norcuron whats your thoughts

[runswithneedles]

My boss is considering adding norcuron as the paralytic in our revamped protocols. (RSI is new in our upcoming protocols as a whole). Ive only been around sux and rocuronium (pardon if the spelling is off).

Has anybody here used norcuron in the field to facilitate RSI?

[paramedicmike]

As the initial paralytic? Is that *really* what you mean when you say "... to facilitate RSI"?

Have you read your new protocols yet?

What does your research tell you about the drug and its use?

[runswithneedles]

to be used as the paralytic for RSI. The new protocols are not yet available for us to look at as they are still in the works. I know its a non depolarizing paralytic with an onset time of one minute given IVP at .1mg per kilogram. It is contra indicated in newborns ans myasthenia gravis (that I know of).

my critical care guide says 1 minute onset time. medscape tells me 3-5 minutes. do you know what it normally takes to go into affect

[HarryM]

We use Suxamethonium for initial paralytic pre-intubation then Vecuronium post-intubation to maintain paralysis. Never seen or heard any problems with it. But again we only use it post-intubation and not pre-intubation. I'm not sure as to exact rationale of one over the other (not yet within my scope) but I do know that suxamethonium has shown to be superior over rocuronium when inducing paralysis for RSI.

[chbare]

Vecuronium is a competitive agent in that it must compete with acetylcholine at the receptor site. This means that it's onset can take minutes at standard doses.

When used as a paralytic agent for the RSI procedure, I can see a few pitfalls:

1) Intubating conditions will take longer to develop

2) The duration is longer than the duration of many commonly used induction agents

3) There is no chance of a salvage after a few minutes if a failed airway situation develops

Personally, I'd say it's a suboptimal agent for facilitating RSI. I've used other competitive agents such as rocuronium but at relatively large doses to produce a relatively rapid onset. I also worked at a facility where vecuronium was used with varying degrees of success.

[runswithneedles]

so in the case of a failed airway can a dual lumen such as the combi-tube or a king LT be used as a last resort?

[paramedicmike]

I would argue that anytime an RSI is attempted under any circumstances the providers should have at least one back up airway immediately available whether that be a combi-tube, King airway, LMA or similar.

[chbare]

Yes, supraglottic airways can be used as a rescue. I'm still not convinced that vecuronium is an optimal agent, but there are probably worse ways to do it.

[paramedicmike]

I've not come across anyone that uses vecuronium for initial paralysis. I'll also suggest you wait and see what the guidelines actually say before getting too concerned with the updated guidelines.

If this will, in fact, be new for your system then expect some education to go along with it.

[systemet]

I don't know why you'd use vecuronium. Roc is a superior agent if there's a contraindication to succinylcholine. RSI is an inherrently comitting procedure that can be very dangerous. While succinylcholine is fraught with risk and danger, using even longer-lasting agents takes away some of the remaining safety margin.

I realise that there's discussion in anesthesia / EM about using rocuronium more commonly as an initial agent. Given the number of RSIs most providers perform, I think having multiple agents available only complicated an already potentially dangerous procedure.