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Postaci A, Ozcan NN, Aydin-Guzey N, Ersoy UC. The effect of rocuronium priming dose based on actual versus corrected body weight in modified rapid sequence intubation. Niger J Clin Pract 2023; 26:742-748. [PMID: 37470647 DOI: 10.4103/njcp.njcp_610_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Background Rapid sequence intubation (RSI) is a technique that allows patients to be quickly intubated and have the airway secured. Aims The purpose of this study was to investigate the effect of rocuronium priming and intubation dose calculated according to actual body weight (ABW) or corrected body weight (CBW) on the neuromuscular block and intubation quality in rapid sequence induction and intubation (RSII). Patients and Methods This prospective randomized, double-blind study was conducted on a total of 60 patients randomized into two groups using the closed-envelope method between January 2021 and December 2021, with 30 individuals in each group. In group 1, CBW was used with the formula to calculate the neuromuscular blocking drug (NMBD) dose. The ABW of patients was used to calculate the NMBD dose in group 2. Results The data of 50 female patients who underwent group 1 (CBW, n = 25) and group 2 (ABW, n = 25) were analyzed. Age, weight, height, body mass index (BMI), quality of laryngoscopy, post-priming side effects, mean arterial pressure (MAP), and heart rate (HR) values did not differ across the groups. When train-of-four (TOF) values, priming and intubation dose, and laryngoscopy time were compared, a statistically significant difference was found between the two groups of TOF count (TOF C) 1 (the duration of action). Conclusion This study suggests that the application of rocuronium priming and intubation dose according to CBW in RSII, especially during the pandemic, provided similar intubation conditions as the application according to ABW, while its shorter duration of action shows that it can be preferred, especially in short-term surgical cases.
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Affiliation(s)
- A Postaci
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Health Application and Research Center, University of Health Sciences, Turkey
| | - N N Ozcan
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Health Application and Research Center, University of Health Sciences, Turkey
| | - N Aydin-Guzey
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Health Application and Research Center, University of Health Sciences, Turkey
| | - U C Ersoy
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Health Application and Research Center, University of Health Sciences, Turkey
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Pai SL, Grech D, Gayer S, Rodriguez L, Joshi GP, Rajan N. Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings? Minerva Anestesiol 2023; 89:197-205. [PMID: 36326774 DOI: 10.23736/s0375-9393.22.16852-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA -
| | - Dennis Grech
- New Jersey Medical School, Department of Anesthesiology, Rutgers, Newark, NJ, USA
| | - Steven Gayer
- Miller School of Medicine, Department of Anesthesiology, University of Miami, Miami, FL, USA
| | - Leopoldo Rodriguez
- Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, Boulder, CO, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX, USA
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
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Deng C, Liu J, Zhang W. Structural Modification in Anesthetic Drug Development for Prodrugs and Soft Drugs. Front Pharmacol 2022; 13:923353. [PMID: 35847008 PMCID: PMC9283706 DOI: 10.3389/fphar.2022.923353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
Among the advancements in drug structural modifications, the increased focus on drug metabolic and pharmacokinetic properties in the anesthetic drug design process has led to significant developments. Drug metabolism also plays a key role in optimizing the pharmacokinetics, pharmacodynamics, and safety of drug molecules. Thus, in the field of anesthesiology, the applications of pharmacokinetic strategies are discussed in the context of sedatives, analgesics, and muscle relaxants. In this review, we summarize two approaches for structural optimization to develop anesthetic drugs, by designing prodrugs and soft drugs. Drugs that both failed and succeeded during the developmental stage are highlighted to illustrate how drug metabolism and pharmacokinetic optimization strategies may help improve their physical and chemical properties.
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Affiliation(s)
- Chaoyi Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wensheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wensheng Zhang,
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Ender V, Leisten D, Zheng H, Dunn M, Frakes M, Cohen JE, Wilcox SR. Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization. Air Med J 2022; 41:287-291. [PMID: 35595336 DOI: 10.1016/j.amj.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. METHODS Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. RESULTS We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. CONCLUSIONS Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.
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Affiliation(s)
- Vahé Ender
- Boston MedFlight, Bedford, Massachusetts
| | | | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Jason E Cohen
- Boston MedFlight, Bedford, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Tang L, Zhao X, Li S, Huang L, Li J, Chen L, Huang S. Impact of Succinylcholine vs. Rocuronium on Apnea Duration for Rapid Sequence Induction: A Prospective Cohort Study. Front Med (Lausanne) 2022; 9:717477. [PMID: 35223887 PMCID: PMC8864070 DOI: 10.3389/fmed.2022.717477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The present study aimed to evaluate the impact of 1.5 mg/kg succinylcholine or 1.2 mg/kg rocuronium, vs. 1.0 mg/kg succinylcholine on apnea duration in patients underwent rapid sequence induction (RSI). Methods This prospective cohort study was conducted in the Department of Anesthesiology in Shanghai General Hospital from July 2020 to November 2020. Apnea duration was defined as the time from apnea prompted by the PETCO2 waveform to the time the point of oxygen saturation declined to 90% (T90) and 95% (T95) after succinylcholine or rocuronium administration. The primary outcome included T90 and T95 changes in 1.5 mg/kg vs. 1.0 mg/kg succinylcholine groups and 1.5 mg/kg succinylcholine vs. 1.2 mg/kg rocuronium groups. Results A total of 265 participants were subjected for analysis. The succinylcholine (1.0 mg/kg) group had a significantly longer T90 (50.72, 95% confidence interval [CI, 7.60, 94.38], P = 0.015) and T95 (48.09, 95% CI [7.11, 89.07], P = 0.012) than the succinylcholine (1.5 mg/kg) group. In addition, significantly longer T90 (56.84, 95% CI [16.24, 97.44], P = 0.003) and T95 (50.57, 95% CI [12.58, 88.57], P = 0.003) were observed in the rocuronium (1.2 mg/kg) group than those in the succinylcholine (1.5 mg/kg) group. No severe side events were observed during the operation. Conclusion Rocuronium and the lower dose of succinylcholine may be recommended to patients underwent RSI.
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Affiliation(s)
- Lijun Tang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Xiao Zhao
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shitong Li
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lina Huang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jinbao Li
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Shiwei Huang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
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Ryden A, Fisichella S, Perchiazzi G, Nyman G. Comparison of two injectable anaesthetic techniques on induction and subsequent anaesthesia in pigs. Lab Anim 2021; 55:540-550. [PMID: 34325556 DOI: 10.1177/00236772211029810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pig experiments often require anaesthesia, and a rapid stress-free induction is desired. Induction drugs may alter the subsequent anaesthesia. Therefore, the aim of the present study was to compare, in pigs, the effects of two different injectable anaesthetic techniques on the induction and on the physiological variables in a subsequent eight hours of total intravenous anaesthesia (TIVA). Twelve domestic castrates (Swedish Landrace/Yorkshire) 27‒31 kg were used. The pigs were randomly assigned to different induction drug combinations of zolazepam-tiletamine and medetomidine intramuscularly (ZTMe) or midazolam, ketamine intramuscularly and fentanyl intravenously (MiKF). Time from injection to unconsciousness was recorded and the ease of endotracheal intubation assessed. The TIVA infusion rate was adjusted according to the response exhibited from the nociceptive stimulus delivered by mechanically clamping the dewclaw. The time from injection to unconsciousness was briefer and intubation was easier in the ZTMe group. Results from the recorded heart rate, cardiac index and arterial blood pressure variables were satisfactorily preserved and cardiovascular function was maintained in both groups. Shivering was not observed in the ZTMe group, but was observed in four of the pigs in the MiKF group. The requirement of TIVA was lower in the ZTMe group. In conclusion, ZTMe had better results than MiKF in areas such as shorter induction time, better intubation scoring results and less adjustment and amount of TIVA required up to six hours of anaesthesia. The results may have been due to a greater depth of anaesthesia achieved with the ZTMe combination at the dose used.
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Affiliation(s)
- Anneli Ryden
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Sweden
| | - Sheila Fisichella
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Uppsala University, Sweden
- Department of Anaesthesia, Operation and Intensive Care, Uppsala University Hospital, Sweden
| | - Görel Nyman
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Sweden
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Ayanmanesh F, Abdat R, Jurine A, Azale M, Rousseaux G, Coulons S, Samain E, Brasher C, Julien-Marsollier F, Dahmani S. Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children. Anaesth Crit Care Pain Med 2021; 40:100817. [PMID: 33677095 DOI: 10.1016/j.accpm.2021.100817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 10/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). METHODS In this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year). RESULTS Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). CONCLUSIONS Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.
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Affiliation(s)
- Fanny Ayanmanesh
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Rachida Abdat
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Amélie Jurine
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Mehdi Azale
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Guillaume Rousseaux
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Sarah Coulons
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Emmanuel Samain
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia; Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Florence Julien-Marsollier
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Souhayl Dahmani
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France.
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Abu Yazed MM, Ahmed SA. Comparison of vecuronium or rocuronium for rapid sequence induction in morbidly obese patients: a randomized study. Egyptian Journal of Anaesthesia 2020. [DOI: 10.1080/11101849.2020.1783179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Mohamed M. Abu Yazed
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sameh Abdelkhalik Ahmed
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Abstract
Residual neuromuscular blockade following the use of non-depolarizing neuromuscular blocking agents (NMBAs) can lead to postoperative respiratory complications, including oxygen desaturation, atelectasis, and pneumonia. Sugammadex rapidly reverses steroidal NMBAs by encapsulating them in a highly stable water-soluble complex. This NMBA-sugammadex complex then undergoes renal elimination. In patients with renal insufficiency or failure, concern has been expressed regarding the elimination of the NMBA-sugammadex complex. We present a 19-year-old patient with renal failure who received sugammadex for reversal of neuromuscular blockade. The use of sugammadex in patients with renal dysfunction is discussed and safety concerns are reviewed.
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Kim JT, Shim JK, Kim SH, Ryu HG, Yoon SZ, Jeon YS, Bahk JH, Kim CS. Remifentanil vs. Lignocaine for Attenuating the Haemodynamic Response during Rapid Sequence Induction Using Propofol: Double-Blind Randomised Clinical Trial. Anaesth Intensive Care 2019; 35:20-3. [PMID: 17323661 DOI: 10.1177/0310057x0703500102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was conducted to determine whether lignocaine or remifentanil effectively attenuate the response to endotracheal intubation during rapid sequence induction. Forty-eight patients were randomly divided into three groups: Group NS (n=16) received normal saline 0.1 ml/kg, Group L (n=16) received lignocaine 1.5 mg/kg, and Group R (n=16) received remifentanil 1 /μg/kg. Anaesthesia was induced with propofol 2 mg/kg after glycopyrrolate 0.2 mg IV. Each study drug was given intravenously over 30 seconds after loss of consciousness. Cricoid pressure was applied until intubation. Succinylcholine 1.0 mg/kg was administered to facilitate tracheal intubation. After intubation, the patient's lungs were ventilated with sevoflurane 1% and nitrous oxide 50% in oxygen. Mean arterial pressure and heart rate were recorded before induction, at loss of consciousness, immediately before laryngoscopy and every minute after intubation for 10 minutes. Mean arterial pressure fell following propofol in all groups. The maximum increase in mean arterial pressure in Group NS and Group L were 46% and 38% respectively above the baseline value one minute after intubation, whereas the mean arterial pressure in Group R increased only back to the baseline value. Heart rate in Group NS and Group L were increased by 27% and 33% above baseline value respectively one minute after intubation, while that in Group R was increased only to the baseline value. The results indicate that remifentanil 1 μg/kg, but not lignocaine 1.5 mg/kg, effectively attenuates the haemodynamic response to endotracheal intubation during rapid sequence induction using propofol.
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Affiliation(s)
- J T Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital and Yonsei University Hospital, Seoul, Korea
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April MD, Arana A, Pallin DJ, Schauer SG, Fantegrossi A, Fernandez J, Maddry JK, Summers SM, Antonacci MA, Brown CA. Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study. Ann Emerg Med 2018; 72:645-653. [DOI: 10.1016/j.annemergmed.2018.03.042] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/04/2018] [Accepted: 03/06/2018] [Indexed: 12/20/2022]
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Shoenberger JM, Mallon WK. Rocuronium Versus Succinylcholine Revisited: Succinylcholine Remains the Best Choice. Ann Emerg Med 2018; 71:398-399. [DOI: 10.1016/j.annemergmed.2017.07.478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Indexed: 02/08/2023]
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Cham EYK, Wong OF, Yip KH. Clinical Practice and Risk Factors for Immediate Complications of Endotracheal Intubation by Intensive Care Unit Doctors in a Regional Hospital in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Endotracheal intubation in critically ill patients is often challenging and is associated with a high complication rate. Intensive Care Unit (ICU) doctors are often responsible for emergency intubation but local data about their experience is lacking. Objective To describe the ICU team's practice of endotracheal intubation in critically ill patients in a regional hospital; to evaluate the incidence of immediate complications; and to identify risk factors for complications and predictors for successful intubation. Design Retrospective, observational study Patients All patients who received endotracheal intubation by the ICU team of the study centre between the 1st July 2013 and 31st December 2013. Results Complete data from 325 endotracheal intubations were analyzed. The commonest diagnosis was pneumonia (41.5%) and the mostly frequently cited indication for endotracheal intubation was respiratory failure (50.8%). Complications occurred in 25.5% of all intubations including 4 cases of cardiac arrest after the procedure. Haemodynamic alterations (hypotension and hypertension occurred in 9.2% and 7.4% respectively) were the most common complications. Overall, 96.6% of intubations were successful on the first two attempts. Logistic regression analyses showed that reduced mouth opening was a significant risk factor for immediate complications (odds ratio [OR] 15.98, 95% confidence interval [CI]: 2.71 to 94.41, P=0.006). Cormack-Lehane laryngoscope grading below 2b (OR 0.2, 95% CI: 0.07-0.59, P=0.003) and operator with more than 6 months of formal anaesthetic training (OR 7.06, 95% CI: 1.63 to 30.62, P=0.009) were independent predictors for successful intubation. Conclusion The ICU team achieves a high successful rate of emergency endotracheal intubation. High rates of anticipated and unanticipated difficult airway are encountered. Reduced mouth opening is a significant risk factor for complications occurrence. Cormack-Lehane laryngoscopic grading below 2b and intubation performer with more than 6 months of formal anaesthetic training are significant independent predictors for successful intubation. (Hong Kong j.emerg.med. 2016;23:135-144)
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Pillay L, Hardcastle T. Collective Review of the Status of Rapid Sequence Intubation Drugs of Choice in Trauma in Low- and Middle-Income Settings (Prehospital, Emergency Department and Operating Room Setting). World J Surg 2017; 41:1184-1192. [PMID: 27646281 DOI: 10.1007/s00268-016-3712-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Establishing a definitive airway in order to ensure adequate ventilation and oxygenation is an important aspect of resuscitation of the polytrauma patient . AIM To review the relevant literature that compares the different drugs used for rapid sequence intubation (RSI) of trauma patients, specifically reviewing: premedication, induction agents and neuromuscular blocking agents across the prehospital, emergency department and operating room setting, and to present the best practices based on the reviewed evidence. METHOD A literature review of rapid sequence intubation in the trauma population was carried out, specifically comparison of the drugs used (induction agent, neuromuscular blocking drugs and adjuncts). DISCUSSION Studies involving the comparison of drugs used in RSI in, specifically, the trauma patient are sparse. The majority of studies have compared induction agents, etomidate, ketamine and propofol, as well as the neuromuscular blocking agents, succinylcholine and rocuronium. CONCLUSION There currently exists great variation in the practice of RSI; however, in trauma the RSI armamentarium is limited to agents that maintain hemodynamic stability, provide adequate intubating conditions in the shortest time period and do not have detrimental effects on cerebral perfusion pressure. Further, multicenter randomized controlled studies to confirm the benefits of the currently used agents in trauma are required.
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Affiliation(s)
- Leressè Pillay
- Department of Anaesthetics, Inkosi Albert Luthuli Central Hospital, Mayville, Durban, KwaZulu-Natal, South Africa. .,Division of Anaesthesiology and Critical Care, University of KwaZulu-Natal, Durban, South Africa.
| | - Timothy Hardcastle
- Trauma Unit, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Rd, Mayville, Durban, 4058, KwaZulu-Natal, South Africa.,Trauma Training Unit, Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
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Lin SH, Chi CH, Chuang CC, Chan TY. Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart. J Acute Med 2017; 7:67-74. [PMID: 32995174 PMCID: PMC7517902 DOI: 10.6705/j.jacme.2017.0702.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/13/2016] [Accepted: 11/21/2016] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED). METHODS This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention. RESULTS A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects. CONCLUSIONS Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.
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Affiliation(s)
- Shih-Hao Lin
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Chih-Hsien Chi
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Chia-Chang Chuang
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Tsung-Yu Chan
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
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Tran DTT, Newton EK, Mount VAH, Lee JS, Mansour C, Wells GA, Perry JJ. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia 2017; 72:765-777. [DOI: 10.1111/anae.13903] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 12/16/2022]
Affiliation(s)
- D. T. T. Tran
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - E. K. Newton
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - V. A. H. Mount
- Department of Family Medicine; Queen's University; Kingston
| | - J. S. Lee
- Emergency Department; Sunnybrook and Women's College Health Sciences Centre; Toronto
| | - C. Mansour
- Division of Cardiac Anesthesiology; Department of Anesthesiology and Pain Medicine; School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - G. A. Wells
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
| | - J. J. Perry
- School of Epidemiology; Public Health and Preventive Medicine; University of Ottawa Heart Institute; Ottawa
- Clinical Epidemiology Programme; Department of Emergency Medicine; The Ottawa Hospital; Ottawa Canada
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Choi ES, Jeong WJ, Ahn SH, Oh AY, Jeon YT, Do SH. Magnesium sulfate accelerates the onset of low-dose rocuronium in patients undergoing laryngeal microsurgery. J Clin Anesth 2017; 36:102-6. [PMID: 28183544 DOI: 10.1016/j.jclinane.2016.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/04/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We evaluated the effect of magnesium sulfate-an enhancer of neuromuscular blockade-on onset and duration of low dose of rocuronium, and on operating conditions during laryngeal microsurgery. DESIGN Randomized, prospective, double-blinded study. PATIENTS Eighty-four patients scheduled for elective laryngeal microsurgery. INTERVENTIONS Patients were randomly allocated to receive different doses of rocuronium: 0.6 mg/kg (group C, n=28), 0.45 mg/kg (group LR, n=28), or 0.45 mg/kg plus magnesium sulfate 30 mg/kg (group LM, n=28). MEASUREMENTS We measured the onset time and duration of action of rocuronium, and evaluated the surgeon's satisfaction with the operating conditions. MAIN RESULTS Group LR showed significantly delayed onset time (group C: 87±22 seconds, group LR: 127±47 seconds, and group LM: 89±32 seconds; P=.001) and maximal suppression than did other groups (group C: 102±30 seconds, group LR: 155±66 seconds, and group LM: 105±36 seconds; P=.002). Duration of action of rocuronium was significantly longer in group C than in other groups (group C: 39±7 minutes, group LR: 28±8 minutes, group LRM: 31±8 minutes; P<.001). Laryngoscope placement score (P=.002), surgeon's satisfaction (P=.005), and sore throat (P=.035) were significantly worse in group LR. CONCLUSIONS Magnesium sulfate 30 mg/kg accelerated the onset and improved operating conditions of low-dose rocuronium without prolongation of action.
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Beck W, Kabiche S, Balde IB, Carret S, Fontan JE, Cisternino S, Schlatter J. Stability of suxamethonium in pharmaceutical solution for injection by validated stability-indicating chromatographic method. J Clin Anesth 2016; 35:551-559. [PMID: 27871592 DOI: 10.1016/j.jclinane.2016.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 08/24/2016] [Accepted: 09/06/2016] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To assess the stability of pharmaceutical suxamethonium (succinylcholine) solution for injection by validated stability-indicating chromatographic method in vials stored at room temperature. METHODS The chromatographic assay was achieved by using a detector wavelength set at 218 nm, a C18 column, and an isocratic mobile phase (100% of water) at a flow rate of 0.6 mL/min for 5 minutes. The method was validated according to the International Conference on Harmonization guidelines with respect to the stability-indicating capacity of the method including linearity, limits of detection and quantitation, precision, accuracy, system suitability, robustness, and forced degradations. RESULTS Linearity was achieved in the concentration range of 5 to 40 mg/mL with a correlation coefficient higher than 0.999. The limits of detection and quantification were 0.8 and 0.9 mg/mL, respectively. The percentage relative standard deviation for intraday (1.3-1.7) and interday (0.1-2.0) precision was found to be less than 2.1%. Accuracy was assessed by the recovery test of suxamethonium from solution for injection (99.5%-101.2%). CONCLUSION Storage of suxamethonium solution for injection vials at ambient temperature (22°C-26°C) for 17 days demonstrated that at least 95% of original suxamethonium concentration remained stable.
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Affiliation(s)
- William Beck
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Sofiane Kabiche
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Issa-Bella Balde
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Sandra Carret
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Jean-Eudes Fontan
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Salvatore Cisternino
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France
| | - Joël Schlatter
- Service Pharmacie, Hôpital Jean Verdier-AP-HP, Hôpitaux universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France.
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Mosier JM, Sakles JC, Stolz U, Hypes CD, Chopra H, Malo J, Bloom JW. Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis. Ann Am Thorac Soc 2015; 12:734-41. [PMID: 25719512 DOI: 10.1513/AnnalsATS.201411-517OC] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE The use of neuromuscular blocking agents (NMBAs) has been shown to be valuable in improving successful tracheal intubation in the operating room and emergency department. However, data on NMBA use in critically ill intensive care unit (ICU) patients are lacking. Furthermore, there are no data on NMBA use with video laryngoscopy. OBJECTIVES To evaluate the effect of NMBA use on first-attempt success (FAS) with tracheal intubation in the ICU. METHODS Single-center observational study of 709 consecutive patients intubated in the medical ICU of a university medical center from January 1, 2012 to June 30, 2014. Data were collected prospectively through a continuous quality improvement program on all patients intubated in the ICU over the study period. Data relating to patient demographics, intubation, and complications were analyzed. We used propensity score (propensity to use an NMBA) matching to generate 5,000 data sets of cases (failed first intubation attempts) matched to controls (successful first attempts) and conditional logistic regression to analyze the results. MEASUREMENTS AND MAIN RESULTS There were no significant differences in patient demographics, except median total difficult airway characteristics were higher in the non-NMBA group (2 vs. 1, P < 0.001). There were significant differences in the sedative used between groups and the operator level of training. More patients who were given NMBAs received etomidate (83 vs. 35%) and more patients in the non-NMBA group received ketamine (39 vs. 9%) (P < 0.001). The FAS for NMBA use was 80.9% (401/496) compared with 69.6% (117/168) for non-NMBA use (P = 0.003). The summary odds ratio for FAS when an NMBA was used from the propensity matched analyses was 2.37 (95% confidence interval, 1.36-4.88). In the subgroup of patients intubated with a video laryngoscope, propensity-adjusted odds of FAS with the use of an NMBA was 2.50 (1.43-4.37; P < 0.001). There were no differences in procedurally related complications between groups. CONCLUSIONS After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of FAS at intubation in the ICU with the use of an NMBA. This improvement in FAS is seen even with the use of a video laryngoscope.
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Chavan SG, Gangadharan S, Gopakumar AK. Comparison of rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries. Saudi J Anaesth 2016; 10:379-383. [PMID: 27833478 PMCID: PMC5044719 DOI: 10.4103/1658-354x.177330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia. Materials and Methods: Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared. Statistical Analysis Used: To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t-test were used. Results: The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg. Conclusion: Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated.
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Affiliation(s)
- S G Chavan
- Department of Anesthesiology, ESIC Medical College and Hospital, Parippally, Kollam, Kerala, India
| | - S Gangadharan
- Department of Anesthesiology, ESIC Medical College and Hospital, Parippally, Kollam, Kerala, India
| | - A K Gopakumar
- Department of Anesthesiology, ESIC Medical College and Hospital, Parippally, Kollam, Kerala, India
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Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115:827-48. [PMID: 26556848 PMCID: PMC4650961 DOI: 10.1093/bja/aev371] [Citation(s) in RCA: 1178] [Impact Index Per Article: 130.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
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Affiliation(s)
- C Frerk
- Department of Anaesthesia, Northampton General Hospital, Billing Road, Northampton NN1 5BD, UK
| | - V S Mitchell
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Crewe Road South, Edinburgh EH4 2XU, UK
| | - C Mendonca
- Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health, West Smithfield, London EC1A 7BE, UK
| | - A Patel
- Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London WC1X 8DA, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, PO Box 580, James's Street, Dublin 8, Ireland
| | - N M Woodall
- Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
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Abstract
BACKGROUND Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015. OBJECTIVES To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation. SEARCH METHODS In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations. SELECTION CRITERIA We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg. DATA COLLECTION AND ANALYSIS Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model. MAIN RESULTS The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action. AUTHORS' CONCLUSIONS Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.
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Affiliation(s)
- Diem TT Tran
- The University of Ottawa Heart InstituteDivision of Cardiac Anesthesiology, Department of Anesthesia40 Ruskin StOttawaONCanadaK1Y 4W7
| | - Ethan K Newton
- The University of Ottawa Heart InstituteDivision of Cardiac Anesthesiology, Department of Anesthesia40 Ruskin StOttawaONCanadaK1Y 4W7
| | | | - Jacques S Lee
- Sunnybrook and Women's College Health Sciences CentreEmergency DepartmentTorontoONCanada
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
| | - Jeffrey J Perry
- The Ottawa HospitalClinical Epidemiology Programme1053 Carling AvenueF6 Clinical Epidemiology ProgrammeOttawaONCanadaK1Y 4E9
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Lee JH, Kim Y, Lee KH, Rim SK, Lee JY, Lee C. The effects of nicardipine or esmolol on the onset time of rocuronium and intubation conditions during rapid sequence induction: a randomized double-blind trial. J Anesth 2014; 29:403-408. [PMID: 25374138 DOI: 10.1007/s00540-014-1940-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/17/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE The main aims of rapid sequence induction (RSI) are prompt and adequate muscle relaxation for tracheal intubation and hemodynamic stability during and after intubation. The purpose of the present study was to investigate the effects of nicardipine and esmolol on the action of rocuronium and intubation conditions during RSI. METHODS Adult patients (n = 82) were randomly allocated to one of three groups. One minute prior to the induction of sevoflurane-based general anesthesia, patients received 20 μg/kg of nicardipine (N group; n = 27) or 0.5 mg/kg of esmolol (E group; n = 27), or 5 ml of saline (C group; n = 28). Patients were assessed according to intubation conditions, the onset time of rocuronium, mean arterial pressure (MAP), and heart rate (HR) during RSI. RESULTS The intubation conditions and score were significantly better in the C and N groups than in the E group (P < 0.001). The onset time of rocuronium was shortened in the N group and prolonged in the E group when compared to the C group (P < 0.001). A significant attenuation in the increase of MAP immediately after intubation was observed in the N group as compared with the C and E groups (P < 0.008). HR was significantly lower in the E group than in the N and C groups (P < 0.01). CONCLUSION Pretreatment with nicardipine for RSI improved intubation conditions and shortened the onset time of rocuronium and attenuated changes in MAP after intubation. Esmolol may disturb intubation conditions and the onset of action of rocuronium, despite being effective in alleviating responses of HR after RSI.
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Affiliation(s)
- Ji Heui Lee
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea.
| | - Yunkwang Kim
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea
| | - Kye Hyeok Lee
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea
| | - Sung Kyu Rim
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea
| | - Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea
| | - Cheong Lee
- Department of Anesthesiology and Pain Medicine, Korean Cancer Center Hospital, 215-4, Gongneug-dong, Nowon-gu, Seoul, 139-706, Republic of Korea
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Doğruel B, Varnalı G, Selek Ç, Telci L, Akıncı İÖ. Comparison of Different Induction Doses of Rocuronium and Vecuronium in Neuroanaesthesia Practice. Turk J Anaesthesiol Reanim 2014; 42:6-11. [PMID: 27366381 DOI: 10.5152/tjar.2013.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/07/2013] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate the efficiency of use of rocuronium and vecuronium in different dose regimens in neuroanaesthesia practice in terms of intubation time and first additional dose requirement. METHODS Sixty-eight neurosurgery patients with intracranial mass that were operated on were included in our study. Patients were randomly divided into 4 groups according to the induction dose of neuromuscular blocker (NMB) as: Group 1: Vecuronium 0.1 mg kg(-1), Group 2: Priming, 20% of total vecuronium (0.1 mg kg(-1)) needed for induction injected 5 minutes before induction and then the rest used for induction, Group 3: Rocuronium group: 0.6 mg kg(-1), Group 4: Rocuronium with rapid-sequence induction dose (RSID) (1.2 mg kg(-1)). TOF (Train of four) test was used to decide on intubation and an additional NMB dose during surgery. Intubation quality, time from induction to intubation, time until the first additional NMB dose and subsequent NMB dose intervals were recorded. RESULTS The RSID of rocuronium provided a significantly shorter time period for intubation against the other groups. Also, the time period from induction to first additional NMB requirement was significantly longer in the RSID group than the others. There were no statistically significant differences between the groups' in terms of time period for monitorisation, positioning and start of surgery. CONCLUSION With the use of RSID of rocuronium, it was seen that excellent intubation quality is provided at around 1 minute and, with its longer duration of action until a first additional dose, it covers the time period for monitorisation, positioning and start of surgery. Because of these effects, we think that RSID of rocuronium may be a better choice of dose regimen for neuroanaesthesia practice.
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Affiliation(s)
- Behiye Doğruel
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Giray Varnalı
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Çiğdem Selek
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Lütfi Telci
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - İbrahim Özkan Akıncı
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, İstanbul University, İstanbul, Turkey
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Park SJ, Cho YJ, Oh JH, Hwang JW, Do SH, Na HS. Pretreatment of magnesium sulphate improves intubating conditions of rapid sequence tracheal intubation using alfentanil, propofol, and rocuronium - a randomized trial. Korean J Anesthesiol 2013; 65:221-7. [PMID: 24101956 PMCID: PMC3790033 DOI: 10.4097/kjae.2013.65.3.221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 12/19/2022] Open
Abstract
Background We investigated the effects of a magnesium sulfate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI) in this double-blind randomized study. Methods Adult patients (n = 154) were randomly allocated to a rocuronium-0.6, rocuronium-0.9, or magnesium group. The magnesium group was pretreated with 50 mg/kg MgSO4, and the other two groups received the same volume of isotonic saline. Anesthesia was induced with alfentanil, propofol, and either 0.6 mg/kg (rocuronium-0.6 and magnesium groups) or 0.9 mg/kg (rocuronium-0.9 group) rocuronium. An anesthesiologist, blinded to the group assignments, performed RSI and assessed the intubating conditions. Systolic arterial pressure (SAP) and heart rate (HR) were recorded before the magnesium sulfate or normal saline was administered, before anesthesia induction, before intubation, and every minute after intubation for 5 min. Results Airway features were similar among the three groups. The intubating conditions were improved significantly in the magnesium group (P < 0.001) compared with the other two groups. Significant increases in SAP at 1 min after intubation were observed in the rocuronium-0.6 and -0.9 groups when compared with the magnesium group (P < 0.05). HR was comparable among the three groups (P > 0.05). No hypertensive episode occurred during the immediate post-intubation period in the magnesium group (P = 0.001), and tachycardia occurred most frequently in the rocuronium-0.6 group (P < 0.05). Conclusions MgSO4 administered prior to RSI using alfentanil, propofol, and rocuronium may improve intubating conditions and prevent post-intubation hypertension.
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Affiliation(s)
- Seong-Joo Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Kwon MA, Song J, Kim JR. Tracheal intubation with rocuronium using a "modified timing principle". Korean J Anesthesiol 2013; 64:218-22. [PMID: 23560186 PMCID: PMC3611070 DOI: 10.4097/kjae.2013.64.3.218] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/16/2012] [Accepted: 09/18/2012] [Indexed: 11/28/2022] Open
Abstract
Background Rapid sequence induction (RSI) is indicated in various situations. Succinylcholine has been the muscle relaxant of choice for RSI, and rocuronium has become an alternative medicine for patients who cannot be administered succinylcholine for various reasons. Although rocuronium has the most rapid onset time among non-depolarizing muscle relaxants, the standard dose of rocuronium (0.6 mg/kg) takes 60 seconds to achieve appropriate muscle relaxation. We evaluated intubating conditions using the "modified timing principle" with rocuronium and succinylcholine. Methods In this prospective controlled blinded study, all patients received 1.5 µg/kg fentanyl intravenously with preoxygenation for 2 minutes and were randomized to receive 0.6 mg/kg rocuronium followed by 1.5 mg/kg propofol or 1.5 mg/kg propofol and 1.5 mg/kg succinylcholine. The rocuronium group was intubated just after confirming loss of consciousness, and the succinylcholine group was intubated 1 minute after injecting succinylcholine. Intubation condition, timing of events, and complications were recorded. Results All patients were successfully intubated in both groups. Apnea time of the rocuronium group (38.5 seconds) was significantly shorter than that in the succinylcholine group (100.7 seconds). No significant differences were observed in loss of consciousness time or intubation time. The succinylcholine group tended to show better intubation conditions, but no significant difference was observed. None of the patients complained awareness of the intubation procedure or had respiratory difficulty during a postoperative interview. Conclusions The modified RSI with rocuronium showed shorter intubation sequence, acceptable intubation conditions, and a similar level of complications compared to those of conventional RSI with succinylcholine.
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Affiliation(s)
- Min A Kwon
- Department of Anesthesia and Pain Medicine, College of Medicine, Dankook University, Cheonan, Korea
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Lee H, Jeong S, Choi C, Jeong H, Lee S, Jeong S. Anesthesiologist's satisfaction using between cisatracurium and rocuronium for the intubation in the anesthesia induced by remifentanil and propofol. Korean J Anesthesiol 2013; 64:34-9. [PMID: 23372884 PMCID: PMC3558647 DOI: 10.4097/kjae.2013.64.1.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/11/2012] [Accepted: 07/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although cisatracurium has many advantages in anesthetic practices, the best choice of a nondepolarizing neuromuscular blocking agent that can replace succinylcholine is rocuronium. However, it is reported that remifentanil with propofol might provide reliable intubating condition, even without a neuromuscular blocking agent; therefore, it might improve the intubating condition with cisatracurium. This study examined intubating conditions after administering rocuronium or cisatracurium in a rapid sequence induction with remifentanil-propofol. METHODS Fifty two ASA physical status 1 or 2 adult patients scheduled for an elective surgery were enrolled in a randomized double-blinded trial. Anesthesia was induced in all patients with propofol 2.0 mg/kg and remifentanil 0.5 µg/kg, administered over 60 seconds. Rocuronium 0.9 mg/kg (3 × ED(95), R group, n = 23) or cisatracurium 0.15 mg/kg (3 × ED(95), C group, n = 29) was administered after the induction sequence. Laryngoscopy was attempted when the anesthesiologist thought it was 90 seconds after drug administration and appropriate time for intubation. The examiner, another anesthesiologist, recorded the exact time to intubation and suppression of maximal T1 on TOF. The intubating condition was assessed by the first anesthesiologist, as excellent, good, poor or not possible. RESULTS The best time to laryngoscopy was predicted by measuring TOF and was found to be significantly longer in the C group (197 ± 53 s) than in the R group (102 ± 49 s) (P value < 0.05). However, time to larygoscopy, intubating condition during the laryngoscopy, and hemodynamic changes after intubation was similar in both groups. CONCLUSIONS Despite fundamentally slower onset time, cisatracurium can provide quite good intubating conditions, which were comparable to those achieved with equipotent doses of rocuronium, which is more expensive in anesthesia inducted with remifentanil and propofol.
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Affiliation(s)
- Hyunjung Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Hwasun, Korea
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Poveda Jaramillo R, Dueñas Castell C, Ortiz Ruiz G. Secuencia rápida de intubación en cuidados intensivos. Revista Colombiana de Anestesiología 2013; 41:24-33. [DOI: 10.1016/j.rca.2012.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Poveda Jaramillo R, Dueñas Castell C, Ortiz Ruiz G. Rapid sequence intubation in the intensive care unit. Colombian Journal of Anesthesiology 2013; 41:24-33. [DOI: 10.1016/j.rcae.2012.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Jeong HJ, Lee SH, Kim HJ, Kwak SH. Effects on Intubating Conditions of Pretreatment with Remifentanil before Administration of Cisatracurium. Chonnam Med J 2012; 48:96-102. [PMID: 22977750 PMCID: PMC3434798 DOI: 10.4068/cmj.2012.48.2.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 08/09/2012] [Accepted: 08/13/2012] [Indexed: 11/16/2022] Open
Abstract
Cisatracurium provides superior hemodynamic stability with only minor release of histamine, and its metabolism via Hoffman elimination is independent of organ function. However, use of cisatracurium is limited because of reportedly slower onset and unsatisfactory intubating conditions. Many studies have shown that remifentanil might provide reliable intubating conditions; thus, we hypothesized that pretreatment with remifentanil before administration of cisatracurium might result in acceptable intubating conditions. Sixty healthy patients scheduled for elective surgery were enrolled and randomly divided into three groups: saline (Group I, n=20), remifentanil 0.5 µg/kg (Group II, n=20), and remifentanil 1.0 µg/kg (Group III, n=20). The anesthesia was induced with propofol 2.0 µg/kg given intravenously over 30 s followed by injection over 30 s of a different dose of remifentanil according to the study protocol. We examined the intubating condition by jaw relaxation, vocal cord state, and diaphragmatic response 90 s after administering cisatracurium. We also measured mean blood pressure, heart rate, and the onset time, which is the interval from the end of neuromuscular blocking agent administration until suppression of maximal T1 on a train-of four sequence. The mean values of the intubating condition after endotracheal intubation in Groups II and III were significantly lower than that in Group I (p<0.005), although the overall onset time of cisatracurium did not differ significantly between the three groups. Our results suggest that supplementation with remifentanil in an induction regimen with cisatracurium improves the quality of the intubating condition even though the onset time of cisatracurium is not shortened.
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Affiliation(s)
- Hye Jin Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
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Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, Eikermann M, Schmidt U. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 2012; 40:1808-13. [PMID: 22610185 DOI: 10.1097/CCM.0b013e31824e0e67] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. METHODS Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. RESULTS The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07). CONCLUSION The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.
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Kadoi Y, Hoshi H, Nishida A, Saito S. Comparison of recovery times from rocuronium-induced muscle relaxation after reversal with three different doses of sugammadex and succinylcholine during electroconvulsive therapy. J Anesth 2011; 25:855-9. [PMID: 21947754 DOI: 10.1007/s00540-011-1236-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 09/05/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE This study was conducted to compare recovery times from rocuronium-induced muscle relaxation after reversal with three different doses of sugammadex with succinylcholine during electroconvulsive therapy (ECT). METHODS Seventeen patients who were scheduled to undergo ECT were studied. Anesthesia was induced by use of propofol (1.0 mg/kg) followed by either succinylcholine (SCC) (1 mg/kg) or rocuronium (0.6 mg/kg). Assisted mask ventilation was initiated with 100% oxygen. After T1 was assessed as being zero by neuromuscular monitoring, an electroshock stimulus was applied bilaterally. Patients receiving rocuronium were infused with 16, 8, or 4 mg/kg sugammadex immediately after the seizure stopped to reverse the muscle relaxation. Neuromuscular monitoring was continued until recovery of the train-of-four ratio to 0.9 at the tibial nerve in the leg. The times to recovery of T1 to 10 and 90% with both relaxants were compared. RESULTS The time to recovery of T1 to 90% after 16 mg/kg sugammadex was shorter than that in subjects treated with SCC (p = 0.046), whereas that after 4 mg/kg sugammadex was longer than that in subjects treated with SCC (SCC group: 429 ± 65 s, 16 mg/kg sugammadex group: 387 ± 63 s*, 8 mg/kg sugammadex group: 462 ± 66 s, 4 mg/kg sugammadex group: 563 ± 45 s(*,#); *p < 0.05 compared with SCC, (#)p < 0.01 compared with 16 mg/kg sugammadex). CONCLUSIONS This study demonstrates the efficacy of rocuronium-sugammadex as an alternative to SCC for muscle relaxation during ECT, and indicates that 8 mg/kg sugammadex produces equally rapid recovery from rocuronium muscular relaxation compared with spontaneous recovery from 1 mg/kg SCC during ECT.
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Affiliation(s)
- Yuji Kadoi
- Department of Anesthesiology, Gunma University, School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
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Abstract
Succinylcholine has been indicted on account of the diverse risks associated with its administration, which include hyperkalemia, vagal arrest, and malignant hyperthermia. However, it provides excellent intubating conditions reliably and quickly, characteristics that sustain its appeal for use in the intensive care unit, where airway management is challenging. There is an increasing body of evidence, outlined here, that rocuronium is an acceptable alternative to succinylcholine.
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Affiliation(s)
- Gerard F Curley
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland.
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Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, Hunziker PR, Siegemund M. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial. Crit Care 2011; 15:R199. [PMID: 21846380 PMCID: PMC3387641 DOI: 10.1186/cc10367] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 07/07/2011] [Accepted: 08/16/2011] [Indexed: 11/22/2022]
Abstract
Introduction Succinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI. Methods This was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5% leading to a saturation value of ≤ 80%. Results There was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups. Conclusions In critically ill patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium. Trial Registration ClinicalTrials.gov, number NCT00355368.
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Affiliation(s)
- Stephan C Marsch
- Department of Medical Intensive Care, University Hospital Basel, University of Basel, Petersgraben 4, Basel 4031, Switzerland.
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Affiliation(s)
- Jeremy P. Hampton
- School of Pharmacy, University of Missouri—Kansas City, Kansas City, and Clinical Specialist—Emergency Medicine, Truman Medical Center, Kansas City
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Abstract
The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.
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Abstract
In critically ill patients, endotracheal intubation is associated with a high risk of complications, including severe hypoxemia and hypotension. The purpose of this review is to discuss the definitions, complications, airway assessment, and patient optimization with respect to these patients. In addition, we present different approaches and techniques to help secure the airway in critically ill patients. We also discuss strategies to help minimize the risk of a difficult or failed airway and to mitigate the severe life-threatening complications associated with this high-risk procedure.
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Affiliation(s)
- Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Kim WJ, Choi SS, Kim DH, Seo HJ, Suk EH, Ku SW, Park PH. The effects of sevoflurane with propofol and remifentanil on tracheal intubation conditions without neuromuscular blocking agents. Korean J Anesthesiol 2010; 59:87-91. [PMID: 20740212 PMCID: PMC2926435 DOI: 10.4097/kjae.2010.59.2.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 03/30/2010] [Accepted: 05/10/2010] [Indexed: 11/10/2022] Open
Abstract
Background Propofol and remifentanil are used for tracheal intubation in the absence of neuromuscular blocking agents. We hypothesized that the addition of sevoflurane to propofol and remifentanil would improve intubation conditions and provide hemodynamic stability. Methods Seventy-six patients scheduled for elective surgery were randomly allocated to be ventilated with either 4% (group I) or 7% sevoflurane (group II) after propofol injection (2 mg/kg). All patients received remifentanil (1 µg/kg) 30 seconds after administration of propofol. Ninety seconds after remifentanil was given, laryngoscopy and tracheal intubation were performed. Intubation conditions and hemodynamic changes were evaluated. Results The overall incidence of clinically acceptable intubation conditions was significantly higher in group II (92%) than group I (58%) (P = 0.001). Scores for vocal cord position, coughing, and limb movement were significantly better in group II (P < 0.05). Mean blood pressure remained significantly lower than the pre-induction level throughout the investigation in both groups (P < 0.001), but there was no incidence of bradycardia or hypotension requiring treatment. Conclusions Tracheal intubation without neuromuscular blocking agents can be achieved safely and reliably by adding 7% sevoflurane to propofol (2 mg/kg) and remifentanil (1 µg/kg).
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Affiliation(s)
- Wook Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Light S. The importance of staying current on rapid sequence intubation. JAAPA 2010; 23:37-43. [DOI: 10.1097/01720610-201008000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Istvan J, Belliveau M, Donati F. Rapid sequence induction for appendectomies: a retrospective case-review analysis. Can J Anaesth 2010; 57:330-6. [PMID: 20049576 DOI: 10.1007/s12630-009-9260-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 12/18/2009] [Indexed: 12/19/2022] Open
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Abstract
PURPOSE OF REVIEW To bring together in one review article, the most current and relevant evidence relating to military trauma resuscitation. RECENT FINDINGS The main themes highlighted by this review are coagulopathy of trauma shock (CoTS), damage control resuscitation, haemostatic resuscitation, the management of massive transfusion, use of adjuvant drugs for haemostasis and use of an empiric massive transfusion protocol. SUMMARY The review aims to educate the readership in recent advances in trauma practice, culminating in a novel empiric massive transfusion algorithm seamlessly guiding the clinician through the initial resuscitation stage resulting in reduced mortality, morbidity, coagulopathy and decreased overall blood product usage.
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Affiliation(s)
- Rob Dawes
- 16 Air Assault Medical Regiment, Royal Army Medical Corps, UK
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Matsumoto N, Tomioka A, Sato T, Kawasaki M, Kadoi Y, Saito S. Relationship between cardiac output and onset of succinylcholine chloride action in electroconvulsive therapy patients. J ECT 2009; 25:246-9. [PMID: 19252443 DOI: 10.1097/YCT.0b013e3181926ac0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Succinylcholine chloride (Sch) is ideal for electroconvulsive therapy (ECT). However, the appropriate interval between Sch administration and electrical stimulation has not been reported. Cardiac output at the time of drug administration seems to be the major contributing factor for variability in onset time. The present study therefore investigated relationships between cardiac output before Sch administration and the onset of Sch action. METHODS Cardiac output and cardiac index (CI) were continuously monitored in 24 patients using a noninvasive impedance cardiac output monitor. Anesthesia was induced using intravenous propofol at 1 mg kg(-1). After loss of consciousness, dorsiflexion of the hallux was monitored as single-twitch stimulations using a peripheral nerve stimulator equipped with an acceleration sensor. A 1 mg kg(-1) dose of Sch was administered, and patients were assisted by mask ventilation with 100% oxygen. A bilateral ECT was performed after single-twitch response reached zero. We measured the intervals between Sch administration and the appearance of the first fasciculation (int-F), and between Sch administration and the loss of the single twitch response (int-S0) as time of Sch onset. To determine the effective duration of Sch action, we measured the intervals between the first fasciculation and the single-twitch response above zero (int-A) and between loss of the single-twitch response and recovery above zero (int-R). RESULTS The alteration in CI during ECT was biphasic. The CI before Sch administration (pre-CI) varied from 2.01 to 5.94 L min(-1) m(-2) (4.23 +/- 1.20 L min(-1) m(-2)). The int-F was 40 +/- 5 seconds (range, 31-49 seconds) and int-S0 was 90 +/- 17 seconds (range, 58-124 seconds). The correlations were significantly inverse between int-F and pre-CI (n = 10, R2 = 0.504, P = 0.0189), and between int-S0 and pre-CI (n = 17, R2 = 0.339, P = 0.0127). The int-A was 236 +/- 95 seconds (range, 119-391 seconds) and int-R was 184 +/- 106 seconds (range, 60-369 seconds). We also found correlations between int-A and pre-CI (n = 10, R2 = 0.413, P = 0.0438) and between int-R and pre-CI (n = 17, R2 = 0.405, P = 0.0466). CONCLUSIONS The onset of muscle relaxation varies among patients receiving ECT and is related to CI before Sch administration. In patients for whom fasciculation is difficult to determine, the effects of a muscle relaxant should be objectively confirmed before electrical stimulation of the brain.
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Siddik-Sayyid SM, Taha SK, Kanazi GE, Chehade JMA, Zbeidy RA, Al Alami AA, Zahreddine BW, Khatib MF, Baraka AS, Aouad MT. Excellent intubating conditions with remifentanil–propofol and either low-dose rocuronium or succinylcholine. Can J Anaesth 2009; 56:483-8. [PMID: 19440810 DOI: 10.1007/s12630-009-9106-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 03/18/2009] [Accepted: 03/31/2009] [Indexed: 12/19/2022] Open
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Abstract
Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.
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Affiliation(s)
- Sharon Elizabeth Mace
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve, Cleveland, OH 44195, USA.
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Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs. succinylcholine in the emergency department: a critical appraisal. J Emerg Med 2009; 37:183-8. [PMID: 19097730 DOI: 10.1016/j.jemermed.2008.07.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 07/11/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND Two methods of paralysis are available for rapid sequence intubation (RSI) in the emergency department (ED): depolarizing agents such as succinylcholine, and non-depolarizing drugs such as rocuronium. Rocuronium is a useful alternative when succinylcholine is contraindicated. Contraindications to succinylcholine include allergy, history of malignant hyperthermia, denervation syndromes, and patients who are 24-48 h post burn or crush injury. Non-depolarizing drugs have the advantage of causing less pain due to post-paralysis myalgias. CLINICAL QUESTION Can rocuronium replace succinylcholine as the paralytic of choice for RSI in the ED? EVIDENCE REVIEW Four relevant studies were selected from an evidence search and a structured review performed. RESULTS For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Succinylcholine seems to produce conditions that have higher satisfaction scores. CONCLUSION Succinylcholine remains the drug of choice for ED RSI unless there is a contraindication to its usage.
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Abstract
BACKGROUND Patients requiring emergency endotracheal intubation often require a rapid sequence induction (RSI) intubation technique to protect against aspiration or increased intracranial pressure, or to facilitate intubation. Succinylcholine is the most commonly used muscle relaxant because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This meta-analysis is an update since our initial Cochrane systematic review in 2003. OBJECTIVES To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made based on dose of rocuronium, narcotic use, emergency versus elective intubation, age and induction agent. The primary outcome was excellent intubation conditions. The secondary outcome was acceptable conditions. SEARCH STRATEGY In our initial systematic review we searched all databases until March 2000. We have updated that search and searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007 issue 3), MEDLINE (1966 to June Week 3 2007), EMBASE (1988 to 2007 Week 26) for randomized controlled trials or controlled clinical trials relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations. SELECTION CRITERIA We included all trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, main outcomes of intubation conditions). DATA COLLECTION AND ANALYSIS Two authors (JP, JL or VS) independently extracted data and assessed methodological quality for allocation concealment. We combined the outcomes in RevMan using relative risk (RR) with a random-effects model. MAIN RESULTS In our initial systematic review we identified 40 studies and included 26. In this update we identified a further 18 studies and included 11. In total, we identified 58 potential studies; 37 were combined for meta-analysis. Overall, succinylcholine was superior to rocuronium, RR 0.86 (95% confidence interval (95% CI) 0.80 to 0.92) (n = 2690). In the group that used propofol for induction, the intubation conditions were superior with succinylcholine (RR 0.88, 95% CI 0.80 to 0.97) (n = 1183). This is contrary to our previous meta-analysis results where we reported that intubation conditions were superior in the rocuronium group when propofol was used. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action. AUTHORS' CONCLUSIONS Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions.
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Affiliation(s)
- Jeffrey J Perry
- Clinical Epidemiology Programme, Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9
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