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Quantification of the neuromuscular blocking agent rocuronium and its putative metabolite 17-desacetylrocuronium in heparinized plasma by capillary gas chromatography using a nitrogen sensitive detector.

We have developed a sensitive and specific capillary GC (cGC) assay for the quantification of the quarternary aminosteroidal compound rocuronium (roc), a neuromuscular blocking agent, and its putative metabolite 17-desacetylrocuronium (17OH-roc), using 3-desacetylvecuronium (3OH-vec) as an internal standard (I.S.). This novel method has been applied to a pharmacokinetic study with roc, monitoring sixty patients who were classified according to four different body mass index (BMI) groups. The isolation of these drugs from plasma was carried out using a dichloromethane liquid-liquid extraction after ion-pairing of the positively charged ammonium compounds with iodide. To achieve thermal stability, tert.-butyldimethylsilyl-ethers were formed at the 3OH- and 17OH-steroidal positions by reaction with N-methyl-N-(tert.-butyldimethylsilyl)-trifluoroacetamide at 70 degrees C overnight. An automated cGC system fitted with a nitrogen sensitive detector with a specially prepared glass phase bead and a computer controlled data handling system was used to analyze and quantify the compounds, which were separated on a DB1 capillary column with helium as the carrier gas and a temperature program ranging from 120 to 300 degrees C. The method is linear for 50-6400 ng/ml for roc and 80-6400 ng/ml for 17OH-roc. The detection limits were 10 ng/ml for roc and 50 ng/ml for 17OH-roc. The lower limit of quantification was 50 ng/ml for roc and 80 ng/ml for 17OH-roc. Intra-assay coefficients of variation (C.V.s) were 10% and 15% and the inter-assay C.V.s 8-18% and 16-21% for roc and 17OH-roc, respectively.

Androstanols↗

[Severe anaphylactic reactions after administration of rocuronium].

The authors report four cases of severe anaphylactic reactions (grade III or IV) to rocuronium bromide. In three of them, it was the first contact with a muscle relaxant. In three patients the reaction was mediated by IgE anti-bodies. A cross-reactivity with other muscle relaxants was existing in two cases (suxamethonium, vecuronium and atracurium in one patient, suxamethonium, vecuronium and pancuronium in the other.

Adult↗

[Anaphylaxis after rocuronium: advantage of blood tests for early diagnosis].

A 56-year-old patient was scheduled for coronary artery bypass surgery, because of a severe coronary artery disease. Soon after induction of anaesthesia, he rapidly developed a cardiovascular collapse with bronchospasm and rash. Specific immunoglobulin E and tryptase measurements supported the diagnosis of grade III anaphylactic shock due to rocuronium bromide. A few days later, a general anaesthesia was administered without muscle relaxant and was uneventful.

Anaphylaxis↗

Anaphylactic reactions during induction of anaesthesia using rocuronium for muscle relaxation: a report including 3 cases.

Anaphylaxis during induction of anaesthesia is a dreaded complication with a mortality rate of 3-6%, most frequently associated with the use of muscle relaxants. Current knowledge on this matter is reviewed in relation to the presentation of 3 cases of anaphylaxis and bronchospasm associated with the use of the recently released nondepolarizing muscle relaxant rocuronium. Bronchospasm may be the sole sign of a serious drug reaction, triggered by precipitation of insoluble thiopental crystals when mixed with a muscle relaxant in the intravenous (iv) line. It is recommended that these drugs are administered via different injection ports. The hypotension requires immediate treatment with oxygen, epinephrine and large amounts of iv fluids. Epinephrine infusion may be needed for hours. It is recommended that serum tryptase is measured approximately 2 h after debut of the serious drug reaction. Allergy testing should be performed for all the drugs the patient was exposed to, 4-8 weeks after the incident, and due to cross-reactivity, including all available muscle relaxants. Doctors are urged to inform their patients, and systematically register adverse drug reactions.

Adult↗

Prehospital tracheal intubating conditions during rapid sequence intubation: rocuronium versus vecuronium.

INTRODUCTION: The study purpose was to evaluate tracheal intubating conditions and cardiovascular effects of rocuronium (roc) and vecuronium (vec) in the transport setting. METHODS: A prospective blinded study of adult patients requiring emergency rapid sequence oral tracheal intubation using direct laryngoscopy. Patients received equipotent doses of roc 1.0 mg/kg (n = 44) or vec 0.15 mg/kg (n = 56) on an alternate day basis. RESULTS: Intubation was successful in 95% of patients in the vec group and 100% in the roc group. The percentage of patients having good or excellent jaw relaxation and vocal cord exposure was similar between groups (vec/79%, roc/77%). Eleven patients (vec/7, roc/4) had difficult intubation as evidenced by Grade III or IV view and more than three attempts. Five patients in the vec group had inadequate neuromuscular blockade versus 1 patient in the roc group (P = 0.17). No cardiovascular differences occurred between groups after intubation. CONCLUSION: Tracheal intubating conditions and clinical evidence of complete neuromuscular blockade tended to be better after roc than after vec.

Adult↗

Comparison of intubating conditions after administration of Org 9246 (rocuronium) and suxamethonium.

We have assessed intubating conditions after administration of Org 9426 (rocuronium) 600 micrograms kg-1 at 60 or 90 s in groups of 20 patients anaesthetized with thiopentone, nitrous oxide in oxygen and small doses of fentanyl, and compared the data with those obtained after suxamethonium 1 mg kg-1 in similar groups of patients. The influence of prior suxamethonium administration on the potency of Org 9426 was studied also by constructing a dose-response curve. Intubating conditions after Org 9426 were found to be clinically acceptable (good or excellent) in 95% of patients at 60 s and in all patients at 90 s and in all patients at both times after suxamethonium. The average time for the onset of block following Org 9426 at this dose was 89 s (which is shorter than with any of the currently available non-depolarizing neuromuscular blocking drugs); the duration of clinical relaxation (25% recovery of twitch height) 30 min. Prior administration of suxamethonium did not appear to influence the potency of Org 9426.

Adolescent↗

The clinical effect of mixing different proportions of rocuronium and mivacurium.

BACKGROUND: A synergistic effect has been described when rocuronium (Roc) and mivacurium (Miv) are combined in equal (i.e. 1:1) ED95 proportions at various total doses. We have investigated the effect of Roc or Miv alone and four different ratios (1:4, 2:3, 3:2 and 4:1) of Roc and Miv mixed to a total dose of 1.33 x ED95. The primary outcome is the ratio producing the maximum enhancement of duration of clinical effect. METHODS: Sixty-eight healthy children were anaesthetized with propofol, nitrous oxide and fentanyl. They then randomly received either Roc 0.4 (mg.kg(-1)), Miv 0.133 (mg.kg(-1)) or one of four Roc + Miv combinations (mg.kg(-1)): Roc 0.32 + Miv 0.027; Roc 0.24 + Miv 0.053; Roc 0.16 + Miv 0.08; and Roc 0.08 + Miv 0.106. The mechanical response of the adductor pollicis muscle to supramaximal stimulation of the ulnar nerve at the wrist was recorded. RESULTS: Duration of effect was greater in the combination groups than that predicted from the duration of Roc or Miv used alone. Duration was maximally increased around a 1:1 ratio (2:3 and 3:2) of Roc and Miv. The likelihood of achieving 100% block was greater in combination groups compared with Roc or Miv used alone. CONCLUSIONS: Combinations of Roc and Miv show a synergistic effect, which appears maximal as the mixture approaches a 1:1 ratio of their ED95s. This combination acted as if a larger effective dose of a single (new) drug had been given, but did not offer the advantage of both rapid onset and short duration of effect.

Analysis of Variance↗

Use of low-dose rocuronium for intubation of children during volunteer surgery abroad.

BACKGROUND: Low-dose rocuronium (ROC) might improve safety during volunteer surgery abroad (VSA) by facilitating intubation with a lower halothane concentration than is typically used. We hypothesized that 0.25 mg.kg(-1) of ROC would improve intubation conditions during 3% halothane induction and still allow for rapid return to spontaneous ventilation (SV). METHODS: During Operation Smile's 2002 mission to Honduras, patients aged 3 months-11 years were randomized to receive ROC 0.25 mg.kg(-1) (n = 19), or placebo (n = 23). Induction was with 3% halothane in 100% O(2), with ventilation assisted and controlled when possible, and normocarbia maintained. An i.v. was placed after induction, and ROC or placebo given. Direct laryngoscopy (DL) was performed 3 min later by a blinded laryngoscopist who assessed conditions according to predetermined criteria. RESULTS: Adequate intubation conditions occurred in 89 and 87% of patients (P = 0.59), and mean times from DL until the return to SV were 9.8 and 4.3 min (P = 0.003), in the ROC and placebo groups, respectively. For the placebo group, the presence of SV at DL was predictive of inadequate intubation conditions (P = 0.006). CONCLUSIONS: When administering 3% halothane for induction of VSA patients, a high frequency of adequate intubation conditions can be achieved without a relaxant, rendering the known benefits of 0.25 mg.kg(-1) of ROC unapparent. ROC 0.25 mg.kg(-1) does allow rapid return to SV.

Age Factors↗

Succinylcholine or rocuronium? A meta-analysis of the effects on intubation conditions.

This meta-analysis was undertaken to compare the effects of succinylcholine (SCH) and rocuronium (RCR) on endotracheal intubation (ETI) conditions. Eligible randomised controlled trials (RCTs) were identified via medline and a manual search of references. The frequencies of excellent and unacceptable ETI conditions in subjects receiving SCH 1.0-1.5 mg/kg and RCR 0.6-1.2 mg/kg were determined using standard statistical methods. Inclusion criteria were met by 16 RCTs, representing 1362 subjects. SCH was associated with a 17.7% increase (95% CI = 13-22) in the frequency of excellent ETI conditions and a 5.1% decrease (95% CI = -7.3 to -2.9) in the frequency of unacceptable ETI conditions, when compared with RCR. In the subgroup undergoing true rapid sequence intubation, SCH was associated with a 19.1% increase (95% CI = 13.7-24.5) in the frequency of excellent ETI conditions. SCH appears to be superior to RCR in creating excellent ETI conditions and avoiding unacceptable ETI conditions.

Androstanols↗

Bispectral index during modified rapid sequence induction using thiopentone or propofol and rocuronium.

This randomized controlled trial compared Bispectral Index (BIS) values in 40 patients after a modified rapid sequence induction using thiopentone 4 mg/kg or propofol 2 mg/kg with rocuronium 0.6 mg/kg as muscle relaxant. Endotracheal intubation was performed at 60 seconds from induction of anaesthesia and BIS values were recorded for three minutes after induction. At the 120, 150 and 180 second measurements there was a significantly greater proportion of subjects with BIS values < or = 60 ("anaesthetized") in the propofol group compared with the thiopentone group (P values < 0.02, < 0.01 and < 0.01 respectively). All intubations were completed within two minutes. No explicit recall of intubation was detected clinically with either induction agent. The BIS scores we have measured suggest that thiopentone 4 mg/kg is more likely to be associated with lighter planes of anaesthesia and consequent risk of awareness than propofol 2 mg/kg, if intubation is delayed or prolonged.

Adult↗

[Comparative assessment of rocuronium bromide and cysatracurium besylate used during endosurgical operations in children].

The authors have studied the effects of the muscular relaxants rocuronium bromide and cysatracurium besylate on neuromuscular conduction, respiration mechanics, and hemodynamics in 120 children during endosurgical operations. The paper comparatively assesses the muscular relaxants and the procedures of their use, which made it possible to ensure controlled and deep relaxation.

Adolescent↗

[Neuromuscular blocking effects, pharmacokinetics and safety of Org 9426 (rocuronium bromide) in Japanese patients].

BACKGROUND: The purpose of this study was to examine pharmacodynamics, pharmacokinetics and safety of Org 9426 (rocuronium bromide) in Japanese patients. METHODS: Seventy-eight patients anesthetized with thiopental, droperidol, fentanyl and nitrous oxide, were randomized to receive either a single dose of Org 9426 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1). Contraction of the adductor pollicis to the ulnar nerve stimulation (0.1 Hz) was measured by acceleromyography. Blood was sampled over 6 hr and pharmacokinetic variables were calculated by plasma concentrations of Org 9426. RESULTS: Onset times for patients receiving 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1) were 271.5 s, 140.0s and 125.4s, respectively. There was a dose-dependent increase in clinical durations until 25% recovery of twitch height (17.4 min in 0.3 mg x kg(-1) group, 37.2 min in 0.6 mg x kg(-1) and 60.4 min in 0.9 mg x kg(-1) group). Pharmacokinetic study revealed that elimination half life, steady state volume of distribution and plasma clearance of Org 9426 were 48-76 min, 146-181 ml x kg(-1), and 3.8-4.5 ml x min(-1) x kg(-1), respectively. No adverse effects were found except a case of local erythema on a forearm. CONCLUSIONS: The efficacy of neuromuscular block, stable pharmacokinetic behavior and excellent safety of Org 9426 were also confirmed in Japanese surgical patients.

Adult↗

[Effects of sevoflurane and propofol on neuromuscular blocking action of Org 9426 (rocuronium bromide) infused continuously in Japanese patients].

BACKGROUND: The purpose of this study was to investigate the interaction of anesthetic agents with Org 9426 (rocuronium bromide) infused continuously. The effect of intubation dose of Org 9426 on its infusion rate was also investigated. METHODS: Total of 38 Japanese patients were randomly allocated either to receive intubation dose of 0.6 or 0.9 mg x kg(-1) of Org 9426. These patient groups were anesthetized with either sevoflurane or propofol. Infusion of Org 9426 was started with the initial infusion rate of 7 microg x kg(-1) x min(-1) when T1 reappeared after the intubation dose. The infusion rate was adjusted to keep the height of T1 between 3-10% of the control value. RESULTS: The rates of infusion 90 min after the start of infusion were 3.4, 7.5, 3.9 and 7.7 microg x kg(-1) x min(-1) for the 0.6 mg x kg(-1)-sevoflurane, 0.6 mg x kg(-1) propofol, 0.9 mg x kg(-1)-sevoflurane and 0.9 mg x kg(-1) propofol groups, respectively. Sevoflurane significantly reduced the infusion rate with both intubation doses. The mean infusion rates of 0.9 mg x kg(-1) groups were slower than those of 0.6 mg x kg(-1) groups up to 60 min after the start of infusion. Mean clearance of Org 9426 during infusion was not different between sevoflurane and propofol anesthesia. CONCLUSIONS: Patients receiving sevoflurane anesthesia required a markedly lower Org9426 infusion rate compared with patients receiving propofol anesthesia.

Adult↗

The use of rocuronium and sevoflurane in acute intermittent porphyria--a case report.

Acute intermittent porphyria (AIP) is an inherited metabolic disorder caused by deficiency of porphobilinogen deaminase, an enzyme found in the synthetic pathway of heme. Acute attack of AIP may be precipitated by many factors during operation and anesthesia, including fasting, dehydration, stress, infection, and drugs. Acute attack of AIP is likely fatal. Therefore, the drugs recommended as being safe in anesthesia for porphyria patients are up-to-dately refreshed and renovated and the identification of whether a drug is safe or not is based on cumulative anecdotal experiences. Here, we report the safe use of rocuronium and sevoflurane for long exposure in a patient affected with acute intermittent porphyria.

Androstanols↗

Safety aspects of non-depolarizing neuromuscular blocking agents with special reference to rocuronium bromide.

The safety of neuromuscular relaxants can be assessed according to their cardiovascular and autonomic effects, their liability to release histamine, their tendency to cause anaphylactic/anaphylactoid reactions, their effect on cholinesterase, on intra-ocular and intracranial pressure, their tendency to cumulation and their reversibility. Any adverse effects of metabolites are also potential problems. Against these standards, rocuronium may have some mild vagolytic activity. Apart from that, its safety profile is indistinguishable from that of vecuronium.

Androstanols↗

Interactions of volatile anaesthetics with rocuronium bromide in perspective.

A review of several publications shows that there is general agreement that inhalational anaesthetic agents potentiate the neuromuscular effects of rocuronium in the same order as other similar agents, namely; enflurane and isoflurane > halothane > intravenous anaesthetics. However, such potentiation is not evident during induction and only becomes significant as anaesthesia becomes more prolonged. It is manifest as a prolongation in the duration of action of maintenance doses and a decrease in the recovery rate. During long-lasting procedures in which enflurane or isoflurane are used, smaller than usual maintenance doses or lower infusion rates should be employed.

Androstanols↗

Comparison of haemodynamic effects of rocuronium bromide with those of vecuronium in patients undergoing CABG surgery.

In a double-blind study, cardiovascular parameters (cardiac output, heart rate, systolic and diastolic arterial pressure, pulmonary and systemic vascular resistances) were measured invasively in two groups of patients receiving 3 x ED90 of rocuronium or vecuronium. Measurements were made at 2, 5 and 7 min after administration and 10 and 15 min after subsequent intubation. Systemic vascular resistance mostly increased, sometimes quite markedly, although, because of the variability, rarely statistically significantly. However, heart rate, arterial pressure and cardiac output were not altered to a clinically relevant degree.

Adolescent↗

Pharmacodynamics and pharmacokinetics of rocuronium following continuous infusion in patients during intravenous anaesthesia.

After an initial bolus dose (0.6 mg kg-1), 10 patients received a continuous infusion of rocuronium, initially at 0.5 mg kg-1h-1, and then adjusted to maintain 90% twitch depression. Blood samples were analysed for 420 min after switching off the infusion. The dose required to maintain the block was 595 +/- 146 micrograms kg-1h-1, 7-9 times that reported for vecuronium under similar conditions. The pharmacokinetic parameters (volume of distribution at steady state, 309 +/- 80 ml kg-1, plasma clearance 4.5 +/- 1.96 ml kg-1 min-1, and elimination half-life 107 +/- 37 min) were similar to those previously reported after a large single bolus.

Adult↗