Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation

OBJECTIVE

In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile.

METHODS

Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded.

RESULTS

A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002).

CONCLUSION

It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05343702.

Differential effects of the novel neurosteroid hypnotic (3β,5β,17β)-3-hydroxyandrostane-17-carbonitrile on electroencephalogram activity in male and female rats

BACKGROUND

We recently showed that a neurosteroid analogue, (3β,5β,17β)-3-hydroxyandrostane-17-carbonitrile (3β-OH), induced hypnosis in rats. The aim of the present study was to evaluate the hypnotic and anaesthetic potential of 3β-OH further using electroencephalography.

METHODS

We used behavioural assessment and cortical electroencephalogram (EEG) spectral power analysis to examine hypnotic and anaesthetic effects of 3β-OH (30 and 60 mg kg-1) administered intraperitoneally or intravenously to young adult male and female rats.

RESULTS

We found dose-dependent sex differences in 3β-OH-induced hypnosis and EEG changes. Both male and female rats responded similarly to i.p. 3β-OH 30 mg kg-1. However, at the higher dose (60 mg kg-1, i.p.), female rats had two-fold longer duration of spontaneous immobility than male rats (203.4 [61.6] min vs 101.3 [32.1] min), and their EEG was suppressed in the low-frequency range (2-6 Hz), in contrast to male rats. Although a sex-dependent hypnotic effect was not confirmed after 30 mg kg-1 i.v., female rats appeared more sensitive to 3β-OH with relatively small changes within delta (1-4 Hz) and alpha (8-13 Hz) bands. Finally, 3β-OH had a rapid onset of action and potent hypnotic/anaesthetic effect after 60 mg kg-1 i.v. in rats of both sexes; however, all female rats and only half of the male rats reached burst suppression, an EEG pattern usually associated with profound inhibition of thalamocortical networks.

CONCLUSIONS

Based on its behavioural effects and EEG signature, 3β-OH is a potent hypnotic in rats, with female rats being more sensitive than male rats.

Intubation Conditions following Rocuronium: Influence of Induction Agent and Priming

A small priming dose of rocuronium can shorten the onset time of neuromuscular blockade. Induction agents with less cardiovascular depression also reduce the onset time. We hypothesized that ketamine, compared to thiopentone, would reduce onset time and improve intubating conditions following priming. Sixty patients ASA I to II, randomized by computer-generated sequence to four groups were investigated in a double-blind controlled trial. In the two groups with priming, 0.04 mg/kg of rocuronium was followed by three minutes of priming interval. Induction was followed by an intubation dose of 0.4 mg/kg of rocuronium. After 30 seconds, intubation was attempted within a further 20 seconds. In the two control groups, the same sequence was repeated except sham priming (saline) was given. For induction, S-ketamine (1 mg/kg) or thiopentone (4 mg/kg) were administered. Intubating conditions were graded as excellent, good, poor, or not possible. Neuromuscular transmission was monitored by acceleromyography of the thumb. There were no measured differences in onset time of neuromuscular block or in haemodynamics between the groups. The proportion of good to excellent intubating conditions was higher when ketamine was preceded by priming compared to ketamine without priming (87% vs 20%; P<0.05). In both priming and control groups intubating conditions were improved when using ketamine compared to thiopentone (P<0.05). The mechanism of this effect was not clear from this study.

The effect of low-dose rocuronium on rapid tracheal intubation using a video laryngoscope: A randomized double blind controlled study

BACKGROUND

The aim of this study was to investigate the clinical effectiveness of rocuronium in low doses on conditions during rapid tracheal intubation using video laryngoscope.

METHODS

Ninety-eight patients undergoing otolaryngologic surgery were randomly divided into 2 groups: group L using 0.3 mg/kg of rocuronium intravenously (n = 49) and group C using 0.6 mg/kg of rocuronium (n = 49). Sixty seconds after rocuronium administration, tracheal intubation was performed using a video laryngoscope. The overall intubation condition was evaluated along with specific conditions, including laryngoscopy condition, vocal cord position, and intubation response. Intubation profiles, including Cormack-Lehane grade, 1st attempt success rate, and intubation time, were also evaluated.

RESULTS

Overall intubation conditions showed a significant difference between group L and group C (P = .003). Although the incidence of vigorous response after tracheal intubation was higher in group L than in group C (P = .022), laryngoscopy condition and vocal cord position were similar between the 2 groups (P = .145 and .070, respectively). Intubation profiles showed no differences between the 2 groups. The frequency and amount of additional rocuronium administration during surgery were also similar.

CONCLUSIONS

Low-dose rocuronium provided significantly worse overall intubation conditions compared to the conventional dose of rocuronium for rapid tracheal intubation. However, when using a video laryngoscope, it may provide clinically acceptable laryngeal muscle relaxation.

Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery

Recent data shows that a neuromuscular block (NMB) induced by administration of high doses of rocuronium improves surgical conditions in certain procedures. However, there are limited data on the effect such practices on postoperative outcomes. We performed a retrospective analysis to compare unplanned 30-day readmissions in patients that received high-dose versus low-dose rocuronium administration during general anesthesia for laparoscopic retroperitoneal surgery. This retrospective cohort study was performed in the Netherlands in an academic hospital where routine high-dose rocuronium NMB has been practiced since July 2015. Charts of patients receiving anesthesia between January 2014 and December 2016 were searched for surgical cases receiving high-dose rocuronium and matched with respect to procedure, age, sex and ASA classification to patients receiving low-dose rocuronium. The primary post-operative outcome was unplanned 30-day readmission rate. There were 130 patients in each cohort. Patients in the high- and low-dose rocuronium cohorts received 217 ± 49 versus 37 ± 5 mg rocuronium, respectively. In the high-dose rocuronium group neuromuscular activity was consistently monitored; matched patients were unreliably monitored. All patients receiving high-dose rocuronium were reversed with sugammadex, while just 33% of matched patients were reversed with sugammadex and 20% with neostigmine; the remaining patients were not reversed. Unplanned 30-day readmission rate was significantly lower in the high-dose compared to the low-dose rocuronium cohort (3.8% vs. 12.7%; p = 0.03; odds ratio = 0.33, 95% C.I. 0.12–0.95). This small retrospective study demonstrates a lower incidence of unplanned readmissions within 30-days following laparoscopic retroperitoneal surgery with high-dose relaxant anesthesia and sugammadex reversal in comparison to low-dose relaxant anesthesia. Further prospective studies are needed in larger samples to corroborate our findings and additionally assess the pharmacoeconomics of high-dose relaxant anesthesia taking into account the benefits (reduced readmissions) and harm (cost of relaxants and reversal agents) of such practice.

Optimal dose of combined rocuronium and cisatracurium during minor surgery: A randomized trial

BACKGROUND

Combined rocuronium and cisatracurium have synergistic effects. We investigated whether reduced doses are effective during coadministration, by monitoring neuromuscular relaxation during surgery.

METHODS

This randomized, controlled clinical trial was registered at http://clinicaltrials.gov (registration number NCT02495038). The participants were 81 patients scheduled for elective mastoidectomy and tympanoplasty. Participants were assigned to groups, including the intubating dose group (Group I, n = 27; combined ED95 rocuronium and ED95 cisatracurium), the small reduction group (Group S, n = 27; dose reduced by 10% of each ED95), or the large reduction group (Group L, n = 27; dose reduced by 20% of each ED95). Drugs were administered to patients and a timer was started using TOF-Watch monitoring. TOF (train-of-four) was monitored at the ulnar nerve, at a setting of 2 Hz/12 s. We recorded the time to TOF ratio = 0 (onset), time to first TOF ratio > 25% (duration 25%), and TOF 25-75% (recovery index) under total intravenous anesthesia. One-way analysis of variance was used for statistical analyses (α = 0.05, β = 0.2).

RESULTS

There were no significant demographic differences between groups. Group L had a longer duration to onset (mean ± standard deviation, 399.3 ± 147.8 seconds) and shorter duration 25% (39.4 ± 6.8 minutes) compared to Group I (212.8 ± 56.0 s and 51.3 ± 8.47 minutes, respectively) and Group S (230.7 ± 60.6 s and 47.9 ± 10.7 minutes, respectively). There were no other significant differences between groups.

CONCLUSION

Our findings contribute to determining clinically effective combinations of rocuronium and cisatracurium, as well as to predicting the pharmacokinetic characteristics of the synergistic effects. We suggest that reducing doses of both drugs by approximately 10% of their respective ED95 values is sufficient to maintain neuromuscular relaxation during minor surgery.

Comparison of postoperative coagulation profiles and outcome for sugammadex versus pyridostigmine in 992 living donors after living-donor hepatectomy

Donor safety is the major concern in living donor liver transplantation, although hepatic resection may be associated with postoperative coagulopathy. Recently, the use of sugammadex has been gradually increased, but sugammadex is known to prolong prothrombin time (PT) and activated partial thromboplastin time (aPTT). We compared the postoperative coagulation profiles and outcomes of sugammadex versus pyridostigmine group in donors receiving living donor hepatectomy.Consecutive donor hepatectomy performed between September 2013 and August 2016 was retrospectively analyzed. For reversal of rocuronium-induced neuromuscular blockade, donors received sugammadex 4 mg/kg or pyridostigmine 0.25 mg/kg. The primary end-points were laboratory findings (PT, aPTT, hemoglobin, platelet count) and clinically evaluated postoperative bleeding (relaparotomy for bleeding, cumulative volume collected in drains). Secondary outcomes were anesthesia time, postoperative hospital day.Of 992 donors, 383 treated with sugammadex and 609 treated with pyridostigmine for the reversal of neuromuscular blockade. There were no significant differences between both groups for drop in hemoglobin and platelet, prolongation in PT, aPTT, and the amount of 24-h drain volume. Bleeding events within 24 h were reported in 2 (0.3%) for pyridostigmine group and 0 (0%) for sugammadex group (P = .262). Anesthesia time was significantly longer in pyridostigmine group than that in sugammadex group (438.8 ± 71.4 vs. 421.3 ± 62.3, P < .001). Postoperative hospital stay was significantly longer in pyridostigmine group than that in sugammadex group (P = .002).Sugammadex 4 mg/kg was not associated with increased bleeding tendency, but associated with reduced anesthesia time and hospital stay. Therefore, sugammadex may be safely used and will decrease morbidity in donor undergoing living-donor hepatectomy.

Anaesthesia and orphan disease: airway and anaesthetic management in Huntington's disease

We present a case that highlights the issues surrounding the delivery of a safe general anaesthetic to a patient with Huntington's disease (HD) and bulbar dysfunction. In the case of a 46-year-old patient undergoing laparoscopic percutaneous endoscopic gastrostomy tube insertion, we discuss the rationale behind our chosen method and anaesthetic agents as well as airway issues specific to HD. In a patient whose condition would not allow for an awake fibreoptic intubation, we opted for a modified rapid sequence induction. Special considerations were made with regard to muscle relaxation given the complications associated with inadequate paralysis and reversal in patients with HD. The technique we describe may also apply to other patient categories, such as patients with movement disorders, bulbar dysfunction and dementia.

Neuroprotective effect of 5ɑ-androst-3β,5,6β-triol on retinal ganglion cells in a rat chronic ocular hypertension model

Previous studies have demonstrated that 5ɑ-androst-3β,5,6β-triol (Triol), a synthesized steroid compound, showed notable neuroprotective effect in cultured cortical neurons. In the present study, we explored whether and how Triol have neuroprotective effect on retinal ganglion cells (RGCs) in a chronic ocular hypertension (COH) rat model. COH model was produced by injecting superparamagnetic iron oxide micro-beads into the anterior chamber, and Triol was administrated (4.8μg/100g, i.p., once daily for 4 weeks). Immunohistochemistry experiments showed that in whole flat-mounted COH retinas, the number of CTB-labeled survival RGCs was progressively reduced, while TUNEL-positive signals were significantly increased from 1 to 4 weeks after the micro-bead injection. Triol administration significantly attenuated the reduction in the number of CTB-labeled RGCs, and partially reduced the increased number of TUNEL-positive signals in COH retinas. Furthermore, Triol administration partially reduced the levels of malondialdehyde (MDA) and reactive oxygen species (ROS), and significantly rescued the activities of mitochondrial respiratory chain complex (MRCC) I/II/III in COH retinas. Our results suggest that Triol prevents RGCs from apoptotic death in COH retinas by reducing the lipid peroxidation and enhancing the activities of MRCCs.

The effect of deep muscle relaxation on the force required during Latissimus Dorsi dissection for breast reconstructive surgery: results of a prospective, double-blinded observational pilot study

BACKGROUND

The use of neuromuscular blocking agents has previously been suggested to facilitate the dissection of the latissimus dorsi muscle during breast reconstructive surgery. The aim of this study was to quantify the influence of deep muscle relaxation on the force required to lift the latissimus dorsi muscle during flap preparation.

METHODS

After ethics approval and written informed consent 15 patients scheduled for elective breast reconstruction with a latissimus dorsi pedicled flap (muscle flap, not myocutaneous flap) under general anaesthesia were prospectively included. Midway through the muscle dissection a sterile cotton tape was slung around the mid portion of the muscle and connected with a sterile strain gauge stably positioned just above the patient. Thereafter, the muscle was lifted by moving the strain gauge vertically upwards until a muscle tension similar to that created manually during muscle dissection was achieved. The force (N) and distance required to tension the muscle were recorded and the tension released. In a randomized and blinded crossover design either rocuronium (0.6 mg.kg-1) or normal saline were given intravenously, and the tension protocol was repeated 2 min after each drug administration.

RESULTS

Muscle relaxation significantly reduced the force for flap tensioning (median [percentiles] - 22 [-32/-13] %; P = 0.011) in 10/15 patients. However, in the remaining 5 patients no significant effect was measured. Normal saline had no effect on the measured force.

CONCLUSIONS

Deep muscle relaxation significantly reduces the force required to manually elevate the latissimus dorsi muscle during its dissection in the majority of but not all patients.

TRIAL REGISTRATION

The study was retrospectively registered on [17.6.2014] with the Australian and New Zealand Clinical Trials Registry. ACTRN12614000637640.

The utility of bispectral index monitoring for prevention of rocuronium-induced withdrawal movement in children: A randomized controlled trial

BACKGROUND

This study was designed to determine whether a deep hypnotic state with a bispectral index (BIS) value less than 40 could alleviate withdrawal movement (WM) upon rocuronium injection during anesthesia induction in children.

METHODS

Finally, 135 healthy children (3-12 years) scheduled for minor elective surgery were studied. Without premedication, anesthesia was induced with thiopental sodium 5 mg/kg. Patients were randomized into 2 groups (control vs experimental) and then by virtue of rocuronium injection time, patients in the experimental group were allocated into 2 groups, as follows: in the control group (group C; n = 45), rocuronium 0.6 mg/kg was administered at the loss of eyelash reflex; in the 1st experimental group, rocuronium 0.6 mg/kg was administered when BIS fell to less than 40 (group T; n = 45); however, if BIS did not fall below 40 after thiopental sodium administration, manual ventilation was provided with oxygen 6 L/minute using sevoflurane 8% and then rocuronium was administered when BIS fell below 40 (the 2nd experimental group, group S; n = 45). Rocuronium-induced WM was evaluated using a 4-point scale (no movement; movement/withdrawal involving the arm only; generalized response, with movement/withdrawal of more than 1 extremity, but no requirement for restraint of the body; and generalized response which required restraint of the body and caused coughing or breath-holding).

RESULTS

No significant differences were found among the groups for patient characteristics including age, sex, height, and location of venous cannula. However, body weight, height, and body mass index in group S were all smaller than those in group T. The incidence of WM caused by rocuronium was 100% in group C, 95.6% in group T, and 80% in group S, and was significantly lower in group S than in group C. The grade of WM was 3.7 ± 0.6 in group C, 3.2 ± 0.9 in group T, and 2.6 ± 1.0 in group S. It was significantly lower in group T than in group C and significantly lower in group S than in groups C and T.

CONCLUSION

The confirmation of a deep hypnotic state with BIS values lower than 40 using BIS monitoring can reduce the grade of rocuronium-induced WMs during anesthesia induction using thiopental sodium or sevoflurane in children.

Operating room discharge after deep neuromuscular block reversed with sugammadex compared with shallow block reversed with neostigmine: a randomized controlled trial

OBJECTIVE

To determine if reversing a deep or moderate block with sugammadex, compared with a shallow block reversed with neostigmine, reduces the time to operating room discharge after surgery and the time spent in the postanesthesia care unit.

DESIGN

A randomized controlled trial.

SETTING

Monocentric study performed from February 2011 until May 2012.

PATIENTS

One hundred consenting women with American Society of Anesthesiologists grade I or II were randomized into 2 groups.

INTERVENTION

Laparoscopic hysterectomy was performed under desflurane general anesthesia. For the neostigmine (N) group, 0.45 mg · kg^-1 rocuronium was followed by spontaneous recovery. A 5-mg rescue bolus was administered only if surgical evaluation was unacceptable. At the end of surgery, 50 μg · kg^-1 neostigmine with glycopyrrolate was administered. For the sugammadex (S) group, a higher intubating rocuronium dose (0.6 mg · kg^-1) was followed by 5-mg boluses each time the train-of-four count exceeded 2. Sugammadex (2-4 mg · kg^-1) was administered to reverse the block. All patients were extubated after obtaining a train-of-four ratio of 0.9.

MEASUREMENTS

The duration between the end of surgery and operating room discharge and the time spent in the postanesthesia care unit.

MAIN RESULTS

The time till operating room discharge was shorter and more predictable in group S (9.15±4.28 minutes vs 13.87±11.43 minutes in group N; P=.005). The maximal duration in group S was 22 minutes, compared with 72 minutes in group N. The time spent in the postanesthesia care unit was not significantly different (group S: 47.75±31.77 minutes and group N: 53.43±40.57 minutes; P=.543).

CONCLUSION

Maintaining a deep neuromuscular block during laparoscopic hysterectomy reversed at the end of the procedure with sugammadex enabled a faster and more predictable time till operating room discharge than did the classical combination of a shallower block reversed with neostigmine.

The effects of intra-cerebroventricular administered rocuronium on the central nervous system of rats and determination of its epileptic seizure-inducing dose

BACKGROUND

The aim of this study was to investigate the effects of intracerebroventricularly administered rocuronium bromide on the central nervous system, determine the seizure threshold dose of rocuronium bromide in rats, and investigate the effects of rocuronium on the central nervous system at 1/5, 1/10, and 1/100 dilutions of the determined seizure threshold dose.

METHODS

A permanent cannula was placed in the lateral cerebral ventricle of the animals. The study was designed in two phases. In the first phase, the seizure threshold dose of rocuronium bromide was determined. In the second phase, Group R 1/5 (n=6), Group 1/10 (n=6), and Group 1/100 (n=6) were formed using doses of 1/5, 1/10, and 1/100, respectively, of the obtained rocuronium bromide seizure threshold dose.

RESULTS

The rocuronium bromide seizure threshold value was found to be 0.056±0.009μmoL. The seizure threshold, as a function of the body weight of rats, was calculated as 0.286μmoL/kg^-1. A dose of 1/5 of the seizure threshold dose primarily caused splayed limbs, posturing, and tremors of the entire body, whereas the dose of 1/10 of the seizure threshold dose caused agitation and shivering. A dose of 1/100 of the seizure threshold dose was associated with decreased locomotor activity.

CONCLUSIONS

This study showed that rocuronium bromide has dose-related deleterious effects on the central nervous system and can produce dose-dependent excitatory effects and seizures.

[Utility of McGRATH MAC for a Patient with a Large Epiglottic Cyst]

A 76-year-old man with an epiglottic cyst was scheduled for transoral rigid endoscopic epiglottic cystectomy under general anesthesia. The epiglottic cyst was found accidentally when he had an operation of radical cystectomy 2 weeks before. When he had the radical cystectomy, the ventilation through a mask was easy. He had no subjective respiratory symptoms. We chose rapid induction with propofol, remifentanl, and rocuronium. When we inserted the McGRATH MAC laryngoscope, we could only see a big epiglottic cyst not vocal cord but the pressure on the neck enabled the laryngologist to see the vocal cord. We could identify the space through which we could insert tracheal tube without touching the cyst. After the operation, his trachea was extubed.

[The Influence of Preoperative Oral Carbohydrate Administration on Perioperative Blood Sugar Levels and Patients' Satisfaction]

BACKGROUND

After introducing preoperative oral carbohydrate as a part of enhanced recovery after surgery (ERAS) protocols, we assessed the influence of carbohydrate administration on the perioperative blood sugar levels (BS), the variation of vital signs and patients' satisfaction.

METHODS

After IRB's approval and obtaining patients' consent, patients were divided into two groups; taking carbohydrate (Group AW) or not (Group NAW). Anesthesia was induced and maintained with total intravenous anesthesia using propofol, remifentanil and rocuronium. We measured BS six times during perioperative period. We also compared blood pressures and heart rates during induction of anesthesia. Moreover, we carried out questionnaire surveys about degree of satisfaction for ERAS among patients and nurses.

RESULTS

Heart rates were significantly higher in Group AW (P < 0.05), but there were no significant difference in blood pressures or BS between the groups. Patients in Group AW had more anxiety for surgeries (P = 0.003), but more than 85% of patients and nurses were satisfied with carbohydrates.

CONCLUSIONS

The carbohydrate administration had little influence on the perioperative vital signs. However, we gained high reputations from patients and paramedics.

Maintaining Optimal Surgical Conditions With Low Insufflation Pressures is Possible With Deep Neuromuscular Blockade During Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind, Parallel-Group Clinical Trial

Carbon dioxide (CO2) absorption and increased intra-abdominal pressure can adversely affect perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the surgical conditions during laparoscopic surgery. We aimed to compare the effects of deep and moderate neuromuscular block in laparoscopic colorectal surgery, including intra-abdominal pressure. In this prospective, double-blind, parallel-group trial, 72 adult patients undergoing laparoscopic colorectal surgery were randomized using an online randomization generator to achieve either moderate (1-2 train-of-four response, n = 36) or deep (1-2 post-tetanic count, n = 36) neuromuscular block by receiving a continuous infusion of rocuronium. Adjusted intra-abdominal pressure, which was titrated by a surgeon with maintaining the operative field during pneumoperitoneum, was recorded at 5-minute intervals. Perioperative hemodynamic parameters and postoperative outcomes were assessed. Six patients from the deep and 5 from the moderate neuromuscular block group were excluded, leaving 61 for analysis. The average adjusted IAP was lower in the deep compared to the moderate neuromuscular block group (9.3 vs 12 mm Hg, P < 0.001). The postoperative pain scores (P < 0.001) and incidence of postoperative shoulder tip pain were lower, whereas gas passing time (P = 0.002) and sips of water time (P = 0.005) were shorter in the deep neuromuscular block than in the moderate neuromuscular block group. Deep neuromuscular blocking showed several benefits compared to conventional moderate neuromuscular block, including a greater intra-abdominal pressure lowering effect, whereas surgical conditions are maintained, less severe postoperative pain and faster bowel function recovery.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Comparison of the effect of rocuronium dosing based on corrected or lean body weight on rapid sequence induction and neuromuscular blockade duration in obese female patients

OBJECTIVES

To compare onset time, duration of action, and tracheal intubation conditions in obese patients when the intubation dose of rocuronium was based on corrected body weight (CBW) versus lean body weight (LBW) for rapid sequence induction. 

METHODS

This prospective study was carried out at Numune Education and Research Hospital, Ankara, Turkey between August 2013 and May 2014. Forty female obese patients scheduled for laparoscopic surgery under general anesthesia were randomized into 2 groups. Group CBW (n=20) received 1.2 mg/kg rocuronium based on CBW, and group LBW (n=20) received 1.2 mg/kg rocuronium based on LBW. Endotracheal intubation was performed 60 seconds after injection of muscle relaxant, and intubating conditions were evaluated. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis. Onset time, defined as time to depression of the twitch tension to 95% of its control value, and duration of action, defined as time to achieve one response to train-of-four stimulation (T1) were recorded.

RESULTS

No significant differences were observed between the groups in intubation conditions or onset time (50-60 seconds median, 30-30 interquartile range [IQR]). Duration of action was significantly longer in the CBW group (60 minutes median, 12 IQR) than the LBW group (35 minutes median, 16 IQR; p less than 0.01).

CONCLUSION

In obese patients, dosing of 1.2 mg/kg rocuronium based on LBW provides excellent or good tracheal intubating conditions within 60 seconds after administration and does not lead to prolonged duration of action.

[A Case of General Anesthesia in a Patient with Spinal and Bulbar Muscular Atrophy]

We report a successful management of anesthesia in a 55-year-old male patient with spinal and bulbar muscular atrophy (SBMA). His respiratory and swallowing functions were preserved preoperatively. He underwent an osteosynthesis for a femoral neck fracture under general anesthesia using nondepolarizing muscle relaxant. The anesthetic concerns in patients with SBMA are the possibility of postoperative respiratory dysfunction due to anesthetics or muscle relaxants and that of postoperative neurological deterioration due to spinal or epidural anesthesia. In this case, the effect of an intubating dose of rocuronium (0.5 mg · kg(-1)) was markedly prolonged, but it was completely reversed by sugammadex (2 mg · kg(-1)). Postoperative course was uneventful and clinical symptoms of SBMA did not become exacerbated.

Rocuronium versus succinylcholine for rapid sequence induction intubation

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.

RECURARIZATION AFTER ACUTE INTRAOPERATIVE NORMOVOLEMIC HEMODILUTION AND USE OF SUGAMMADEX

Acute normovolemic hemodilution (ANH) is a blood conservation procedure that can be used in cases of refusal of blood transfusion for religious reasons. Herein, we describe a case of recurarization after reinfusion of collected blood. A combination of rocuronium/sugammadex has the potential to increase the safety of patients if ANH is done after induction. Prospective controlled studies evaluating this unique indication for sugammadex use are thus warranted.

Rocuronium: automatic infusion versus manual administration with TOF monitorisation

TOF (train-of-four) monitoring provides objective data in application of neuromuscular blocking agent. Thus, applicator-based differences are eliminated and optimum muscle relaxation is maintained during operation. In the present study, we aimed to compare the effects of target-controlled infusion system and standard TOF monitoring, on use of rocuronium. ASA I-II patients, who were aged between 18 and 75 years and scheduled for elective abdominal surgery at Haydarpaşa Numune Training and Research Hospital, were enrolled in the study. In order to evaluate neuromuscular blockade, the patients in Group 1 were connected to the acceleromyography device of the target-controlled infusion pump (Veryark-CLMRIS-I-China) while the ones in Group 2 were connected to the routinely used acceleromyography device (TOF Watch SX). There was no significant difference between groups regarding patient characteristics, the durations of anaesthesia and surgery, quality of intubation, time to extubation and time to recovery (TOF ratio of 0.9). Intubation time was significantly longer in Group 1 (Automated group) as compared to Group 2 (Control group) (p < 0.05). The total rocuronium amount used in Group 1 was found to be significantly higher than the amount used in Group 2 (p < 0.05). There was no clinical evidence of residual neuromuscular blockage or reoccurrence of neuromuscular blockage in any patient in either group. Both methods can be used for administration of neuromuscular blocker agent during moderate time anesthesia. No advantage was noted when rocuronium was administered via automatical infusion pump during anaesthesia.

Quantitative Intraoperative Torsional Forced Duction Test

PURPOSE

We developed a method for quantifying intraoperative torsional forced ductions and validated the new test by comparing patients with oblique dysfunction and controls.

DESIGN

Comparative case series.

SUBJECTS

We studied 33 eyes with oblique dysfunction (9 with presumed congenital superior oblique palsy [SOP], 13 with acquired SOP, 7 with Brown syndrome, and 4 with inverted Brown syndrome) and 31 controls. We also studied 6 eyes after superior oblique (SO) disinsertion and 2 eyes after inferior oblique (IO) disinsertion.

METHODS

Under deep general anesthesia, the 12 and 6 o'clock positions at the limbus were marked and the globe was maximally excyclorotated and incyclorotated without retroplacement until the first resistance was felt, and the angle of rotation (in degrees) was read on a Mendez ring by the surgeon. A photograph was taken in each position to be read by a masked observer.

MAIN OUTCOME MEASURES

Maximal excyclorotation and maximal incyclorotation in each oblique dysfunction and in controls by both surgeon's report and photographic assessment. We duplicated the photographs to evaluate test-retest reliability and to evaluate agreement between the surgeon's assessments and the photographic assessment.

RESULTS

Surgeon's assessment revealed greater maximal excyclorotation in eyes with presumed congenital SOP than in controls (median, 40 vs. 30 degrees). Maximal excyclorotation in eyes with acquired SOP was similar to that in controls (30 degrees in both). Eyes with Brown syndrome and inverted Brown syndrome had lower maximal excyclorotation than in controls (10 and 20 vs. 30 degrees, respectively). Maximal incyclorotation in eyes with inverted Brown syndrome was lower than in controls (12.5 vs. 30 degrees), whereas it was similar to that of controls in eyes with presumed congenital SOP, acquired SOP, and Brown syndrome (30 degrees in each condition). Median maximal excyclorotation after SO disinsertion was 62.5 degrees, and maximal incyclorotation after IO disinsertion was 60 degrees. Photographic assessment yielded findings essentially identical to the surgeon's report. Test-retest reliability of the photographic reading was excellent, and agreement between the surgeon's report and the photographic reading was also excellent (95% limits of agreement, 4.4 and 11.6; intraclass correlation coefficient, 0.97 and 0.82, respectively).

CONCLUSIONS

The new torsional forced duction test enables quantitative assessment of SO and IO tightness and laxity.

[EFFICACY AND SAFETY OF ROCURONIUM BROMIDE PRODUCED IN THE RUSSIAN FEDERATION: A SINGLE-BLIND RANDOMIZED CLINICAL TRIAL]

DESIGN

A single-blind comparative prospective randomised clinical trial.

OBJECTIVE

To evaluate the efficacy and safety of Russian muscular relaxant (Kruarone) in comparison with Esmerone in multicomponent balanced anesthesia during laparoscopic cholecystectomy. 80 patients (23-68 years old) were examined. The patients were randomized into two equal groups. The results showed that Kruarone was effective relaxant with rapid onset of action, providing optimal conditions for muscle relaxation for laryngoscopy and tracheal intubation. Kruarone did not require frequent administration supports, providing high quality and stable neuromuscular blockade during surgery. There was no any one case of adverse events for the entire period of 24-hour surveillance, the drug has no cumulative effect. Kruarone did not cause allergic reactions and had no significant effect on hemodynamics. Thus Kruarone 0.6 mg/kg with an average total flow rate of the drug within 55 mg (39.6-75.43 mg) has the same effectiveness and safety with Esmerone in similar dosages.

Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia

INTRODUCTION

Rapid Sequence Induction of anaesthesia (RSI) is the recommended method to facilitate emergency tracheal intubation in trauma patients. In emergency situations, a simple and standardised RSI protocol may improve the safety and effectiveness of the procedure. A crucial component of developing a standardised protocol is the selection of induction agents. The aim of this study is to compare the safety and effectiveness of a traditional RSI protocol using etomidate and suxamethonium with a modified RSI protocol using fentanyl, ketamine and rocuronium.

METHODS

We performed a comparative cohort study of major trauma patients undergoing pre-hospital RSI by a physician-led Helicopter Emergency Medical Service. Group 1 underwent RSI using etomidate and suxamethonium and Group 2 underwent RSI using fentanyl, ketamine and rocuronium. Apart from the induction agents, the RSI protocol was identical in both groups. Outcomes measured included laryngoscopy view, intubation success, haemodynamic response to laryngoscopy and tracheal intubation, and mortality.

RESULTS

Compared to Group 1 (n = 116), Group 2 RSI (n = 145) produced significantly better laryngoscopy views (p = 0.013) and resulted in significantly higher first-pass intubation success (95% versus 100%; p = 0.007). A hypertensive response to laryngoscopy and tracheal intubation was less frequent following Group 2 RSI (79% versus 37%; p < 0.0001). A hypotensive response was uncommon in both groups (1% versus 6%; p = 0.05). Only one patient in each group developed true hypotension (SBP < 90 mmHg) on induction.

CONCLUSIONS

In a comparative, cohort study, pre-hospital RSI using fentanyl, ketamine and rocuronium produced superior intubating conditions and a more favourable haemodynamic response to laryngoscopy and tracheal intubation. An RSI protocol using fixed ratios of these agents delivers effective pre-hospital trauma anaesthesia.

Arousal withiv epinephrine depends on the depth of anesthesia

PURPOSE

To investigate whether the depth of anesthesia affects the change in the bispectral index (BIS) caused by iv epinephrine during propofol anesthesia.

METHODS

Forty women undergoing elective lower abdominal surgery received a propofol target controlled infusion (TCI) to maintain a modified Observer's Assessment of Alertness/Sedation (OAA/S) score of 2 (sedation period). Subsequently anesthesia was induced with propofol TCI 5 mug.mL(-1) and rocuronium 0.9 mg.kg(-1), and propofol continued so as to maintain general anesthesia at a BIS of 50 (general anesthesia period). Intravenous epinephrine at a dose of 10 mug.5 mL(-1) in normal saline (epinephrine group, n = 20) or normal saline 5 mL (control group, n = 20) was administered during both periods. The BIS, mean arterial pressure (MAP) and heart rate (HR) were measured immediately before, and one, two, three, four, six, eight, and ten minutes after injection. The modified OAA/S scale was evaluated during the sedation period.

RESULTS

There was no significant change in the modified OAA/S scale, BIS, or hemodynamic variables compared to preinjection values during either sedation or general anesthesia in the control group. Intravenous epinephrine increased the BIS and modified OAA/S scale during sedation, but there was no increase in BIS during general anesthesia. Increases in HR and MAP were observed during both periods after iv epinephrine.

CONCLUSION

Intravenous epinephrine 10 mug resulted in an arousal effect and an increase in BIS during sedation, but did not change the BIS during general anesthesia. These results suggest that the arousal effect of iv epinephrine during propofol anesthesia depends on anesthetic depth.

[AIRWAY MANAGEMENT IN CHILDREN DURING RESECTION OF THE TONSILS]

MATERIALS AND METHODS

We conducted a comparative evaluation of anesthesia used during tracheal intubation with and without the application of muscle relaxants in cases of adenotonsillectomy in children. Intubation parameters were evaluated according to Cormack-Lehane scale; the presence of cough reflex, limb movement, laryngospasm and desaturation during intubation was also taken into account. The presence of cough, husky voice, and complaints of pain in the throat were recorded in the monitoring report after extubation. We used the MOPS scale to evaluate postoperative pain and discomfort in children.

RESULTS

Tracheal intubation in children with adenotonsillectomy without the use of muscle relaxants was successfid in 100% of the cases, despite the fact that, according to the Cormack-Lehane classification, first degree of visualisation of the glottis during direct laryngoscopy was observed in 79.3% of the cases and the second degree was observed in 20.7% of the cases. No significant reactions in the cardiovascular system to the endotracheal tube were noted. The group without the use of muscle relaxants (p < 0.05) experienced earlier extubation and a shorter duration of anesthesia, which in turn contributed to a more rapid activation of the patients. According to the number of post-intubation complications, no significant differences in the two groups were observed. According to the MOPS scale, higher scores (p < 0.05), indicating discomfort in the early postoperative (within the first 15 minutes after the operation) period were observed in the group with the use of muscle relaxants.

CONCLUSIONS

Thus, the method of tracheal intubation without the use of muscle relaxants can be used for adenotonsillectomy in children.

Effective method of continuous rocuronium administration based on effect-site concentrations using a pharmacokinetic/pharmacodynamic model during propofol-remifentanil anesthesia

BACKGROUND

Rocuronium bromide (Rb) is a rapid onset, intermediate-acting neuromuscular blocking agent that is suitable for continuous administration. The appropriate rate of rocuronium administration is, however, difficult to determine due to large interindividual differences in sensitivity to rocuronium. The aim of this study was to clarify whether the simulated rocuronium concentration at the time of recovery to %T1 > 0 % after the initial administration of rocuronium is a good indicator of optimal effect-site concentrations during continuous rocuronium administration.

METHODS

Twenty-one patients were anesthetized with propofol. After induction, Rb 0.6 mg/kg was administered intravenously, and nerve stimulation using the single stimulation mode was conducted every 15 s. When %T1 recovered to >0 % after the initial administration of Rb, the effect-site concentration of rocuronium, calculated by pharmacokinetic simulation with Wierda's set of parameters, was recorded and defined as the recovery concentration (Rb r.c.). The administration rate of rocuronium was adjusted to maintain the Rb r.c. during surgery. Rb administration was discontinued just before the end of surgery, and the recovery time until %T1 > 25 % was recorded. Plasma Rb concentrations were measured at 1 and 3 h after the initiation of continuous Rb administration.

RESULT

The mean Rb r.c. was 1.56 ± 0.35 μg/ml, with minimum and maximum values of 1.09 and 2.08 μg/ml, respectively. The %T1 did not increase above 10 % in any of the patients during continuous administration of Rb, and the recovery period to %T1 > 25 % ranged from 9 to 29 min. The effect-site concentrations of Rb calculated with Wierda's parameters significantly correlated with plasma concentrations (P < 0.01) at both 1 and 3 h after the initial administration of Rb.

CONCLUSION

The results suggest that our method may be one of the most reliable protocols for the continuous administration of Rb described to date for maintaining suitable muscle relaxation during surgery without excessively prolonged effects.

Muscle relaxant effects on insertion efficacy of the laryngeal mask ProSeal(®) in anesthetized patients: a prospective randomized controlled trial

BACKGROUND

Anesthesiologists often encounter LMA-ProSeal(®) (ProSeal) insertion difficulty due to its large cuff size. We performed a randomized clinical trial to examine how insertion efficacy and sealing pressure of ProSeal are affected by muscle relaxant administration in anesthetized patients.

METHODS

Our adult patients were either administered rocuronium (0.9 mg kg(-1)) as a muscle relaxant (R group; 40 patients) or not (C group; 40 patients). Anesthesia was induced with propofol and fentanyl. We compared the two groups with regard to the number of attempts required for successful insertion, sealing pressure, and subjective difficulty for insertion.

RESULTS

Total insertion attempts required for successful ventilation in the two groups were one (R group, 38 patients; C group, 28 patients), two (R group, one patient; C group, seven patients), and three (R group, one patient; C group, five patients), revealing a significant difference between groups (p < 0.001). Sealing pressure was significantly higher in the R group than in the C group (R group, 27.4 ± 5.4 cmH2O; C group, 21.2 ± 5.2 cmH2O; p < 0.001). Leakage volume by mechanical ventilation was significantly smaller in the R group than in the C group (R group, 17.4 ± 29.1 ml; C group, 46.8 ± 45.5 ml; p < 0.001). Subjective difficulty of insertion was significantly lower in the R group than in the C group (R group, 12.3 ± 23.1 mm; C group, 39.4 ± 31.9 mm; p < 0.001).

CONCLUSIONS

Muscle relaxation appears to facilitate ProSeal insertion efficacy by enabling higher successful insertion rates, higher sealing pressure, lower leakage volume, and lower subjective difficulty of insertion in anesthetized patients.

The effects of nicardipine or esmolol on the onset time of rocuronium and intubation conditions during rapid sequence induction: a randomized double-blind trial

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.

[Efficacy and safety of sugammadex (Org 25969) in reversing moderate neuromuscular block induced by rocuronium or vecuronium in Japanese patients]

BACKGROUND

Efficacy and safety of sugammadex in reversing neuromuscular block induced by rocuronium or vecuronium were investgated in Japanese patients.

METHODS

We studied 98 Japanese patients undergoing surgery requiring general anesthesia. Patients were allocated randomly to receive intubation dose of rocuronium or vecuronium. During surgery, patients received additional doses of rocuronium or vecuronium for maintenance of moderate block. At T2 reappearance sugammadex 0-4.0 mg . kg-1 was administered. The neuromuscular block was monitored with acceleromyography using TOF stimuli. Sevoflurane was administered to all treatment groups after intubation.

RESULTS

For the rocuronium-induced neuromuscular block, the mean recovery time of the T4/T1 ratio to 0.9 decreased from 82.1 min in the placebo group to 1.8 min in the 4.0 mg . kg-1 sugammadex group. For the vecuronium-induced neuromuscular block, it decreased from 83.2 min in the placebo group to 2.1 min in the sugammadex 4.0 mg . kg-1 group. Plasma concentrations of sugammadex were approximately dose proportional over the dose range of 0.5 to 4.0 mg . kg-1 and independent of the neuromuscular blocking agents used. No clinical evidence of recurarization or residual curarization was observed.

CONCLUSIONS

The efficacy and safety of sugammadex were confirmed in Japanese surgical patients.

[Efficacy and safety of sugammadex (Org 25969) in reversing deep neuromuscular block induced by rocuronium or vecuronium in Japanese patients]

BACKGROUND

Efficacy and safety of sugammadex in reversing neuromuscular block induced by rocuronium or vecuronium were investgated in Japanese patients.

METHODS

We studied 99 Japanese patients undergoing surgery requiring general anesthesia. Patients were allocated randomly to receive intubation dose of rocuronium or vecuronium. During surgery, patients received additional dose of rocuronium or vecuronium for maintenance of deep block. At 1-2 PTC, 0.5-8.0 mg . kg-1 of sugammadex was administered. The neuromuscular block was monitored with acceleromyography using TOF stimuli. Sevoflurane was administered to all treatment groups after intubation.

RESULTS

For the rocuronium-induced neuromuscular block, the mean recovery time of the T4/T1 ratio to 0.9 decreased from 66.9 min in the sugammadex 0.5 mg kg-1 group to 1.3 min in the sugammadex 8.0 mg kg-1 group. For the vecuronium-induced neuromuscular block it decreased from 79.5 min in the sugammadex 0.5 mg . kg-1 group to 2.9 min in the sugammadex 8.0 mg . kg-1 group. No clinical evidence of recurarization or residual curarization was observed.

CONCLUSIONS

The efficacy and safety of sugammadex were confirmed in Japanese surgical patients for reversal from deep block.

[Successful anesthetic management of laparoscopic rectopexy using rocuronium and sugammadex in a patient with Becker muscular dystrophy]

A 70-year-old man with Becker muscular dystrophy (BMD) underwent laparoscopic rectopexy under general anesthesia. For anesthetic induction, we administered total 0.6 mg · kg-1 of rocuronium with titration. Eight minutes later, train-of-four (TOF) count reached to 0 and the patient was intubated smoothly. One hundred and five minutes later, TOF ratio recovered to 100% and we administered rocuronium 10 mg additionally. Surgery was finished without any problems 95 minutes after thereafter. TOF ratio was 45% and we administered sugammadex 3 mg · kg-1, reversing neuromuscular blockade to TOF ratio 100% within 1.5 minute. The patient awoke clearly and respiratory condition was good. He was extubated without remaining neuromuscular blockade. Postoperative course was stable and there was no serious adverse effect on his muscular function intra- and post-operatively. In conclusion, rocuronium and sugammadex can be used safely and effectively in general anesthetic management for patients with muscular dystrophy. However, as the onset times and durations of these agents can be longer, we should administer these agents with titration carefully under periodic neuromuscular monitoring.

Effect of general anesthesia and muscle relaxants on keratometry measurements using a handheld keratometer

PURPOSE

Keratometry measurements are often obtained under general anesthesia in the supine position in difficult patients and pediatric procedures. This study investigates the effect of general anesthesia and muscle relaxants on keratometry readings using a handheld keratometer.

METHODS

Fifty patients (with no history of intraocular surgery or corneal pathology) undergoing general anesthesia were prospectively enrolled. Keratometry readings were obtained using the Nidek KM-500 handheld keratometer (Nidek, Inc., Fremont, CA). in three settings: when the patient was awake in the upright and supine positions, and after general anesthesia. Readings were averaged in each eye and compared among the three settings; patients were also subgrouped by whether muscle relaxants were administered at induction. Intraclass correlation coefficients were calculated and Bland-Altman analysis was performed.

RESULTS

Keratometry readings were comparable between the upright and supine positions before anesthesia in all groups. In the muscle relaxant group, keratometry readings were flatter after anesthesia and this was statistically significant for right eyes (P = .02), but not for left eyes (P = .16). In the group with no muscle relaxant, no significant differences were noted. Intraclass correlation coefficients of the differences were high (≥ 0.97) for all eyes in both groups and Bland-Altman plots showed most of the differences to be within the limits of agreement.

CONCLUSIONS

Keratometry readings using the handheld keratometer obtained under general anesthesia were as reliable as readings obtained in the awake state, regardless of posture; administration of muscle relaxants at induction may produce flatter keratometry readings.

[Effect of an oral anti-estrogen agent (mepitiostane) on the regression of intracranial meningiomas in the elderly]

We report here the regression of meningioma following treatment with the anti-estrogen agent mepitiostane in a series of cases. The first case was that of a 72-year-old woman who presented with coma status due to non-communicating hydrocephalus. A large presumed meningioma within the cerebello-pontine angle was detected on gadolinium-enhanced magnetic resonance imaging (MRI). The patient recovered from the neurological deficit following endoscopic third ventriculostomy treatment, and was administered mepitiostane (10mg/day) orally. Gadolinium-enhanced MRI showed a marked regression (85%) of the meningioma following 60 months of oral medication. The second case was that of a 79-year-old woman with no neurological deficit; however, a presumed meningioma located in the frontal skull base was detected on gadolinium-enhanced MRI. Mepitiostane (10mg/day) was administered orally. Again, a marked regression (88%) of the meningioma was demonstrated after 115 months of oral medication. The third case was that of a 71-year-old woman who presented with right visual disturbance and a visual field defect. Gadolinium-enhanced MRI demonstrated a presumed meningioma located in the left sphenoidal bone. Mepitiostane (20mg/day) was administered orally. An 79% regression of the meningioma was observed after 21 months of oral medication. In these three cases, the marked reduction in meningioma following anti-estrogen agent (mepitiostane) administration suggested that this oral medication could be an effective therapeutic option in elderly patients.

The concept behind sugammadex

Sugammadex is the first selective relaxant binding agent. It allows rapid reversal of any degree of neuromuscular blockade induced by steroidal neuromuscular blocking agents. Sugammadex acts by encapsulation of the neuromuscular blocking agent. This prevents the drug from acting on prejunctional and postjunctional nicotinic receptors, allowing acetylcholine to activate these receptors, and resulting in reversal of the neuromuscular blockade. Objective monitoring of the degree of neuromuscular blockade is strongly recommended to determine the optimal dose of sugammadex. A good understanding of the concept behind sugammadex is essential in order to use this reversal agent in clinical practice.

Reversal of a rocuronium-induced grade IV anaphylaxis via early injection of a large dose of sugammadex

AIM

To report rapid recovery from grade IV rocuronium-induced anaphylaxis with a large dose of sugammadex administered early after the onset of symptoms.

CLINICAL FEATURES

A 22-yr-old female without relevant medical history developed an anaphylactic reaction within three minutes of rocuronium injection at induction of anesthesia for a routine cholecystectomy. During the first six minutes, she was unresponsive to usual treatment and her condition evolved to a grade IV anaphylaxis reaction despite a cumulated dose of epinephrine 0.7 mg. Sugammadex 14 mg·kg(-1), injected six minutes after rocuronium, resulted in total resolution of all manifestations of anaphylaxis within three minutes. The patient was discharged from hospital the next day. Allergy investigations confirmed rocuronium as the cause of anaphylaxis.

CONCLUSION

Very early administration of a large dose of sugammadex may be an effective treatment for rocuronium-induced anaphylaxis.

[Effects of magnesium on the onset time of rocuronium in patients for cesarean delivery]

BACKGROUND

Although magnesium can potentially shorten onset time of a muscle relaxant, it is unclear whether it does shorten the onset time of rocuronium for patients in cesarean delivery (CD). Thus the purpose of this study is to compare the onset time of rocuronium in patients with or without preoperative magnesium treatment.

METHODS

In 9 CD patients without magnesium (CD group) and 8 CD patients with magnesium (CD-Mg group), neuromuscular function was continuously assessed with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.6 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection until complete absence of twitch height, was measured.

RESULTS

The onset time of both groups did not significantly differ (50 +/- 10 seconds vs. 51 +/- 11 seconds; P = 0.93, unpaired t-test). Median magnesium concentration, 5.2 mg x dl(-1) (3.8-6.3), and the onset time of CD-Mg group did not correlate magnesium concentrations (P = 0.23, Pearson's correlation coefficient test).

CONCLUSIONS

Magnesium did not shorten the onset time of rocuronium 0.6 mg x kg(-1) in CD patients.

[Reversal of rocuronium-induced neuromuscular blockade with sugammadex in patients for cesarean delivery treated with magnesium sulfate]

BACKGROUND

We investigated whether sugammadex could reverse neuromuscular blockade induced by rocuronium in patients for cesarean delivery treated with magnesium sulfate preoperatively.

METHODS

Twenty-three pregnant women received general anesthesia induced with thiopental and rocuronium. They were maintained by nitrous oxide, oxygen and sevoflurane (GOS) before delivery and after delivery by GOS, midazolam, and propofol. After the surgery, the patients with two or more counts of train-of-four (TOF), the moderate block group were classified into Mg (-) M and Mg (+) M, depending whether magnesium sulfate had been injected or not, and sugammadex 2 mg x kg(-1) was administered to both groups. Patients with PTC 2 or more, the profound block group, were classified into Mg (-) P or Mg (+) P and sugammadex 4 mg x kg(-1) was administered to both groups. Recovery time was defined as the time required to reach TOFR 0.9 or more after the injection of sugammadex.

RESULTS

Median recovery times of the Mg (-) M, the Mg (-) P, the Mg (+) M and the Mg (+) P were 63 seconds (range: 26-130, N = 7), 127 seconds (range: 63-228, N = 7), 104 seconds (range: 67-133, N = 5), and 142 seconds (range: 57-209, N = 4), respectively.

CONCLUSIONS

Sugammadex could reverse rocuronium-induced neuromuscular blockade in a dose-response manner even in the patients treated with magnesium sulfate.

[Effects of pregnancy on the onset time of rocuronium]

BACKGROUND

Rapid onset of a muscle relaxant is required for general anesthesia with rapid sequence induction technique. Although a high dose of rocuronium was demonstrated to achieve the rapid onset in non-pregnant persons, it is still unknown whether this is true in women during late pregnancy. The purpose of this study is to compare the onset time of high dose rocuronium between pregnant and non-pregnant women.

METHODS

Ten pregnant women undergoing cesarean delivery and 10 age, height, and body weight-matched non-pregnant women were enrolled in the study. Neuromuscular function was continuously assessed by twitch response with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.9 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection to complete absence of twitch height, was measured.

RESULTS

The onset time of rocuronium in pregnant women was significantly shorter than that in non-pregnant women (42 +/- 9 seconds vs. 56 +/- 10 seconds; P = 0.0039. unpaired t-test).

CONCLUSIONS

The onset time of high dose of rocuronium in pregnant women was significantly shorter than that of non-pregnant women.

[Insufficient sugammadex effect in an obese pregnant woman undergoing cesarean section under general anesthesia]

A 32-year-old pregnant woman (height 162 cm, weight 86 kg, age of fetus 25 weeks) without preoperative complications underwent an emergent cesarean section under general anesthesia. She was intubated with a 7.0-mm tracheal tube 40 s after receiving rocuronium 0.93 mg x kg(-1) and thiamilal 375 mg. Anesthesia was maintained with oxygen, air, sevoflurane 1.0-2.5%, and fentanyl 425 microg. Nine minutes after the end of surgery (operation time 71 minutes), a train-of-four count of 2 with 20 spontaneous breaths was noted, and sugammadex 2.3 mg x kg(-1) was administered. However, the train-of-four count was 3 even five minutes after sugammadex administration. Fifteen minutes after sugammadex administration (train-of-four ratio 14%), she received atropine 0.5 mg and neostigmine 1.0 mg. Ten minutes later, the train-of-four ratio increased to 89%, and the patient was successfully extubated with no respiratory suppression. We speculate that the rocuronium dose (0.93 mg x kg(-1)) was too high in this obese patient, and sugammadex dose at the end of the surgery was not enough for reversal of rocuronium-induced neuromuscular blockade.

[Anesthesia for pneumothorax surgery in a patient with type II chronic respiratory failure associated with inclusion body myositis]

A 40-year-old man was scheduled for video assisted thoracoscopic surgery due to pneumothorax. He had been diagnosed with inclusion body myositis and received nocturnal non-invasive positive pressure ventilation. Anesthesia was induced with propofol, remifentanil, and rocuronium, and maintained with propofol, remifentanil and fentanyl. The dosage of rocuronium was 10 mg. Although we administered neostigmine at the end of the operation and TOF ratio was over 90%, he was transported to the ICU with tracheal intubation because of poor spontaneous respiration. On POD 1, the tracheal tube was extubated and NPPV was administered again. Minitrach was inserted on POD 2, and he left the ICU on POD 4. Generally, in patients with myopathy the dose of muscle relaxant should be decreased in proportion to their muscle atrophy. Rocuronium 10 mg was administered in this case and we thought it could be antagonized by neostigmine, but extubation on the day of operation was impossible. We think this is not because of the residual effect of muscle relaxant, but because of decreases in pulmonary function. In this case, we expected long-term mechanical ventilation might be necessary, but he showed a good postoperative course owing to minimally invasive surgery, NPPV, and suctioning of sputum via Minitrach.

Biochemical changes following succinylcholine administration after pretreatment with rocuronium at different intervals

OBJECTIVE

To evaluate the biochemical changes associated with succinylcholine administration after pretreatment with rocuronium at different time intervals.

METHOD

The prospective, randomised, single-blinded study was conducted at the Combined Military Hospital, Rawalpindi, from January to May 2010. Ninety male, aged 18-60 years, American Society of Anaesthesiology I or II patients undergoing elective inguinal herniotomy or external haemorrhoidectomy were included. The patients were randomly divided into three equal groups. Group A received a normal saline 5 ml as placebo 1 minute before succinylcholine; Group B received rocuronium 0.06 mg/kg 1 intravenously minute before succinylcholine, while Group C received intravenous injection of rocuronium 0.06 mg/kg 5 minute before succinylcholine. Venous blood samples for creatinine phosphokinase, lactate dehydrogenase and myoglobin plasma concentrations were obtained at 0, 30 minutes, 6 hours and 24 hours after succinylcholine administration.

RESULTS

Mean serum creatinine phosphokinase and myoglobin concentrations were significantly decreased in Groups B and C compared to Group A at 30 minutes and 24 hours (p < 0.05). However, no significant difference in the enzyme levels at any time interval was observed among the rocuronium groups. There was a significant rise in lactate dehydrogenase concentrations at 6 hours and 24 hours in Group A compared to Groups B and C (p < 0.05).

CONCLUSION

Pretreatment with rocuronium effectively reduces the biochemical changes associated with succinylcholine-induced muscle fasciculations. However, whether it is given 1 minute or 5 minutes before succinylcholine does not make much difference.

[Assessment of sugammadex use efficiency and safety for neuromuscular block reversion]

Blockade of neuromuscular conductivity is a considered one of basic part of a patient protection in a concept of a balanced multicomponent anesthesia. The controlled neuromuscular paralysis in a combination of a sedation, an analgesia and a hyporeflection not only provides comfortable conditions to surgeons for carrying out surgeries, but also allows to manage a gas exchange, blood circulation and a metabolism in a patient. However in clinical practice there is such complication after application of muscular relaxant (not depolarizing) as a residual curarization. The residual curarization is interfaced to deterioration of the respiratory answer to a hypoxemia, swallowing dysfunction that significantly increased risk of aspiration and risk of postoperative pulmonary complications. Until recent time acetylcholinesterase inhibitors or prolonged ALV before spontaneous regression of the neuromuscular block were applied in clinical practice for the purpose of restoration of adequate neuromuscular conductivity and elimination of a residual curarization. However there are number of the circumstances limiting application of preparations of this group including it is related with rather high frequency of side effects and lack of efficiency at the deep neuromuscular block. Today in an arsenal of the anesthesiologist there was the latest chemical - sugammadex. Sugammadex realizes a new approach to restoration of the neuromuscular conductivity.

Total intravenous anesthesia for aortic aneurysm replacement surgery in a patient with limb-girdle dystrophy

We report the anesthetic management with total intravenous anesthesia of a 61-year-old male diagnosed with limb-girdle muscular dystrophy admitted for replacement of ascending aorta due to an aortic aneurysm. Limb-girdle muscular dystrophy belongs to a genetically heterogeneous group of muscular dystrophies involving shoulder and hip girdles. Although the risk of malignant hyperthermia does not seem to be increased in these patients compared with the general population, the exposure to inhaled anesthetics and succinylcholine should probably be avoided because these patients have a predisposition to hyperkalemia and rhabdomyolysis. We chose to use total intravenous anesthesia with propofol, remifentanil and muscle relaxants to reduce oxygen consumption, and later to reduce the doses of propofol and remifentanil. The combination of a carefully planned anesthetic strategy, anesthetic depth, and neuromuscular blockade monitoring is explained.

Effects of rocuronium pretreatment on muscle enzyme levels following succinylcholine

Succinylcholine revolutionized anaesthetic practice by providing intense neuromuscular blockade of very rapid onset and ultrashort duration, thereby greatly easing the maneuver of tracheal intubation. However the worth of succinylcholine is limited by the frequent occurrence of muscular side effects which manifest biochemically in the form of rise in serum creatine kinase (CK). The administration of small doses of nondepolarizing muscle relaxants before the administration of succinylcholine has been shown to decrease the incidence and severity of muscular side effects experienced by the patients. This study was aimed at evaluating the efficacy of technique in reducing the muscular side effects of succinylcholine, biochemically manifested as rise in CK. Sixty healthy adults were enrolled in the study who were scheduled for minor muscle cutting surgeries under general anaesthesia. They were assigned at random to two groups of thirty patients each. They randomly received succinylcholine for intubation and a precurarization dose of rocuronium followed by succinylcholine for intubation. Blood samples were drawn for estimation of serum creatinine kinase. There was a significantly raised CK in the succinylcholine group. In the precurarization group the rise in CK was prevented and the levels were significantly less as compared to the group which received succinylcholine alone. Present study concluded that precurarization with rocuronium was effective in reducing the succinylcholine-induced rise in creatinine kinase.

[General anesthetic management of a patient with spinal muscular atrophy type III]

We report a 61-year-old woman (weight 49 kg, height 156 cm) with Kugelberg-Welander disease who was scheduled for bilateral mastectomy under general anesthesia. We administered rocuronium 10 mg (0.20 mg x kg(-1)) for tracheal intubation. After 80 min, train-of-four ratio (TOFR) was 46%. During the operation, we did not administer rocuronium. After surgery, TOFR was 62%. Therefore, we administered sugammadex 100 mg (2 mg x kg(-1)). After 4 min, TOFR became above 90%, and the patient was extubated. There was no respiratory distress, muscle weakness, or neurologic untoward event after the use of sugammadex in the postoperative period. Sugammadex was effective in reversing rocuronium induced neuromuscular block in a patient with Kugelberg-Welander disease.

[Rocuronium bromide as component of general anaesthesia in patients with traumatic cerebral compression]

The choice of myorelaxation agent for rapid sequence tracheal intubation for surgical cerebral decompression is a less studied question in neuroanaesthesiology. 32 patients with cerebral trauma (GCS<8) were involved in the study. Influence of succinylcholine and rocuronium bromide on cerebral circulation, intracranial pressure, cerebral perfusion pressure and systemic haemodynamics was assessed. Rocuronium bromide in dose 0.6 mg/kg provides good conditions for tracheal intubation in 40-60 seconds and does not influence on studied parameters. Rocuronium bromide is a drug of choice for general anaesthesia in patients with traumatic cerebral compression.