Roc rocks but we still Sux. Why?

The pharmacological properties of rocuronium make it a better choice for rapid sequence induction compared to suxamethonium (see here). We could argue, unless there’s a history of rocuronium anaphylaxis or if sugammadex has recently been administered, rocuronium should be used for all rapid sequence inductions. However many of us, perhaps the majority, still use suxamethonium.


‘It’s hard to commit to a scary new path that questions the usual ways. It’s hard to stand against tradition. There’s always opposition from the system and the people within it who don’t want change to happen, those who like the comfort of tradition and who are scared of learning how to be different.’

‘Implementation Science’ teaches us, even when there is common agreement, the implementation of practice change is often very slowly adopted.

From ‘The Science of implementation: changing the practice of critical care

Changes in practice that are less likely to be implemented include:

  • those that require repeated effort without rapid evidence of improvement
  • information retrieval not immediately available at the time of decision making
  • contradict the clinician’s experience
  • have an insignificant effect on patient out-come
  • substantially prolong the patient encounter
  • appear to inconvenience the patient or make them appear more ill

Those in bold appear most relevant for the case of rocuronium vs suxamethonium.

In turn we enter the bell shaped curve:


There will be those who adopt the practice early through to those who lag behind. All of us, depending on our characteristics, end up somewhere on this graph.


The laggards may claim – we’ve been using suxamethonium for years and never had a problem with it. Unfortunately safety science teaches us if we keep exposing patients to known hazards then eventually there will be an adverse event:


A similar line of discussion can be used for most safer innovative practices in healthcare. For example while we all must do our best to drive the cost of Sugammadex down, we can see cost is not the only thing getting in the way – we are.

Can the laggards justify their use of suxamethonium if they had a problem tomorrow?

Well, yes.

While a sufficient percentage of doctors use the same practice, these practices may be justified in a court of law. However this is not in the interest of our patients.

We write these posts to encourage more rapid movement to the right of the bell shaped curve. More staff adopt improved practices and hazardous practices become more rapidly unjustifiable.

Patientsafe declares no conflict of interest with any of the drugs, equipment, or any other products we discuss on this website. Life is too short. We do it for #patientsafety.




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