A Comparative Study Between Rocuronium And Succinylcholine In Evaluating Endotracheal Intubating Conditions In Day Care Surgeries

Background: Succinylcholine has been the main neuromuscular blocking agent for the endotracheal intubation in rapid sequence induction with some adverse effects. This study was conducted to find a better alternate drug with minimal adverse effects and easy for intubations. Thus, our study aimed to compare the onset time, duration of action, intubating condition and hemodynamic effect of rocuronium bromide at the dose of 0.8 mg/kg and Succinylcholine at the dose of 1.5 mg/kg. Materials and methods: A double blinded randomized control study was conducted among 60 patients undergoing surgery each groups having 30 patients, Duration of action, Hemodynamic parameters, and intubating conditions were assessed after administering drugs in each group. Appropriate statistical tests were applied P value < 0.05 was considered to be significant Results: The mean of onset of action of succinylcholine is significantly shorter than that of rocuronium (48.07 ± 4.04 Vs 74.4 ± 9.1); and duration of action succinylcholine is significantly shorter than that of the rocuronium (3.85 ± 0.33 Vs 44.4 ± 4.7). Both the drugs significantly elevated mean Heart rate, Systolic Blood Pressure, Diastolic Blood pressure, MAP from intubation to subsequent intervals. Conclusion: The rocuronium bromide (0.8 mg/kg) has longer duration of action and slower onset of action than succinylcholine (1.5 mg/kg) with excellent intubating condition and minimal alteration in hemodynamic profile. Hence rocuronium bromide (0.8 mg/kg) can be used as an alternative to Succinylcholine (1.5 mg/kg) in selected situations.

Evaluation Of Intubating Conditions With Rocuronium By Priming Technique. A Randomized Double Blind Study

BACKGROUND: a prospective, randomized, double-blind study was designed to evaluate the effects of priming technique with rocuronium bromide for intubation in adult patients undergoing surgical procedures.METHODS: sixty adult patients of 20-60 years of age with asa-1 physical status posted for surgical procedures were divided in to two groups. group c received normal saline (2ml) as priming dose and group p received 0.06mg/kg rocuronium (2 ml) as priming dose and after 3 minutes intubating dose group c received 6 mg /kg (5 ml) group p received the 5.4 mg /kg (5 ml) as intubating dose .muscle relaxation was assessed with nerve stimulator for every 10 seconds and assessed visually for loss of adduction of thumb and disappearance of t1 of train of four (TOF) stimuli. By this we can note the onset time of intubation (Ti) and intubating conditions were assessed buy cooper et al scoring system. Any adverse effects were also noted.RESULTS: The mean onset of intubation time (Ti) in the group P was 52.33±6.79 sec, in the group C was 95.67±11.04 sec ,P value is 0.00 it is highly significant. Minimum Ti is 80 sec. and maximum Ti is 120 sec. intubation scores as per “cooper et al scoring”were 8 or 9 in both the groups. There were no incidences of weakness, aspiration, bradycardia, ptosis, hypotension, in either of the groups during study observation.CONCLUSION: administration of Priming dose of rocuronium before the intubating dose causes the onset of neuromuscular block is rapid and onset time of intubation is became comparable to that of suxamethonium with excellent intubating conditions and without adverse effects.

A Comparative Study of the Effect of Priming and Sevoflurane on Intubating time and Intubating Conditions with Rocuronium as Intubating Agent in Neurosurgical Patients.

Background: Rocuronium provides good intubating conditions but large doses causes prolongation of its duration of action, making it unsuitable for short surgical procedures. Aims: This study was designed to compare the effects of rocuronium with 3min priming interval and 2% sevoflurane on the time of intubation and intubating conditions. Methods: the study design is that of randomized, prospective double‑blind trial. Forty five adult patients were randomly allocated into three equal groups: Group R received 0.8 mg/kg rocuronium, Group RS received 0.8 mg/kg of rocuronium with 2% sevoflurane andGroup RP patients received a priming dose of 0.08 mg/kg of rocuronium followed by 0.72 mg/kg rocuronium 3 min later. Onset time of intubation, intubating conditions and time for loss of thumb adduction were assessed. Analysis of variance (ANOVA) test was used to compare the demographic data and intubating conditions among the groups.Intergroup comparison between R and RS,R and RP,RS and RP of the time for intubation and time for the loss of thumb adduction were done using student t test. A P value <0.05 was considered significant. Results: The onset time of intubation (loss of T1 of TOF) was 100.53+2.03s in group 62.9+1.9 s in-group RS, and 61.88+1.9s in group RP. The time for the loss of thumb adduction in R,RS,RP were 98.53+2.03, 60.93+1.9, 60+2.12 respectively. There is statistical significance p=0.001 between R and RS ,R and RP group while comparing the onset time for intubation and time for the loss of thumb adduction. Mean intubating scores were excellent in all the three groups.Conclusion: Both rocuronium (0.08mg/kg) along with 2% sevoflurane and priming principle for rocuronium provide excellent intubating conditions within 60-66 sec in neurosurgical patients.

Comparison of intubating conditions and hemodynamic responses to tracheal intubation with different effect-site concentrations of remifentanil without muscle relaxants during target-controlled infusion of propofol / 대한마취과학회지

BACKGROUND: We compared the effects of different remifentanil effect-site concentrations on intubating conditions, and cardiovascular and bispectral index score (BIS) responses to intubation at a fixed effect-site concentration of propofol without muscle relaxants. METHODS: Sixty-four patients were randomly assigned to one of three groups: remifentanil 2 (group R2, n = 22), 4 (group R4, n = 21), or 6 ng/ml (group R6, n = 21). Anesthesia was induced using target-controlled infusion of propofol 5 microgram/ml and each concentration of remifentanil. Laryngoscopy and intubation was attempted at 2.5 min following induction. Intubating conditions were assessed as excellent, good or poor using a standard scoring system. Mean arterial pressure (MAP), heart rate (HR), and BIS values were assessed. RESULTS: Excellent or good intubating conditions were obtained in 91% of group R4 and 95% of R6, both of which are higher compared with 32% of R2 (P < 0.01). MAP and HR decreased significantly after induction in all groups. After intubation, they recovered to baseline value in group R2 and R4 but were significantly less than baseline values in R6. BIS response to intubation was attenuated in group R4 and R6 but not R2. Hypotension was more frequent in group R6 than R2. CONCLUSIONS: Remifentanil target concentrations of 4 or 6 ng/ml combined with 5 microgram/ml propofol provided good or excellent conditions for tracheal intubation and prevented cardiovascular and BIS response during induction without muscle relaxants. However, the use of 6 ng/ml dose was associated with frequent occurrence of hypotension and bradycardia requiring treatment.

A Comparative Study of Different Induction Techniques (Propofol-Placebo, Propofol-Ephedrine and Propofol-Placebo-Crystalloid) on Intubating Conditions after Rocuronium Administration

This was a prospective randomized double blind controlled study to compare intubating conditions at 60 seconds with rocuronium 0.6 mg/kg by using three different induction techniques: propofol-placebo (PP), propofol-ephedrine (PE) and propofol-placebocrystalloid (PC). Ninety patients were included and randomly allocated to receive one of the three combinations. The patients were induced using fentanyl 2 μg/kg, followed by propofol 2.5 mg/kg with normal saline as placebo (Group PP and Group PC) or ephedrine 70 μg/kg (Group PE) given over 30 seconds. Subsequently, rocuronium 0.6 mg/kg was given over five seconds and endotracheal intubations were performed 60 seconds later. Intubating conditions were clinically acceptable in all patients except in four patients in PP group, who had poor intubating conditions. The proportion of excellent intubating conditions was significantly highest in Group PE (94%) followed by Group PC (81%) and lowest in Group PP (50%). In conclusion, induction with propofol-ephedrine and propofol-placebo-crystalloid combinations provided significantly better intubating conditions than propofol alone, when rocuronium 0.6 mg/kg was used for intubation at 60 seconds.

Effects of Dosages of Remifentanil Calculated by Total Body Weight and Ideal Body Weight to Intubation Circumstances and Adverse Hemodynamic Responses

BACKGROUND: Remifentanil presents good intubation conditions and blunting adverse hemodynamic responses following intubation. So, we evaluated to determine optimal dosage of remifentanil for intubation which consider ideal body weight. METHODS: 160 ASA class 1-2 patients were selected and divided 4 groups, which were composed of 40 patients. Group 1 and 2 were administrated dosage calculated by TBW (total body weight). Each group was administrated intravenous continuous infusion dose of 1.0 ug/kg/min of remifentanil during 2 minutes followed by intravenous bolus dose of 2 mg/kg of propofol (Group 1) and 2.0 ug/kg/min of remifentanil followed by same dose of propofol (Group 2). Group 3 and 4 were administerated same dosage of Group 1 and 2 but administrated dosage calculated by IBW (ideal body weight). We didn't use any muscle relaxant. Intubation conditions and postintubation hemodynamic responses were assessed by 5 items based on GCRP (good clinical research practice), MAP (mean arterial pressure) and HR (heart rate). RESULTS: We have done intubation safely 60, 75, 55 and 98% of Group 1, 2, 3 and 4 respectively. Group 1, 3 have 'technically unacceptable' cases, but group 2, 4 have 'clinically unacceptable' cases. Hemodynamic responses of Group 4 were more stable than Group 2, especially obese patients. Obese patients present a problem for the appropriate dosing of remifentanil and profound hypotension and/or bradycardia developed more frequently when administerated agent calculated by total body weight. CONCLUSIONS: The optimal dosage which produce best intubation conditions and least side effects has to be determined according to IBW.

Tracheal Intubation using Remifentanil and No Muscle Relaxants: the Effect of Thiopental, Propofol, or Etomidate on Tracheal Intubating Conditions and Hemodynamic Changes / 대한마취과학회지

BACKGROUND: Many studies have suggested that propofol in combination with remifentanil may provide adequate conditions for tracheal intubation without the use of muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. The goal of our study was to evaluate the effect of thiopental, propofol or etomidate on tracheal intubating conditions and hemodynamic changes using remifentanil in the absence of muscle relaxants. METHODS: A total of 45 healthy adults were divided randomly into three groups. After iv lidocaine 1.5 mg/kg, thiopental 5 mg/kg (thiopental group) or propofol 2.5 mg/kg (propofol group), or etomidate 0.4 mg/kg (etomidate group) were injected. After the injection of study drugs, remifentanil 2 mcg/kg was administered. Ninety seconds after the administration of remifentanil, laryngoscopy and intubation were attempted. Intubating conditions were assessed and the mean arterial pressure and the heart rate was measured. RESULTS: There were no significant differences in intubating conditions between patients in the three groups. The heart rate was significantly lower in the propofol and etomidate group patients when compared to the thiopental group patients after anesthetic induction. The mean arterial pressure was significantly lower in the propofol group patients when compared to the thiopental and etomidate group patients. Both heart rate and mean arterial pressure after tracheal intubation were significantly elevated in etomidate group patinets when compared to their preintubation value. CONCLUSIONS: The use of thiopental 5 mg/kg, propofol 2.5 mg/kg, and etomidate 0.4 mg/kg did not differ in effect under intubating conditions for tracheal intubation using remifentanil in the absence of muscle relaxants. Thiopental provided the best hemodynamic conditions.

Tracheal Intubating Conditions and Hemodynamic Change in Ambulatory Surgery: Propofol and Remifentanil Target Controlled Infusions with Low Dose Rocuronium / 대한마취과학회지

BACKGROUND: This study evaluated the tracheal intubating conditions and hemodynamic changes in tracheal intubation according to the different effect-site concentrations of remifentanil combined with a target controlled infusion (TCI) of propofol using low dose rocuronium. METHODS: Forty-five patients presenting for ambulatory surgery were randomly assigned to one of three groups according to the target effect-site concentration of remifentanil: 2.5 ng/ml (group R2.5), 3.0 ng/ml (group R3.0), 3.5 ng/ml (group R3.5). After midazolam administration, anesthesia was induced using a target effect-site controlled infusion of propofol 4.0microgram/ml, which was then reduced to 2.5microgram/ml. At the same time, a TCI of remifentanil was started. A neuromuscular blockade was produced by rocuronium 0.4 mg/kg. The trachea was intubated 4 min after induction. The tracheal intubation conditions were assessed using a standard scoring system. The noninvasive arterial blood pressure, heart rate (HR), and bispectral index were recorded at 1 min intervals from the start of induction to 5 min after intubation. RESULTS: Intubation was successful in all patients except for one in the R2.5 group. The number of excellent intubating conditions was significantly higher in the R3.5 group (12/15) than in the R2.5 group (6/15) (P < 0.05). The mean arterial pressure (MAP) in the R2.5 and R3.0 groups increased significantly at 1 min after intubation (P < 0.05), but the MAP in the R3.5 group increased slightly at 1 min after intubation. CONCLUSIONS: The effect-site concentration of remifentanil 3.5 ng/ml combined with a TCI of propofol using rocuronium 0.4 mg/kg provides the most adequate intubating conditions and hemodynamic stability.

Intubating Conditions and Hemodynamic Changes during Tracheal Intubation with Propofol Followed by Remifentanil without the Use of Muscle Relaxant / 대한마취과학회지

BACKGROUND: Studies have shown that tracheal intubation can be facilitated safely and effectively after induction of anesthesia with hypnotic and opioid without employing any muscle relaxants. Remifentanil is a new, ultra-short acting, selective mu-receptor agonist. The goal of our present study was to evaluate the appropriate induction dose of remifentanil with propofol for tracheal intubation without employing any muscle relaxants. METHODS: We have assessed intubating conditions in three groups of 45 ASA I or II Patients. Each group received intravenous dosage of 2 mg/kg of propofol with remifentanil 1microgram/kg (Group I), 2microgram/kg (Group II) or 3microgram/kg (Group III), respectively. No muscle relaxant was administered. Intubating conditions were assessed based on jaw relaxation, vocal cord position, vocal cord movement, airway reaction, and movement of limbs. Intubating conditions, mean arterial blood pressure and heart rate were measured just before induction (T00, baseline), before intubation (T0), 1 minute after intubation (T1), 2 minutes after intubation (T2) and 3 minutes after intubation (T3). RESULTS: Intubating conditions were clinically acceptable in 26.7, 86.7 and 93.3% of patients, after 1, 2 or 3microgram/kg administration of remifentanil, respectively. Clinically acceptable intubating conditions were significantly more in Group II and III when compared with Group I (P<0.05). Both HR (heart rate) and MAP (mean arterial pressure) were significantly lower in Group III when compared with Group I before intubation (T0), 1 minute after intubation (T1), 2 minutes after intubation (T2) and 3 minutes after intubation (T3) (P<0.05). CONCLUSIONS: We conclude that 2-3microgram/kg of remifentanil may reliably provide 'good' to 'excellent' conditions for tracheal intubation when administered after administration of 2 mg/kg propofol. The conditions for intubation were significantly better in patients receiving 2 mg/kg of propofol followed by 2-3microgram/kg of remifentanil than those receiving 1microgram/kg of remifentanil.

Rapid Tracheal Intubation with High-dose Vecuronium / 대한마취과학회지

For the rapid endotracheal intubation, the ideal neuromuscular blocking drug with short onset time, short duration and few side effects has so far not been found. Succinylcholine is still, inspite of its side-effects and contraindications, the standard drug of choice for rapid intubation. But, high-dose vecuronium as an alternative to succinylcholine for rapid intubation may be recommended. To compare the intubating conditions with that in succinylcholine, the onset and cardiovascular effects of high-dose vecuronium(0.3 mg/kg) were evaluated clinically with a scoring system. The results are as follows ; 1) High-dose vecuronium may provide an alternative means of achieving a rapid onset of neuromuscular blockade. 2) High-dose vecuronium shows minimal effects on cardiovascular system. In concluson, high-dose vecuronium as an alternative method for rapid endotracheal intubation may be recommended without any significant cardiovascular change if succinylcholine is contraindicated.