Comparison of the effect of rocuronium dosing based on corrected or lean body weight on rapid sequence induction and neuromuscular blockade duration in obese female patients

The Dosage of Muscle Relaxants in Morbidly Obese Patients in Daily Practice - A Narrative Review

The prevalence of morbid obesity in today's population around the world is alarming. Morbid obesity involves substantial changes in body composition and function, which can affect the pharmacodynamics and pharmacokinetics of many drugs. This paper aims to discuss the application of muscle relaxants and their reversing agents in patients with morbid obesity. This work is based both on the available literature and the author's personal experience. Dosage recommendations for muscle relaxants in morbidly obese patients are as follows: non-depolarizing relaxants like rocuronium, vecuronium, atracurium, and cisatracurium should be based on ideal body weight. Succinylcholine dosage should be adjusted to total body weight with a 200 mg maximum, while mivacurium should also be based on total body weight. Pancuronium is not used due to its long duration. Neostigmine dosing remains uncertain, but some suggest using total body weight. When it comes to Sugammadex opinions of the authors are divided, some indicate that it should be dosed based on ideal body weight, but more recent studies show that it should be based on 40% of corrected body weight.

Feasibility of calculating rocuronium dosage by skeletal muscle weight in patients with obesity

This study aimed to investigate the dose-response relationship of rocuronium administered based on skeletal muscle weight and to assess the feasibility of calculating rocuronium dosage by skeletal muscle weight in short surgeries for patients with obesity. This single-center, randomized controlled clinical trial included 71 patients with obesity aged 28-70 years, with body fat percentages (PBF) >20% in men and > 28% in women, ASA status I-III, scheduled for tracheoscopy. Patients were randomly allocated into two groups: skeletal muscle group (SM group) received rocuronium based on the skeletal muscle content (1.0 mg/kg, n = 31), and the conventional administration group (conventional group) received rocuronium based on total body weight (0.45 mg/kg, n = 30). General anesthesia was administered using the same protocol. Parameters recorded included patients' general condition, muscle relaxant usage, onset time of muscle relaxants, non-response time, clinical effect time, 75% recovery time, and recovery index. Additionally, occurrences of body movement, choking, and incomplete muscle relaxation during surgery were recorded. Compared to the conventional group, the SM group required significantly less rocuronium dosage, resulting in significantly lower non-response time, clinical effect time, 75% recovery time, and recovery index (p < 0.05), and the onset time is slightly longer. Neither group experienced body movement, choking, or incomplete muscle relaxation (p > 0.05). Utilizing skeletal muscle weight to calculate rocuronium dosage in short surgeries for patients with obesity can reduce dosage, shorten recovery time, and prevent residual muscle relaxation while achieving satisfactory muscle relaxation to meet surgical requirements.

A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity

Introduction

Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.

Methods

The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.

Results

Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.

Conclusions

Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Effects of a single dose of rocuronium in patients with different body fat percentages: A randomised controlled trial

The pharmacodynamics in patients with high body fat percentage might be similar to those in obese patients. This randomised controlled clinical trial observed the effects of rocuronium in patients with different percent body fats (PBFs). Fifty-four patients who underwent elective urological or pelvic surgery under general anaesthesia at Shanghai General Hospital were included in the present study; 51 patients were included for data analysis. Patients with normal PBF (<25%) were given a single dose of rocuronium calculated based on total body weight (N-TBW, control group). Patients with a higher PBF (≥25%) were given a single dose of rocuronium calculated based on total body weight (H-TBW). Patients with higher PBF and rocuronium were dosed based on fat-free mass (H-FFM). A train of four (TOF)-Watch acceleromyography monitor was used to measure the effects of the rocuronium. H-TBW (91.9 ± 28.8 s) had significantly shorter onset time than N-TBW and H-FFM (p = 0.003). H-TBW had significantly longer clinical duration time and pharmacological duration time than the other groups (p = 0.000 and 0.000, respectively); the TOF ratio0.25-0.9 time was significantly different among the three groups (p = 0.005). There were no significant differences in the recovery time (p = 0.103) or recovery index (p = 0.159) among the three groups. The effects of rocuronium dosed based on FFM in patients with high PBFs are similar to those in normal patients. A single dose of rocuronium calculated based on TBW might shorten the onset time, prolong the clinical and pharmacological duration times, and prolong the recovery time.

General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances

Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.

The effect of rocuronium priming dose based on actual versus corrected body weight in modified rapid sequence intubation

Background

Rapid sequence intubation (RSI) is a technique that allows patients to be quickly intubated and have the airway secured.

Aims

The purpose of this study was to investigate the effect of rocuronium priming and intubation dose calculated according to actual body weight (ABW) or corrected body weight (CBW) on the neuromuscular block and intubation quality in rapid sequence induction and intubation (RSII).

Patients and Methods

This prospective randomized, double-blind study was conducted on a total of 60 patients randomized into two groups using the closed-envelope method between January 2021 and December 2021, with 30 individuals in each group. In group 1, CBW was used with the formula to calculate the neuromuscular blocking drug (NMBD) dose. The ABW of patients was used to calculate the NMBD dose in group 2.

Results

The data of 50 female patients who underwent group 1 (CBW, n = 25) and group 2 (ABW, n = 25) were analyzed. Age, weight, height, body mass index (BMI), quality of laryngoscopy, post-priming side effects, mean arterial pressure (MAP), and heart rate (HR) values did not differ across the groups. When train-of-four (TOF) values, priming and intubation dose, and laryngoscopy time were compared, a statistically significant difference was found between the two groups of TOF count (TOF C) 1 (the duration of action).

Conclusion

This study suggests that the application of rocuronium priming and intubation dose according to CBW in RSII, especially during the pandemic, provided similar intubation conditions as the application according to ABW, while its shorter duration of action shows that it can be preferred, especially in short-term surgical cases.

Does Rocuroinum Dose Adjusted Due to Lean Body Weight Provide Adequate Intubation Conditions?: A Prospective Observational Study

METHODS

This is a prospective, observational study. Patients between the ages of 18 and 65 with BMI of 18.5-34.9, who are expected to be under general anesthesia for less than 6 hours, were divided into 3 groups according to their BMI (Group 1 BMI = 18.5-24.9, Group 2 BMI = 25-29.9, Group 3 BMI = 30-34.9). These groups were randomly divided into 2 subgroups: Groups LBW; 1 LBW, 2 LBW, and 3 LBW were given rocuronium intubation dosages based on their LBW while control groups; 1K, 2K, and 3K were given 0.6 mg/kg rocuronium according to their total body weight. The data on the duration of action of rocuronium and its effects on the endotracheal intubation conditions were evaluated.

RESULTS

In Group 1, T1 time was found to be significantly longer (p=0.001). Intubation score and the use of additional rocuronium dose were found to be significantly higher in Group 1 LBW than in Group 1K (p=0.001). In Group 1, an additional rocuronium dose was needed to achieve optimal intubation conditions for subgroup 1 LBW. Rocuronium duration of action was found to be significantly longer in control groups 2 and 3, that received TBW-based dosage.

CONCLUSION

In adult patients with a BMI of 18.5 and 24.9 BMI, we report optimal intubation conditions with the LBW-adjusted rocuronium dosage. This trial is registered with NCT05476952.

Rocuronium Reversal in the Emergency Department: Retrospective Evaluation of Hemodynamic Instability Following Administration of Sugammadex Versus Neostigmine With Glycopyrrolate

BACKGROUND

Rocuronium is an intermediate-acting non-depolarizing neuromuscular blocking agent frequently used in the emergency department for rapid sequence intubation. The prolonged effects of rocuronium may prevent the ability to conduct a meaningful neurological examination, thereby delaying appropriate diagnosis and treatment. Sugammadex and neostigmine are pharmacologic agents commonly used to reverse rocuronium. The safety of sugammadex versus neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department has not been well described.

OBJECTIVE

Evaluate the occurrence of hemodynamic instability post-administration of sugammadex versus neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium.

METHODS

A retrospective cohort study conducted among adult patients that received sugammadex or neostigmine with glycopyrrolate in the emergency department for the reversal of rocuronium. The primary outcome was occurrence of hemodynamic instability that required escalation of treatment. Secondary outcomes included occurrence of hypotensive, bradycardic, or cardiac arrest events.

RESULTS

A total of 37 patients met inclusion criteria (n = 10, sugammadex; n = 27, neostigmine). There was no difference between the two groups in regard to hemodynamic instability that required escalation of treatment within 30 minutes after receiving either sugammadex or neostigmine with glycopyrrolate (P = .557).

CONCLUSION

There was no difference between the two groups in regard to occurrence of hemodynamic instability that required escalation of treatment. Given the small sample size, future studies are warranted to further delineate the safety of sugammadex and neostigmine with glycopyrrolate for the reversal of rocuronium in the emergency department.

Dosing of neuromuscular blocking agents in patients with obesity: A narrative review

There is no consensus on which weight clinicians should use for weight-based dosing of neuromuscular blocking agents (NMBAs), as exemplified by differing or absent recommendations in clinical practice guidelines. The purpose of this paper is to review studies that evaluated various size descriptors for weight-based dosing of succinylcholine and non-depolarising NMBAs, and to provide recommendations for the descriptors of choice for the weight-based dosing of these agents in patients with obesity. All of the studies conducted to date involving depolarising and non-depolarising NMBAs in patients with obesity have assessed single doses or short-term infusions conducted in perioperative settings. Recognising that any final dosing regimen must take into account patient-specific considerations, the available evidence suggests that actual body weight is the size descriptor of choice for weight-based dosing of succinylcholine and that ideal body weight, or an adjusted (or lean) body weight, is the size descriptor of choice for weight-based dosing of non-depolarising NMBAs.

Anesthetic management of a morbidly obese patient with endometrial cancer during robot-assisted laparoscopic surgery

Background

The number of robot-assisted surgeries being performed has increased in recent years, even in patients with risk factors, such as obesity, owing to advancements in medical technologies. We here report the anesthetic management of a morbidly obese woman who underwent robot-assisted surgery.

Case presentation

A 44-year-old woman (height, 165 cm; weight, 147 kg; body mass index, 54 kg/m²) was scheduled to undergo robot-assisted laparoscopic hysterectomy for endometrial cancer. Preoperative weight loss and rehearsal of positioning during induction of anesthesia and surgical procedures greatly contributed to the surgical success. Monitoring of oxygen reserve index in combination with SpO₂ was useful for appropriate airway and respiratory management. During anesthesia induction, the ramp position using a special commercially available cushion facilitated manual mask ventilation and tracheal intubation. Lung-protective ventilation using a limited tidal volume with moderate PEEP was applied during the robot-assisted surgical procedure.

Conclusion

We successfully managed anesthesia without any complications.

Pharmacodynamic comparison of rocuronium bromide between patients from the plateau area and from the plain area

OBJECTIVES

We aimed to conduct a pharmacodynamic comparison of rocuronium bromide between patients from the plateau area and from the plain area.

METHODS

A total of 104 patients who received laparoscopic cholecystectomy in Sichuan Provincial People's Hospital and Aba Autonomous Prefecture People's Hospital from October 2015 to December 2015 were included in this study. Among them, 46 patients were from the plateau area and 58 were from the plain area. Both groups received total intravenous anesthesia (TIVA) with a dose of 0.6 mg/kg rocuronium bromide during induction. In the meantime, neuromuscular block was monitored using a train-of-four (TOF) stimulation mode. The onset time (time to achieve the lowest TOF value after the injection of rocuronium bromide), duration of maximal neuromuscular block (duration of lowest T1 value), time to 25% recovery, time to 75% recovery, recovery index (time from 25% recovery to 75% recovery), time to extubation, length of stay in Post Anesthesia Care Unit (PACU) and muscle strength upon PACU discharge were all recorded.

RESULTS

The onset time, time to 25% recovery, time to 75% recovery and time to extubation were all significantly prolonged in patients from the plateau area after receiving one single dose of rocuronium bromide (P < 0.05). However, both groups didn't show any significant difference in maximal neuromuscular block, recovery index (time from 25% recovery to 75% recovery), length of stay in PACU, or muscle strength upon PACU discharge (P > 0.05).

CONCLUSIONS

Compared to patients from the plain area, patients from the plateau area showed prolonged onset time of rocuronium bromide, reduced metabolic capabilities, and longer duration of muscular relaxation.