Pharmacological interventions for acceleration of the onset time of rocuronium: a meta-analysis

Magnesium as an Adjuvant to Rocuronium to Improve Intubation Conditions and Shorten the Intubation Time: A Randomized Controlled Study

AIM AND OBJECTIVE

The purpose of the study is to compare the effects of rocuronium priming with the combined technique of magnesium pretreatment and rocuronium priming and to investigate whether this pretreatment could further accelerate the onset of neuromuscular blockade during intubation.

MATERIALS AND METHODS

 A double-blinded randomized controlled trial (RCT) clinical study was done on patients at a tertiary care center for six months after obtaining approval from the institutional ethical committee. A total of 150 patients were randomly allocated as Group MP (infusion of 50 mg/kg of MgSo4 over 10 min was given 10 mins prior to premedication and dose of rocuronium 0.06 mg/kg given three minutes), Group P (priming dose of rocuronium 0.06 mg/kg given three minutes before the intubating dose), and Group C (control group with the same volume of 0.9% saline and rocuronium bolus of 0.6 mg/kg on intubation). Parameters such as demographic and hemodynamical data, American Society of Anesthesiologists (ASA) score, Mallampati scoring, neuromuscular monitoring, intubation grading, and number of successful/failed attempts were recorded.

RESULTS

 Our results showed that Group MP had a rapid onset of action of rocuronium with 58.90 +/- 4.77 seconds and a longer duration of action of rocuronium with 54.92 +/- 10.39 minutes, which are statistically significant compared to Group P (onset of action of ROC 106.70 +/- 4.24 seconds and duration of action rocuronium 45.88 +/- 6.22 minutes) and Group C (onset of action of ROC 154.56 +/- 11.39 seconds and duration of ROC 40.56 +/- 3.96 minutes). The maximum number of patients in Group MP (33 patients) showed good intubation conditions compared to Group P (23 patients) and Group C (16 patients), which was statistically significant.

CONCLUSION

We conclude that magnesium sulfate pretreatment in combination with rocuronium priming (Group MP) considerably accelerates the onset of rocuronium action, increases the duration of action of rocuronium, and enhances the intubation procedure without any adverse effect of rocuronium and magnesium sulfate.

Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation

OBJECTIVE

In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile.

METHODS

Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded.

RESULTS

A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002).

CONCLUSION

It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05343702.

Intravenous propofol, ketamine (ketofol) and rocuronium after sevoflurane induction provides long lasting anesthesia in ventilated rats

Rats are commonly used animals for laboratory experiments and many experiments require general anesthesia. However, the lack of published and reproducible intravenous anesthesia protocols for rats results in unnecessary animal use to establish new anesthesia techniques across institutions. We therefore developed an anesthesia protocol with propofol, ketamine, and rocuronium for mechanically ventilated rats, and evaluated vital parameters and plasma concentrations. 15 male Sprague-Dawley rats underwent inhalation induction with sevoflurane and tracheal, venous and arterial cannulation. After established venous access, sevoflurane was substituted by propofol and ketamine (ketofol). Rocuronium was added under mechanical ventilation for 7 h. Drug dosages were stepwise reduced to prevent accumulation. All animals survived the observation period and showed adequate depth of anesthesia. Mean arterial pressure and heart rate remained within normal ranges. Median propofol plasma concentrations remained stable: 1, 4, 7 h: 2.0 (interquartile range (IQR): 1.8–2.2), 2.1 (1.8–2.2), 1.8 (1.6–2.1) µg/ml, whereas median ketamine concentrations slightly differed after 7 h compared to 1 h: 1, 4, 7 h: 3.7 (IQR: 3.5–4.5), 3.8 (3.3–4.1), 3.8 (3.0–4.1) µg/ml. Median rocuronium plasma concentrations were lower after 4 and 7 h compared to 1 h: 1, 4, 7 h: 3.9 (IQR: 3.5–4.9), 3.2 (2.7–3.3), 3.0 (2.4–3.4) µg/ml. Our anesthesia protocol provides stable and reliable anesthesia in mechanically ventilated rats for several hours.

Efficacy of magnesium sulfate as an adjuvant to rocuronium in general anaesthesia: a meta-analysis

Objective

Magnesium sulfate is considered to be an effective adjuvant to rocuronium in general anaesthesia. We conducted a meta-analysis to clarify its efficacy.

Methods

We searched the PubMed, Embase, Web of Science, Cochrane Library, WanFang, Chinese Biomedical Literature, and China National Knowledge Infrastructure databases for randomized controlled trials (RCTs) of magnesium sulfate as an adjuvant to rocuronium from the start of the database establishment until May 2020.

Results

Eleven RCTs were analysed. The pooled meta-analysis showed that using magnesium sulfate as an adjuvant significantly shortened the onset time and prolonged the clinical duration of neuromuscular blockade by rocuronium compared with the control group without magnesium sulfate. However, there was no significant difference in recovery index of neuromuscular block between the magnesium and control groups. Furthermore, magnesium sulfate significantly increased the rates of excellent and clinically acceptable intubation conditions.

Conclusion

Adding magnesium sulfate to rocuronium during general anaesthesia can alter the neuromuscular parameters, including shortening the anaesthesia-onset time and prolonging the clinical duration, without significantly increasing the recovery time. Pretreatment with magnesium sulfate may also improve intubation conditions during general anaesthesia.

Effects of cranial electrotherapy stimulation on preoperative anxiety and blood pressure during anesthetic induction in patients with essential hypertension

Objective

Cranial electrotherapy stimulation (CES) is a non-invasive treatment that improves symptoms such as anxiety and pain. The purpose of this study was to analyze the effect of CES pretreatment on levels of preoperative anxiety, pain, and hemodynamic responses—especially changes in blood pressure—during anesthetic induction in patients with essential hypertension.

Methods

Eighty patients undergoing general anesthesia were randomly assigned to receive either no pretreatment (control group, n = 40) or CES pretreatment (CES group, n = 40). Anxiety scores, systolic and diastolic blood pressures, mean arterial pressure, and heart rate were measured in the general ward the evening before surgery, as well as in the preoperative holding area, operating room, and after intubation. Withdrawal responses to rocuronium injection were also measured.

Results

Anxiety scores in the operating room were significantly lower in the CES group. Withdrawal responses to rocuronium injection were also significantly lower in the CES group. There were no significant differences in hemodynamic values between the two groups.

Conclusions

CES pretreatment reduces both preoperative anxiety levels and withdrawal responses to rocuronium injection. However, it does not have a significant effect on hemodynamic responses.

Effect of pretreatment with magnesium sulphate on the duration of intense and deep neuromuscular blockade with rocuronium: A randomised controlled trial

BACKGROUND

Magnesium sulphate is an important adjuvant drug in multimodal anaesthesia. In combination with rocuronium it can enhance neuromuscular blockade (NMB). Limited data exist concerning the effect of magnesium sulphate on the duration of deep or intense NMB and the period of no response.

OBJECTIVE(S)

To determine the role of magnesium sulphate on the duration of rocuronium-induced deep and intense NMB, and the period of no response to nerve stimulation.

DESIGN

A randomised controlled trial.

SETTING

A public tertiary care hospital, Rio de Janeiro, Brazil, from February 2017 to March 2018.

PATIENTS

All patients between 18 and 65 years of age scheduled to undergo elective otorhinolaryngological surgery, with a BMI between 18.5 and 24.9 kg m and an American Society of Anesthesiologists physical status classification of I or II.

INTERVENTION(S)

Before induction of anaesthesia 60 patients were pretreated with an intravenous infusion of either 100 ml 0.9% saline (saline group), or 60 mg kg magnesium sulphate (magnesium group). After loss of consciousness, a bolus of rocuronium (0.6 mg kg) was administered. Neuromuscular function was measured by TOF-Watch SX monitor.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were the duration of the period of no response to nerve stimulation and intense and deep NMB, respectively. An additional outcome was the NMB onset time.

RESULTS

Median [IQR] durations of deep NMB were 20.3 [12.0 to 35.4] and 18.3 [11.2 to 26.3] min in the magnesium and saline groups, respectively (P = 0.18). Median durations of intense NMB were 21.7 [0.0 to 32.2] min and 0.0 [0.0 to 6.2] min (P = 0.001) in the magnesium and saline groups, respectively. Median durations of the period of no response were 40.8 [51.4 to 36.0] min and 28.0 [21.9 to 31.6] min (P = 0.0001) in the magnesium and saline groups, respectively.

CONCLUSION

Magnesium sulphate increased both the duration of intense NMB and the period of no response. The duration of deep NMB was similar in the magnesium sulphate group and saline group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02989272.

Effect of the infusion rate of propofol on the onset time of rocuronium

BACKGROUND

Administration of propofol, especially rapid administration, decreases patient cardiac output (CO) to various degrees. CO might influence the buildup of an effective drug level within the neuromuscular junction and affect the onset time of neuromuscular blockers. The present study aimed to investigate the effects of different infusion rates of propofol on patient CO and the onset time of rocuronium.

METHODS

A total of 90 patients were randomly assigned to receive propofol (2.5 mg/kg) at an infusion rate of 480 mg/min (group A), 240 mg/min (group B), or 120 mg/min (group C). After the administration of propofol, rocuronium (0.6 mg/kg) was administered to facilitate tracheal intubation. The Finometer monitor was used to obtain the cardiovascular profile during the induction of general anesthesia. Neuromuscular relaxation was monitored by acceleromyography using the ulnar nerve at the wrist surface and electrodes with repeated single twitches. Onset time was defined as the time from the beginning of rocuronium injection until 95% twitch depression. The onset time of rocuronium in the three groups was compared using analysis of variance with the post-hoc Tukey test. A p-value <0.05 was considered statistically significant.

RESULTS

After induction, a significant decrease in CO was observed in group A (21.6% ± 4.6%) when compared with the findings in group B (11.6% ± 4.5%) and group C (9.8% ± 4.6%). The onset time of rocuronium was significantly longer in group A (177.7 ± 17.6 seconds) than in group B (121.3 ± 18.3 seconds) and group C (118.3 ± 12.3 seconds).

CONCLUSION

Rapid administration of propofol significantly delays the onset time of rocuronium by altering CO as measured with the Finometer monitor.

Intubation of non-difficult airways using video laryngoscope versus direct laryngoscope: a randomized, parallel-group study

BACKGROUND

The video laryngoscope is recommended for intubating difficult airways. The present study aimed to determine whether the video laryngoscope can further improve intubation success rates compared with the direct laryngoscope in patients with non-difficult airways.

METHODS

In total, 360 patients scheduled for elective abdominal surgeries were randomly assigned to undergo intubation using either a video laryngoscope (n = 179) or a direct laryngoscope (n = 181). The following parameters were measured: mouth opening; thyromental distance; sternomental distance; shape angle of the tracheal catheter; and glottic exposure grade.

RESULTS

The percentage of patients with level I-II of total glottic exposure in the video laryngoscope group was 100% versus 63.5% in the direct laryngoscope group (P < 0.001). The one-attempt success rate of intubation was 96.1% using a video laryngoscope versus 90.1% using a direct laryngoscope (P = 0.024). The intubation success rate using a video laryngoscope was 100% versus 94.5% using a direct laryngoscope (P = 0.004). Immediate oropharyngeal injury occurred in 5.1% of patients intubated using a direct laryngoscope versus 1.1% using a video laryngoscope (P = 0.033). On postoperative day 1, obvious hoarseness was exhibited by 7.9% of patients intubated using a direct laryngoscope versus 2.8% using a video laryngoscope (P = 0.035). The grade of glottic exposure and catheter shape angle were independent risk factors for tracheal intubation failure. Thyromental distance, shape angle, glottic exposure time, and surgical position were independent risk factors for postoperative complications. Thyromental distance and glottic exposure time were independent risk factors for complications lasting > 2 days.

CONCLUSIONS

Intubation using a video laryngoscope yielded significantly higher intubation success rates and significantly fewer postoperative complications than direct laryngoscopy in patients with non-difficult airways.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. No: ChiCTR-IOR-16009023 . Prospective registration.

Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium

Background:

Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO₄ pretreatment is good options.

Aims:

To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium.

Settings and Design:

A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital.

Materials and Methods:

After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18–60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40–70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted.

Statistical Analysis Used:

Chi-square test and independent t-test were done with PASW statistics 18 to analyze data.

Results:

The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s (P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups (P = 0.791). Hemodynamic parameters were comparable between groups at all time frames (P > 0.05).

Conclusion:

Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation.