Advantages	Disadvantages
Succinylcholine	When a laryngospasm can't be broken by chin lift, jaw thrust or positive pressure ventilation with 100% oxygen, succinylcholine is typically administered in a dose of 0.25 to 1.0 mg/kg and usually lets you easily intubate and ventilate the patient within 30 to 60 seconds. It wears off quickly, usually letting patients return to spontaneous respirations in 5 minutes or less.	Malignant hyperthermia. It's rare, but for patients who've never had surgery, it's a real possibility. Stocking succinylcholine adds several expenses to an endoscopy center, from the cost of dantrolene or a similar agent to training staff to respond in an MH emergency. Bradycardia. Sometimes causes significant bradycardia, which must be followed with doses of atropine. Pseudocholinesterase deficiency. As with MH, it's rare, but when it happens, a patient may require ventilator support for many hours. Potassium elevation. Patients who already have elevated potassium can have significant cardiac issues. It can increase intracranial pressure. It can cause muscle soreness from fasciculation at the time of administration. It can further dehydrate patients who are already dehydrated (which many colonoscopy patients are, due to the bowel prep).
Rocuronium	In doses of 0.6 to 1.2 mg/kg, it's proven to be as effective in muscle relaxation and emergency intubation as succinylcholine. If rocuronium is stocked, the only other medications needed are neostigmine and either robinul or atropine for reversal. Other than causing a significant histamine release at large doses, there are no hidden side effects.	Larger doses are needed to facilitate similar onset times to that of succinylcholine. The clinical duration of action at larger doses is significantly longer than that of succinylcholine. However, once acceptable nerve stimulator responses are achieved, it can be reversed with neostigmine and either robinul or atropine. Myasthenic patients require smaller doses.

One legacy of Joan Rivers's tragic death is that endoscopy centers throughout the country are supplementing their formularies with the depolarizing muscle relaxant succinylcholine. Whether succinylcholine could have saved Ms. Rivers is up for debate, since many of the circumstances surrounding her demise are still shrouded in mystery. But there's no question that a medication that has traditionally been given little consideration in the endoscopy setting is suddenly garnering much more attention.

For many anesthesia providers. succinylcholine is the first choice for breaking a laryngospasm. Others, however, advocate rocuronium. Which is the better choice? Incidentally, laryngospasm can often be "broken" by using positive pressure ventilation with an Ambu bag, but let's focus on situations in which medication intervention is necessary.

I polled many anesthesia providers to get their thoughts on which agent should be added to the endoscopy formulary. Both have advocates, but by a slight edge, the majority said they find rocuronium adequate as a muscle relaxant for any adverse airway event.