Rocuronium combined with i.v. lidocaine for rapid tracheal intubation

Effects of intravenous administration of fentanyl and lidocaine on hemodynamic responses following endotracheal intubation

OBJECTIVES

To compare the effects of intravenous fentanyl and lidocaine on hemodynamic changes following endotracheal intubation in patients requiring Rapid Sequence Intubation (RSI) in the emergency department (ED).

METHODS

A single-centered, prospective, simple non-randomized, double-blind clinical trial was conducted on 96 patients who needed RSI in Edalatian ED. They were randomly divided into three groups (fentanyl group (F), lidocaine group (L), and fentanyl plus lidocaine (M) as our control group). M was administered with 3 μgr/kg intravenous fentanyl and 1.5 μgr/kg intravenous lidocaine, F was injected with 3g/kg intravenous fentanyl and L received 1.5mg/kg intravenous lidocaine prior to endotracheal intubation. Heart rate (HR) and mean arterial pressure (MAP) were assessed four times with the chi-square test: before, immediately after, 5 and 10 min after intubation. Intervention was discontinued for five people due to unsuccessful CPR.

RESULTS

HR was notably different in F, L and M groups during four time courses (p<0.05). Comparison of MAP at measured points in all groups exhibited no significant difference (p>0.05). In fentanyl group both HR and MAP increased immediately after intubation, and significantly decreased 10 min after intubation (p<0.05).

CONCLUSIONS

Overall, the result of this study shows that lidocaine effectively prevents MAP and HR fluctuations following the endotracheal intubation. According to our findings, lidocaine or the combination of fentanyl and lidocaine are able to diminish hemodynamic changes and maintain the baseline conditions of the patient, thus could act more effectively than fentanyl alone.

Rocuronium versus succinylcholine for rapid sequence induction intubation

BACKGROUND

Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015.

OBJECTIVES

To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation.

SEARCH METHODS

In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.

SELECTION CRITERIA

We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg.

DATA COLLECTION AND ANALYSIS

Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model.

MAIN RESULTS

The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

AUTHORS' CONCLUSIONS

Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.

Intravenous lidocaine increases the depth of anaesthesia of propofol for skin incision--a randomised controlled trial

BACKGROUND

The anaesthetic potency of intravenous propofol is quantified by its Cp50 value, which is defined as the plasma concentration required to prevent movement response in 50% of patients to surgical stimuli. We hypothesised that, in addition to propofol anaesthesia, an intravenous bolus of lidocaine 1.5 mg/kg will decrease the Cp50 value of propofol during anaesthesia.

METHODS

We enrolled 54 elective surgical patients undergoing propofol-based anaesthesia, and randomised them to either lidocaine 1.5 mg/kg, lidocaine 0.5 mg/kg or placebo (NaCl 0.9%) 3 min before skin incision. The propofol Cp50 value was then calculated using the 'up-and-down' method of Dixon and Massey.

RESULTS

There was no significant reduction in propofol requirements after the administration of 0.5 mg/kg lidocaine from 8.5 μg/ml [confidence interval (CI) 6.0-11.625] to 8.25 μg/ml (CI 6.75-9.76); however, a bolus of 1.5 mg/kg lidocaine decreased the Cp50 value of propofol by 42% from 8.5 μg/ml (CI 6.0-11.625) to 4.92 μg/ml (CI 4.5-5.78) (P < 0.05).

CONCLUSION

An intravenous bolus injection of 1.5 mg/kg lidocaine 2% caused a significant reduction of the propofol Cp50 value.

The effect of intravenous magnesium sulfate and lidocaine in hemodynamic responses to endotracheal intubation in elective coronary artery bypass grafting: a randomized controlled clinical trial

BACKGROUND

There have been many concerns about alteration in hemodynamic parameters within and shortly after endotracheal intubation (ETI) in patients scheduled for elective coronary artery bypass grafting (CABG).

OBJECTIVES

We compared the attenuation effect of magnesium sulfate and lidocaine on hemodynamic responses after ETI, in patients undergoing CABG.

PATIENTS AND METHODS

In this randomized controlled trial 150 patients undergoing elective CABG were enrolled. Included patients were randomly allocated to three groups and received lidocaine (1.5 mg/kg), magnesium sulfate (50 mg/kg within five minute), or normal saline, 90 seconds before ETI. Baseline hemodynamic parameters including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded immediately before anesthesia induction, before intubation, immediately after intubation, and at second and fifth minutes after intubation.

RESULTS

The baseline hemodynamic variables had no deference among the three groups. HR between intubation and five minute after intubation was significantly lower in two groups received lidocaine or magnesium sulfate in comparison with placebo group. Lidocaine induced more than 20% decrease in HR and MAP immediately after intubation; hence, lidocaine group showed significant MAP reduction in comparison with the two other groups.

CONCLUSIONS

Lidocaine induced hemodynamic instability but premedication of magnesium sulfate maintained hemodynamic stability after intubation. Therefore, in patients undergoing CABG who received high-dose intravenous analgesic for general anesthesia, the administration of magnesium sulfate might result in maintaining hemodynamic stability after ETI in comparison with lidocaine.

Comparison of the Effects of Different Concentrations of Rocuronium on Injection Pain and Hemodynamics Using Isolated Forearm Technique

OBJECTIVE

We aimed to evaluate Visual-Analogue-Scale (VAS) scores, hand-withdrawal, rash and skin eruptions after injections of different concentrations of rocuronium in intubation doses in alert patients using the isolated-forearm technique.

METHODS

Eighty ASA I-II patients were included in a randomized, controlled, single-blinded study. Two 20 G cannulas were inserted into the dorsum of the left and right hand in each patient. A tourniquet was applied to the left arm and inflated to 50 mm Hg above the patient's systolic blood pressure. Group 1 (n=20) received 2.5 mg mL(-1) rocuronium diluted with 0.9% NaCl, Group 2 (n=20) received 5 mg mL(-1) rocuronium diluted with 0.9% NaCl, Group 3 (n=20) received 10 mg mL(-1) rocuronium and 0.4 mg mL(-1) lidocaine mixture, and Group 4 (n=20) received 10 mg mL(-1) rocuronium via a cannula on the left hand, provided that a dose of 0.6 mg mL(-1) were given to all groups of patients. VAS0-VAS60 values, hand-withdrawal, rash and skin eruptions were assessed in patients who were administered rocuronium but not under the effects of hypnotic or neuromuscular agents. Hemodynamic values were recorded both before and after the administration of hypnotic-neuromuscular agents.

RESULTS

VAS0 values were significantly higher in Group 4 when compared to Groups 1, 2 and 3 (p=0.032). No significant difference was observed between VAS0 and VAS60 values in Groups 1, 2 and 3. In Group 4, VAS0 values were significantly higher than VAS60 values (p=0.003). No significant difference was observed between groups in terms of side effects and hemodynamic values.

CONCLUSION

In conclusion, we determined that using rocuronium diluted with 0.9% NaCl was more effective in preventing injection pain than using a rocuronium-lidocaine mixture.

Intravenous lidocaine does not affect the anesthetic depth during rapid sequence induction and intubation as assessed by Bispectral Index monitoring: a randomized double blind study

INTRODUCTION

We investigated the impact of intravenous lidocaine on anesthetic depth, as assessed by Bispectral Index score (BIS), and hemodynamic responses to rapid sequence induction/intubation.

MATERIAL AND METHODS

Eighty-four surgical patients with risk factors for regurgitation/aspiration were randomized to receive either lidocaine 1.5 mg/kg or normal saline in a double-blind fashion. Propofol 2 mg/kg, lidocaine or normal saline, followed by rocuronium 1 mg/kg were administered intravenously and trachea was intubated under cricoid pressure application. The BIS scores were recorded before induction of anesthesia, immediately after, at 30 s and 1 min after rocuronium injection and every 30 s after intubation, for 10 min. Systolic/diastolic blood pressure and heart rate were measured before induction, immediately after and at 1 min following rocuronium administration, and every minute for 10 min after intubation.

RESULTS

Data from 78 patients were analyzed. Demograpic characteristics did not differ between the study groups. A total of 24 BIS scores were recorded for each patient. No difference was found in BIS values between lidocaine and control groups at any time point (F = 2.936, p = 0.91). Also no difference was detected in heart rate, systolic and diastolic blood pressure at any time point of the study period between the two groups (F = 0.063, p = 0.80, F = 0.007, p = 0.93, F = 0.435, p = 0.51 respectively). No episodes of significant bradycardia occurred and none of the patients reported awareness/recall of the procedure.

CONCLUSIONS

Lidocaine 1.5 mg/kg given intravenously during rapid sequence induction does not affect BIS values, or blunt the hemodymanic response to laryngoscopy and intubation.

Effect of lidocaine (40 mg) mixed to prevent injection pain of propofol on the intubating conditions and onset time of rocuronium

Background

To analyze how lidocaine 40 mg mixed prevents injection pain of propofol affects the onset time of rocuronium, tracheal intubating conditions and intubation related hemodynamic changes.

Methods

This study consisted of 70 patients with an American Society of Anesthesiologists (ASA) physical status class 1 or 2 for general anesthesia. All the patients were randomly allocated into two groups: propofol 2 mg/kg plus normal saline 2 ml (Group C) and propofol 2 mg/kg plus 2% lidocaine 40 mg (Group L). Each group was administrated intravenously during induction and the patient was intubated 1 minute after an injection of 0.6 mg/kg of rocuronium. The time at disappearance of the first twitch and intubation scores were recorded. Also, blood pressure and heart rate were measured at the baseline, after intravenous injection of propofol, before intubation, and at 0, 1, 2, 3 and 5 minutes after intubation.

Results

There were no significant differences between group C and L (P > 0.05).

Conclusions

40 mg of lidocaine mixed with propofol to prevent injection pain did not affect the onset time of rocuronium, intubating conditions and intubation related hemodynamic changes.

Intravenous lidocaine has no impact on rocuronium-induced neuromuscular block. Randomised study

BACKGROUND

Intravenous lidocaine is increasingly used in surgical patients. As it has neuromuscular blocking effects, we tested the impact of an intravenous lidocaine infusion on the time course of a rocuronium-induced neuromuscular block.

METHODS

Fifty-two adults undergoing surgery were randomly allocated to intravenous lidocaine 1.5 mg/kg followed by a continuous infusion of 2 mg/kg/h or physiological saline (control) throughout surgery. Anaesthesia was induced and maintained with a target-controlled propofol infusion and sufentanil. After loss of consciousness, rocuronium 0.6 mg/kg was given. Neuromuscular transmission was measured using train-of-four (TOF)-watch SX (Organon, Swords Co., Dublin, Ireland) acceleromyography.

RESULTS

Onset time (to 95% depression of first twitch) was on average 113.9 s (standard deviation 35.3) with lidocaine and 119.5 s (44.9) with saline (P = 0.618). Total recovery time (TOF ratio 0.9) was on average 58.1 min (15.1) with lidocaine and 54.3 min (16.9) with saline (P = 0.394). Clinical duration (until first twitch has recovered to 25%) was on average 33.3 min (7.2) with lidocaine and 30.6 min (8.1) with saline (P = 0.21). Recovery index (time between 25% and 75% recovery of the first twitch) was on average 11.5 min (5.0) with lidocaine and 10.6 min (4.1) with saline (P = 0.458). Recovery time (between 25% recovery of the first twitch and TOF ratio 0.9) was on average 24.8 min (9.3) with lidocaine and 23.2 min (9.2) with saline (P = 0.541).

CONCLUSION

A continuous intravenous infusion of lidocaine has no impact on the time course of the neuromuscular blockade induced by a standard intubation dose of rocuronium.

Effects of 2 mg.kg⁻¹ of intravenous lidocaine on the latency of two different doses of rocuronium and on the hemodynamic response to orotracheal intubation

BACKGROUND AND OBJECTIVES

Lidocaine potentiates the effects of neuromuscular blockers and attenuates the hemodynamic response to orotracheal intubation. The objective of the present study was to test the effects of lidocaine on the latency of two different doses of rocuronium and on the hemodynamic response to intubation.

METHODS

Eighty patients were distributed in 4 groups: Groups 1 and 2 received 0.6 mg.kg(-1) of rocuronium; patients in Group 2 also received 2 mg.kg(-1) of lidocaine before intubation. Patients in Groups 3 and 4 received 1.2 mg.kg(-1) of rocuronium; patients in Group 4 received additional 2 mg.kg(-1) of lidocaine. The latency of the neuromuscular blockade was measured by acceleromyography. Hemodynamic evaluation was performed at baseline, immediately before, and 1 minute after orotracheal intubation (OI).

RESULTS

Statistically significant differences were not observed between the latency from 0.6 mg.kg(-1) and 1.2 mg.kg(-1) of rocuronium in patients who received lidocaine before induction and those who did not. The latency in patients who received 0.6 mg.kg(-1) of rocuronium with lidocaine was statistically similar to that of those who received 1.2 mg.kg(-1) rocuronium independently of whether lidocaine was administered or not. Patients who did not receive lidocaine before induction showed the same increases in systolic, diastolic, and mean arterial pressure and heart rate after OI, which was not observed in those patients who received lidocaine.

CONCLUSIONS

Intravenous lidocaine before anesthetic induction was capable of attenuating the hemodynamic response associated to OI maneuvers, but it did not reduce the latency of the neuromuscular blockade produced by two different doses of rocuronium.

Rocuronium versus succinylcholine for rapid sequence induction intubation

BACKGROUND

Patients requiring emergency endotracheal intubation often require a rapid sequence induction (RSI) intubation technique to protect against aspiration or increased intracranial pressure, or to facilitate intubation. Succinylcholine is the most commonly used muscle relaxant because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This meta-analysis is an update since our initial Cochrane systematic review in 2003.

OBJECTIVES

To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made based on dose of rocuronium, narcotic use, emergency versus elective intubation, age and induction agent. The primary outcome was excellent intubation conditions. The secondary outcome was acceptable conditions.

SEARCH STRATEGY

In our initial systematic review we searched all databases until March 2000. We have updated that search and searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007 issue 3), MEDLINE (1966 to June Week 3 2007), EMBASE (1988 to 2007 Week 26) for randomized controlled trials or controlled clinical trials relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations.

SELECTION CRITERIA

We included all trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, main outcomes of intubation conditions).

DATA COLLECTION AND ANALYSIS

Two authors (JP, JL or VS) independently extracted data and assessed methodological quality for allocation concealment. We combined the outcomes in RevMan using relative risk (RR) with a random-effects model.

MAIN RESULTS

In our initial systematic review we identified 40 studies and included 26. In this update we identified a further 18 studies and included 11. In total, we identified 58 potential studies; 37 were combined for meta-analysis. Overall, succinylcholine was superior to rocuronium, RR 0.86 (95% confidence interval (95% CI) 0.80 to 0.92) (n = 2690). In the group that used propofol for induction, the intubation conditions were superior with succinylcholine (RR 0.88, 95% CI 0.80 to 0.97) (n = 1183). This is contrary to our previous meta-analysis results where we reported that intubation conditions were superior in the rocuronium group when propofol was used. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action.

AUTHORS' CONCLUSIONS

Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions.

Impact of the intubation model on the efficacy of rocuronium during rapid sequence intubation: systematic review of randomized trials

BACKGROUND

Propofol-rocuronium is thought to be superior to thiopental-rocuronium for rapid sequence intubation (RSI). The role of the intubation model per se has never been investigated.

METHODS

Randomized comparisons of rocuronium with succinylcholine for true RSI (administration of muscle relaxant immediately after the hypnotic, intubation within 60 s) or modified RSI (delay between administration of the hypnotic and the muscle relaxant, intubation within 60 s) were sought. Good or excellent intubation conditions were expressed as relative risks (RR) with 95% confidence intervals (CI).

RESULTS

Twelve trials (1,471 patients) used a true RSI. With propofol for induction, RR for good or excellent intubation conditions with conventional rocuronium doses (0.6-0.7 mg/kg) was 0.95 (95%CI, 0.90-1.00), with high doses (0.9-1.2 mg/kg) was 0.96 (0.92-1.01) compared with succinylcholine. With thiopental for induction, RR with conventional rocuronium doses was 0.69 (0.61-0.78) and with high doses was 0.99 (0.95-1.03). Nine trials (340 patients) used a modified RSI. With propofol for induction, RR with conventional rocuronium doses was 0.98 (0.91-1.06); data on high rocuronium doses were lacking. With thiopental for induction, RR with conventional rocuronium doses was 0.97 (0.92-1.02) and with high doses was 1.0. There was no evidence that concomitantly used opioids or the dose of the induction agent had an impact on intubation conditions, independent of the intubation model.

CONCLUSION

The efficacy of rocuronium for RSI is influenced by both, the induction agent and the intubation model. To test the clinical usefulness of alternatives to succinylcholine for RSI, a true RSI model should be used.

Lidocaine does not prevent bispectral index increases in response to endotracheal intubation

We investigated the effect of IV lidocaine on the hemodynamic and bispectral index responses to induction of general anesthesia and endotracheal intubation. Forty patients (ASA I) were randomly allocated into 2 groups of 20 to receive normal saline or lidocaine 1.5 mg/kg IV 30 s after induction. Ninety seconds later, endotracheal intubation was performed. Systolic blood pressure, heart rate, and bispectral index were measured at baseline, 1 min after induction, at preintubation, and every minute until 5 min after endotracheal intubation. Bispectral index at 1 min after induction and preintubation in the lidocaine group were significantly lower compared with the control group (P < 0.05). Systolic blood pressure increased significantly at 1 and 2 min after intubation in the control group compared with the baseline value (P < 0.05) but did not increase significantly in the lidocaine group. Heart rate increased at 1 to 3 min in both groups (P < 0.05), but there was no significant difference between the two groups. One patient in the control group had recall of the procedure. We conclude that the administration of IV lidocaine (1.5 mg/kg) does not suppress the hypnotic response to endotracheal intubation.

Tracheal intubating conditions and apnoea time after small-dose succinylcholine are not modified by the choice of induction agent

BACKGROUND

In a randomized, double-blind clinical trial, we studied the effect of different i.v. induction drugs on tracheal intubation conditions and apnoea time after small-dose (0.6 mg kg(-1)) succinylcholine used to facilitate orotracheal intubation at an urban, university-affiliated community medical centre.

METHODS

One hundred and seventy-five ASA I and II adult patients scheduled to undergo surgical procedures requiring general anaesthesia and tracheal intubation were allocated to one of five groups according to i.v. anaesthetic induction drug used. General anaesthesia was induced by i.v. administration of lidocaine 30 mg and propofol 2.5 mg kg(-1) (Group 1), thiopental 5 mg kg(-1) (Group 2), lidocaine 30 mg and thiopental 5 mg kg(-1) (Group 3), etomidate 0.3 mg kg(-1) (Group 4), or lidocaine 30 mg and etomidate 0.3 mg kg(-1) (Group 5). After loss of consciousness, succinylcholine 0.6 mg kg(-1) was given i.v. followed by direct laryngoscopy and tracheal intubation after 60 s. Measurements included intubation conditions recorded during laryngoscopy 60 s after succinylcholine administration, and apnoea time.

RESULTS

Overall, clinically acceptable intubation conditions were met in 168 out of the 175 patients studied (96%). They were met in 35/35 patients in Group 1, 33/35 patients in Group 2, 34/35 patients in Group 3, 33/35 patients in Group 4, and 33/35 patients in Group 5. Mean (SD) apnoea time was 4.0 (0.4), 4.2 (0.3), 4.2 (0.6), 4.1 (0.2) and 4.1 (0.2) min respectively in Groups 1-5. There were no differences in the intubation conditions or apnoea times between the groups.

CONCLUSIONS

The use of succinylcholine 0.6 mg kg(-1) produced the same favourable intubation conditions and a short apnoea time regardless of the induction drug used.