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

Trial Sequential Analysis explained using a post-hoc analysis of meta-analyses published in Korean Journal of Anesthesiology

Background

Trial sequential analysis (TSA) is a recent cumulative meta-analysis method used to weigh type I and II errors and to estimate when the effect is large enough to be unaffected by further studies. The aim of this study was to illustrate possible TSA scenarios and their significance using meta-analyses published in the Korean Journal of Anesthesiology (KJA) as working material.

Methods

We performed a systematic medical literature search for meta-analyses published in the KJA. TSA was performed on each main outcome, estimating the required sample size on the calculated effect size for the intervention, considering a type I error of 5% and a power of 90% or 99%.

Results

Six meta-analyses with a total of ten main outcomes were included in the analysis. Seven TSAs confirmed the results of the meta-analyses. However, only three of them reached the required sample size. In the two TSAs, the cumulative z-lines were not statistically significant. One TSA boundary for effect was reached with the 90% analysis, but not with the 99% analysis.

Conclusions

In TSA, a meta-analysis pooled effect may be established to assess if the cumulative sample size is large enough. TSA can be used to add strength to the conclusions of meta-analyses; however, pre-registration of the TSA protocol is of paramount importance. This study could be useful to better understand the use of TSA as an additional statistical tool to improve meta-analysis quality.

Prediction of emergence agitation using withdrawal reaction following rocuronium injection in preschool-aged patients undergoing inguinal herniorrhaphy: a preliminary exploratory observational trial

Purpose

The development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA.

Methods

A total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale.

Results

There was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU.

Conclusion

The findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated.

Large vein injection alleviates rocuronium-induced pain in gynaecologic patients

BACKGROUND

Rocuronium-induced pain upon injection is very common in the clinical setting. Using the antecubital rather than the hand vein can avoid pain due to propofol injection. We aimed to investigate whether the use of the antecubital vein for injection would alleviate rocuronium-induced pain in a similar fashion.

METHODS

Sixty patients (ASA classes I and II) scheduled for gynaecologic laparoscopy were randomised into two groups. Rocuronium (0.6mg/kg) was injected either into the vein on the dorsum of the hand (group D) or a large vein in the antecubital fossa (group A). Pain was assessed and recorded using a four-point scale.

RESULTS

Compared with group D, the incidence of pain and severe pain was lower in group A patients. The rate of no pain was also higher in group A patients.

CONCLUSION

The incidence and severity of rocuronium-induced injection pain were significantly alleviated via use of a large vein for rocuronium injection.