Prevention of rocuronium-induced withdrawal movement in children: a comparison of remifentanil with alfentanil

Time interval between alfentanil and rocuronium administration necessary to prevent rocuronium-induced withdrawal movement

BACKGROUND

We aimed to determine the time interval between alfentanil and rocuronium administration, at a 50% probability of preventing pain-induced withdrawal movement from rocuronium injection (Time_AR50).

METHODS

A total of 64 patients scheduled for general anesthesia were enrolled in this study (33 men and 31 women). Anesthesia was induced with target-controlled infusion of propofol, at an effect-site target concentration of 3 μg/mL. Then, alfentanil 15 μg/kg was injected for 30 s. After 60 s, rocuronium 0.6 mg/kg was administered to the first patient. The Dixon's up-and-down method was used to determine the time interval for each subsequent patient (interval of 5 s). Mean arterial pressure (MAP) and heart rate (HR) were recorded at three time points: T0, pre-induction; T1, before rocuronium injection; and T2, 1 min after rocuronium injection.

RESULTS

The Time_AR50 ± standard deviation (SD) was 5.6 ± 3.7 s and 21.9 ± 5.6 s in the male and female patients, respectively. Based on the probit regression, the Time_AR50 was 4.7 s (95% confidence interval [CI], 1.2-7.6 s) and 20.3 s (95% CI, 7.7-26.1 s) in the male and female patients, respectively. The Time_AR95 was 10.6 s (95% CI, 7.7-25.3 s) and 35.0 s (95% CI, 28.1-95.5 s) in the male and female patients, respectively, with significantly higher values in females than in males (P < 0.001). Compared with the T0, MAP and HR decreased significantly at T1 and T2 in both groups.

CONCLUSION

The Time_AR50 required for preventing rocuronium-induced withdrawal movement were 4.7 s and 20.3 s in male and female patients, respectively.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trials Registry on April 7, 2021 (URL: http://www.chictr.org.cn . Registry number: ChiCTR2100045137 ) .

Anesthesia with propofol-remifentanil combined with rocuronium for bronchial foreign body removal in children: Experience of 2 886 cases

IMPORTANCE

The appropriate anesthetic method can reduce the complications of children with tracheal foreign body and reduce the mortality rate of children. What kind of anesthetic method to choose has always been the focus of debate.

PURPOSE

To evaluate the efficacy and safety of anesthesia with propofolremifentanil combined with rocuronium for foreign body aspiration (FBA) removal with the positive-pressure ventilation technique.

METHODS

Medical records of patients who underwent bronchoscopy for evaluation of FBA in our unit from January 2015 to January 2018 were retrospectively reviewed. Demographic data (age and sex), nature of foreign body and location, complications, length of hospital stay and outcome were analyzed.

RESULTS

A total of 2 886 children were included in this study. The median age was 24 months (8 months to 10 years). FBA was detected and removed in 95.6% of patients. The average operation time was 17 ± 5 min and average length of hospital stay was 2 days. Observed peri-interventional complications included desaturation (n = 66), laryngospasm (n = 19), laryngeal or subglottic edema (n = 15), irritating cough (n = 3), body movement (n = 76) and pneumonia (n = 206). No deaths occurred during hospitalization or follow-up in this series.

INTERPRETATION

Anesthesia with propofol-remifentanil combined with rocuronium under positive-pressure ventilation is an effective and safe technique during FBA removal in children.

The efficacy of sevolflurane inhalation alone or its combination with intravenous remifentanil against withdrawal movements on rocuronium injection in children

Background

The aims of this study were to compare the efficacy of sevoflurane inhalation alone, intravenous remifentanil alone, and the combination of sevoflurane inhalation and remifentanil as pretreatment for the prevention of rocuronium-induced withdrawal movement in pediatric patients.

Methods

In this prospective, randomized study, 90 American Society of Anesthesiologists physical status I or II pediatric patients aged 3 to 10 years were randomly allocated to one of three treatment groups: The Group S comprising the patients receiving sevoflurane inhalation, the Group R comprising those doing intravenous remifentanil 0.5 µg/kg and the Group C comprising those doing sevoflurane inhalation+intravenous remifentanil 0.5 µg/kg. The response of the patients was graded based on a 4-point scale.

Results

The overall incidence of withdrawal movement on rocuronium injection was 54% (16/30) in the Group S, 57% (17/30) in the Group R and 17% (5/30) in the Group C. There was no significant difference in the incidence of withdrawal movements on rocuronium injection between the Group S and Group R. In addition, the incidence of withdrawal movements and generalized movement on rocuronium injection was significantly lower in the Group C as compared with the Group S and R (P < 0.05).

Conclusions

Our results indicate not only that there was no significant difference in the degree of the effect in lowering the incidence of withdrawal movements on rocuronium injection between sevoflurane inhalation and intravenous remifentanil but also that it was significantly higher when combined with intravenous remifentanil as compared with the single use of sevoflurane inhalation or intravenous remifentanil.

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.

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.

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.