• Matias Vested, Andreas Creutzburg, Christian S Meyhoff, Marie Louise Rovsing, Tatiana Nielsen, Fabio Rosa, Eske K Aasvang, Hannah Mollerup, Thomas Fuchs-Buder, and Lars Simon Rasmussen.
• Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
• Acta Anaesthesiol Scand. 2025 Mar 1; 69 (3): e14589e14589.

BackgroundDuring rapid sequence induction, either rocuronium 1.0 mg kg-1 or suxamethonium 1.0 mg kg-1 can be administered to facilitate endotracheal intubation. We hypothezised that rocuronium provided a larger proportion of excellent intubating conditions compared to suxamethonium in elderly patients.MethodsA total of 90 patients 80 years or above with American Society of Anesthesiologists physical health Classes I-IV, and a body mass index < 35 kg m-1-2 were randomised to either rocuronium 1.0 mg kg-1 or suxamethonium 1.0 mg kg-1 during rapid sequence induction with intubation using a video laryngoscope. After 60 s, tracheal intubating conditions were evaluated using the Fuchs-Buder scale by a blinded investigator, and the primary outcome was the proportion of patients with excellent intubating conditions. Further outcomes included first pass success rate, intubating conditions according to the intubating difficulty scale (IDS), onset time and postoperative occurrence of muscle soreness, hoarseness and sore throat.ResultsAll patients were evaluated for the primary outcome. Excellent intubating conditions occurred in 36 patients (73%) versus 31 (75%) in the rocuronium group and suxamethonium group, respectively (95% confidence interval [CI]: -16 to 20) (p = .82). The first pass success rate was 48 (98%) versus 40 (98%) comparing the rocuronium group with the suxamethonium group, respectively (p = .90). No difference in IDS score was found; median 0 (interquartile ranges [IQR]: 0-1) versus median 0 (IQR: 0-1) (p = .48). Onset time was significantly shorter in the suxamethonium group 99 versus 131 s (p = .01) (95% CI: 7 to 57). Finally, no difference was found in the occurrence of muscle soreness, hoarseness or sore throat postoperatively.ConclusionNo important difference in intubating conditions was found during rapid sequence induction after the administration of either rocuronium 1.0 mg kg-1 or suxamethonium 1.0 mg kg-1 in patients 80 years or above.Editorial CommentThis reports a superiority trial comparing standardised doses of rocuronium and suxamethonium at 60 s for quality of intubating conditions in the rapid sequence context, and this in an elderly cohort. The findings showed no difference between the drugs concerning intubation outcomes, though the onset or time to peak effect was shorter for suxamethonium, again demonstrated in a cohort 80 years old or older.© 2025 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.

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