Comparison of four strategies to reduce the pain associated with intravenous administration of rocuronium

Reduction of the rocuronium-induced withdrawal reflex by MR13A10A, a generic rocuronium with a novel solution: A randomized, controlled study

Background

Rocuronium induces venous pain and the withdrawal reflex during injection. MR13A10A, generic rocuronium with a novel solution, reduced the injection-induced withdrawal reflex in rodents. We hypothesized that MR13A10A would reduce the frequency and severity of injection-induced withdrawal reflexes compared with original rocuronium during clinical anesthesia induction.

Methods

This prospective, open (but assessor-blinded), randomized, controlled study was conducted at a single academic hospital. The assessor was blinded to the study condition in order to minimize observer bias. Participants were allocated to either MR13A10A or traditional formula groups by a blocked stratified randomization method. Participants in the MR13A10A group received MR13A10A, whereas the original rocuronium group received the same amount of original rocuronium. The primary outcome was presence of the withdrawal reflex after rocuronium injection. Severity of the withdrawal reflex, changes in blood pressure and heart rate, and the train of four (TOF) ratio were measured as secondary outcomes. The withdrawal reflex was assessed using a video recording in a blinded manner.

Results

Of the 149 participants, 76 were allocated to the MR13A10A group and 73 to the original rocuronium group. The frequency of the withdrawal reflex was significantly lower with MR13A10A compared with original rocuronium (19.7% and 54.8% for MR13A10A and original rocuronium groups, respectively, p<0.001). The odds ratio adjusted for cannulation site, cannula size, induction agent and age was 6.27 (95% CI, 2.87, 13.73 p<0.001). Original rocuronium was an independent factor related to a higher post-treatment heart rate. The proportions of TOF ratios = 0 were similar between the two groups.

Conclusion

The frequency and severity of the withdrawal reflex after injection were significantly reduced by using MR13A10A. MR13A10A might contribute to safe and less invasive anesthesia management.

Rocuronium Bromide Intravenous Solution Maruishi® is more suitable than ESLAX Intravenous® during rapid-sequence induction of anesthesia

PURPOSE

Rocuronium Bromide Intravenous Solution® (Maruishi Pharmaceutical Co., Ltd, Osaka, Japan) is a newly developed generic drug and we have noticed that compared with conventional rocuronium formulations [e.g. Esmeron (Eslax), MSD Co. Ltd., Tokyo, Japan], rocuronium Maruishi appeared to cause less pain or withdrawal movement. The aim of this study was to assess the hypothesis that the injection of rocuronium Maruishi causes less body movement than rocuronium MSD does, during rapid-sequence induction of anesthesia.

METHODS

Sixty patients were allocated randomly to one of two groups. In one group, rocuronium MSD was used and in the other group, rocuronium Maruishi was used. After induction of general anesthesia, a test drug (containing rocuronium) 0.9 mg/kg was injected. Patient's withdrawal movement was graded with the scale. Primary outcome measure was the incidence of moderate or severe movement after the injection of rocuronium. Secondary outcome measure was the degree of movement between the groups.

RESULTS

Moderate or severe withdrawal movement was observed after the injection of rocuronium MSD in 11 of 30 patients (37%) and after the injection of rocuronium Maruishi in 3 of 30 patients (10%). There was a significant difference in the incidence between the groups (P = 0.013, 95% CI for difference 26-28%). The degree of movement was also significantly greater for rocuronium MSD than for rocuronium Maruishi (P = 0.015).

CONCLUSION

Compared with rocuronium MSD, rocuronium Maruishi is more suitable than conventional rocuronium formulations, for rapid-sequence induction of anesthesia.

The evaluation of the effect of venous diameter measurement by ultrasonography on pain and withdrawal response

PURPOSE

Rocuronium and propofol are used in the induction of anesthesia give discomfort to the patients. We aimed to investigate the relationship between venous diameter measured using ultrasonography, and pain and withdrawal movements after propofol and rocuronium applied with intravenous (IV).

METHODS

This prospective-observational study was performed on 142 voluntary patients undergoing surgical operation under general anesthesia. An ultrasonography was used to measure the vein transverse diameter. Patients with a venous transverse diameter of ≤2 mm were classified as group 1 (n = 50), while patients with a diameter of > 2 mm were classified as group 2 (n = 92). The propofol pain was assessed according to the verbal rating scale (VRS). In addition, the withdrawal movements of the rocuronium injection were evaluated using the four-point scale.

RESULTS

There was no difference between the two groups in terms of the demographic data. The patients have pain after propofol 38.2% and withdrawal movements after rocuronium 42.4% were detected. The maximum number of patients without pain after propofol injection (78.2%) and without withdrawal movements after rocuronium (76%) was found to be higher in group 2 (p = 0.001).

CONCLUSION

In this study, we found a reduction in the incidence and severity of pain and withdrawal movements in intravenous propofol and rocuronium administration through peripheral venous vessels of large diameter. We believe that the clinical drug injection through vessels with large venous diameter with the help of USG may be a non-invasive, simple, and reliable method to reduce pain and withdrawal movements in propofol and rocuronium injections.

Pharmacological and non-pharmacological interventions for reducing rocuronium bromide induced pain on injection in children and adults

BACKGROUND

Rocuronium bromide is a routinely used muscle relaxant in anaesthetic practice. Its use, however, is associated with intense pain on injection. While it is well established that rocuronium bromide injection causes pain in awake patients, anaesthetized patients also tend to show withdrawal movements of the limbs when this muscle relaxant is administered. Various strategies, both pharmacological and non-pharmacological, have been studied to reduce the incidence and severity of pain on rocuronium bromide injection. We wanted to find out which of the existing modalities was best to reduce pain on rocuronium injection.

OBJECTIVES

The objectives of this review were to assess the ability of both pharmacological and non-pharmacological interventions to reduce or eliminate the pain that accompanies rocuronium bromide administration.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE via Ovid SP (1966 to July 2013) and EMBASE via Ovid SP (1980 to July 2013). We also searched specific websites. We reran the searches in February 2015 and will deal with the 11 studies of interest found through this search when we update the review.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared the use of any drug or a non-pharmacological method with control patients, or those receiving no treatment to reduce the severity of pain with rocuronium injection. Our primary outcome was pain on rocuronium bromide injection measured by a pain score assessment. Our secondary outcomes were rise in heart rate and blood pressure following administration of rocuronium and adverse events related to the interventions.

DATA COLLECTION AND ANALYSIS

We used the standardized methods for conducting a systematic review as described in the Cochrane Handbook for Systematic Reviews of Interventions. Two authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis. We used a fixed-effect model where there was no evidence of significant heterogeneity between studies and a random-effects model if heterogeneity was likely.

MAIN RESULTS

We included 66 studies with 7840 participants in the review, though most analyses were based on data from fewer participants. In total there are 17 studies awaiting classification. No studies were at a low risk of bias. We noted substantial statistical and clinical heterogeneity between trials. Most of the studies reported the primary outcome pain as assessed by verbal response from participants in an awake state but some trials reported withdrawal of the injected limb as a proxy for pain after induction of anaesthesia in response to rocuronium administration. Few studies reported adverse events and no study reported heart rate and blood pressure changes after administration of rocuronium. Lidocaine was the most commonly studied intervention drug, used in 29 trials with 2256 participants. The risk ratio (RR) of pain on injection if given lidocaine compared to placebo was 0.23 (95% confidence interval (CI) 0.17 to 0.31; I² = 65%, low quality of evidence). The RR of pain on injection if fentanyl and remifentanil were given compared to placebo was 0.42 (95% CI 0.26 to 0.70; I² = 79%, low quality of evidence) and (RR 0.10, 95% CI 0.04 to 0.26; I² = 74%, low quality of evidence), respectively. Pain on injection of intervention drugs was reported with the use of lidocaine and acetaminophen in one study. Cough was reported with the use of fentanyl (one study), remifentanil (five studies, low quality evidence) and alfentanil (one study). Breath holding and chest tightness were reported with the use of remifentanil in two studies (very low quality evidence) and one study (very low quality evidence), respectively. The overall rate of complications was low.

AUTHORS' CONCLUSIONS

The evidence to suggest that the most commonly investigated pharmacological interventions reduce pain on injection of rocuronium is of low quality due to risk of bias and inconsistency. There is low or very low quality evidence for adverse events, due to risk of bias, inconsistency and imprecision of effect. We did not compare the various interventions with one another and so cannot comment on the superiority of one intervention over another. Complications were reported more often with use of opioids.

EC50 and EC95 of remifentanil to prevent rocuronium-induced withdrawal movements in children

Background

Intravenous administration of rocuronium induces intense pain in most patients (60-100%). This could be harmful during anesthesia induction because of the unintended reflex movement of an unconscious patient in response to the pain. Previous studies have reported that remifentanil effectively reduces rocuronium-induced pain and withdrawal movements. This study was designed to evaluate the EC₅₀ and EC₉₅ of remifentanil to prevent withdrawal movements in children.

Methods

We enrolled a total of 171 pediatric patients scheduled for general anesthesia in this study. Remifentanil was administrated by target-controlled infusion. Effect-site target concentrations ranged from 0.5 to 3.0 ng/ml. At each concentration, experiments were repeated in 10-20 patients. Propofol 2 mg/kg and rocuronium 0.9 mg/kg were administrated after equilibration of plasma and effect-site target remifentanil concentration. The withdrawal movements were graded on a 4-point scale. The EC₅₀ and EC₉₅ of remifentanil to prevent rocuronium-induced withdrawal movements were determined by using a logistic regression model.

Results

The logistic regression model showed that the probability of preventing rocuronium-induced withdrawal movement was as follows: exp (-3.49 + 2.07 × remifentanil concentration) / (1 + exp [-3.49 + 2.07 × remifentanil concentration]). EC₅₀ and EC₉₅ were 1.69 ng/ml (95% confidence intervals [CIs], 1.42-1.87) and 3.11 ng/ml (95% CIs, 2.79-3.72), respectively.

Conclusions

Administration of remifentanil at an effect-site target concentration of 3.1 ng/ml could effectively prevent rocuronium-induced withdrawal movements.

A comparison of granisetron and nitroglycerine for attenuating rocuronium pain: A double-blinded randomized, placebo controlled trial

BACKGROUND

The incidence of pain reported in literature after IV administration of rocuronium is 50-80%. The aim of our study was to determine whether pre-treatment with intravenous granisetron and nitroglycerine would reduce rocuronium-induced pain.

METHODS

One hundred fifty patients of either sex, aged 18-65 years, American society of Anaesthesiologist grading (ASA) I-II, scheduled for various surgeries under general anesthesia were randomly assigned to one of the groups. Group G: received 2 granisetron (1mg/ml) diluted with 3 ml of 0.9% normal saline) while the Group C: received 5 ml of 0.9% normal saline. Group N: received 200΅g of nitroglycerine diluted to a total of 5 ml(with 0.9% normal saline). It was accompanied by manual venous occlusion for 20 seconds. Then 0.06mg/kg of rocuronium was injected through same cannula over 10-15 sec. Patients were asked by a blinded investigator to score the pain on injection of rocuronium using visual analogue scale (0-10) with 0-no pain,1-3 mild pain, 4-6 moderate and >=7 severe pain. At the same time discomfort in the form of patient's movement, such as no movement (grade 0), movement only wrist (grade 1), movement to the upper arm and shoulder of injected arm (grade 2) or generalized movements (grade3) was observed. Statistical analysis using independent t test, Mann-Whitney test and reverse ANOVA was done.

RESULTS

1. At 0 seconds, in group G number of patients who experienced withdrawl score of 0-1 were 92%,group N were 82% while only 26% of patients in group C had favourable withdrawl score.74% of patients in group C had score of 2-3 at same time. 2. At 0 sec, in group G number of patients who experienced VAS score of 0-3 were 96%, group N 72%. At same time Group C 48 % of patients had VAS score of 2-3.

CONCLUSION

We conclude that pre-treatment with granisetron or nitroglycerine both are highly effective in attenuation of rocuronium induced pain.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pharmacological prevention of rocuronium-induced injection pain or withdrawal movements: a meta-analysis

Rocuronium is reported to be associated with injection pain or withdrawal movement (IPWM). This meta-analysis assessed the efficacy of different pharmacological treatments used to decrease the incidence of the rocuronium-induced IPWM. We searched the Cochrane Library, Embase and PubMed for randomized controlled trials comparing a pharmacological drug with a placebo to prevent the rocuronium-induced IPWM and found 37 studies with 5,595 patients. Overall incidence of rocuronium-induced IPWM was 74%. Pretreatment with opioids [risk ratio (RR) 0.16; 95% confidence interval (95% CI) 0.09-0.29], lidocaine (0.47; 0.35-0.64), and ketamine (0.41; 0.22-0.77) were effective in decreasing IPWM. Lidocaine pretreatment with venous occlusion (0.40; 0.32-0.49) and opioids pretreatment with venous occlusion (0.77; 0.61-0.96) were also effective. Mixing sodium bicarbonate (NaHCO3) with rocuronium (0.15; 0.06-0.34) was also efficacious in reducing IPWM. Indirect comparison shows that the RR of NaHCO3 admixture and pretreatment with opioids were lower than that of the other four interventions (pretreatments of ketamine or lidocaine, and lidocaine or opioids with venous occlusion). This meta-analysis suggests that opioids, lidocaine, ketamine, and NaHCO3 are effective in decreasing rocuronium-induced IPWM. Considering the efficacy and convenience, pretreatment with opioids without venous occlusion is recommended for reducing rocuronium-induced IPWM.

Can ephedrine pretreatment be effective in alleviating rocuronium injection pain?

OBJECTIVE

The aim of this randomized, double-blind, placebo-controlled study was to evaluate the effect of ephedrine pretreatment on the intensity of rocuronium injection pain when rocuronium was applied by timing principle and also to compare this effect with lidocaine and placebo.

SUBJECTS AND METHODS

120 American Society of Anesthesiology risk score I-II patients scheduled for elective surgery under general anesthesia were randomized into three groups to receive either 70 μg/kg ephedrine (ephedrine group, n = 40) or 0.5 mg/kg lidocaine (lidocaine group, n = 40) or 5 ml NaCl 0.9% (placebo group, n = 40) as pretreatment. Thirty seconds after pretreatment drugs, rocuronium 0.6 mg/kg was administered by the timing principle and rocuronium injection pain scores were recorded. Twenty seconds after rocuronium administration, anesthesia was induced with thiopental and the patient's trachea was intubated. Hemodynamic parameters and adverse effects were recorded.

RESULTS

The overall frequency of having pain was 82.5, 52.5 and 22.5% in placebo, ephedrine and lidocaine groups, respectively. Although the frequency of mild and moderate pain scores was higher in the ephedrine group than in the lidocaine group, this difference was not statistically significant (p = 0.032 and p = 0.001, respectively).

CONCLUSION

Although not as effective as lidocaine 0.5 mg/kg, 70 μg/kg ephedrine pretreatment was able to alleviate rocuronium injection pain when rocuronium was applied by timing principle.

Effect of pretreatment with gabapentin on withdrawal movement associated with intravenous rocuronium injection

BACKGROUND

The major disadvantage of rocuronium is the withdrawal movement associated with its injection. The analgesic effect of perioperative gabapentin has been evaluated. We investigated the effects of gabapentin on the withdrawal movement induced by rocuronium injection.

METHODS

86 ASA physical status I or II patients, aged 18-69 years who were scheduled to undergo elective surgery with general anesthesia were enrolled. Patients were randomly allocated into two groups to receive either gabapentin 600 mg or placebo 2 hours prior to surgery. The patient's response to rocuronium injection was graded using a 4-point scale.

RESULTS

The incidence of withdrawal movement after rocuronium administration was significantly lower in the gabapentin group (55.0% in the control group vs 28.6% in the gabapentin group). The number of patients with generalized response indicating severe pain, was 9 (22.5%) in the control group and 3 (7.1%) in the gabapentin group.

CONCLUSIONS

Pretreatment with a single oral dose of gabapentin 600 mg reduced the incidence and severity of withdrawal movement after rocuronium administration.

Effect of nitrous oxide on pain due to rocuronium injection: A randomised, double-blind, controlled clinical trial

A prospective, randomised, double-blind, placebo-controlled study was carried out to determine the effect of nitrous oxide (N₂O) on the frequency and severity of pain and withdrawal reactions after injection of rocuronium. Eighty ASA physical status I and II patients undergoing general anaesthesia for elective surgery were enrolled. The patients were randomised to receive 100% oxygen (O₂), or 50% N₂O in O₂ for 3 minutes followed by a subparalysing dose of rocuronium 0.06 mg/kg. After induction of anaesthesia with thiopentone 5 mg/kg, an intubating dose of rocuronium 0.6 mg/kg was given. The patients were observed after injection of rocuronium 0.06 mg/kg, and asked to rate pain in the arm on a 4-point (0–3) verbal rating scale (none, mild, moderate or severe). After the intubating dose of rocuronium, withdrawal reactions were recorded. Thirty-six patients (90%) in the group N₂O and 15 patients (37.5%) in the group O₂ reported no pain (P < 0.001). The pain was mild in 1 (2.5%) and 9 (22.5%) patients in N₂O and O₂ groups, respectively (P = 0.006). Moderate pain occurred in 2 (5%) patients in group N₂O and 15 (37.5%) patients in group O₂ (P = 0.001). Severe pain was reported by one patient in each group (P = 0.47). Withdrawal response after an intubating dose of rocuronium was observed in 6 (15%) and 18 (45%) patients in the N₂O and O₂ groups, respectively (P < 0.05). Inhalation of 50% N₂O in O₂ reduces the incidence and severity of pain and the withdrawal reactions associated with rocuronium injection.

Potency and recovery characteristics of rocuronium mixed with sodium bicarbonate

Sodium bicarbonate may be added to rocuronium to decrease pain on injection. However, this mixture may result in the formation of carbon dioxide bubbles. We investigated whether the addition of sodium bicarbonate to rocuronium alters neuromuscular blockade, in 120 patients randomly assigned to receive rocuronium mixed with saline or bicarbonate 8.4%, either in varying doses (for dose-response measurements; 60 patients) or a fixed dose of 600 μg.kg(-1) (for time-course measurements; 60 patients). Sodium bicarbonate resulted in a left-shift of the rocuronium dose-response curve. The effective doses of rocuronium to produce 95% twitch depression were 331.6 (95% CI: 310.4-352.8) and 284.3 (95% CI: 262.0-306.6) μg.kg(-1) mixed with isotonic saline or sodium bicarbonate, respectively (p < 0.001). The mean (SD) onset times of rocuronium 600 μg.kg(-1) were 3.6 (0.6) and 2.7 (0.5) min in the corresponding groups, respectively (p < 0.001). The mean (SD) times to 95% recovery were 35.8 (5.8) and 47.9 (7.1) min, respectively (p < 0.001). We conclude that the mixing of sodium bicarbonate with rocuronium enhances the potency, shortens the onset and prolongs the duration of action.

Pretreatment with nafamostat mesilate, a kallikrein inhibitor, to decrease withdrawal response associated with rocuronium

PURPOSE

This randomized, double-blind, placebo-controlled study was conducted to examine the preventive effect of nafamostat mesilate, a kallikrein inhibitor, on the withdrawal response associated with rocuronium injection.

METHODS

Ninety American Society of Anesthesiology (ASA) physical status I or II patients, aged 18-65 years, were randomly divided into two groups that received either a 1.5-ml solution containing 1.5 mg nafamostat mesilate diluted in a 5% glucose solution or a 1.5-ml 5% glucose solution. Anesthesia was induced by 5 mg/kg 2.5% thiopental. After confirming loss of consciousness, a tourniquet was applied to the mid forearm and tightened to block venous flow. The test solution was then administered, 1 min after which the tourniquet was removed and 0.6 mg/kg rocuronium was administered. Each patient's response to rocuronium injection was graded on a four-point scale in a double-blind manner. Activated coagulation time and plasma potassium concentration were measured before and 5 and 10 min after nafamostat administration.

RESULTS

The incidence of withdrawal response was 68.9% in the control group and 24.4% in the nafamostat group (P < 0.001). The number of patients showing generalized movement (response 4) with the rocuronium injection was significantly lower in nafamostat group [1 (2.2%)] than the control group [15 (33.3%)], P < 0.001. Five and 10 min after nafamostat administration, measured potassium and activated coagulation time were similar to baseline values.

CONCLUSION

Pretreatment with 1.5 mg nafamostat mesilate decreased withdrawal response associated with rocuronium injection.

The influence of age and gender on remifentanil EC(50) for preventing rocuronium induced withdrawal movements

Background

Rocuronium-induced withdrawal movements can be harmful to patients during the induction period. Remifentanil has been reported to reduce these movements effectively. In this study, we determined the EC₅₀ of remifentanil for the prevention of rocuronium induced withdrawal movements in male, female, old and child group.

Methods

We included patients scheduled for general anesthesia and assigned them into 4 groups depending on their age and gender: male group (20-60 yr), female group (20-60 yr), old group (>65 yr) and child group (6-12 yr). Remifentanil was administered by target controlled infusion. Propofol 2 mg/kg was then administered after equilibration between the effect and plasma concentration of remifentanil was reached. After loss of consciousness, rocuronium 0.6 mg/kg was administered. Patient's response to the rocuronium was graded using a 4 point scale in a blinded manner. The EC₅₀ of remifentanil for preventing rocuronium induced withdrawal movements was determined using Dixon's up-and -down method.

Results

The EC₅₀ of remifentanil for preventing rocuronium induced withdrawal movements was 1.8 ± 0.5 ng/ml [95% confidence interval 1.3-2.2] in the male group, 2.3 ± 1.0 ng/ml [1.3-3.2] in the female group, 0.5 ± 0.4 ng/ml [0.2-0.8] in the old group and 2.8 ± 0.8 ng/ml [2.1-3.5] in the child group.

Conclusions

The EC₅₀ of remifentanil for preventing rocuronium induced withdrawal movements was lowest in the elderly and higher in children than male adult patients. No difference in the EC₅₀ of remifentanil was seen between male and female adult patients.

Rapid injection of rocuronium reduces withdrawal movement on injection

STUDY OBJECTIVE

To test whether rapid injection of rocuronium reduces withdrawal movement on injection.

DESIGN

Randomized, prospective trial.

SETTING

Operating room in a university hospital.

PATIENTS

150 ASA physical status I and II patients aged 18 to 60 years, undergoing general anesthesia.

INTERVENTIONS

Patients were randomized to three groups. After undergoing anesthesia induction with thiopental sodium, then 5 seconds later receiving a rubber tourniquet applied to the mid-forearm to stop intravenous (IV) flow by gravity, the pretreatment drug was injected. The tourniquet was held for 15 seconds then released, and 1.0 mg/kg of 1% rocuronium was injected IV. Group C patients (n = 50) were pretreated with 0.1 mL/kg of 0.9% NaCl and then injected with rocuronium slowly within 10 seconds. Group L patients (n = 50) were pretreated with 0.1 mL/kg of preservative-free 1% lidocaine and then injected with rocuronium slowly within 10 seconds. Group R patients (n = 50) were pretreated with 0.1 mL/kg of 0.9% NaCl and then rapidly injected with rocuronium within approximately one second (as quickly as possible).

MEASUREMENTS

After injection of the patient with the study drug, a single anesthesiologist with no knowledge of the study protocol graded each patient's response as follows: 0 = no response; 1 = mild movement limited to the wrist only; 2 = moderate movement involving the elbow and shoulder; and 3 = severe movement involving more than one extremity.

MAIN RESULTS

Group C had the most intense and frequent withdrawal response. The frequency and intensity of withdrawal movement was significantly less in Groups L and R than Group C. No significant difference in withdrawal response between Groups L and R was noted.

CONCLUSIONS

Withdrawal response can be significantly reduced for rocuronium injection without lidocaine pretreatment, simply through rapid injection.

Antihistamine pretreatment to reduce incidence of withdrawal movement after rocuronium injection

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Alfentanil is comparable to remifentanil in preventing withdrawal movement following rocuronium injection

STUDY OBJECTIVE

To evaluate and compare the efficacy and related side effects of alfentanil and remifentanil in preventing the withdrawal movement associated with rocuronium injection.

DESIGN

Prospective, randomized, blinded, placebo-controlled clinical trial.

SETTING

Operating room of a university hospital.

PATIENTS

115 ASA physical status I and II adult patients.

INTERVENTIONS

Patients were randomly allocated to one of three study groups. Group C received saline, Group A received alfentanil 10 microg/kg, and Group R received remifentanil one microg/kg, each in a volume of three mL. Treatments were injected over 30 seconds, followed by thiopental sodium. At 90 seconds after the start of the study drug injection, rocuronium 0.6 mg/kg was injected over 10 seconds.

MEASUREMENTS

Cough, breathholding, and thoracic muscle rigidity were observed while injecting the study drug. Each patient's response to the rocuronium injection was graded on a 4-point scale in a blinded manner.

MAIN RESULTS

During injection of the study drug, Group R showed a significantly higher frequency of cough than Group A (24% vs. 2%; P < 0.05). One Group R patient presented with apnea. Frequency of withdrawal movement in Groups A and R were significantly lower than that in Group C (6% and 0% vs. 63%; P < 0.0001) but there was no significant difference between the two groups.

CONCLUSION

When administered 90 seconds before rocuronium injection, alfentanil showed a comparable effect to that of remifentanil in attenuating rocuronium-associated withdrawal movement, and a lower frequency of side effects such as cough.

Remifentanil prevents withdrawal movements caused by intravenous injection of rocuronium

PURPOSE

The incidence of pain induced withdrawal movement following intravenous injection of rocuronium is high. This randomized, double-blind, placebo-controlled study was designed to evaluate the effect of pretreatment of remifentanil on the withdrawal movements due to intravenous injection of rocuronium during anesthetic induction.

MATERIALS AND METHODS

Ninety adult female patients undergoing thyroidectomy were randomly allocated to three groups. Each patient intravenously received one of three solutions of equal volume (4 mL): normal saline (Group I, n=30), 0.5 microg/kg remifentanil (Group II, n=30) or 1 microg/kg remifentanil (Group III, n=30). Thirty seconds after remifentanil administration, anesthesia was induced with 5 mg/kg IV thiopental. Twenty seconds after thiopental injection, 0.6 mg/kg IV rocuronium was administered (injection rate of 0.5 mL/sec) and patients' withdrawal movements were assessed. Mean arterial pressure (MAP) and heart rate were assessed on arrival in the operation room, before the tracheal intubation and immediately, 1 and 2 min after the tracheal intubation.

RESULTS

The incidence of withdrawal movements was significantly lower in both of the remifentanil groups (3 and 0% in Group II and III, respectively) than in the saline group (70%). Remifentanil attenuated the increase of heart rate and MAP immediately and 1 min after the tracheal intubation.

CONCLUSION

The pretreatment with 0.5 and 1.0 microg/kg remifentanil of bolus doses prevented the withdrawal movements caused by rocuronium injection, and effectively blunted cardiovascular activation following tracheal intubation.

Neutralized rocuronium (pH 7.4) before administration prevents injection pain in awake patients: a randomized prospective trial

STUDY OBJECTIVE

To determine (1) the amount of 8.4% sodium bicarbonate (NaHCO(3)) to adjust the pH of rocuronium to 7.4 (neutralization), (2) to show whether neutralizing the pH of rocuronium can prevent pain, and (3) to confirm that rocuronium mixed with NaHCO(3) does not change the physical property and efficacy of rocuronium.

DESIGN

Prospective studies.

SETTING

University medical center.

PATIENTS

180 ASA physical status I and II women patients undergoing elective gynecologic surgery.

INTERVENTIONS AND MEASUREMENTS

60 patients were randomly allocated to group 1 (rocuronium only), group 2 (rocuronium 50 mg mixed with 0.9% NaCl 3 mL), and group 3 (rocuronium 50 mg mixed with 8.4% NaHCO(3) 3 mL). All patients received mixtures equal to 0.04 mg/kg of rocuronium and were asked to evaluate their pain with visual analog scale (VAS) and pain scores. In other settings, the onset time and duration of action of each group of rocuronium were measured. The dose of rocuronium required to produce a 50% twitch depression (ED(50)) was calculated.

MAIN RESULTS

The amount of 8.4% NaHCO(3) needed to neutralize 50 mg of rocuronium was 3.1 +/- 0.3 mL. VAS scores were lower in group 3 than in groups 1 or 2 (P < 0.05). There were no differences in onset time, duration of action, or ED(50) values among the groups.

CONCLUSIONS

Rocuronium neutralized with NaHCO(3) prevents intravenous injection pain. The physical and pharmacologic properties of rocuronium mixed with NaHCO(3) immediately before administration are not altered.

Prevention of withdrawal movement associated with injection of rocuronium in children: comparison of remifentanil, alfentanil and fentanyl

BACKGROUND

We compared the efficacy of remifentanil, alfentanil and fentanyl in reducing withdrawal movement associated with the injection of rocuronium in children.

METHODS

In total, 164 ASA physical status I or II pediatric patients, aged 1-14 years, were randomly assigned to four treatment groups: group C received saline; group R, remifentanil 1 microg/kg; group A, alfentanil 10 micro/kg; and group F, fentanyl 2 microg/kg. Treatments were injected over 30 s, followed by thiopental 5 mg/kg. At 90 s after the start of the study drug injection, rocuronium 0.6 mg/kg was injected over 10 s. The patient's response to the injection of rocuronium was graded on a four-point scale in a double-blinded manner.

RESULTS

The incidence of withdrawal movement was 89.5% in group C, 70.3% in group F, 36.3% in group A and 7.2% in group R. The incidence of generalized movement (grade 4) was 86.9% in group C, 58.5% in group F, 15.9% in group A and 2.4% in group R.

CONCLUSION

Remifentanil, alfentanil and fentanyl all reduced the incidence of withdrawal movement when administered 90 s before the injection of rocuronium compared with saline. Remifentanil was the most effective, followed by alfentanil. Fentanyl was less effective but significantly different from the saline in reducing withdrawal movement in children.

A comparison of the efficacies of different pre-treatment drugs in resolving the injection pain of rocuronium

Efficacies of pre-treatment with lidocaine, remifentanil and metoclopramide in the reduction of pain and withdrawal movements induced by rocuronium injection were evaluated. Forty-four adult patients, American Society of Anesthesiologists (ASA) Physical Status I-II, undergoing elective surgery were randomly assigned to four groups. Each patient received intravenously either 10 mg metoclopramide, 50 mg lidocaine, 1 microg/kg remifentanil or 3 ml of 0.9% sodium chloride (control group); followed by occlusion with a tourniquet on the forearm. After 10 s, occlusion stopped and a priming dose of 0.06 mg/kg rocuronium was injected. The patient's response to rocuronium was graded using a four-point scale in a double-blind manner. All groups had significantly lower incidences of pain compared with the control group. After loss of consciousness with sodium thiopental, 0.6 mg/kg rocuronium was administered for intubation and withdrawal movements were assessed. The number of patients in whom withdrawal movements were lowest was in the lidocaine-treated group. Although there was no difference among the study drugs in the prevention of rocuronium-induced pain, lidocaine and remifentanil seemed to be clinically more effective than metoclopramide.

Prevention of withdrawal associated with the injection of rocuronium in adults and children

STUDY OBJECTIVE

To determine which technique prevents the withdrawal associated with rocuronium administration in adults and children.

DESIGN

Blinded, randomized, prospective trial.

SETTING

This study was set at an inpatient anesthesia in a university teaching hospital.

PATIENTS

200 adult patients (aged 19-63 years) and 150 children (aged 2-9 years) undergoing elective surgery requiring endotracheal intubation.

INTERVENTIONS

Four groups in adult and 3 groups in children of 50 patients each were investigated. In adult study, control groups with free intravenous (IV) flow (C-F) or the occlusion of IV flow (C-O) received saline as the pretreatment of rocuronium; lidocaine groups with free IV flow (L-F) or the occlusion of IV flow (L-O) received lidocaine as the pretreatment of rocuronium, preceded by thiopental 5 seconds before. In children study, groups P and L received saline and lidocaine as the pretreatment of rocuronium, respectively, and group S received rocuronium mixed with sodium bicarbonate after the pretreatment of placebo preceded by thiopental.

MEASUREMENTS AND MAIN RESULTS

The patient's response to rocuronium injection was graded using a 4-point scale. The pH and osmolality of treatment solution were measured. The incidence of no movement after rocuronium was 96% in L-O, 46% in L-F, 26% in C-O, and 18% in C-F in adult and 96% in S, 58% in L, and 8% in P in children.

CONCLUSIONS

Withdrawal after rocuronium can be eliminated by the pretreatment of lidocaine during the occlusion of the IV flow in adults and addition of sodium bicarbonate in children.

The effect of pretreatment with thiopental on reducing pain induced by rocuronium injection

We examined whether pretreatment with a small dose of thiopental was effective in reducing pain induced by the intravenous injection of rocuronium. Withdrawal movement was used to assess pain reduction. Ninety patients were randomly assigned to one of two groups: patients in the control group were pretreated with 2 mL saline, and those in the thiopental group were pretreated with 2 mL (50 mg) thiopental. Thiopental 5 mg/kg was injected intravenously. After a loss of consciousness, the upper arm was compressed with a rubber tourniquet, and the pretreatment drugs were administered. Thirty seconds later the tourniquet was removed and 0.6 mg/kg rocuronium was administered. Withdrawal movement was assessed using a four-grade scale: no movement, movement limited to the wrist, to the elbow or to the shoulder. The frequency of withdrawal movement in the group pretreated with thiopental was lower than in the control group (34 vs. 13, p < 0.05). We concluded that pretreatment with 2 mL (50 mg) thiopental is effective in reducing pain caused by the intravenous injection of rocuronium.

Women report more pain on injection of a precurarization dose of rocuronium: a randomized, prospective, placebo-controlled trial

BACKGROUND

The purpose of this study was to investigate whether gender influences the perception of pain on injection of rocuronium.

METHODS

In this prospective, placebo-controlled trial 120 patients were randomized into four groups to receive rocuronium 0.03 mg kg(-1) (40 female and 40 male patients) or saline (20 female and 20 male patients). The incidence and severity of the injection pain after administration of the study drug was compared between female and male patients using a numerical rating scale (0-10). Signs of local irritation, i.e. erythema and thrombophlebitis, were assessed up to 48 h after surgery.

RESULTS

In 26 (32.5%) of the 80 patients receiving rocuronium, pain on injection was observed. This occurred significantly more frequently in the female compared with male patients: 18 (45%) vs. eight (20%), respectively (P = 0.032). The severity was more pronounced in the women than in the men (P = 0.020). The incidence of the rocuronium-associated pain was significantly increased compared with the Saline groups (P < 0.001). After surgery no patient complained of any residual pain and no local signs were observed in any patient during the study period.

CONCLUSIONS

Women experienced more pain on injection of rocuronium than men, moreover this is an additional evidence for gender-related differences in pain perception. When rocuronium is used as a precurarization agent, an analgesic pretreatment (e.g. opioids) should be considered, especially for female patients.

Dilution of rocuronium to 0.5 mg/mL with 0.9% NaCl eliminates the pain during intravenous injection in awake patients

In a randomized, double-blinded, controlled study, we evaluated the effect of diluting rocuronium 10 mg/mL to 1 or 0.5 mg/mL with 0.9% NaCl on the pain associated with IV administration of rocuronium with small doses given before succinylcholine or nondepolarizing agent administration. One hundred fifty patients undergoing surgical procedures that required general anesthesia were randomized into three groups. Group 1 received rocuronium 10 mg/mL. Groups 2 and 3 received 1 and 0.5 mg/mL of rocuronium, respectively. Patient demographics, pain scores, osmolality, and the pH of the solutions were recorded. Group 1 had the most intense and frequent pain response. Eighty percent of patients in this group reported pain on injection. In Group 2, the incidence and intensity of pain were significantly less when compared with those of Group 1. In this group, 38% of patients reported pain during injection. In Group 3, none of the patients experienced pain on injection. The pH values and osmolalities of study solutions were not significantly different among groups. In conclusion, in awake patients, dilution of rocuronium 10 mg/mL at small doses given before succinylcholine or nondepolarizing agent administration of 0.06 mg/kg to 0.5 mg/mL with 0.9% NaCl is a simple and cost-effective strategy for preventing pain during IV rocuronium injection.