS-CoV-2 virus is known for causing severe acute 
respiratory symptoms (eg, dry cough, dyspnea, adult respiratory 
distress syndrome (ARDS).12 The virus gains access into the host 
through angiotensin converting enzyme 2 (ACE2) receptors in 
the pulmonary epithelium.13  Once SARS-CoV-2 enters the 
alveolar epithelium, it elicits an intense inflammatory response 
that can lead to pneumonia, and in many cases ARDS.  There are 
several host factors that make certain people more susceptible 
to a severe form of the disease.  These include increased age, 
and comorbidities such as hypertension, chronic kidney disease, 
cardiovascular disease, and diabetes.13–15 One of the unique factors 
of  SARS-CoV-2 is that it has a long incubation period, up to 14 
days.12  Most people start with symptoms of dry cough, malaise, 
and fever. 12,16  Dyspnea usually develops days after first symptoms 
emerge, and progresses to pneumonia and ARDS quickly 
thereafter.17  
SARS-CoV-2 can affect other organ systems as well.  One of 
the most common complications is acute renal insufficiency, in as 
many as 20-30% of patients with severe SARS-CoV-2.15,17  The 
cause of this is multifactorial, including cytotoxic effects of viral 
accumulation in the renal tissue after entrance in circulation, 
possibly through renal ACE2 receptors, deposits of inflammatory 
mediators in the kidney, and end-organ effects of hypoxia, 
shock, and rhabdomyolysis.13  In a study by Cheng et al, 15% of 
patients admitted to the hospital diagnosed with COVID-19 had 
new elevated baseline serum creatinine level ranging up to 359 
micromoles/liter. The authors concluded that the mortality for 
all patients with COVID-19 was 12.5% but those with elevated 
serum creatinine increased to 30.9% .13 
Pharmacology of Muscle Relaxants and Reversal
Because of increased likelihood of acute renal injury in this 
population, succinylcholine should be avoided as part of RSI 
and endotracheal intubation.18 Rapid sequence induction can 
be accomplished with the use of high dose rocuronium (1.2 to 
1.5 mg/kg).  Succinylcholine is a depolarizing skeletal muscle 
relaxant that has been used by anesthesia providers since 1952 
for endotracheal intubation.9 It binds, as an agonist, to nicotinic 
receptors at the neuromuscular junction resulting in temporary 
flaccidity of striated muscles.  It is rapidly hydrolyzed by plasma 
pseudocholinesterase into succinylmonocholine, within 4-6 
minutes.  This time can be extended by drug-drug interactions, 
or if the patient has a deficiency in pseudocholinesterase.  
The likelihood of this deficiency is low (1:2500).9  It is also 
well-known that succinylcholine can produce acute lethal 
hyperkalemia leading to ventricular tachycardia and fibrillation in 
certain populations (eg, active infection, paralysis, or immobility) 
and is a trigger for malignant hyperthermia leading to death if 
untreated.9 As many COVID patients suffer from acute renal 
injury, lethal hyperkalemia could be possible. 

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 9 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 28



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 9 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 29

Rocuronium, an aminosteroidal nondepolarizing neuromuscular 
blocking agent, is another choice commonly used by anesthesia 
providers for endotracheal intubation.  It antagonistically 
attaches to nicotinic receptors, preventing acetylcholine binding, 
thereby preventing muscle cell depolarization.10 Rocuronium is 
primarily metabolized in the liver and undergoes biliary excretion.  
Rocuronium does not have the precautions or contraindications 
that are unique to succinylcholine.  The recommended dose 
producing standard intubating conditions is 0.6 mg/kg, however 
intubating conditions have been reported as suboptimal and 
unpredictable.10  Administration of 1.2 mg/kg of rocuronium is 
recommended for optimal RSI intubating conditions however 
muscle relaxation can exceed 60 minutes .10  Reversal with an 
anticholinesterase such as neostigmine would be ineffective at this 
higher dose, but could be achieved with sugammadex.
Sugammadex is a modified gamma cyclodextrin.  It binds to 
rocuronium and to a lesser degree vecuronium, to form a complex 
that can no longer actively bind to nicotinic receptors.  The 
complex molecule is excreted unchanged in the urine without 
affecting acetylcholine concentrations. A sufficient dose of 
sugammadex (16 mg/kg to reverse a rocuronium dose of 1.2 mg/
kg) delivers a sufficient and complete reversal.11  Sugammadex: 
rocuronium binding is 1:1, so dosing in the presence of COVID 
would be unaffected.11

COVID-19 Intubation Pharmacologic Plan
Current literature supports rapid sequence induction with 
minimal or no manual positive pressure ventilation is preferred 
over standard induction techniques.7which causes coronavirus 
disease 2019 (COVID-19,8  The choice of muscle relaxant during 
RSI is primarily determined by a need for a rapid onset of quality 
intubating conditions.  A recent 2015 Cochrane systematic 
review comparing succinylcholine to rocuronium determined 
that rocuronium was “slightly less effective than succinylcholine 
for creating excellent and acceptable intubation conditions.”20  
Most studies included in the systematic review compared 
succinylcholine to a rocuronium dose closer to the standard 
intubating dose of 0.6mg/kg.  However, sugammadex provided 
rapid and complete reversal of even higher doses of 1.2 mg/kg.11  
More recent studies have indicated no significant differences in 
time to intubation, vocal cord movement, or patient movement 
when rocuronium doses of 1.2 mg/kg are utilized.21-24 

Evidence suggests that a rocuronium-sugammadex combination 
would also improve recovery time compared to succinylcholine 
alone. A 2010 systematic review found significant improvement 
in recovery time using rocuronium-sugammadex compared to 
succinylcholine (p<0.0001) (See Figure 1).26 Another study 
examining 110 adults ages 18-65 undergoing general anesthesia, 
compared succinylcholine 1 mg/kg to rocuronium 1.2 mg/kg 
from induction administration to full recovery when sugammadex 
was utilized for reversal.  Individuals in the rocuronium 
group were given sugammadex 16 mg/kg three minutes after 
rocuronium administration.  End point measures were a T4 of 
10% and 90% of the T1 on a train of four measurement with 
accelerometry.  Succinylcholine mean recovery times were 7.1 and 
10.9 minutes.  The rocuronium/sugammadex group was 4.4 and 
6.2 minutes.   It was important to note that the study included 
a three minute wait before administering sugammadex, which 

indicated that recovery endpoints were reached at an average 
of 1.4 and 3.2 minutes once sugammadex was administered.23  
Another randomized, controlled, double-blinded study compared 
succinylcholine 1 mg/kg to rocuronium 1 mg/kg in 61 adults 
ages 18-60 requiring rapid sequence induction.  Patients were 
given rocuronium, then sugammadex 16 mg/kg was administered 
as soon as tracheal intubation was achieved.  Primary measures 
were duration from tracheal intubation to return of spontaneous 
ventilation and T4 return of 90% of T1.  Average time for the 
succinylcholine group was 406 seconds for return of spontaneous 
ventilation and 518 seconds for T1=90%.  Average time for the 
rocuronium/sugammadex group was 216 seconds for return 
of spontaneous ventilation and 168 seconds respectively.  It is 
important to note that when comparing the time from muscle 
relaxant administration to T1=90%, the mean times were 719 
seconds for the succinylcholine group and 282 seconds for the 
rocuronium/sugammadex group.24

Figure 1. Time (seconds) from Administration of Succinylcholine 
or Rocuronium/sugammadex to 90% Recovery of T1 on a Train 
of Four (TOF)     

Note:  Time from administration of rocuronium to administration 
of sugammadex was 180 seconds in Study 1 and 114 seconds in 
Study 2
CONCLUSION
This literature review suggests that patients with SARS-CoV-2 
could benefit from a pharmacologic intubation plan that includes 
RSI using rocuronium 1.2 mg/kg with sugammadex 16 mg/
kg. Current literature is limited by small sample sizes and lack 
of high-quality studies.  Other considerations include the 
availability of sugammadex and provider comfort with these 
agents.  In some cases, patients emergently intubated are done 
so by non-anesthesia personnel with limited knowledge of both 
the pharmacologic implications of commonly used medications 
and disease process of SARS-CoV-2. The evidence in this 
review should be considered when determining implications of 
the pharmacologic plan on outcome of intubating patients with 
SARS-CoV-2. 



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 9 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 30

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“The Science Behind the Art” 
Volume 8 - No. 9 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

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