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PubMed2005

Effects of ephedrine on intubating conditions following priming with rocuronium.

BACKGROUND: Onset of action of muscle relaxants is influenced by cardiac output and muscle blood flow. Ephedrine reduces the onset time of rocuronium. Onset is also shortened by priming. Accordingly, we hypothesized that priming combined with ephedrine is superior to either technique used separately. METHODS: Four groups of randomly allocated patients (n = 31), ASA I - II, were induced with propofol 2.5 mg kg(-1). In groups I and II, 0.04 mg kg(-1) of rocuronium was followed by a 3-min priming interval. Induction was followed by an intubation dose of 0.04 mg kg(-1). Then a 30-s intubation was attempted. In groups III and IV the same sequence was repeated except for sham priming and an intubation dose of 0.44 mg kg(-1). In groups I and II, ephedrine (210 microg kg(-1)) was injected before propofol. In groups II and V, an equivalent volume of normal saline was injected. Jaw relaxation, vocal cord position, and diaphragmatic response were used to assess intubating conditions. RESULTS: All patients of group I were intubated 30 s after the intubating dose and within a 20-s interval compared with 74% of patients in groups II and III, and 84% of patients in group IV. Intubating conditions were graded good to excellent in all patients in group I compared with 42% of those in group II, 35% in group III and 52% in group IV (P < 0.01 vs. group I). During the priming interval, no adverse effects were observed or reported. CONCLUSIONS: Ephedrine in combination with propofol significantly improved clinical intubating conditions at 30 s following priming with rocuronium compared with priming with ephedrine without priming.

Adolescent↗
PubMed2005

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.

Adult↗
PubMed1993

Muscle paralysis by rocuronium during halothane, enflurane, isoflurane, and total intravenous anesthesia.

We determined the dose-response relationship, the onset time, the duration, and the recovery time of a rocuronium neuromuscular block under four anesthesia techniques. Patients were equally randomized to four different groups (n = 20) receiving 0.5%-1% halothane, 1.5%-2% enflurane, 1.2%-1.8% isoflurane end-tidal concentration in 34%/66% O2/N2O, or 6.0 mg.kg-1 x h-1 propofol without N2O for anesthesia and alfentanil for analgesia. Strength of thumb adduction in response to single and train-of-four stimulation of the ulnar nerve was quantitated. Rocuronium 0.15, 0.2, 0.25, and 0.3 mg/kg were given intravenously. When maximal depression of twitch tension occurred, supplemental doses up to a total of 0.5 mg/kg were given. If required, additional doses of 0.15 mg/kg were given at 25% recovery of control twitch tension. Standard hemodynamics, end-tidal CO2, and anesthetic gas concentrations were monitored continuously. The mean ED50 (SD) was 0.133 (+/- 0.009) mg/kg for the halothane group, 0.118 (+/- 0.012) mg/kg for the enflurane group, 0.069 (+/- 0.026) mg/kg for the isoflurane group, and 0.167 (+/- 0.007) mg/kg for the total intravenous anesthesia (TIVA) group, respectively. There was a statistically significant difference between the halothane and TIVA, and between the enflurane and TIVA groups (P < 0.05). Rocuronium has a short onset time and an intermediate duration of action. The neuromuscular blocking potency and pharmacodynamic profile are moderately influenced by volatile anesthetics.

Adult↗
PubMed2004

Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockade during propofol or sevoflurane anesthesia.

We sought to determine whether tactile train-of-four (TOF) count can predict the efficacy of neostigmine administration for rocuronium-induced blockade during propofol or sevoflurane anesthesia, and to follow subsequent recovery until the TOF ratio reached 0.9. One-hundred-sixty patients, divided into eight equal groups, were randomly allocated to maintenance of anesthesia with propofol or sevoflurane. The tactile response of the adductor pollicis to TOF stimulation was evaluated on one arm, and the mechanomyographic response was recorded on the other. Neuromuscular block was induced with rocuronium 0.6 mg/kg and maintained with rocuronium to 15% of the control first twitch in TOF. Neostigmine 0.07 mg/kg was administered on reappearance of the first (Group I), second (Group II), third (Group III), or fourth (Group IV) tactile TOF response in each anesthesia. At this time, sevoflurane or the propofol dosage was reduced in each group (n = 20 in each group). The times from administration of neostigmine until the TOF ratio recovered to 0.7, 0.8, and 0.9 were recorded. The times [median (range)] to TOF ratio = 0.9 were 8.6 (4.7-18.9), 7.5 (3.4-9.8), 5.4 (1.6-8.6), and 4.7 (1.3-7.2) min in Groups I-IV during propofol anesthesia, respectively, and 28.6 (8.8-75.8), 22.6 (8.3-57.4), 15.6 (7.3-43.9), and 9.7 (5.1-26.4) min in corresponding groups during sevoflurane anesthesia, respectively (P < 0.0001). We recommend more than 2 TOF responses with propofol anesthesia and 4 TOF responses with sevoflurane anesthesia for adequate reversal within 10 and 15 min, respectively. The more tactile TOF responses present at the time of reversal achieved greater adequate recovery; however, tactile TOF responses are not a completely reliable predictor within a reasonable time period.

Adolescent↗
PubMed2004

Xenon does not prolong neuromuscular block of rocuronium.

With the exception of xenon, the interaction between muscle relaxants and inhaled anesthetics is known. We therefore compared the pharmacodynamics of rocuronium during xenon anesthesia versus a total IV anesthesia with propofol. Anesthesia was induced with propofol and remifentanil in both the xenon and propofol groups (each n = 20). The xenon group received xenon via face mask until an end-expiratory concentration of 60% was maintained for 1 min. Meanwhile, the acceleromyograph (TOF-Watch SX(R)) was calibrated and a frequent train-of-four stimulation of the musculus adductor pollicis was started. After stabilization of the signal for 5 min, a single bolus of 0.6 mg/kg rocuronium was injected. Anesthesia was maintained with xenon and remifentanil (xenon group) or with propofol and remifentanil (propofol group). There were no significant differences between the groups concerning the onset time (xenon group 125 +/- 33 and propofol group 144 +/- 43 s), duration (xenon group 33.2 +/- 10.8 and propofol group 32.6 +/- 8.4 min), recovery index (xenon group 9.4 +/- 6.6 and propofol group 8.4 +/- 5.3 min), and clinical recovery (xenon group 18.0 +/- 10.2 and propofol group 17.1 +/- 8.5 min). We conclude that the neuromuscular blocking effects of rocuronium are not different when given during propofol versus xenon anesthesia.

Adolescent↗
PubMed2005

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

We compared the efficacy of IV fentanyl with IV lidocaine as pretreatment for the prevention of withdrawal response after rocuronium injection. For this prospective, randomized, placebo-controlled, double-blind study we recruited 90 patients aged between 18 and 65 yr, ASA physical status I or II, who had undergone elective surgery requiring general anesthesia and positive pressure ventilation. Patients were randomly allocated to 1 of 3 groups: group F received 2 mL IV fentanyl 50 microg/mL (100 microg), group L received 2 mL of preservative-free lidocaine 2% (40 mg), and group P (placebo) received 2 mL of normal saline. The incidence of withdrawal response after rocuronium was 57%, 30%, and 7% in the placebo, lidocaine, and fentanyl groups, respectively. We found a significant reduction in incidence of withdrawal response in both the fentanyl and lidocaine groups when compared with the placebo group (P < 0.05), with the fentanyl group being most effective (P < 0.05). In conclusion, both fentanyl and lidocaine are effective clinical treatments to alleviate the withdrawal response associated with rocuronium injection, with fentanyl being more effective.

Adolescent↗
PubMedDate not supplied

[Suicide by intravenous injection of rocuronium-bromide--case report].

Suicides by intravenous injection of an overdose of medicaments are uncommon. In this paper, we present the case of a suicide by rocuronium-bromide injection in combination with an oral overdose of metoprolol. Unfortunately, in Belgrade, there is no toxicological laboratory capable of detecting rocuronium. The interpretation of autopsy and toxicological data in this case was made difficult due to the extreme putrefaction of the body of the deceased. So, by forensic investigation, the case was solved indirectly, through circumstantial evidence: an empty ampoule of rocuronium found near the body, as well as a plastic syringe and cloth-bandage found in the left hand of the deceased.

Adult↗
PubMed2005

The effect of pretreatment with thiopental on reducing pain induced by rocuronium injection.

We examined whether pretreatment with a small dose of thiopental was effective in reducing pain induced by the intravenous injection of rocuronium. Withdrawal movement was used to assess pain reduction. Ninety patients were randomly assigned to one of two groups: patients in the control group were pretreated with 2 mL saline, and those in the thiopental group were pretreated with 2 mL (50 mg) thiopental. Thiopental 5 mg/kg was injected intravenously. After a loss of consciousness, the upper arm was compressed with a rubber tourniquet, and the pretreatment drugs were administered. Thirty seconds later the tourniquet was removed and 0.6 mg/kg rocuronium was administered. Withdrawal movement was assessed using a four-grade scale: no movement, movement limited to the wrist, to the elbow or to the shoulder. The frequency of withdrawal movement in the group pretreated with thiopental was lower than in the control group (34 vs. 13, p < 0.05). We concluded that pretreatment with 2 mL (50 mg) thiopental is effective in reducing pain caused by the intravenous injection of rocuronium.

Adult↗
PubMed1993

Clinical study of interaction between rocuronium and some commonly used antimicrobial agents.

The onset and duration of clinical relaxation and reversibility of rocuronium bromide (ORG 9426) 0.6 mg kg-1 were studied following administration of netilmicin 2 mg kg-1 (n = 10) or cefuroxime 20 mg kg-1 (n = 10) in patients undergoing urological surgery; and cefuroxime 20 mg kg-1 (n = 10) metronidazole 7.5 mg kg-1 (n = 10), metronidazole 7.5 mg kg-1 and cefuroxime 20 mg kg-1 (n = 10), or placebo (n = 10) in patients undergoing abdominal surgery under anaesthesia with thiopentone, nitrous oxide in oxygen, fentanyl and halothane. The antimicrobial agents were administered intravenously 5 min before rocuronium. Neuromuscular function was monitored using mechanomyography and train-of-four (TOF) mode of stimulation. Onset of neuromuscular block occurred in approximately 60 s with all patients achieving complete block. The mean clinical duration (+/- SD) was 50 +/- 10.7 and 44 +/- 6.7 min following netilmicin and cefuroxime respectively in patients undergoing urological surgery; and 49 +/- 13.7, 44 +/- 11.1, 48 +/- 11.1 and 38 +/- 7.3 min in the groups undergoing abdominal surgery receiving cefuroxime, metronidazole, cefuroxime and metronidazole combination and placebo respectively. There were no statistically significant differences between the groups in either the onset or the duration of clinical relaxation. Reversal of neuromuscular block with neostigmine carried out at spontaneous recovery of T1 (first response in the TOF) of 25% or more was easily achieved in all groups in 2-4 min. It is concluded that there is no significant interaction between rocuronium and single doses of the antimicrobial agents used in the present study.

Adolescent↗
PubMed2005

Variable designs of clinical trials of neuromuscular blocking agents: an example of studies comparing rocuronium and vecuronium.

BACKGROUND: Published clinical trials on neuromuscular blocking (NMB) agents are being reported with large variations in their protocols and conflictiing results may emerge from these differences. Because they have been compared in several clinical trials, the study was focused on rocuronium and vecuronium in order to evaluate whether these NMB agents were compared under homogeneous conditions. MATERIAL/ METHOD: A search was made in PubMed, Embase Drugs and Pharmacology, Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews. Studies on the neuromuscular response at the adductor pollicis to an i.v. bolus dose of rocuronium or vecuronium in humans were included. Quality of all reports was assessed by means of the 3-item Jadad et al. scale. Twenty-five studies met our inclusion criteria and all were retrieved. RESULTS: Randomization was performed in 21 (80.8%) studies. Blinding procedure for drug administration was mentioned in only one study without clarifying the procedure. Induction was most commonly performed with thiopental, followed by propofol. Two studies were performed in children and two in elderly patients. Withdrawals or dropouts were not mentioned in any paper. Electromyography and mechanomyography were the most common monitoring procedures. The time to maximal response, the maximum effect and the time to reach 25% recovery of neuromuscular function were the most used pharmacodynamic parameters. CONCLUSIONS: Clinical trials on neuromuscular blocking agents, e.g. vecuronium versus rocuronium, are being performed with large variability and without following established guidelines.

Adolescent↗
PubMed2006

[An overview of the pharmacokinetics and pharmacodynamics of rocuronium bromide].

For many years, much effort has been done to develop non-depolarizing neuromuscular blocking agents of rapid onset and short duration. It has been shown that rocuronium bromide is a nondepolarizing, steroidal muscle relaxant with fast onset and short-to-intermediate duration of action. In addition, rocuronium-induced neuromuscular blockade can be readily and consistently reversed following the administration of reversal agents. The pharmacology and pharmacodynamics of rocuronium bromide are summarized in this review.

Aged↗
PubMed2006

[Randomized, multicenter study of interaction between Org 9426 (rocuronium bromide) and anesthetic agents in Japanese population].

BACKGROUND: The purpose of this randomized, multi-center phase III trial was to investigate the influence of sevoflurane and propofol on the neuromuscular blocking effects and pharmacokinetic parameters of Org 9426 (rocuronium bromide) in Japanese population. METHODS: Thirty-nine adult Japanese patients participated in this randomized, multi-center study. Neuromuscular function was monitored continuously with TOF-Watch SX (Organon NV, Netherlands) after anesthetic induction with propofol. These subjects randomly received either 0.6 mg x kg(-1) or 0.9 mg x kg(-1) of rocuronium for endotracheal intubation. These two groups were further divided to two anesthetic regiments : sevoflurane group and propofol group. The difference in onset and recovery of rocuronium-induced neuromuscular block was statistically analyzed with two-way ANOVA. RESULTS: Mean duration for maximal block was 76 seconds and 66 seconds, respectively. The duration between Org 9426 administration and 25% recovery of first twitch response was significantly prolonged in patients given 0.9 mg x kg(-1) of Org 9426. Sevoflurane also significantly increased this duration. However, the serum concentration of Org 9426 was not statistically different between the four study groups. CONCLUSIONS: The duration of Org 9426-induced neuromuscular blockade was significantly increased under sevoflurane anesthesia compared to propofol anesthesia. This difference may be attributed to pharmacodynamic change.

Adult↗
PubMed1994

Neuromuscular and cardiovascular effects of neostigmine and methyl-atropine administered at different degrees of rocuronium-induced neuromuscular block.

The neuromuscular and cardiovascular effects of neostigmine, 40 micrograms kg-1, and methyl-atropine, 7 micrograms kg-1, administered at different degrees of rocuronium-induced (600 micrograms kg-1) neuromuscular block were evaluated. In one group of patients spontaneous recovery was awaited (Group A; n = 20). Neostigmine and methyl-atropine were administered 2 minutes after rocuronium (Group B; n = 20) or at 25% twitch recovery (Group C; n = 20). Neuromuscular transmission was monitored mechanomyographically. Data are presented as mean (SD) [95%-CI]. The initial rate of recovery (time until a TOF ratio of 0.2) in group B, i.e. 14.2 (4.5) [12.1-16.3] min, was significantly faster than in group C, i.e. 28.7 (5.3) [26.3-31.1] min. However, the time until clinically sufficient recovery (time until a TOF ratio of 0.7) was similar for groups B, i.e. 29.3 (9.5) [24.9-33.7] min and group C, i.e. 31.8 (5.6) [29.2-34.4] min, both significantly different from that of group A, i.e. 53.2 (14.5) [46.5-59.9] min. The increase in heart rate following neostigmine/methyl-atropine was more pronounced in the group reversed at 2 min after rocuronium (P < 0.01).

Adult↗
PubMed1994

[Mechanomyographic and electromyographic studies of endotracheal intubation with 2 different rocuronium dosages].

Rocuronium is a new, intermediate-acting, nondepolarizing relaxant with rapid onset of action leading to both good and very good intubation conditions. It was the aim of our study to investigate the onset of action, the intubation conditions and the course of relaxation using two different dosage regimes. Thirty consenting ASA 1 and 2 patients received either 0.6 mg/kg (2 x ED 95; group 1) or 0.06 mg/kg as priming dose followed by an intubating dose of 0.24 mg/kg rocuronium (group 2) four min later. Anaesthesia was induced with propofol (2 mg/kg) and alfentanil (0.02 mg/kg) and maintained with nitrous oxide/oxygen and propofol (6 to 8 mg/kg/h). Neuromuscular function was monitored mechanomyographically and electromyographically with TOF stimulation at the wrist every 10 seconds. Intubation conditions were determined using a semiquantitative score system, and times to 90% block (intubation time), maximum block (onset time) and recovery from neuromuscular blockade to 25%, 50%, 75% and 90% were calculated and comparisons were made between the corresponding results of the two groups. The intubation dose of 2 x ED 95 (group 1) was followed by a significantly shorter intubation time (39.1 +/- 9.6 sec.) than in group 2 with priming and an intubation dose of 0.24 mg/kg (50.7 +/- 11.0 sec). The intubation conditions showed no differences. In both groups they were good or very good. The clinical duration of action was significantly longer in group 1 (28.4 +/- 8.0 min) than in group 2 (14.8 +/- 2.5 min). It can be concluded that rocuronium which has shorter intubation times than atracurium and vecuronium is very useful for endotracheal intubation in both dosage regimes in long and very long lasting operations. Using the "priming principle" the patient has to be carefully controlled during priming time.

Adult↗
PubMed1994

Dose-response relationship of rocuronium bromide during intravenous anaesthesia.

The dose-response relationship and time course of neuromuscular block following bolus injections of rocuronium was determined in four groups of nine patients each under nitrous oxide-narcotic anaesthesia. Each patient received a total of 800 micrograms kg-1 rocuronium in two divided doses, i.e. 120 and 680, 200 and 600, 250 and 550, or 300 and 500 micrograms kg-1. The respective second dose was injected when, following the first dose, the evoked twitch tension had recovered to 95% of its control value. The mean ED50 and ED95 values, calculated from the first doses, were 103 and 271 micrograms kg-1, respectively. The DUR25 ranged between 11 +/- 4 (200 micrograms kg-1) to 14 +/- 3 min (300 micrograms kg-1) following the first and from 30 +/- 6 (500 micrograms kg-1) to 43 +/- 11 min (680 micrograms kg-1) following the second doses. The recovery index following the second doses varied between 14 +/- 5 (500 micrograms kg-1) and 24 +/- 20 min (600 micrograms kg-1), more than twice as long as following the first doses. We conclude that rocuronium is a muscle relaxant of low potency with an intermediate duration of action.

Adult↗
PubMed1994

Rocuronium--onset times and intubating conditions.

Many factors influence the minimum time required to achieve an easy and successful tracheal intubation after a non-depolarizing relaxant. The ideal study design has never been achieved in practice: an overall picture of the efficacy of rocuronium depends on careful interpretation of studies with different methodologies, which have usually compared the new drug with vecuronium or suxamethonium, currently the best alternatives. Despite lack of supporting animal data, the rapidity of onset of rocuronium in man appears to be due to an early presynaptic effect. Observations which are difficult to explain are that increasing the dose above about 2 x ED90 does not shorten the time to onset and 'priming' also has no beneficial effect. Although some studies have produced evidence that rocuronium can produce smooth easy intubation conditions in 60 s, 90 s would appear to be closer to the time when excellent conditions can be guaranteed. Whether this is an acceptable alternative to the 45 s or so needed after suxamethonium is a matter of clinical judgement which only testing in practice will answer.

Androstanols↗
PubMed1994

Pharmacokinetics of rocuronium bromide in paediatric patients.

Rocuronium 0.8 mg kg-1 was given to 22 children between the ages of 3 months and 8 years during anaesthesia with N2O/O2, 60:40, and halothane. Blood samples were collected for 360 min for determination of rocuronium concentrations. The pharmacokinetics were best described by a two-compartment model. Two models were fitted, one proportional to weight and the other adjusted for age. Using the first model, volumes and clearances were all proportional to weight: in the second model, only the volume of the second compartment and clearance from the central compartment were proportional to age. The results do not support the use of body surface area, rather than weight for the calculation of paediatric doses of rocuronium. In this study, the volume of the central compartment was larger than the figure obtained in an adult population.

Androstanols↗
PubMed1994

Pharmacokinetics and pharmacokinetic/dynamic relationship of rocuronium bromide in humans.

The existing human pharmacokinetic studies have been reviewed and compared with data derived from animals. The earliest study confirms the similarity of rocuronium to vecuronium with respect to the variables derived from the plasma concentration decay curves and the proportion excreted renally. Other studies led to the conclusion that concurrent administration of volatile anaesthetics did not significantly influence rocuronium pharmacokinetics and that the potentiation must be due to an increased sensitivity of the neuromuscular junction. These studies do not provide an explanation for the clinical observation of a more rapid onset of action. One possible explanation was the finding of a more rapid onset of block in the laryngeal muscles than in the adductor pollicis. However, no pharmacokinetic explanation for this observation has emerged. Alternative concepts need to be modelled. There is a need for comparative pharmacokinetic studies which focus on the period immediately following administration of rocuronium and vecuronium.

Age Factors↗