Rocuronium-Sugammadex vs Succinylcholine ECT: Is the Standard of Care Shifting?

A recent meta-analysis claims that the combination of rocuronium and sugammadex (RS) offers a feasible, and potentially safer, alternative to the traditional succinylcholine (SCC) regimen for muscle relaxation during electroconvulsive therapy (ECT). For decades, clinicians have relied on SCC for its rapid onset and offset, accepting the trade-off of adverse effects like severe myalgia and potassium release as unavoidable costs of doing business.

Technical Contrast: Rocuronium-Sugammadex vs Succinylcholine ECT

The fundamental divergence between these protocols lies in their mechanism of action and termination. SCC is a depolarizing blocker; it mimics acetylcholine, causing initial fasciculation followed by paralysis, and relies on plasma pseudocholinesterase for hydrolysis—a biological process the clinician cannot control. Conversely, rocuronium is a non-depolarizing agent. It competes for the cholinergic receptor without activating it. The innovation lies in sugammadex, a cyclodextrin that encapsulates rocuronium molecules in the blood, effectively scrubbing the active drug from the system to reverse paralysis on command. While SCC leaves the patient's recovery to enzymatic chance, the RS protocol offers a deterministic chemical "off switch".

In the specific context of Rocuronium-Sugammadex vs Succinylcholine ECT, the data presents a complex picture. The pooled analysis indicated that RS might support longer seizure durations, which is often a proxy for therapeutic efficacy. However, the analysts noted that when they stripped away observational data to focus solely on randomised controlled trials, this advantage disappeared. The difference became statistically non-significant. This suggests that earlier observational studies may have introduced selection bias favoring the new protocol.

Recovery times followed a similar pattern of ambiguity. Despite trends favouring the new method in half the studies, the aggregate data showed no statistically significant difference in how quickly patients woke up or resumed spontaneous breathing. We must treat these findings with caution. The statistical heterogeneity was massive (I-squared exceeding 89%). This implies that variability in dosing or procedural timing across the included studies muddies the water. Furthermore, while RS appears to cause less myalgia, the reporting of side effects was inconsistent across the literature. The study suggests promise, but it does not yet provide the concrete proof required to dethrone SCC entirely.