Effects of precurarisation on suxamethonium-induced postoperative myalgia during the first trimester of pregnancy

Local anaesthesia for pain control in first trimester surgical abortion

BACKGROUND

Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure.

OBJECTIVES

To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

SEARCH METHODS

We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles.

SELECTION CRITERIA

We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events.

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.

Effect of Non-depolarizing Muscle Relaxants Rocuronium Versus Vecuronium in the Assessment of Post-Succinylcholine Complications in Surgeries Under General Anesthesia: A Randomized Double-Blind Study at a Tertiary Care Hospital

Background and objective

Several drugs have been used to prevent or attenuate succinylcholine-induced muscle fasciculations and myalgia. We designed the present study to evaluate the efficacy of rocuronium (ROC) and vecuronium (VEC) in preventing succinylcholine-induced fasciculations and postoperative myalgia (POM) in patients undergoing surgery under general anesthesia.

Materials and methods

After obtaining written informed consent, 125 patients were randomly selected to receive either ROC 0.06 mg/kg or VEC 0.01 mg/kg, with both diluted up to 2 ml, 90 seconds before the administration of propofol followed by succinylcholine. A standardized balanced anesthetic technique was used for all patients. The intensity of fasciculations and intubating conditions were assessed using a 4-point rating scale. All patients were evaluated up to the third postoperative day for the presence of POM, the severity of which was graded on a 4-point scale.

Results

The incidence of post-succinylcholine fasciculations during induction was nil in 74.58% of patients in the ROC group and 51.52% in the VEC group. Mild fasciculation was seen in 22.03% in the ROC group and 33.33% in the VEC group. Moderate fasciculation was seen in 3.39% and 15.15% in ROC and VEC groups respectively. When comparing both the groups, a significant decrease (p=0.015) in intraoperative fasciculation was observed in the ROC group than in the VEC group. Both drugs provided good intubating conditions without any statistical significance and with an overall intubating score of 8-9 in both groups as per Lund. On day one, 91.53% (n=54) of the ROC group and 65.15% (n=43) of the VEC group patients did not have any myalgia symptoms. Mild myalgia was observed in 8.47% (n=5) in the ROC group and 31.82% (n=21) in the VEC group, and only 1.8% had moderate myalgia in the VEC group. The results of the study showed that POM was significantly decreased in the ROC group than in the VEC group on day one (p=0.001). The incidence of POM on day two was significantly low in both groups. There was no statistical significance between the two groups based on Fisher's exact test (p=1.000). None of the patients had myalgia on day three.

Conclusion

Our results showed that the incidence and severity of fasciculations and POM were significantly decreased by pretreatment with ROC in contrast to that with VEC. Hence, ROC is a better option than VEC to combat succinylcholine-related complications like fasciculation and myalgia.

Effects of low-dose ketamine on succinylcholine-induced postoperative myalgia in outpatient surgeries: a randomized, double-blind study

Objective

Despite the many complications of succinylcholine, it is still widely used as a superior muscle relaxant for rapid sequence induction. One of these complications is postoperative myalgia (POM). The aim of this study was to investigate the prophylactic effect of low-dose ketamine on the incidence and severity of POM.

Materials and methods

In this double-blind clinical study, a total of 148 patients scheduled for general anesthesia were randomly divided into two equal groups. Initially, in Group K, 0.5 mg/kg of ketamine was injected intravenously, whereas in Group N, the same volume (5 mL) of normal saline was injected. Thereafter, anesthesia was induced in all patients, by injecting 1.5 mg/kg of fentanyl and 2 mg/kg of propofol intravenously. Following the loss of eyelid reflex, 1.5 mg/kg of succinylcholine was injected intravenously as a muscle relaxant and then the patients were intubated. POM was defined as a pain with no surgical interferences, and its intensity was graded based on a four-point scale. The incidence and severity of myalgia were assessed by a blinded observer 24 hours after surgery.

Results

In terms of demographic data, the results of this study showed that there is no significant difference between patients in both groups (P>0.05). Overall, the incidence of POM in Group K was significantly less, when compared with Group N (P<0.05), but both groups were comparable based on the grade 2 of POM. After the induction of anesthesia, the systolic and diastolic blood pressure values were found to reduce in both groups (P<0.05). However, the changes were somehow similar, and repeated measures of variance analysis showed no significant difference in the two study groups (P>0.05).

Conclusion

The addition of 0.5 mg/kg of ketamine to propofol for the induction of anesthesia can be effective in reducing the incidence of low-grade POM.

Optimal precurarizing dose of rocuronium to decrease fasciculation and myalgia following succinylcholine administration

Background

Succinylcholine commonly produces frequent adverse effects, including muscle fasciculation and myalgia. The current study identified the optimal dose of rocuronium to prevent succinylcholine-induced fasciculation and myalgia and evaluated the influence of rocuronium on the speed of onset produced by succinylcholine.

Methods

This randomized, double-blinded study was conducted in 100 patients randomly allocated into five groups of 20 patients each. Patients were randomized to receive 0.02, 0.03, 0.04, 0.05 and 0.06 mg/kg rocuronium as a precurarizing dose. Neuromuscular monitoring after each precurarizing dose was recorded from the adductor pollicis muscle using acceleromyography with train-of-four stimulation of the ulnar nerve. All patients received succinylcholine 1.5 mg/kg at 2 minutes after the precurarization, and were assessed the incidence and severity of fasciculations, while myalgia was assessed at 24 hours after surgery.

Results

The incidence and severity of visible muscle fasciculation was significantly less with increasing the amount of precurarizing dose of rocuronium (P < 0.001). Those of myalgia tend to decrease according to increasing the amount of precurarizing dose of rocuronium, but there was no significance (P = 0.072). The onset time of succinylcholine was significantly longer with increasing the amount of precurarizing dose of rocuronium (P < 0.001).

Conclusions

Precurarization with 0.04 mg/kg rocuronium was the optimal dose considering the reduction in the incidence and severity of fasciculation and myalgia with acceptable onset time, and the safe and effective precurarization.

Pain control in first trimester surgical abortion

BACKGROUND

First trimester abortions especially cervical dilation and suction aspiration are associated with pain, despite various methods of pain control.

OBJECTIVES

Compare different methods of pain control during first trimester surgical abortion.

SEARCH STRATEGY

We searched multiple electronic databases with the appropriate key words, as well as reference lists of articles, and contacted professionals to seek other trials.

SELECTION CRITERIA

Randomized controlled trials comparing methods of pain control in first trimester surgical abortion at less than 14 weeks gestational age using electric or manual suction aspiration. Outcomes included intra- and postoperative pain, side effects, recovery measures and satisfaction.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Meta-analysis results are expressed as weighted mean difference (WMD) or Peto Odds ratio with 95% confidence interval (CI).

MAIN RESULTS

We included forty studies with 5131 participants. Due to heterogeneity we divided studies into 7 groups:Local anesthesia: Data was insufficient to show a clear benefit of a paracervical block (PCB) compared to no PCB or a PCB with bacteriostatic saline. Pain scores during dilation and aspiration were improved with deep injection (WMD -1.64 95% CI -3.21 to -0.08; WMD 1.00 95% CI 1.09 to 0.91), and with adding a 4% intrauterine lidocaine infusion (WMD -2.0 95% CI -3.29 to -0.71, WMD -2.8 95% CI -3.95 to -1.65 with dilation and aspiration respectively).PCB with premedication: Ibuprofen and naproxen resulted in small reduction of intra- and post-operative pain.Analgesia: Diclofenac-sodium did not reduce pain.Conscious sedation: The addition of conscious intravenous sedation using diazepam and fentanyl to PCB decreased procedural pain.General anesthesia (GA): Conscious sedation increased intraoperative but decreased postoperative pain compared to GA (Peto OR 14.77 95% CI 4.91 to 44.38, and Peto OR 7.47 95% CI 2.2 to 25.36 for dilation and aspiration respectively, and WMD 1.00 95% CI 1.77 to 0.23 postoperatively). Inhalation anesthetics are associated with increased blood loss (p<0.001).GA with premedication: The COX 2 inhibitor etoricoxib, the non-selective COX inhibitors lornoxicam, diclofenac and ketorolac IM, and the opioid nalbuphine were improved postoperative pain.Non-pharmacological intervention: Listening to music decreased procedural pain.No major complication was observed.

AUTHORS' CONCLUSIONS

Conscious sedation, GA and some non-pharmacological interventions decreased procedural and postoperative pain, while being safe and satisfactory to patients. Data on the widely used PCB is inadequate to support its use, and it needs to be further studied to determine any benefit.

Pretreatment before succinylcholine for outpatient anesthesia?

IMPLICATIONS

This study demonstrated that pretreatment of succinylcholine with rocuronium failed to decrease the incidence or the severity of postoperative myalgia. However, in most patients, pretreatment was associated with muscle weakness before loss of consciousness. Thus, there is no convincing evidence supporting routine pretreatment with succinylcholine.

Is succinylcholine after pretreatment with d-tubocurarine and lidocaine contraindicated for outpatient anesthesia?

Because succinylcholine has obvious advantages for facilitating endotracheal intubation in the ambulatory setting (e.g., low cost, fast onset, and no need for reversal of neuromuscular block), it is important to determine whether this muscle relaxant is indeed associated with an increased incidence of postoperative myalgias, compared with alternative but more expensive nondepolarizing muscle relaxants. We studied 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. The anesthetic technique consisted of propofol/lidocaine for induction, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed by using a fiberscope. Patients were randomly assigned to one of two muscle relaxant groups. Group 1 patients received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Group 2 patients received mivacurium 0.2 mg/kg. After recovery from anesthesia, patients were asked whether they had any muscle pain and/or stiffness. Pain was categorized by location and quantified by using a verbal scale (from 0 to 10). Analgesic usage and myalgias limiting ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on Postoperative Day 1. If patients complained of myalgias, they were contacted by telephone on Days 2 and 3. Only one patient (in the mivacurium-treated group) reported myalgia as a limiting factor in ambulation or resumption of normal activity. There were no differences between groups with respect to the incidence (21% in the succinylcholine-treated group and 18% in the mivacurium-treated group), location, or severity of myalgia. In conclusion, succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) is not associated with an increased incidence of myalgias, compared with mivacurium, when used to facilitate tracheal intubation in patients undergoing ambulatory nasal surgery.

IMPLICATIONS

The results of this study show that the frequency of muscle pains after surgery in outpatients is approximately 20%, regardless of whether succinylcholine (after precurarization) or mivacurium is used to assist in insertion of the breathing tube.

Continuous propofol administration for suxamethonium-induced postoperative myalgia

The effect of continuous propofol administration on creatine kinase and suxamethonium-induced postoperative myalgia was evaluated in 50 patients randomised into two groups of 25 patients each. Induction of anaesthesia was identical in all patients. Anaesthesia was maintained with 66% nitrous oxide in oxygen supplemented by either isoflurane 1% or continuous propofol. Creatine kinase was measured before and after operation. Myalgia was evaluated postoperatively by a blinded observer. The median level of myalgia was reduced significantly in the continuous propofol group (p = 0.011). The median creatine kinase value increased significantly in the isoflurane group (from 90 to 160 IU, p = 0.001).

Comparison of rocuronium and d-tubocurarine for prevention of succinylcholine-induced fasciculations and myalgia

PURPOSE

We compared d-tubocurarine and rocuronium for the prevention of succinylcholine-induced fasciculations and postoperative myalgia (POM) and evaluated the influence of both drugs on the speed of onset and recovery of succinylcholine.

METHODS

Seventy-five women undergoing surgery of short duration were studied. They were randomized to one of three groups: group SAL received normal saline followed three minutes later by 1.0 mg.kg-1 succinylcholine; group ROC received 0.05 mg.kg-1 rocuronium + 1.5 mg.kg-1 succinylcholine; group DTC received 0.05 mg.kg-1 d-tubocurarine + 1.5 mg.kg-1 succinylcholine. Single-twitch stimulation was applied to the ulnar nerve every 10 sec and the EMG response of the adductor pollicis was recorded. Fasciculations were assessed by a blinded observer on a scale of 0-3. Patients were asked 24 and 48 hr later to rate POM using a scale of 0-10.

RESULTS

The interval needed for twitch height to decrease to 10% of initial value after succinylcholine was longer in group ROC (58 +/- 20 sec) (mean +/- SD) compared with group SAL (44 +/- 13 sec) (P < 0.05). Recovery to 20% occurred faster in group ROC (324 +/- 83 sec) than in groups SAL (456 +/- 103 sec) and DTC (450 +/-132 sec) (P < 0.05). Fasciculations were more intense in groups SAL than in groups ROC and DTC (P < 0.001). Patients rated POM as less intense 24hr postoperatively only in group ROC (1.2 +/- 2.4) compared with group SAL (3.3 +/- 3.5) (P < 0.05).

CONCLUSION

Rocuronium prevents succinylcholine-induced fasciculations and POM. Rocuronium also delays the onset of succinylcholine and shortens its duration compared with d-tubocurarine.