Comparison of intubating conditions after rocuronium and suxamethonium following "rapid-sequence induction" with thiopentone in elective cases

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION

In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities.

EVIDENCE ACQUISITION

A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence.

EVIDENCE SYNTHESIS

The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions.

CONCLUSIONS

The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Comparison of rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries

Background:

The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia.

Materials and Methods:

Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared.

Statistical Analysis Used:

To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t-test were used.

Results:

The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg.

Conclusion:

Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated.

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.

[Modified rapid sequence induction for Caesarian sections : case series on the use of rocuronium and sugammadex]

BACKGROUND

Aspiration is a feared complication of anesthesia and is accompanied by increased morbidity and mortality. Rapid sequence induction (RSI) describes the preferred procedure to perform endotracheal placement of the tubus in emergency cases of patients with an increased risk of aspiration of gastric contents. For more than 50 years RSI has consisted of the application of suxamethonium for neuromuscular blockade because of its fast onset and ultra short duration. Due to the serious side effects of suxamethonium attempts were made to find better alternative neuromuscular blocking drugs, e.g. rocuronium, to perform RSI.

MATERIALS AND METHODS

In this small clinical series RSI was performed for general anesthesia of ten pregnant women for Caesarean sections using 1.0 mg/kgBW rocuronium for induction and maintaining deep relaxation until the end of surgery. For rapid reversal of the neuromuscular blockade to a train-of-four (TOF) ratio of 0.9, the µ-cyclodextrin sugammadex was administered at the end of surgery. Major and minor side effects, such as cardiac dysrhythmia, anaphylactic reactions, hoarseness and postoperative nausea and vomiting were documented.

CONCLUSIONS

The combination of rocuronium and sugammadex for RSI combines rapid onset and rapid reversal of neuromuscular blockades with avoidance of serious side effects and very comfortable conditions for intubation in all cases. Minor side effects such as hoarseness, throat discomfort (in up to 30%) and myalgia (10%) for up to 48 h were documented.

Comparison of intubating conditions following administration of low-dose rocuronium or succinylcholine in adults: A randomized double blind study

CONTEXT

Though rocuronium has a rapid onset of neuromuscular blockade like succinylcholine without the latter's adverse effects, its use is limited due to its prolonged action.

AIM

Aim was to evaluate whether reducing the intubating dose of rocuronium shortens its duration of action, yet provides clinically acceptable intubating conditions.

SETTINGS AND DESIGN

tt was a prospective, randomized, and double blind trial.

MATERIALS AND METHODS

100 American Society of Anaesthesiologists Physical Status (ASAPS) I or II patients aged between 18-65 years scheduled for elective surgery were randomly allotted one of the four rocuronium groups (rocuronium dose of 0.3 mg/kg intubated at 60 s or at 90 s, rocuronium 0.6 mg/kg intubated at 60 s or at 90 s) orsuccinylcholine group (succinylcholine 1.0 mg/kg intubated at 60 s) and intubating conditions were assessed with: Ease of laryngoscopy, vocal cord position, and reaction to insertion of tracheal tube and cuff inflation.

STATISTICAL ANALYSIS

Statistical tests used were analysis of variance (ANOVA), Chi-Square test, Repeated measures of ANOVA and Mann-Whitney U test.

RESULTS

Rocuronium in dosage of 0.3 mg/kg gaveclinically acceptable intubating conditions in 35% and 60% subjects at 60 s or 90 s, respectively, whereas in dosage of 0.6 mg/kg, intubating conditions were acceptable in 80% and 100% subjects intubated at 60 s and 90 s.

CONCLUSION

Rocuronium in dose of 0.3 mg/kg does not give clinically acceptable intubating conditions at 60 or 90 s but has shorter duration of action. Rocuronium in dose of 0.6 mg/kg gives clinically acceptable intubating conditions at 60 or 90 s, comparable to succinylcholine 1 mg/kg.

Evaluation of intubating conditions after rocuronium bromide in adults induced with propofol or thiopentone sodium

AIM

The aims of present study were to compare the propofol and rocuronium with thiopentone and rocuronium in terms of clinically satisfactory intubating conditions and to co-relate intubating conditions with degree of paralysis in adductor pollicis muscle using train of four ratio (TOFR). The intubating conditions were evaluated after rocuronium bromide 0.6 mg kg(-1) at 60 s.

MATERIALS AND METHODS

60 patients of ASA grades I-II of either sex, age 18-50 years, undergoing various elective surgical procedures were randomly divided into two groups, propofol rocuronium (PR group) and thiopentone rocuronium (TR group) of 30 patients in each. In the PR group, patients received propofol 2.5 mg kg(-1) and rocuronium 0.6 mg kg(-1); in TR group, patients received thiopentone 5 mg kg(-1) and rocuronium 0.6 mg kg(-1). In all patients the intubating conditions were evaluated by the observer at 60 s. TOFR was measured at the time of intubation by an assistant.

RESULTS

In the PR group the number of the patients placed in intubating conditions grades I, II, III and IV were 40%, 36.67%, 13.33% and 10% and their mean TOFR were 31.8±17.9%, 61.8±;14.6%, 61.7±27.9%, and 78.3±5.7% respectively. While in theTR group the number of patients placed in intubating condition grade I, II, and III were 60%, 26.67%, and 13.33% and their mean TOFR , 41.2±28.3%, 68.0±10.9% and 78.7±6.8%, respectively. There was no patient in grade lV in theTR group.

CONCLUSION

The clinical intubating conditions and degree of paralysis of adductor pollicis muscle after rocuronium 0.6 mg kg(-1) at 60 s in adults induced with propofol or thiopentone sodium are comparable.

Is the rapid sequence induction possible with 0.6 mg/kg rocuronium in pediatric patient?

Background

We have investigated the possibility of rocuronium 0.6 mg/kg and timing principle application with the same dose for rapid sequence induction (RSI) in 65 children, aged 4-8 yr.

Methods

Sixty five patients were randomly assigned to one of two groups; Group A (n = 31, timing principle application) received rocuronium (0.6 mg/kg) followed by administration of propofol (2.5 mg/kg), and group B (n = 36) received rocuronium (0.6 mg/kg) after administration of propofol. Intubation was assessed at 60 seconds just after administration of last injectants. Intubating conditions (jaw relaxation, vocal cord movement, and response to tracheal intubation) were evaluated as excellent, good, fair and poor.

Results

Excellent intubation conditions were obtained in 87% in group A and 61% in group B. However, clinically acceptable intubation conditions which means excellent and good did not show any significant difference as 100% (group A) and 99% (group B).

Conclusions

In cases of pediatiric patients undergoing elective surgery, RSI was possible irrespective of the use of timing principle.

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.

Succinylcholine or rocuronium? A meta-analysis of the effects on intubation conditions

This meta-analysis was undertaken to compare the effects of succinylcholine (SCH) and rocuronium (RCR) on endotracheal intubation (ETI) conditions. Eligible randomised controlled trials (RCTs) were identified via medline and a manual search of references. The frequencies of excellent and unacceptable ETI conditions in subjects receiving SCH 1.0-1.5 mg/kg and RCR 0.6-1.2 mg/kg were determined using standard statistical methods. Inclusion criteria were met by 16 RCTs, representing 1362 subjects. SCH was associated with a 17.7% increase (95% CI = 13-22) in the frequency of excellent ETI conditions and a 5.1% decrease (95% CI = -7.3 to -2.9) in the frequency of unacceptable ETI conditions, when compared with RCR. In the subgroup undergoing true rapid sequence intubation, SCH was associated with a 19.1% increase (95% CI = 13.7-24.5) in the frequency of excellent ETI conditions. SCH appears to be superior to RCR in creating excellent ETI conditions and avoiding unacceptable ETI conditions.

Rocuronium Is Not Associated with More Vocal Cord Injuries than Succinylcholine After Rapid-Sequence Induction: A Randomized, Prospective, Controlled Trial

Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microg/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group.

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.

Intubation conditions after rocuronium or succinylcholine for rapid sequence induction with alfentanil and propofol in the emergency patient

BACKGROUND AND OBJECTIVE

Previous studies mainly conducted on elective patients recommend doses of 0.9-1.2 mg kg[-1] rocuronium to obtain comparable intubation conditions with succinylcholine 1.0 mg kg[-1] after 60 s during a rapid-sequence induction. We decided to compare the overall intubating conditions of standard doses of rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] during a strict rapid-sequence induction regimen including propofol and alfentanil.

METHODS

Male and female patients (ASA I-III) older than 17 yr scheduled for emergency abdominal or gynaecological surgery and with increased risk of pulmonary aspiration of gastric content were randomized to a rapid-sequence induction with succinylcholine 1.0 mg kg[-1] or rocuronium 0.6 mg kg[-1]. Patients with a predicted difficult airway were excluded. A senior anaesthesiologist 'blinded' for the randomization performed the intubation 60 s after injection of the neuromuscular blocker. Intubating conditions were evaluated according to an established guideline. Tracheal intubation not completed within 30 s was recorded as failed.

RESULTS

222 patients were randomized. Three patients had their operation cancelled and 10 did not fulfil the inclusion criteria. Clinically acceptable intubation conditions were present in 93.5% and 96.1% of patients in the succinylcholine group (n=107) and the rocuronium group (n=102), respectively (P=0.59).

CONCLUSIONS

During a rapid-sequence induction with alfentanil and propofol, both rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] provide clinically acceptable intubation conditions in 60 s in patients scheduled for emergency surgery. Under the conditions of this rapid-sequence induction regimen rocuronium may be a substitute for succinylcholine.

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

BACKGROUND

Rocuronium (ORG 9426) has been shown to have an onset of action more rapid than other nondepolarizing neuromuscular blocking agents and to provide intubating conditions similar to those of succinylcholine 60-90 s after administration. We compared the intubating conditions and hemodynamic changes after the administration of rocuronium 0.6 mg kg(-1) and lidocaine 1.5 mg kg(-1) with rocuronium alone and succinylcholine 60 and 90 s after administration.

METHODS

One hundred and twenty-five adult patients of ASA physical status I or II scheduled for elective surgery were randomly divided into five groups. After propofol administration in all patients, patients in group Su (succinylcholine), group R60 (rocuronium) and group RL60 (rocuronium-lidocaine) were intubated within 60 s, while groups RL90 and R90 were intubated 90 s after the administration of rocuronium and succinylcholine. Laryngoscopy was performed and intubating conditions were graded by an experienced anesthetist blind to the muscle relaxant allocation.

RESULTS

In this study, groups Su, RL60, R90 and RL90 had similar intubation scores, which were significantly better than that for group R60. Heart rate did not increase after intubation in groups Su, RL60 and RL90.

CONCLUSION

The combination of lidocaine (1.5 mg kg(-1)) and low-dose rocuronium (0.6 mg kg(-1)) along with propofol is clinically equivalent to succinylcholine, improves intubating conditions in 60 s and effectively blocks increases in heart rate after intubation.

Rocuronium versus succinylcholine for rapid sequence induction intubation

BACKGROUND

Patients requiring emergent endotracheal intubation often require a rapid sequence induction intubation (RSI) technique to protect against gastric aspiration, to facilitate intubation, or to protect against increased intracranial pressure. Succinylcholine is the most common muscle relaxant used because it has a fast onset and a short duration. Unfortunately it can have serious side effects as a result of it's membrane depolarizing effect and release of potassium. Rocuronium has been suggested to create intubating conditions similar to succinylcholine. Previous studies have been underpowered to determine equivalence and there has been no previous meta-analysis performed.

OBJECTIVES

To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made with succinylcholine based on the dose of rocuronium, use of a narcotic, emergent versus elective intubation, age group and the induction agent used. The primary outcome was excellent intubation conditions. A secondary outcome of clinically acceptable conditions was also performed. These were all dichotomous outcomes using cutpoints from a four point scale by Goldberg to evaluate intubation conditions.

SEARCH STRATEGY

We searched MEDLINE (1966-March 2000), EMBASE (1988-March 2000) and the Cochrane Central Register of Controlled Trials (CENRAL) (March 2000) for randomized controlled trials (RCT) or controlled clinical trials (CCT) relating to the use of rocuronium and succinylcholine. Foreign language journals were included. References of identified studies were hand-searched for citations missed by the electronic searches.

SELECTION CRITERIA

All trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, one of study's main outcomes was scoring of intubation conditions) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted and methodological quality was assessed independently by two reviewers for allocation concealment. The outcomes were combined using MetaView 4.1 with risk differences for all categories and RR for the excellent outcomes with a random effects model.

MAIN RESULTS

40 studies were identified; 26 were combined for analysis. Overall, rocuronium was inferior to succinylcholine, with a RR=0.87 (95%CI = 0.81 to 0.94) (N=1606). In the group that used propofol for induction of anaesthesia, the intubation conditions were similar, with a RR=0.96 (95%CI = 0.87 to 1.06) (N=640). No major adverse events were reported.

REVIEWER'S CONCLUSIONS

Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically different between succinylcholine and rocuronium when propofol was used.

The influence of induction technique on intubating conditions 1 min after rocuronium administration: a comparison of a propofol-ephedrine combination and propofol

We conducted a double blind, prospective, controlled trial comparing intubating conditions after induction with a propofol-ephedrine combination or propofol alone, followed by rocuronium. One hundred adult patients were randomly assigned to receive either propofol 2.5 mg x kg(-1) and ephedrine 15 mg in combination or propofol 2.5 mg x kg(-1) given over 30 s, followed by rocuronium 0.6 mg x kg(-1) given over 5 s. Tracheal intubation was performed 1 min later. Jaw relaxation, vocal cord position and diaphragmatic response were used to assess intubation conditions. Tracheal intubation was successful and acceptable in all patients. There was a significantly higher proportion of intubating conditions graded as 'excellent' in the propofol-ephedrine group (84%) than in the propofol group (32%) (p < 0.0001). Vocal cord position and response to intubation were significantly better in the propofol-ephedrine group, although jaw relaxation was similar. Mean arterial pressure was maintained at pre-induction levels in the propofol-ephedrine group. In conclusion, induction with propofol and ephedrine in combination provided significantly better intubating conditions than propofol alone, when followed by rocuronium.

Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children

BACKGROUND

The purpose of our study was to determine whether a smaller dose of rocuronium than previously reported could provide similar intubating conditions to suxamethonium during rapid-sequence induction of anaesthesia in children.

METHODS

One hundred and twenty ASA I, unpremedicated children, aged 1-10 years, who were undergoing elective surgery, were randomized into three groups to receive rocuronium 0.6 mg.kg-1, rocuronium 0.9 mg.kg-1 or suxamethonium 1.5 mg.kg-1. The study was double-blinded, anaesthesia and timing of injection was standardized to alfentanil 10 microg.kg-1, thiopentone 5 mg.kg-1 and the study drug. Intubation was attempted at 30 s after injection of neuromuscular relaxant and intubating conditions graded as excellent, good, poor or impossible.

RESULTS

All 120 children were successfully intubated within 60 s without need for a second attempt after administration of neuromuscular relaxant. Differences between suxamethonium and rocuronium 0.6 mg.kg-1 and between the two doses of rocuronium were statistically significant (P=0.016 and 0.007, respectively).

CONCLUSIONS

Rocuronium 0.9 mg.kg-1 provides similar intubating conditions to suxamethonium 1.5 mg.kg-1 during modified rapid-sequence induction using alfentanil and thiopentone in children (P=0.671). Rocuronium 0.6 mg.kg-1 was inadequate.

Newer neuromuscular blocking agents: how do they compare with established agents?

Rapacuronium bromide (rapacuronium; ORG-9487) is a nondepolarising muscle relaxant (NMBA) with a low potency [90% effective dose (ED90) 1 mg/kg], which to some extent is responsible for its rapid onset of action. Because of the high plasma clearance (5.3 to 11.1 mg/kg/min) of rapacuronium, its clinical duration of action following single bolus doses up to 2 mg/kg in adults is short (i.e. <20 minutes). Rapacuronium forms a pharmacologically active 3-desacetyl metabolite, ORG-9488, which may contribute to a delay in spontaneous recovery after repeat bolus doses or infusions. After rapacuronium 1.5 mg/kg clinically acceptable intubating conditions are achieved within 60 to 90 seconds in the majority of adult and elderly patients undergoing elective anaesthesia. However, in a rapid-sequence setting. intubating conditions are less favourable after rapacuronium 1.5 to 2.5 mg/kg than after succinylcholine. The most prominent adverse effects of rapacuronium (tachycardia, hypotension and bronchospasm) are dose-related, and in particular pulmonary adverse effects are observed more frequently under conditions of a rapid-sequence induction in adults. Therefore, it seems worthwhile to consider only doses of rapacuronium < or = 1.5 mg/kg to facilitate rapid tracheal intubation, and to use succinylcholine or rocuronium rather than rapacuronium in a rapid-sequence setting. Rapacuronium, however, is a suitable alternative to mivacurium chloride (mivacurium) and succinylcholine for short procedures (e.g. ambulatory anaesthesia). Rocuronium bromide (rocuronium) is a relatively low-potent, intermediateacting NMBA. Its main advantage is the rapid onset of neuromuscular block whereby good or excellent intubating conditions are achieved within 60 to 90 seconds after rocuronium 0.6 mg/kg (2 x ED95), and within 60 to 180 seconds after smaller doses (1 to 1.5 x ED95). Larger doses of rocuronium (> or = 1 mg/kg) seem to be suitable for rapid-sequence induction under relatively light anaesthesia. However, it is still a matter of controversy whether, in the case of an unanticipated difficult intubation, the long duration of rocuronium administered in such large doses outweighs the many adverse effects of succinylcholine. Rocuronium has mild vagolytic effects and does not release histamine, even when administered in large doses. Rocuronium is primarily eliminated via the liver and its pharmacokinetic profile is similar to that of vecuronium bromide (vecuronium). Unlike vecuronium, rocuronium has no metabolite. Cisatracurium besilate (cisatracurium), the IR-cis, 1'R-cis isomer of atracurium besilate (atracurium) is approximately 4 times more potent than atracurium. The onset time of cisatracurium is significantly slower than after equipotent doses of atracurium. The recommended intubating dose is 0.15 to 0.2 mg/kg (3 to 4 times ED95). Over a wide range of clinically relevant doses the recovery properties of cisatracurium are affected by neither the size of the bolus dose nor by the duration of infusion. Unlike atracurium, cisatracurium does not trigger histamine release. Like atracurium, cisatracurium undergoes Hofmann elimination. In contrast to atracurium, cisatracurium does not undergo hydrolysis by nonspecific plasma esterases. Moreover, about 77% of the drug is cleared by organ-dependent mechanisms.

A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients

OBJECTIVE

To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED).

METHODS

A one-year prospective cohort comparison study was performed using a data collection form completed at the time of intubation. Data collected included the reason for the neuromuscular-blocking agent (NMBA) chosen, the time to onset of paralysis, and any complications encountered. Three ten-point numerical descriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall satisfaction with the extent of paralysis.

RESULTS

Succinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (+/- SD) times of onset of succinylcholine and rocuronium were 39 +/- 13 sec and 44 +/- 20 sec, respectively (p = 0.04). No patient desaturated and required assisted ventilations while waiting for paralysis to occur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 +/- 1.1) than rocuronium (median = 10, mean = 9.1 +/- 1. 5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 +/- 1.6) and rocuronium (median = 9, mean = 9.0 +/- 1.6) (p = 0.15). The physician's overall satisfaction with the extent of paralysis was also higher for succinylcholine (median = 10, mean = 9.4 +/- 1.3) than rocuronium (median = 10, mean = 8.8 +/- 2.0) (p < 0.01). Only one complication, widening of the QRS complex secondary to succinylcholine use in a patient with unsuspected hyperkalemia, could be attributed to the choice of NMBA.

CONCLUSIONS

Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance. Approximately a fourth of ED RSI patients qualified for use of rocuronium using these high-risk criteria.

Rapacuronium 2.0 or 2.5 mg kg-1 for rapid-sequence induction: comparison with succinylcholine 1.0 mg kg-1

The purpose of this nine-centre study in 602 patients was to show that the frequency of acceptable intubating conditions after rapacuronium 2.0 or 2.5 mg kg-1 is not more than 10% lower than the frequency after succinylcholine 1.0 mg kg-1 during rapid-sequence induction of anaesthesia with fentanyl 1-2 micrograms kg-1 and thiopental 2-7 mg kg-1. Laryngoscopy and intubation were carried out 60 s after administration of muscle relaxant by an anaesthetist blinded to its identity. Intubating conditions were clinically acceptable (excellent or good) in 91.8% of patients given succinylcholine and in 84.1 and 87.6% of patients given rapacuronium 2.0 and 2.5 mg kg-1 respectively. With respect to the percentage of clinically acceptable intubating conditions, the estimated difference (and the upper limit of the one-sided 97.5% confidence interval) between succinylcholine and rapacuronium 2.0 mg kg-1 was 7.8 (14.4)% and between succinylcholine and rapacuronium 2.5 mg kg-1 it was 4.0 (10.2)%. For both comparisons, the upper limit of the one-sided confidence interval exceeded the predefined 10% difference. Hence, it could not be demonstrated that the intubating conditions with either of the two doses of rapacuronium were not inferior to those with succinylcholine 1.0 mg kg-1. The increase in heart rate was significantly greater during the first 5 min in the rapacuronium groups, but the arterial pressure increased significantly only in the succinylcholine group (P < 0.001). Respiratory side-effects were observed in 4.0, 13.5 and 18.5% of patients after succinylcholine and rapacuronium 2.0 and 2.5 mg kg-1 respectively (P < 0.05). As the non-inferiority of intubating conditions after rapacuronium 2.0 and 2.5 mg kg-1 could not be proven, succinylcholine should be considered the neuromuscular blocking agent that provides better intubating conditions for rapid-sequence induction.

Advances in airway pharmacology. Emerging trends and evolving controversy

The practice of emergency medicine is a constant onslaught of decision making and challenges and the issues of airway management are no exception. Obtaining proper airway control requires thoughtful organization and planning, and necessitates a thorough working knowledge of the drugs or medications employed. Because there are so many agents available, expertise in airway pharmacology has become essential. The emergency physician who is well versed in the uses, and the physiologic effects, contraindications, and alternatives of drugs administered is both providing immediate intervention and positively affecting patient outcome, which is certainly a goal worth achieving.

Rocuronium versus succinylcholine-atracurium for tracheal intubation and maintenance relaxation during propofol anesthesia

STUDY OBJECTIVES

To compare the onset and offset time (clinical duration), and intubating conditions obtained with rocuronium bromide 0.6 mg/kg and succinylcholine 1.0 mg/kg after induction with propofol and fentanyl; and to compare rocuronium with atracurium for maintenance during propofol anesthesia.

DESIGN

Prospective, open-label, parallel group comparative, randomized study.

SETTING

Operating rooms of a university hospital.

PATIENTS

30 ASA physical status I and II adult patients scheduled for elective surgeries with general anesthesia.

INTERVENTIONS

Patients premedicated with midazolam 2 mg were anesthetized with fentanyl 2 microg/kg followed by propofol 2.5 mg/kg and muscle relaxants. Group 1 (n = 15) received succinylcholine 1.5 mg/kg and Group 2 (n = 16) received rocuronium bromide 0.6 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxant. Patients in Group 1 received atracurium and patients in Group 2 received rocuronium for maintenance if required.

MEASUREMENTS

The ease of intubation was scored using a scale of 1 to 4. Onset and offset time monitored with evoked twitch response of the adductor pollicis were recorded.

MAIN RESULTS

Intubation was successful in all patients and there was no difference in scores between the two groups. Although onset time was shorter with succinylcholine than with rocuronium, neuromuscular blockade was successfully antagonized in both groups, and the recovery profile was not different between the two groups.

CONCLUSIONS

Rocuronium bromide at a dose of 0.6 mg/kg, when used with propofol and fentanyl for induction, provides intubating conditions similar to succinylcholine 1.0 mg/kg at 1 minute. The actual onset time and offset time, however, are significantly longer with rocuronium. There was no difference between atracurium and rocuronium as a maintenance drug. Rocuronium is suitable for surgical procedures greater than 30 minutes, eliminating the need for an additional relaxant to succinylcholine.

Comparison of succinylcholine with two doses of rocuronium using a new method of monitoring neuromuscular block at the laryngeal muscles by surface laryngeal electromyography

We compared the onset of neuromuscular block with succinylcholine (1 mg kg-1) and two doses of rocuronium (0.6 and 0.9 mg kg-1) at the adductor pollicis muscle using electromyography (EMG) and acceleromyography (AMG), and at the adductor laryngeal muscles with a new electromyographic method using a disposable surface electrode attached to the cuff of a tracheal tube. At the larynx, the mean (+/- SD) time to 90% block and the onset time of succinylcholine (38 +/- 15 and 47 +/- 19 s, respectively) were significantly shorter (P < 0.01) than for rocuronium 0.6 mg kg-1 (92 +/- 42 and 106 +/- 38 s) and rocuronium 0.9 mg kg-1 (52 +/- 31 and 64 +/- 30 s). We found that, with comparable degrees of neuromuscular block, the onset time of succinylcholine at the adductor pollicis was significantly shorter (P < 0.01) than for rocuronium 0.6 mg kg-1 and 0.9 mg kg-1 (EMG, 80 +/- 39 vs 145 +/- 48 s and 99 +/- 31 s; AMG, 90 +/- 39 vs 124 +/- 53 s and 106 +/- 38 s). Clinical duration at the adductor pollicis (AMG) was significantly longer (P < 0.01) for both rocuronium groups than for succinylcholine (T4:T1 = 0.7, 54 +/- 18 and 77 +/- 21 vs 8 +/- 6 min). The surface laryngeal electrode proved non-invasive, easy to use and reliable in measuring onset of the neuromuscular block at the larynx.

Remifentanil and propofol without muscle relaxants or with different doses of rocuronium for tracheal intubation in outpatient anaesthesia

BACKGROUND

The use of muscle relaxants in outpatient anaesthesia is controversial; some authors recommend an induction regimen including propofol and opioids without muscle relaxants. This study evaluated the requirements for rocuronium after remifentanil/propofol.

METHODS

We examined in four groups of ASA I-II patients (n= 30 for each) the intubating conditions three minutes after induction of anaesthesia with remifentanil 0.5 microg kg(-1) min(-1), propofol 2 mg kg(-1) without muscle relaxants or with different doses of rocuronium (0.6 mg kg(-1), 0.45 mg kg(-1), 0.3 mg kg(-1)) applying the criteria proposed by the Copenhagen Consensus Conference. In the second part of the study the time course of neuromuscular block was determined by electromyography using train-of-four (TOF) stimulation. To this end, another 60 ASA I-II patients were randomly assigned to receive remifentanil 0.5 microg kg(-1) min(-1), propofol 2 mg kg(-1) and either rocuronium 0.6 mg kg(-1), 0.45 mg kg(-1), 0.3 mg kg(-1), or 0.3 mg kg(-1) followed by neostigmine 40 microg kg(-1) and atropine 20 microg kg(-1) at a T1 recovery of 10% (n=15 for each).

RESULTS

Intubating conditions were good or excellent in 30 patients after rocuronium 0.6 mg kg(-1) and in 18 patients when rocuronium was omitted (P<0.01). After 0.45 mg kg(-1) and 0.3 mg kg(-1) rocuronium the numbers were 29 and 30 patients, respectively. Reducing rocuronium from 0.6 mg kg(-1) to 0.45 mg kg(-1) or 0.3 mg kg(-1) increased the onset time from 136 (35) s to 199 (34) s and 249 (52) s (mean (SD)), (P<0.01); the clinical duration decreased from 38 (10) min to 24 (8) min and 16 (5) min, respectively (P<0.01); and the duration to a TOF-ratio of 0.8 decreased from 60 (11) min to 45 (9) min and 34 (7) min (P<0.01). After rocuronium 0.3 mg kg(-1) this time interval further decreased to 22 (3) min when neostigmine was given at a T1 of 10% (P<0.01 compared with spontaneous recovery after rocuronium 0.3 mg kg(-1)).

CONCLUSION

After remifentanil/propofol intubation conditions were poor in 40% of patients without muscle relaxants; adding reduced doses of rocuronium to this regimen improved the intubation conditions significantly. In addition, reducing the initial dose of rocuronium markedly shortened its time course of action.

Rapid tracheal intubation with large-dose rocuronium: a probability-based approach

There are situations in anesthesia in which it may be desirable to achieve rapid tracheal intubation with perfect conditions, i.e., no coughing or straining. To determine the dose of rocuronium that gives a high probability of achieving perfect conditions for rapid (within 60 s) tracheal intubation, we administered a range of doses of rocuronium, some larger than used previously. Sixty adults, anesthetized with thiopental 4 mg/kg IV and alfentanil 10 microg/kg IV, received rocuronium 0.4 to 2.0 mg/kg IV. We used logistic regression to define the relationship of rocuronium dose to probability of achieving perfect intubation conditions. We estimated the doses giving 90% and 95% probability of achieving perfect intubation and used resampling to determine confidence limits for these estimates. Rocuronium 1.85 and 2.33 mg/kg gave, respectively, 90% and 95% probability of perfect intubation conditions. The confidence limits (5th and 95th percentile) for these estimates were 1.15 to 2.31 and 1.23 to 3.22 mg/kg, respectively. In conclusion, it is possible to achieve perfect intubation conditions with large doses of rocuronium, but the long duration of action and expense may limit the usefulness of the technique.

IMPLICATIONS

We found that it is possible to have a 90% probability of achieving perfect conditions for rapid tracheal intubation with large (up to 2.0 mg/kg) doses of rocuronium. These large doses of rocuronium may be useful in, for instance, head trauma or open globe injuries if succinylcholine is contraindicated.

Rocuronium for rapid sequence intubation of emergency department patients

Rocuronium is a recently synthesized non-depolarizing neuromuscular blocking agent (NMBA) that has been demonstrated to have a faster onset of action than any other non-depolarizing NMBA. Although widely studied in the operating room, there are no reports regarding its use for emergent tracheal intubation in the emergency department (ED). The purpose of this study was to evaluate the use of rocuronium for rapid sequence intubation (RSI) in ED patients. An intubation data collection form was completed prospectively for any patient receiving rocuronium for RSI in the ED from July 1-December 31, 1997. Two hundred eighty-eight patients were intubated in the ED over this six-month period, of whom 261 (91%) underwent RSI. Fifty-eight of the patients undergoing RSI received rocuronium for paralysis (22%). The most common reason reported for use of rocuronium was a concern regarding hyperkalemia (53%). The mean dose used was 1.0 +/- 0.2 mg/kg. The mean onset to paralysis was 45 +/- 15 s. Of the complications reported, none appeared to be related to rocuronium. Use of rocuronium in the ED setting appears useful.

Influence of induction of anaesthesia on intubating conditions one minute after rocuronium administration: comparison of ketamine and thiopentone

We compared the effect of thiopentone and ketamine on intubating conditions after rocuronium 0.6 mg.kg-1 in two groups of patients (n = 16 each), aged 21-44 years, undergoing elective surgery. Premedication consisted of alprazolam 1 mg by mouth 1 h before surgery. All patients received midazolam 2 mg intravenously 2 min before intravenous administration of thiopentone 5 mg.kg-1 or ketamine 2.5 mg.kg-1. Muscle relaxation was provided by rocuronium 0.6 mg.kg-1. One minute after rocuronium administration, tracheal intubation was performed within 15 s by a skilled anaesthetist blinded to the treatment group assignment. Intubating conditions were graded as excellent, good, fair or poor on the basis of jaw relaxation, position of vocal cords and diaphragmatic response. Neuromuscular transmission was assessed at the adductor pollicis muscle using a TOF-GUARD monitor. Excellent and good intubating conditions were obtained in 100% of patients in the ketamine group and in 50% of patients in the thiopentone group (p = 0.002). Jaw relaxation was similar in both groups but vocal cord conditions were better and the diaphragmatic response less marked in the ketamine group compared with the thiopentone group (p = 0.002). The degree of neuromuscular block [% decrease of T1, mean (SD)] at the time of intubation was similar: 51.8 (25)% (ketamine group) and 54.3 (23.1)% (thiopentone group). We conclude that ketamine 2.5 mg.kg-1 provides better intubating conditions than thiopentone 5 mg.kg-1 1 min after administration of rocuronium 0.6 mg.kg-1.

Intraocular pressure changes during rapid sequence induction and intubation: a comparison of rocuronium, atracurium, and succinylcholine

STUDY OBJECTIVE

To compare changes in intraocular pressure (IOP) during rapid sequence induction and intubation following rocuronium, succinylcholine, and atracurium.

DESIGN

Open-label, prospective, randomized study.

SETTING

Operating room at the Eye Foundation Hospital (University of Alabama at Birmingham)

PATIENTS

45 ASA physical status I, II, and III patients, aged 18 to 65 years, scheduled for elective eye surgery with general anesthesia.

INTERVENTIONS

Anesthesia was rapidly induced in unpremedicated patients with a fixed combination of midazolam 0.025 mg/kg, alfentanil 0.025 mg/kg, and propofol 1.5 mg/kg. Intubation was performed, as clinically indicated, approximately 60 seconds following administration of rocuronium 0.6 mg/kg, atracurium 0.5 mg/kg, or succinylcholine 1 to 1.5 mg/kg.

MEASUREMENTS AND MAIN RESULTS

Intraocular pressure was measured before induction of anesthesia (baseline), following anesthesia induction and administration of muscle relaxant (before intubation), and after intubation. The percent change in IOP from baseline was significantly decreased in the rocuronium group compared with the succinylcholine group (p = 0.046) before intubation. This trend continued after intubation, but the difference was no longer significant (p = 0.070). Intubation scores for rocuronium and succinylcholine groups were similar, and both scores were superior to that for the atracurium group (p = 0.002).

CONCLUSION

Intraocular pressure can be controlled during emergency induction of anesthesia and intubation with adequate depth of anesthesia and muscle relaxation. Rocuronium, succinylcholine, and atracurium all provided sufficient muscle relaxation to achieve successful intubation and no increase in IOP. However, rocuronium 0.6 mg/kg provided significantly better intubating conditions compared with atracurium, and it resulted in a significantly greater decrease in IOP compared with baseline than succinylcholine.

Comparison of sevoflurane and propofol with rocuronium for modified rapid-sequence induction of anaesthesia

We compared the use of sevoflurane and propofol with three different doses of rocuronium for modified rapid-sequence induction of anaesthesia. One hundred and forty adult patients were randomly allocated to have a rapid-sequence intravenous induction with propofol 2-3 mg.kg-1 (group P) or an inhalational induction with sevoflurane 8% in oxygen, using a vital capacity technique (group S). Following loss of the eyelash reflex, cricoid pressure was applied and 20 patients in each group were administered rocuronium 0.3 (groups P/0.3 and S/0.3), 0.45 (groups P/0.45 and S/0.45) or 0.6 (groups P/0.6 and S/0.6) mg.kg-1. An additional 10 patients in each group received only saline placebo in place of the muscle relaxant (groups P/Saline and S/Saline). Laryngoscopy was started 60 s later and intubating conditions evaluated by a blinded anaesthetist according to a standard scoring system. Intubating conditions were acceptable in one patient and no patient, respectively, following induction with sevoflurane and propofol without the muscle relaxant. The conditions were acceptable in 30, 55 and 90% of subjects with sevoflurane induction, and in 45, 80 and 90% of subjects with propofol induction following 0.3, 0.45 and 0.6 mg.kg-1 of rocuronium, respectively (no significant difference for each dose of rocuronium). The present study shows that intubating conditions during a rapid-sequence induction using rocuronium 0.6 mg.kg-1 following induction of anaesthesia with sevoflurane or propofol are similar.

Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia

We determined the effective time to satisfactory intubation conditions after the administration of rocuronium 0.6 mg.kg-1 to 120 unpremedicated adult patients anaesthetised with propofol 2.5 mg.kg-1 or thiopentone 5 mg.kg-1. Intubation conditions were assessed in 10 subgroups of 12 patients at 30, 40, 50, 60 and 70 s. The effective times to satisfactory intubation conditions in 50 and 90% of patients were obtained by the method of maximum likelihood after log time-probit response transformations. Intubation conditions after induction of anaesthesia with propofol were satisfactory in 5/12 patients at 30 s, 7/12 at 40 s, 10/12 at 50 s, 11/12 at 60 s and 11/12 at 70 s compared with 1/12 patients at 30 s, 2/12 at 40 s, 5/12 at 50 s, 7/12 at 60 s and 8/12 at 70 s after induction with thiopentone. The effective times to satisfactory intubation conditions in 50% and 90% (95% confidence intervals) of patients after rocuronium 0.6 mg.kg-1 were 34 (26-40) s and 61 (50-81) s in patients given propofol compared with 57 (48-69) s and 101 (79-167) s in patients given thiopentone. We conclude that rocuronium 0.6 mg.kg-1 may be a suitable alternative to suxamethonium during rapid sequence induction of anaesthesia with propofol in situations where suxamethonium is contraindicated.

Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia

This study was designed to compare the tracheal intubating conditions during a rapid sequence induction of anaesthesia using rocuronium 0.6 (n = 61) or 1.0 mg.kg-1 (n = 130) or suxamethonium 1.0 mg.kg-1 (n = 127) as the neuromuscular blocking drugs. Anaesthesia was induced with fentanyl 1-2 micrograms.kg-1 and thiopentone 5 mg.kg-1 (median dose) and intubating conditions were assessed 60s after the administration of the neuromuscular blocking drug by an observer unaware of which drug had been given. Intubating conditions were graded on a three-point scale as excellent, good or poor, the first two being considered clinically acceptable. The study was carried out in two parts. At the end of the first part a comparison between the two doses of rocuronium was carried out when at least 50 patients had been enrolled in each group. The results showed the intubating conditions to be significantly superior with the 1.0 mg.kg-1 dose of rocuronium (p < 0.01). Final comparison between the 1.0 mg.kg-1 doses of rocuronium and suxamethonium showed no significant difference in the incidence of acceptable intubations (96 and 97%, respectively). The incidence of excellent grade of intubations was, however, significantly higher with suxamethonium (80% vs. 65%; p = 0.02). It is concluded that rocuronium 1.0 mg.kg-1 can be used as an alternative to suxamethonium 1.0 mg.kg-1 as part of a rapid sequence induction provided there is no anticipated difficulty in intubation. The clinical duration of this dose of rocuronium is, however, 50-60 min.

Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction

We have assessed the effect of two induction agents on tracheal intubating conditions after rocuronium 0.6 mg.kg-1 in unpremedicated patients undergoing simulated rapid sequence induction. Following pre-oxygenation, anaesthesia was induced with propofol up to 2.5 mg.kg-1 (n = 35) or etomidate 0.3 mg.kg-1 (n = 36), and further increments as required. After loss of verbal contact, cricoid pressure was applied and rocuronium was injected. Laryngoscopy was performed at 45 s and intubation attempted at 60 s after rocuronium had been given. Ninety-four per cent of patients in the propofol group had clinically acceptable (good or excellent) intubating conditions compared to only 75% in the etomidate group (p = 0.025). Owing to coughing, one patient in the etomidate group could not be intubated on the first attempt. A greater pressor response also followed intubation after induction with etomidate. We conclude that etomidate and rocuronium alone cannot be recommended for intubation at 60 s under rapid sequence induction conditions.

[Assessment of intubation time and conditions under the influence of rocuronium]

PURPOSE

To evaluate the tracheal intubating conditions when intubation time is determined by the onset time of the neuromuscular block either of the adductor pollicis (AP) or of the orbicularis oculi muscle (OO).

METHODS

In this prospective, double blind, randomised study, 40 adults ASA I-II undergoing general anaesthesia with tracheal intubation were allocated to two groups (n = 20) according to the reference muscle (AP or OO) used to determine the appropriate intubation time. Induction of anaesthesia was achieved with 5-7 mg.kg-1 thiopentone, 1.5-2.5 micrograms.kg-1 fentanyl and 0.9 mg.kg-1 rocuronium (3 x ED95) for muscular relaxation. Supramaximal train of four stimulation of the ulnar and facial nerve every 10 sec was used to monitor the neuromuscular block. After visual loss of AP or OO contraction, tracheal intubation and quality of intubation assessment were performed by two independent anaesthetists. Data are expressed as mean and standard error of the mean (X +/- SEM).

RESULTS

Curarisation time of the OO was shorter (110 +/- 4.9 sec) than that of the AP (144 +/- 5.5 sec; P < 0.0001). Intubation conditions were excellent in 95% and good in 5% of the patients in the AP group whereas in the OO group only 65% of the patients had excellent and 20% good intubation conditions (P < 0.05). Coughing was observed in 15% of patients in the OO group during tracheal intubation.

CONCLUSION

Monitoring neuro-muscular activity of the AP using TOF to determine the appropriate tracheal intubation time and conditions in patients paralysed with rocurorium is more clinically relevant than monitoring the OO muscle.

Double-blind comparison of two doses of rocuronium and succinylcholine for rapid-sequence intubation

STUDY OBJECTIVE

To compare the pharmacodynamics of two commonly recommended doses of rocuronium bromide (0.7 mg/kg and 0.9 mg/kg) and succinylcholine (1.5 mg/kg) when used for rapid-sequence intubation.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Operating rooms at a university hospital.

PATIENTS

45 ASA physical status I and II adult patients scheduled for elective surgeries under general anesthesia.

INTERVENTIONS

Nonpremedicated patients were anesthetized with fentanyl 2 mcg/kg followed by thiopental sodium 4 to 5 mg/kg and muscle relaxant using rapid-sequence technique. Group 1 (n = 15) received rocuronium bromide 0.7 mg/kg. Group 2 (n = 16) received rocuronium bromide 0.9 mg/kg, and Group 3 (n = 14) received succinylcholine 1.5 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxant.

MEASUREMENTS AND MAIN RESULTS

The case of intubation was scored using a scale of 1 to 4. Blood pressure and heart rate were measured beginning one minute before induction of anesthesia up to 5 minutes after intubation. Intubation scores were similar in groups 2 and 3 and were noted as good or excellent in all patients. Group 1 displayed a significantly lower intubation score than the other two groups; 60% were rated as poor. No significant differences in hemodynamic data were seen among the three groups.

CONCLUSIONS

Rocuronium bromide at a dose of 0.9 mg/kg provides intubating conditions similar to succinylcholine 1.5 mg/kg at 1 minute. Intubating conditions at 1 minute following a 0.7 mg/kg dose of rocuronium are not as good as those following a 0.9 mg/kg dose of rocuronium or a 1.5 mg/kg dose of succinylcholine.

Thiopental-rocuronium versus ketamine-rocuronium for rapid-sequence intubation in parturients undergoing cesarean section

We investigated the neuromuscular effects and conditions of tracheal intubation after administration of rocuronium in 40 parturients undergoing elective cesarean section. After preoxygenation, anesthesia was induced in 20 patients by thiopental 4 mg/kg and, in the other 20 patients, by ketamine 1.5 mg/kg. Rocuronium 0.6 mg/kg was then administered, and neuromuscular transmission was assessed using electromyographic response to train-of-four stimulation of the ulnar nerve at the wrist every 10 s. The time to T1/control ratio of 50% neuromuscular block (NMB) as well as the time to maximum NMB (onset time) were compared in the two groups. The time to 50% block was 45 +/- 10 s in the thiopental group and 42 +/- 14 s in the ketamine group, while the onset time was 105 +/- 35 s in the thiopental group and 101 +/- 35 s in the ketamine group. Neither the time to 50% NMB nor the onset time were significantly different between the two groups. Tracheal intubation at 50% NMB was easily performed in all patients in the ketamine-rocuronium group but was difficult in 75% of the thiopental-rocuronium group. We concluded that ketamine 1.5 mg/kg followed by rocuronium 0.6 mg/kg may be suitable for rapid-sequence induction of anesthesia in parturients undergoing cesarean section.