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Should Paralytics Be Given Prior to Induction? - #QLAB

I'd love to answer your questions on the Q-LAB! I'll be posting them here in case others have a similar question. Here are my thoughts -

Hey my friend. What are your thoughts on using paralytics before sedatives for RSI? Had an interesting experience at work last weekend and just wondering what you have to say about the order… - @marcofregoso_

Should Paralytics Be Given Prior to Induction?

  • You'll be able to find some literature that indicates in ideal circumstasnces, paralytics before induction has been associated with a lower time to RSI administration to end of intubation attempt (95% CI: 0 - 6 seconds).

  • The biggest worry is giving rocuronium (or other long-acting nondepolarizing agent) and losing the line. Yes, there is a reversal agent but initial issue of taking away the patient's respiratory drive brings in additional complications.

  • With that being said, I am more in favor of paralytics after induction. Recommending rocuronium at 1.2 mg/kg or greater provides similar onset of action to succinylcholine (~ 30-45 seconds). When thinking of the patient, process familiarity amongst the team, ensuring sedation before paralyzing, and limited patient-centered evidence, the regular induction before paralysis gets the job done. Optimal intubating conditions AND amnestic/ sedative properties.

Thanks for the question!

Mark Nguyen, PharmD, BCEMP


  1. Driver BE, Klein LR, Prekker ME, et al. Drug order in rapid sequence intubation. Acad Emerg Med2019; 26: 1014–21.


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