Preventing the withdrawal response associated with rocuronium injection: a comparison of fentanyl with lidocaine

Effect of injection pain and withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery: a prospective observational study

INTRODUCTION

The experience and perception of pain may vary among individuals.This prospective cohort study aimed to determine the impact of injection pain/withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery.

METHODS

A total of 100 patients aged 19-60 years received propofol and rocuronium injections for the induction of anaesthesia. The incidence of propofol injection pain (PIP) and rocuronium-induced withdrawal movement (RIWM), postoperative pain scores and total opioid consumption were evaluated, and the associations between PIP/RIWM and postoperative pain outcomes were determined.

RESULTS

Visual analogue scale (VAS) for pain after surgery and total opioid consumption after surgery were significantly higher in patients with PIP or RIWM than in patients without PIP or RIWM. The correlations of PIP/RIWM with VAS at 1 h, VAS at 24 h and total opioid consumption were significant and weakly positive ( r = 0.249, r = 0.234, r = 0.22 and r = 0.234, respectively). The RIWM correlated more positively with pain score compared to PIP at 1 h ( r = 0.408 vs. r = 0.234), PIP at 24 h ( r = 0.398 vs. r = 0.227) and with total opioid consumption for 48 h after surgery ( r = 0.457 vs. r = 0.234).

CONCLUSION

During anaesthesia induction, the occurrence of PIP and RIWM may predict the severity of postoperative pain and total opioid consumption, with RIWM emerging as a stronger predictor than PIP.

Effect of Optimizing the Induction Regimen in Preventing Cough Reactions in Patients Undergoing General Anesthesia: A Prospective Randomized Controlled Study

PURPOSE

During the induction of general anesthesia, opioids and endotracheal intubation may cause coughing. This study aimed to investigate the safety and effectiveness of an optimized drug induction scheme for general anesthesia to prevent coughing in patients.

METHODS

A total of 220 patients aged 18 to 65 years who underwent surgery under general anesthesia with endotracheal intubation were randomly assigned to two groups, each with 110 patients. One group was administered a divided sufentanil bolus (group A) and the other with a single sufentanil bolus (group B). Anesthesia induction was performed according to the drug induction scheme of 1st, 2nd, and 3rd minutes. The primary outcome was a coughing episode associated with the administration of opioids during anesthesia induction. We also recorded the pain associated with drug injection, hemodynamics, and blood oxygen saturation during the induction of anesthesia.

FINDINGS

All patients were included in the final statistical analysis. Compared with group B, the incidence of opioid induced cough (OIC) was significantly higher in group A (9.1% vs. 0, P = 0.001). There was no cough reaction of tracheal intubation in either group. There was no severe pain due to propofol and rocuronium injection in either group (P > 0.05). The mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2) values were within the normal range at each time point during the induction period in both groups.

IMPLICATIONS

According to the optimized 1st, 2nd, and 3rd minutes anesthesia induction regimen, with a single final intravenous bolus of sufentanil after the diluted rocuronium bromide administration, no sufentanil and tracheal intubation induced coughing reactions were observed.

TRIAL REGISTRATION

The study protocol was registered in the Chinese Clinical Trial Registry (ChiCTR2200062749, http://www.chictr.org.cn/showproj.aspx?proj=175018) on August 17, 2022.

Personalized Medicine for Classical Anesthesia Drugs and Cancer Progression

In this review, we aim to discuss the use and effect of five different drugs used in the induction of anesthesia in cancer patients. Propofol, fentanyl, rocuronium, sugammadex, and dexamethasone are commonly used to induce anesthesia and prevent pain during surgery. Currently, the mechanisms of these drugs to induce the state of anesthesia are not yet fully understood, despite their use being considered safe. An association between anesthetic agents and cancer progression has been determined; therefore, it is essential to recognize the effects of all agents during cancer treatment and to evaluate whether the treatment provided to the patients could be more precise. We also highlight the use of in silico tools to review drug interaction effects and safety, as well as the efficacy of the treatment used according to different subgroups of patients.

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 ) .

Effect of nalbuphine on rocuronium injection pain

Objective

Rocuronium-associated intravenous injection pain occurs frequently in children during induction of anesthesia. The aim of this study was to systematically evaluate the benefits of nalbuphine in patients with rocuronium-associated injection pain.

Methods

Ninety children undergoing tonsillectomy and adenoidectomy in our hospital between October 2019 and September 2020 were randomly divided into the following groups, with 30 patients per group: control group (group C), lidocaine group (group L), and nalbuphine group (group N). Routine 0.1 mg/kg midazolam and 2 mg/kg propofol were injected intravenously. After sedation, children in group C, group L, and group N were administered an intravenous injection of saline, lidocaine (10 mg/mL), or nalbuphine hydrochloride (2 mg/mL), respectively, at a dosage of 0.1 mL/kg. Intravenous injection of rocuronium stock solution (0.6 mg/kg) was administered 2 minutes later. Pain was evaluated using Ambeshs 4-pointscale. The incidence of rocuronium injection pain was compared among the three groups, and postoperative adverse reactions, such as drowsiness, bradycardia, hypotension, and respiratory depression, were evaluated.

Results

The incidence of injection pain among children in group N was significantly lower than that in group C and group L (p<0.05). The incidence of drowsiness in group N was significantly higher than that in the other groups (p<0.05). The incidences of hypotension, bradycardia, and respiratory depression were not significantly different among the three groups (p>0.05).

Conclusions

Intravenous nalbuphine during induction of anesthesia effectively prevented rocuronium-associated injection pain in children. Drowsiness is a complication.

Generic rocuronium reduces withdrawal movements compared to original rocuronium under target-controlled infusion induction with propofol

PURPOSE

Rocuronium-induced injection pain often causes withdrawal movements leading to accidental disruption of indwelling needles. Generic rocuronium (Maruishi Pharmaceutical Co., Ltd, Osaka, Japan) with a novel solution has been reported to reduce the injection pain compared to original rocuronium [Esmeron^® (Eslax^®), MSD Co. Ltd, Tokyo, Japan], however, no reports have compared the injection pain under sedation with propofol, the most frequently used general anesthetic. This study was carried out to compare the injection pain caused by generic rocuronium and that caused by original rocuronium in patients anesthetized by propofol with a target-controlled infusion system.

METHODS

Forty patients were randomly assigned to two groups in this single-center, prospective, randomized, double-blind study. One group was administered generic rocuronium after sedation with propofol with a target-controlled infusion system. The other group was administered original rocuronium after anesthesia with propofol. Patient's withdrawal movements were assessed with the scale. The primary outcome was the total incidence of movement after administration of rocuronium. Secondary outcome was the incidence of moderate or severe movement after administration of rocuronium.

RESULTS

The total incidence of movement after administration of generic rocuronium (11%) was significantly lower than that after the administration of original rocuronium (79%) (p < 0.01). The incidence of moderate or severe movement after administration of generic rocuronium (0%) was significantly lower than that after the administration of original rocuronium (53%) (p < 0.01).

CONCLUSION

Generic rocuronium was considered more suitable than the original rocuronium for induction of anesthesia by propofol performed with a target-controlled infusion system.

Comparison of injection pain in pediatric population; original versus generic rocuronium

Background

Rocuronium-induced injection pain causes withdrawal movements. These movements may cause accidental disruption of indwelling needles. Generic rocuronium contains low-acid concentration buffer solution compared with original rocuronium. In animal experiments, it has been suggested that the difference of the buffer solution may alleviate injection pain. The purpose of this study was to identify the difference of injection pain between original and generic rocuronium in pediatric population.

Material and Methods

Patients ranging in age from 1 to 15 years, American Society of Anesthesiologists physical status I or II, undergoing elective surgeries were randomly allocated to two groups; generic rocuronium group (Group R) and original rocuronium (Eslax®) group (Group E). Following anesthetic induction with oxygen, nitrous oxide, and sevoflurane, original or generic rocuronium (1 mg/kg) was administered via intravenous catheter. The difference of vital signs and withdrawal movement associated with rocuronium injection were evaluated.

Results

A total of 64 patients were included in the study. Three patients were excluded. Twenty-nine patients were assigned to Group E and 32 patients to Group R. There was no significant difference in mean arterial pressure and heart rate. No withdrawal movements were observed in both groups.

Conclusion

There was no significant difference in injection pain between original and generic rocuronium under inhalational induction.

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 analgesic efficacy and duration of lidocaine on vascular pain induced by hypertonic saline infusion: a double-blinded, randomized control trial

PURPOSE

To determine the analgesic efficacy and analgesic duration of lidocaine 20 mg and 40 mg on eliminating the vascular pain associated with hypertonic saline infusion.

METHOD

Patients who complained pain during infusion of hypertonic saline were randomized into three groups. They received normal saline (Group C), or lidocaine 20 mg (Group L20), or lidocaine 40 mg (Group L40). An electronic stopwatch was used to record the time to onset (T1) and the time to termination (T2) of the analgesic effect, and the analgesic duration (AD) was calculated as T2 - T1.

RESULTS

The incidence of pain elimination was significantly higher in both of the lidocaine groups (83.3 and 56.1% in Groups L40 and L20, respectively) than in the saline group (16.3%). Furthermore, lidocaine 40 mg was significantly more effective than 20 mg in eliminating the pain. The analgesic duration was significantly longer in Group L40 than in Group L20 (211.4 ± 50.2 vs. 130.3 ± 39.5 s, P < 0.001) and Group C (211.4 ± 50.2 vs. 45.1 ± 14.5 s, P < 0.001), and the analgesic duration in Group L20 was significantly longer than in Group C (P < 0.001). The incidence of transient tinnitus/dizziness was significantly higher in Group L40 than in Group L20 (19.0 vs. 2.4%, P < 0.05).

CONCLUSION

A single bolus of Lidocaine was effective in eliminating the pain induced by hypertonic saline infusion, but just for a short period of time. Lidocaine (without venous occlusion) only provides a short analgesic duration for local vein.

[Comparison of granisetron and lidocaine on reducing injection pain of etomidate: a controlled randomized study]

BACKGROUND AND OBJECTIVES

Reducing pain on injection of anesthetic drugs is of importance to every anesthesiologist. In this study we pursued to define if pretreatment by granisetron reduces the pain on injection of etomidate similar to lidocaine.

METHODS

Thirty patients aged between 18 and 50 years of American Society of Anesthesiologists physical status class I or II, whom were candidates for elective laparoscopic cholecystectomy surgery were enrolled in this study. Two 20 gauge cannulas were inserted into the veins on the dorsum of both hands and 100mL of normal saline was administered during a 10min period from each cannula. Using an elastic band as a tourniquet, venous drainage of both hands was occluded. 2mL of granisetron was administered into one hand and 2mL of lidocaine 2% at the same time into the other hand. One minute later the elastic band was opened and 2mL of etomidate was administered to each hand with equal rates. The patients were asked to give a score from 0 to 10 (0=no pain, 10=severe pain) to each the pain sensed in each hand.

RESULTS

Two patients were deeply sedated after injection of etomidate and unable to answer any questions. The mean numerical rating score for injection pain of intravenously administered etomidate after intravenous granisetron was 2.3±1.7, which was lower when compared with pain sensed due to intravenously administered etomidate after administration of lidocaine 2% (4.6±1.8), p<0.05.

CONCLUSION

The result of this study demonstrated that, granisetron reduces pain on injection of etomidate more efficiently than lidocaine.

[The effect of palonosetron on rocuronium-induced withdrawal movement]

BACKGROUND

Rocuronium causes pain and withdrawal movement during induction of anesthesia. In this study, palonosetron was investigated to have analgesic effect on the reduction of rocuronium-induced withdrawal movement.

METHODS

120 patients were randomly assigned to one of three groups to receive either saline, lidocaine 20mg, or palonosetron 0.075mg with a tourniquet applied two minutes before thiopental sodium (5mg.kg^-1) was given intravenously. After loss of consciousness, rocuronium (0.6mg.kg^-1) was injected and the withdrawal movement was estimated by 4-point scale in a double-blind manner.

RESULTS

The overall incidence of rocuronium withdrawal movement was 50% with lidocaine (p=0.038), 38% with palonosetron (p=0.006) compared with 75% for saline. The incidence of no pain to mild pain was significantly lower in the lidocaine and palonosetron groups (85% and 92% respectively) than in the saline group (58%). However, there was no significant difference in withdrawal movement between the lidocaine and palonosetron groups. There was no severe movement with palonosetron.

CONCLUSION

Pretreatment of palonosetron with venous occlusion may attenuate rocuronium-induced withdrawal movement as effective as the use of lidocaine. It suggested that peripheral action of palonosetron was effective to reduce rocuronium-induced withdrawal movement.

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.

The effect of intravenous paracetamol for the prevention of rocuronium injection pain

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50-80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I-II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).

Effects of lidocaine, ketamine, and remifentanil on withdrawal response of rocuronium

BACKGROUND

Rocuronium has been well known to produce withdrawal response in 50-80% patients when administered intravenously. Several drugs are administered prior injection of rocuronium to prevent the withdrawal response. We compared the preventive effect of lidocaine, ketamine, and remifentanil on the withdrawal response of rocuronium.

METHODS

A total of 120 patients undergoing various elective surgeries were enrolled. Patients were allocated into 4 groups according to the pretreatment drugs (Group N, normal saline; Groups L, lidocaine 40 mg; Group K, ketamine 0.5 mg/kg; Group R, remifentanil 1 µg/kg). Patients received drugs prepared by dilution to 3 ml volume before injection of rocuronium. Withdrawal responses after injection of rocuronium were graded on a 4-point scale. Hemodynamic changes were observed before and after administration of pretreatment drugs and after endotracheal intubation.

RESULTS

Incidence of withdrawal response was significantly lower in group L (20%), group K (30%), and group R (0%), than group N (87%). Severe withdrawal response was observed in 5 of the 30 patients (17%) in group L, and in 9 of the 30 patients (30%) in group K. There was no severe withdrawal response in group R. Mean blood pressure and heart rate were significantly decreased in group R compared to other groups.

CONCLUSIONS

It seems that remifentanil (1 µg/kg intravenously) was the strongest and most effective in prevention of withdrawal response after rocuronium injection among the 3 drugs.

Pharmacological and non-pharmacological intervention for rocuronium-induced withdrawal movement in the Korean population: a meta-analysis of 41 studies including 4,742 subjects

BACKGROUND

We purposed to systemically review studies investigating the prophylactic effect of both pharmacological and non-pharmacological modalities against rocuronium induced withdrawal movement (RIWM) in the Korean population.

METHODS

Literature search was performed using MEDLINE, EMBASE, CENTRAL, Koreamed, KMBASE, KISS and RISS up to March 2014. Randomized controlled trials (RCTs) comparing pharmacological and non-pharmacological interventions with placebo aimed for the Korean population were included. Outcome measures were the incidence and severity of RIWM. We conducted subgroup analyses according to each intervention method.

RESULTS

Data were analyzed from 41 RCTs totaling 4,742 subjects. The overall incidence of RIWM was about 80% (range 56-100%). Incidence and severity of RIWM were significantly reduced with lidocaine (risk ratio [RR] 0.60, 95% CI 0.49-0.74; standardized mean difference [SMD] -0.74, 95% CI -1.05 to -0.44), opioids (RR 0.28, 95% CI 0.18-0.44; SMD -1.71, 95% CI -2.09 to -1.34) and hypnotics (RR 0.36, 95% CI 0.25-0.52; SMD -2.20, 95% CI -2.62 to -1.79). Regardless of tourniquet use, lidocaine showed a prophylactic effect against incidence and severity of RIWM: tourniquet (RR 0.36, 95% CI 0.21-0.62; SMD -1.51, 95% CI -2.15 to -0.86); non-tourniquet (RR 0.58, 95% CI 0.47-0.71; SMD -0.74, 95% CI -1.05 to -0.44). Dilution and slow injection of rocuronium decreased incidence and severity of RIWM: dilution (RR 0.47, 95% CI 0.39-0.56; SMD -1.64, 95% CI -2.47 to -0.81); slow injection (RR 0.34, 95% CI 0.17-0.70; SMD -2.13, 95% CI -2.74 to -1.51).

CONCLUSIONS

The greater part of pharmacological and non-pharmacological interventions showed prophylactic effect against the incidence and severity of RIWM in the Korean population.

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.

Effect of nitrous oxide inhalation on pain after propofol and rocuronium injection

PURPOSE

This prospective, double-blind, placebo-controlled study was designed to determine the efficacy of nitrous oxide (N(2)O) in alleviating the pain that followed sequential injection of propofol and rocuronium.

METHODS

A total of 205 adult patients (age, 18-68 years) received one of the following combinations: NaCl and 100 % O(2) (group C); 0.5 mg/kg lidocaine and 100 % O(2) (group L); NaCl and a mixture of 67 % N(2)O/O(2) (group N); or 0.5 mg/kg lidocaine and a mixture of 67 % N(2)O/O(2) (group LN). Vein occlusion was released after 1 min, and 5 ml propofol was injected over 10 s. Pain was evaluated on a visually enlarged, laminated, numeric rating (0-10) scale. The remainder of the induction dose of propofol (with a 3-ml bolus of normal saline and 0.6 mg/kg rocuronium) was then injected. The response to the rocuronium injection was assessed with a four-point scale (0-3).

RESULTS

The incidence and severity of pain from the propofol injection in groups L, N, and LN were significantly lower than those in group C (P < 0.001). Frequency and intensity of the withdrawal response were significantly less in groups N and LN than in groups C and L (no response, P < 0.001; severe response, P < 0.001).

CONCLUSIONS

Pretreatment with inhaled N(2)O can reduce the pain associated with propofol and rocuronium injection. Moreover, N(2)O (with or without lidocaine) is more effective than lidocaine alone in reducing rocuronium-related withdrawal reactions associated with sequential injection of propofol and rocuronium.

Ondansetron reducing pain on injection of etomidate: a controlled randomized study

INTRODUCTION

Etomidate causes pain when injected intravenously. In this study we sought to determine if pretreatment by ondansetron reduces the pain on injection of etomidate.

METHODS

In this randomized, double blinded, placebo-controlled clinical trial, 20 patients of both sexes aged between 18 and 50 years of American Society of Anesthesiologists (ASA) physical status class I or II, whom were candidates for various elective surgical procedures and need more than one intravenous access were enrolled in the study. On arrival to the operating room two 22 gauge cannulas were inserted into veins on the dorsum of both hands. Following the infusion of 100mL normal saline into both intravenous lines, using an elastic band, venous drainage of hands was occluded at midarm. The patients were administered 8 mg (2 mL) of ondansetron into one hand and 2 mL of 0.9% saline into the other hand at the same time. The elastic band was removed after 1 min and 2mg (1 mL) of etomidate was administered at the same rate simultaneously into intravenous lines. The patients were asked to give a score of pain based on a verbal analog scale (VAS) to each hand.

RESULTS

A total number of 20 patients were studied (male = 55%, female = 45%). The mean age of the participants was 37.5 ± 13.1 years old and the mean weight was 67.7 ± 7.3 kg. The mean VAS for injection pain of etomidate after pre-administration of intravenous ondansetron was 1.5 ± 1.2 which was lower compared to pre-administration of placebo (3.2 ± 2.8, p < 0.05).

CONCLUSION

This study illustrates that pre-treatment with intravenous ondansetron significantly reduces the pain on injection of etomidate.

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.

Single pretreatment of remifentanil may reduce pain after propofol and rocuronium injection in rapid sequence induction

Background

We designed this double-blind, placebo-controlled study to compare the efficacy of remifentanil in reducing the pain of both propofol and rocuronium injection during rapid-sequence induction.

Methods

Ninety-five patients, scheduled for elective surgery under general anesthesia, were divided into 3 groups: saline (Group S, n = 31), remifentanil 1 µg/kg (Group R, n = 32), and lidocaine 1.5 mg/kg (Group L, n = 32) were administered after tourniquet application. The occlusion was released after 1 min and 5 ml of 1% propofol was injected over 10 s. Pain on propofol injection was evaluated by a 10-point verbal numeric rating scale (VNRS). The rest of the induction dose of propofol and 1 mg/kg of rocuronium, were injected. Pain on rocuronium injection was evaluated by a four-point score (FPS).

Results

The VNRS of propofol injection was as follows: R (0.78) = L (1.34) < S (4.26). The incidence of withdrawal response due to rocuronium was as follows: R (6.3%) < L (53.1%) < S (83.9%). The FPS of rocuronium injection was as follows: R (0.81) < L (1.78) < S (2.93).

Conclusions

Pretreatment with a bolus of remifentanil was effective in simultaneously reducing injection pain of propofol and rocuronium. In addition, remifentanil pretreatment was more effective in suppression of withdrawal response by rocuronium than lidocaine.

Dilution and slow injection reduces the incidence of rocuronium-induced withdrawal movements in children

Background

The aim of this study was to evaluate whether slow injection of diluted rocuronium could reduce rocuronium-induced withdrawal movements effectively in children.

Methods

After loss of consciousness, rocuronium 0.6 mg/kg was administered into 171 children according to the pre-assigned groups as follows: Group CF, injection of non-diluted rocuronium over 5 seconds; Group CS, injection of non-diluted rocuronium over 1 minute; Group DF, injection of diluted rocuronium (10 times) over 5 seconds; Group DS, injection of diluted rocuronium over 1 minute. An investigator who was blind to the injection techniques recorded patient movements followed by rocuronium injection.

Results

The incidence of withdrawal movement in Group CF was highest among the groups (all P < 0.0001). Moreover, withdrawal movement was less frequently observed in Group DS than in Groups CS and DF (P = 0.021 and P = 0.007, respectively).

Conclusions

Slow injection of diluted rocuronium reduced the incidence of withdrawal movements in children.

The analgesic effect of remifentanil on prevention of withdrawal response associated with the injection of rocuronium in children: no evidence for a peripheral action

Remifentanil pre-treatment has been reported to decrease the incidence of rocuronium injection-associated withdrawal movement. This study was designed to explore the site of action of remifentanil for reducing withdrawal response during rocuronium injection in children. Ninety-six paediatric patients were randomly assigned to three groups. After induction of anaesthesia with 5 mg/kg 2.5% thiopental sodium, 2 ml saline (placebo group) or 0.5 microg/kg remifentanil (group R), was injected intravenously 1 min before 0.6 mg/kg rocuronium. In a third group (group R'), the venous retention of 0.5 microg/kg remifentanil was maintained for 30 s followed by tourniquet release and injection of 0.6 mg/kg rocuronium. Withdrawal response was graded using a four-point scale. The incidence of withdrawal movement after rocuronium administration was 94%, 22% and 81% in the placebo, R, and R' groups, respectively. This study demonstrated that the pre-treatment effect of remifentanil for reducing rocuronium-associated withdrawal response occurs mainly through a central action.

Combination of nitrous oxide and lidocaine to prevent withdrawal after rocuronium in children

Background

Pain at the site of rocuronium injection is a common side-effect in pediatric patients. This prospective, randomized, double-blind study evaluated the efficacy of a combination of nitrous oxide and lidocaine pretreatment on withdrawal response during rocuronium injection in children.

Methods

Sixty six pediatric patients, ages 5 to 12 years, were randomly assigned to two groups. The oxygen group received 100% oxygen, and the nitrous oxide group received 50% N₂O in oxygen over 2 min. After anesthesia was induced with 2.5% thiopental sodium 5 mg/kg and manual occlusion of the forearm was performed, 1% lidocaine 1 mg/kg was injected over 15 sec. After the occlusion was released, 0.1% rocuronium 0.6 mg/kg was injected over 5 sec. Patient response to rocuronium injection was graded using a 4-point scale.

Results

Overall incidence of withdrawal movements was significantly lower in the nitrous oxide group (1 patients; 3.1%) than in the oxygen group (8 patients; 25.8%) (P = 0.013). No patient in the nitrous oxide group displayed arm or generalized movement (grade 3 or 4) associated with rocuronium injection.

Conclusions

This study demonstrated that a combination of inhaled 50% N₂O in O₂ and 1 mg/kg lidocaine pretreatment significantly reduced the incidence of rocuronium-induced withdrawal movements in pediatric patients compared with lidocaine pretreatment alone.

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.

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

BACKGROUND

This study was designed to compare the efficacy of remifentanil and alfentanil without the venous occlusion technique in preventing the withdrawal response associated with rocuronium injection in children.

METHODS

One hundred and twenty children aged between 3 and 10 years were randomly allocated into one of four groups to receive either i.v. remifentanil 0.5 microg.kg(-1) (remi 0.5 group), remifentanil 1 microg.kg(-1) (remi 1.0 group), alfentanil 15 microg.kg(-1) (alfentanil group) or saline 5 ml (saline group). Anesthesia was induced with 2.5% thiopental sodium 5 mg.kg(-1) and the test drug was injected over 30 s. One minute later, 1% rocuronium 0.6 mg.kg(-1) was injected over 5 s and the response was recorded. Mean arterial pressure (MAP) and heart rate (HR) were recorded on arrival in the operating room, before and 1 min after tracheal intubation.

RESULTS

The incidence of withdrawal movement in the saline group (93%) was significantly higher than that in the remi 0.5, remi 1.0, and alfentanil groups (53%, 17%, and 20%, respectively) (P < 0.05). The incidence in the remi 1.0 and alfentanil groups was significantly less than that in the remi 0.5 group (P < 0.05). After intubation, MAP and HR were significantly higher in the saline group than that in remi 1.0 and alfentanil groups.

CONCLUSIONS

Both remifentanil 1 microg.kg(-1) and alfentanil 15 microg.kg(-1) can be used to prevent rocuronium-associated withdrawal movement in children because they are equally effective and attenuate the increase in MAP and HR after intubation.

Pretreatment with remifentanil to prevent withdrawal after rocuronium in children

BACKGROUND

Pain from rocuronium injection is a common side-effect reported to occur in 50-80% of the patients. This randomized, double-blind, placebo-controlled study was designed to evaluate the efficacy of pretreatment with i.v. remifentanil on prevention of withdrawal response during rocuronium injection in paediatric patients.

METHODS

After obtaining parental consents, 70 paediatric patients were randomly allocated into two groups to receive either i.v. remifentanil 1 mug kg(-1) (remifentanil group, n=35) or i.v. saline 5 ml (saline group, n=35). Anaesthesia was induced with thiopental sodium 2.5% (5 mg kg(-1)) and the test drug was injected over 30 s. One minute after the test drug injection, rocuronium 1% (0.6 mg kg(-1)) was injected over 5 s and the response was recorded. Mean arterial pressure (MAP) and heart rate were recorded on arrival in the operating theatre, before and 1 min after the tracheal intubation.

RESULTS

The overall incidence of withdrawal movements was significantly higher in the saline group (33 patients; 94%) than that in the remifentanil group (8 patients; 23%) (P<0.001). No patient in the remifentanil group showed generalized movement, whereas 51% of patients in the saline group did. Remifentanil prevented significant increase in MAP after intubation.

CONCLUSION

This study demonstrated that pretreatment with remifentanil 1 microg kg(-1) provided a safe and simple method for reducing the incidence of rocuronium-associated withdrawal movement with haemodynamic stability in children.