Rocuronium versus succinylcholine: are they equally effective during rapid-sequence induction of anesthesia? A large simple randomized trial of rocuronium versus succinylcholine in rapid-sequence induction of anaesthesia along with propofol. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases. Double-blind comparison of two doses of rocuronium and succinylcholine for rapid-sequence intubation. A mixture of mivacurium and rocuronium is comparable in clinical onset to succinylcholine. Rocuronium versus succinylcholine for rapid-sequence induction using a variation of the timing principle. Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial. Rocuronium combined with i.v. lidocaine for rapid tracheal intubation. Comparison of rocuronium and mivacurium to succinylcholine during outpatient laparoscopic surgery. Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia. Evaluation of the endotracheal intubating conditions of rocuronium (ORG 9426) and succinylcholine in outpatient surgery. Pharmacodynamics of rocuronium with and without prior administration of succinylcholine. Rocuronium versus succinylcholine-atracurium for tracheal intubation and maintenance relaxation during propofol anesthesia. Intraocular pressure changes during rapid sequence induction and intubation: a comparison of rocuronium, atracurium, and succinylcholine. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Effectiveness and safety of rocuronium-hypnotic sequence for rapid-sequence induction. [Intubation requirements after rocuronium and succinylcholine]. Different priming techniques, including mivacurium, accelerate the onset of rocuronium. Comparison of intubating conditions after rocuronium and suxamethonium following "rapid-sequence induction" with thiopentone in elective cases. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Onset of neuromuscular blockade and intubating conditions one minute after the administration of rocuronium in children. Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid-sequence induction using thiopentone and suxamethonium. The effect of rocuronium on intraocular pressure: a comparison with succinylcholine. Rocuronium priming of atracurium-induced neuromuscular blockade: the use of short priming intervals. Visual estimation of onset time at the orbicularis oculi after five muscle relaxants: application to clinical monitoring of tracheal intubation. Comparison of suxamethonium and different combinations of rocuronium and mivacurium for rapid tracheal intubation in children. Comparison of intubating conditions after administration of Org 9246 (rocuronium) and suxamethonium. Is there an ideal approach for rapid-sequence induction in hypertensive patients?
The purpose of our study was to assess the onset and quality of muscle paralysis and intubation conditions with succinylcholine (Sch) or rocuronium (Roc) during rapid-sequence induction. Patients were randomly assigned to receive thiopental (5 mg/kg) and Sch (1.5 mg/kg) or thiopental (5 mg/kg) and Roc (1.2 mg/kg). The anesthesiologists performing the endotracheal intubation were blinded by standing with their back to the patient. Thirty seconds after drug administration, laryngoscopy was performed. Intubating conditions were scored, the clinical onset of apnea was noted, and a train-of-four monitor recorded data. All patients were ASA physical status I-III and scheduled for emergency procedures; both groups were demographically similar. Thirteen patients received Roc and 13 received Sch. There was no significant difference between the two groups in the number of patients receiving excellent intubating scores (P = 0.41) or in the combined number of patients receiving good and excellent scores (P = 1.0). There was no significant difference in time of onset of apnea for Sch (22+/-13 s) versus Roc (16+/-8s). The return of the first twitch response was significantly faster with Sch (5.05+/-2.5 min) compared with Roc (17.3+/-21.7 min) (P = 0.0001).
                In pediatric patients scheduled for emergency surgery, thiopental 5 mg/kg and rocuronium 1.2 mg/kg provided conditions for the completion of intubation in <60 s comparable to those provided by thiopental 5 mg/kg and succinylcholine 1.5 mg/kg. We conclude that rocuronium is a reasonable substitute for succinylcholine in children for rapid-sequence intubation when a rapid return to spontaneous respiration is not desired. Rocuronium has an onset of action more rapid than other non-depolarizing neuromuscular blocking agents, but it is unclear whether it and succinylcholine give equivalent intubating conditions during rapid-sequence induction of anaesthesia. We performed this study to answer the question--are there clinically relevant differences between the use of rocuronium and succinylcholine to secure acceptable intubating conditions during rapid-sequence induction of anaesthesia with propofol?
                Anaesthesia was induced using propofol 2.5 mg/kg in 349 ASA physical status grade I-IV patients who were undergoing either elective or emergency surgery. Propofol was followed immediately by either rocuronium 0.6 or 1 mg/kg or succinylcholine 1.0 mg/kg (randomly selected). Fifty seconds after the end of muscle relaxant injection laryngoscopy was performed and intubating conditions were graded by an experienced anaesthetist blind to the muscle relaxant allocation. This study design was selected so that a 10% difference in clinically acceptable intubating conditions between drugs would be detectable.
                In this setting rocuronium 1.0 mg/kg provided superior intubating conditions compared with rocuronium 0.6 mg/kg. The incidence of clinically acceptable intubating conditions with rocuronium 1.0 mg/kg and succinylcholine 1.0 mg/kg was 93.2% and 97.1% respectively, the difference being -3.9% (95% C.I. -9.7% to 1.9%).
                Rocuronium 1.0 mg/kg given along with propofol in a rapid-sequence induction of anaesthesia is clinically equivalent to succinylcholine 1.0 mg/kg. When anesthesia is induced with propofol in elective cases, endotracheal intubation conditions are not different between succinylcholine and rocuronium approximately 60 s after the injection of the neuromuscular relaxant. In the present study, we investigated whether, in emergent cases, endotracheal intubation conditions obtained at the actual moment of intubation under succinylcholine differ from those obtained 60 s after the injection of rocuronium. One-hundred-eighty adult patients requiring rapid sequence induction of anesthesia for emergent surgery received propofol (1.5 mg/kg) and either rocuronium (0.6 mg/kg; endotracheal intubation 60 s after injection) or succinylcholine (1 mg/kg; endotracheal intubation as soon as possible). The time from beginning of the induction until completion of the intubation was shorter after the administration of succinylcholine than after rocuronium (median time 95 s versus 130 s; P < 0.0001). Endotracheal intubation conditions, rated with a 9-point scale, were better after succinylcholine administration than after rocuronium (8.6 +/- 1.1 versus 8.0 +/- 1.5; P < 0.001). There was no significant difference in patients with poor intubation conditions (7 versus 12) or in patients with failed first intubation attempt (4 versus 5) between the groups. We conclude that during rapid sequence induction of anesthesia in emergent cases, succinylcholine allows for a more rapid endotracheal intubation sequence and creates superior intubation conditions compared with rocuronium. To compare the pharmacodynamics of two commonly recommended doses of rocuronium bromide (0.7 mg/kg and 0.9 mg/kg) and succinylcholine (1.5 mg/kg) when used for rapid-sequence intubation.
                Prospective, double-blind, randomized study.
                Operating rooms at a university hospital.
                45 ASA physical status I and II adult patients scheduled for elective surgeries under general anesthesia.
                Nonpremedicated patients were anesthetized with fentanyl 2 mcg/kg followed by thiopental sodium 4 to 5 mg/kg and muscle relaxant using rapid-sequence technique. Group 1 (n = 15) received rocuronium bromide 0.7 mg/kg. Group 2 (n = 16) received rocuronium bromide 0.9 mg/kg, and Group 3 (n = 14) received succinylcholine 1.5 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxant.
                The case of intubation was scored using a scale of 1 to 4. Blood pressure and heart rate were measured beginning one minute before induction of anesthesia up to 5 minutes after intubation. Intubation scores were similar in groups 2 and 3 and were noted as good or excellent in all patients. Group 1 displayed a significantly lower intubation score than the other two groups; 60% were rated as poor. No significant differences in hemodynamic data were seen among the three groups.
                Rocuronium bromide at a dose of 0.9 mg/kg provides intubating conditions similar to succinylcholine 1.5 mg/kg at 1 minute. Intubating conditions at 1 minute following a 0.7 mg/kg dose of rocuronium are not as good as those following a 0.9 mg/kg dose of rocuronium or a 1.5 mg/kg dose of succinylcholine. To compare the clinical onset and duration of a combination of mivacurium and rocuronium with succinylcholine, and to determine the efficacy of this mixture for rapid tracheal intubation.
                Observer-blind prospective study.
                Teaching hospital.
                70 ASA status I and II patients having general anesthesia for elective surgery.
                After induction of general anesthesia, patients randomly received succinylcholine 1.0 mg/kg, rocuronium 0.6 mg/kg, or a combination of rocuronium 0.6 mg/kg and mivacurium 0.15 mg/kg. Evoked muscular response at the adductor pollicis was measured by mechanomyography. The time from injection of muscle relaxant(s) to ablation of T1 (clinical onset) and recovery of T1 to 25% of control height (clinical duration) was recorded. Intubating conditions 45 seconds after administration of muscle relaxants were assessed. There was no significant difference in clinical onset time between succinylcholine (mean +/- SD, 47.4 +/- 6.5 seconds) and the combination of mivacurium-rocuronium (51.2 +/- 13.4 seconds). Intubating conditions with mivacurium-rocuronium were comparable to those of succinylcholine. The clinical duration of rocuronium 0.6 mg/kg (38.9 +/- 12.3 minutes) was prolonged by the addition of mivacurium (49.0 +/- 9.6 minutes).
                This combination of mivacurium and rocuronium is comparable to succinylcholine in both clinical onset time and quality of intubating conditions. When rapid onset of dense neuromuscular blockade and intermediate clinical duration is desirable, this mixture may be an acceptable alternative to succinylcholine. To determine if, using a variation of the "timing" principle, 0.6 mg/kg of rocuronium can achieve an onset time and intubating conditions similar to those achieved with succinylcholine.
                Prospective, randomized, double-blind clinical comparison.
                Operating room in a university medical center.
                42 ASA physical status I and II patients undergoing general anesthesia for elective surgery.
                All patients were fitted with a Grass FT-10 force transducer attached to the thumb. Supramaximal stimulation was applied to the ulnar nerve with a variable current peripheral nerve stimulator. 22 patients (succinylcholine group) received a placebo bolus injection followed 20 seconds later by thiopental 4 to 5 mg/kg and succinylcholine 1 mg/kg; 20 additional patients (rocuronium group) received a bolus dose of rocuronium 0.6 mg/kg followed 20 seconds later by thiopental 4 to 5 mg/kg and a placebo bolus injection.
                We measured the onset time from administration of the muscle relaxant to 95% twitch reduction and assessed the quality of intubating conditions 60 seconds after the induction of anesthesia. There was a significant difference in the mean onset time of rocuronium (72 sec) versus succinylcholine (42 sec, p < 0.0001). However, there was no significant difference in intubating conditions 60 seconds after administration of thiopental.
                Rocuronium given 20 seconds prior to thiopental provides intubating conditions equivalent to thiopental-succinylcholine for rapid-sequence inductions, circumventing rocuronium's longer onset time to 95% neuromuscular blockade. Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microg/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group. Rocuronium (ORG 9426) has been shown to have an onset of action more rapid than other nondepolarizing neuromuscular blocking agents and to provide intubating conditions similar to those of succinylcholine 60-90 s after administration. We compared the intubating conditions and hemodynamic changes after the administration of rocuronium 0.6 mg kg(-1) and lidocaine 1.5 mg kg(-1) with rocuronium alone and succinylcholine 60 and 90 s after administration.
                One hundred and twenty-five adult patients of ASA physical status I or II scheduled for elective surgery were randomly divided into five groups. After propofol administration in all patients, patients in group Su (succinylcholine), group R60 (rocuronium) and group RL60 (rocuronium-lidocaine) were intubated within 60 s, while groups RL90 and R90 were intubated 90 s after the administration of rocuronium and succinylcholine. Laryngoscopy was performed and intubating conditions were graded by an experienced anesthetist blind to the muscle relaxant allocation.
                In this study, groups Su, RL60, R90 and RL90 had similar intubation scores, which were significantly better than that for group R60. Heart rate did not increase after intubation in groups Su, RL60 and RL90.
                The combination of lidocaine (1.5 mg kg(-1)) and low-dose rocuronium (0.6 mg kg(-1)) along with propofol is clinically equivalent to succinylcholine, improves intubating conditions in 60 s and effectively blocks increases in heart rate after intubation. Tracheal intubating conditions and neuromuscular effects of succinylcholine, rocuronium, and mivacurium were studied in 100 healthy women undergoing outpatient laparoscopic surgery. After a standardized fentanyl-thiopental induction, tracheal intubation was facilitated with succinylcholine 1 mg/kg in Groups I (n = 23) and II (n = 25), rocuronium 0.6 mg/kg in Group III (n = 27), or mivacurium 0.2 mg/kg in Group IV (n = 25). If clinically indicated, bolus doses of rocuronium 5-10 mg (Groups I and III) or mivacurium 2-4 mg (Groups II and IV) were administered during the maintenance period. Anesthesia was maintained with desflurane and nitrous oxide 60% in oxygen. At the end of the surgery, residual neuromuscular block was reversed with edrophonium 0.5 mg/kg and atropine 10 micrograms/kg, if needed. The neuromuscular function was assessed using electromyography with a train-of-four mode of stimulation every 10 s at the wrist. Intubating conditions 90 s after succinylcholine and rocuronium were significantly better than after mivacurium. The onset time (from the end of injection until 95% suppression of the first twitch [T1]) for succinylcholine (63 +/- 21 s and 62 +/- 17 s in Groups I and II, respectively) were significantly shorter than for rocuronium (158 +/- 76 s) or mivacurium (210 +/- 93 s). Moreover, the onset times for rocuronium were significantly shorter than mivacurium. The recovery times (of T1 to 25% of the control value) were significantly shorter with succinylcholine and mivacurium than rocuronium. Significantly fewer patients needed reversal of residual neuromuscular blockade after mivacurium compared to rocuronium. One patient in Group I and six patients in Group IV displayed erythema on the upper body. Postoperative myalgia were experienced by 16% of the patients in Groups I and II compared to none in Groups III and IV. There was on difference in the incidence of postoperative nausea and vomiting among the four groups. In conclusion, rocuronium appears to be an acceptable alternative to succinylcholine for tracheal intubation. However, rocuronium's longer duration of action increases the need for reversal drugs. When rapid tracheal intubation is unnecessary, mivacurium is also an acceptable alternative to succinylcholine and is associated with a more rapid spontaneous recovery than rocuronium. We have compared the effect of rocuronium and succinylcholine on intraocular pressure (IOP) during rapid sequence induction of anaesthesia using propofol and fentanyl, in a randomized double-blind study. We studied 30 adult patients, allocated to one of two groups. Anaesthesia was induced with fentanyl 2 micrograms kg-1 and propofol until loss of verbal response. This was followed by succinylcholine 1.5 mg kg-1 (group S; n = 15) or rocuronium 0.9 mg kg-1 (group R; n = 15). Laryngoscopy was performed 60 s later. IOP, mean arterial pressure (MAP) and heart rate (HR) were measured before induction, immediately before intubation and every minute after intubation for 5 min. A Keeler Pulsair air impulse tonometer was used to measure IOP and the mean of two readings obtained in the right eye at each measurement time was recorded. Intubating conditions were evaluated according to a simple scoring system. IOP in the succinylcholine group was significantly greater than that in the rocuronium group (mean 21.6 (SEM 1.4) mm Hg vs 13.3 (1.4) mm Hg; P < 0.001). Intubating conditions were equally good in both groups. We conclude that with rapid sequence induction of anaesthesia using propofol and fentanyl, rocuronium did not cause as great an increase in IOP as succinylcholine and may be an alternative in open eye injury cases. The time-course of action and tracheal intubating conditions of rocuronium and succinylcholine under intravenous anesthesia with propofol, alfentanil, and nitrous oxide were studied in 30 patients undergoing outpatient surgery. The neuromuscular effects of both drugs were quantified by recording the indirectly evoked twitch response of the adductor pollicis muscle after ulnar nerve stimulation (0.1 Hz, 0.2 ms supramaximal stimuli). Patients were given either 0.6 mg/kg rocuronium (n = 20) or 1 mg/kg succinylcholine (n = 10) intravenously. Sixty seconds after the administration of the muscle relaxant, the trachea was intubated and the intubating conditions were scored by a "blinded" assessor. Intubating conditions were not different (P = 0.34) between the rocuronium and succinylcholine groups. The onset and duration of neuromuscular blockade were shorter with succinylcholine than with rocuronium. The depression of the twitch response to 5% of control value occurred in 0.8 +/- 0.1 min with 1 mg/kg succinylcholine and 1.2 +/- 0.5 min with 0.6 mg/kg rocuronium (P less than 0.01). The recovery of the twitch response to 25%, 75%, and 90% of its control value was shorter after succinylcholine (P less than 0.001) and occurred at 8.1 +/- 2.6, 10.3 +/- 3.9, 11.3 +/- 4.6 and 25.3 +/- 5.0, 33.1 +/- 5.9, 36.1 +/- 6.3 min after succinylcholine and rocuronium, respectively. Also the time required for spontaneous recovery from 25% to 75% of the control twitch response was significantly shorter (P less than 0.001) after succinylcholine (2.2 +/- 1.4 min) than after rocuronium (7.8 +/- 2.1 min). It is concluded that in spite of the pharmacodynamic differences between succinylcholine and rocuronium, the intubating conditions after administration of both compounds are similar and develop at the same rate. To compare succinylcholine (S) and rocuronium (R) used for endotracheal intubation, and to assess the possible action of S on subsequently administered R.
                Double-blind, randomized, phase III study.
                University Medical Center.
                24 ASA physical status I and II patients, ages 28 to 65, undergoing general anesthesia for abdominal procedures.
                Double-blind administration of R 600 mcg/kg (Group A) or S 1 mg/kg was achieved with open label R 150 mcg/kg. Standardized general anesthetic technique with sodium thiopental, fentanyl, and nitrous oxide in oxygen was administered.
                Neuromuscular junction was tested by ulnar nerve stimulation and mechanomyograph. Intubation was attempted at 80% first twitch depression of train-of-four. Heart rate and blood pressure were recorded throughout. Onset times were 74 +/- 37 seconds for S and 130 +/- 46 seconds for R. Intubation times were 76 +/- 29 seconds for S and 85 +/- 23 seconds for R (no significant difference). Good to excellent intubation conditions were achieved in both groups. S given prior to R decreased onset time and increased duration of R, when compared with R given alone. No drug related cardiovascular events were noted.
                Rapid intubation conditions can be obtained after both S and R. Given its overall safety profile, R can be used when S is contraindicated, or in healthy patients with no apparent difficult airway, when procedures are expected to last more than 25 minutes. To compare the onset and offset time (clinical duration), and intubating conditions obtained with rocuronium bromide 0.6 mg/kg and succinylcholine 1.0 mg/kg after induction with propofol and fentanyl; and to compare rocuronium with atracurium for maintenance during propofol anesthesia.
                Prospective, open-label, parallel group comparative, randomized study.
                Operating rooms of a university hospital.
                30 ASA physical status I and II adult patients scheduled for elective surgeries with general anesthesia.
                Patients premedicated with midazolam 2 mg were anesthetized with fentanyl 2 microg/kg followed by propofol 2.5 mg/kg and muscle relaxants. Group 1 (n = 15) received succinylcholine 1.5 mg/kg and Group 2 (n = 16) received rocuronium bromide 0.6 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxant. Patients in Group 1 received atracurium and patients in Group 2 received rocuronium for maintenance if required.
                The ease of intubation was scored using a scale of 1 to 4. Onset and offset time monitored with evoked twitch response of the adductor pollicis were recorded.
                Intubation was successful in all patients and there was no difference in scores between the two groups. Although onset time was shorter with succinylcholine than with rocuronium, neuromuscular blockade was successfully antagonized in both groups, and the recovery profile was not different between the two groups.
                Rocuronium bromide at a dose of 0.6 mg/kg, when used with propofol and fentanyl for induction, provides intubating conditions similar to succinylcholine 1.0 mg/kg at 1 minute. The actual onset time and offset time, however, are significantly longer with rocuronium. There was no difference between atracurium and rocuronium as a maintenance drug. Rocuronium is suitable for surgical procedures greater than 30 minutes, eliminating the need for an additional relaxant to succinylcholine. To compare changes in intraocular pressure (IOP) during rapid sequence induction and intubation following rocuronium, succinylcholine, and atracurium.
                Open-label, prospective, randomized study.
                Operating room at the Eye Foundation Hospital (University of Alabama at Birmingham)
                45 ASA physical status I, II, and III patients, aged 18 to 65 years, scheduled for elective eye surgery with general anesthesia.
                Anesthesia was rapidly induced in unpremedicated patients with a fixed combination of midazolam 0.025 mg/kg, alfentanil 0.025 mg/kg, and propofol 1.5 mg/kg. Intubation was performed, as clinically indicated, approximately 60 seconds following administration of rocuronium 0.6 mg/kg, atracurium 0.5 mg/kg, or succinylcholine 1 to 1.5 mg/kg.
                Intraocular pressure was measured before induction of anesthesia (baseline), following anesthesia induction and administration of muscle relaxant (before intubation), and after intubation. The percent change in IOP from baseline was significantly decreased in the rocuronium group compared with the succinylcholine group (p = 0.046) before intubation. This trend continued after intubation, but the difference was no longer significant (p = 0.070). Intubation scores for rocuronium and succinylcholine groups were similar, and both scores were superior to that for the atracurium group (p = 0.002).
                Intraocular pressure can be controlled during emergency induction of anesthesia and intubation with adequate depth of anesthesia and muscle relaxation. Rocuronium, succinylcholine, and atracurium all provided sufficient muscle relaxation to achieve successful intubation and no increase in IOP. However, rocuronium 0.6 mg/kg provided significantly better intubating conditions compared with atracurium, and it resulted in a significantly greater decrease in IOP compared with baseline than succinylcholine. Succinylcholine has been the agent of choice when clinical conditions require emergency airway protection during a rapid-sequence induction of anesthesia. Rocuronium, a new nondepolarizing muscle relaxant with a brief onset of action, but devoid of the adverse reactions associated with succinylcholine, may be an alternative to succinylcholine. To test this hypothesis, the authors compared rocuronium with succinylcholine and vecuronium for rapid-sequence induction of anesthesia.
                Fifty patients, ASA 1-3, were randomly designated to receive one of three intravenous doses of rocuronium (0.6, 0.9, and 1.2 mg/kg), vecuronium (0.1 mg/kg), or succinylcholine (1.0 mg/kg). Patients were premedicated with midazolam and fentanyl, and received 2-7 mg/kg thiopental for induction of anesthesia. Sixty seconds after receiving a muscle relaxant, intubation of the trachea was attempted by a clinician who was blinded to the muscle relaxant administered. Neuromuscular monitoring was established before administration of the muscle relaxant. The time from injection of muscle relaxant until complete ablation of T1 (onset) and recovery of T1 to 25% (duration) were recorded. Tracheal intubating conditions were evaluated, and the presence or absence of fasciculations was noted.
                Onset times for patients receiving 0.9 mg/kg (75 +/- 28 s) and 1.2 mg/kg rocuronium (55 +/- 14 s), and succinylcholine (50 +/- 17 s) were similar. Onset times for the groups given 0.6 mg/kg rocuronium (89 +/- 33 s) and vecuronium (144 +/- 39 s) were significantly longer. Clinical duration of action was longest with 1.2 mg/kg rocuronium, similar with 0.6 and 0.9 mg/kg rocuronium, and vecuronium, and least with succinylcholine.
                There is a dose-dependent decrease in onset time with rocuronium. The onset times for the two larger doses of rocuronium were similar to that for succinylcholine, but clinical duration of action with rocuronium was significantly longer. The brief onset time achieved with rocuronium indicates that administration of 0.9-1.2 mg/kg is an acceptable alternative to succinylcholine for rapid-sequence induction of anesthesia. Either succinylcholine or rocuronium administered after a hypnotic is the current technique for rapid-sequence induction. It is assumed that rocuronium administered before a hypnotic (Rocuronium-hypnotic sequence) may equally provide an acceptable intubation condition as well as a shorter period of apnea in rapid-sequence induction. We designed a prospective, randomized study to evaluate the effectiveness and safety of the technique in a similar rapid-sequence induction.
                Ninety adult patients receiving elective surgeries were enrolled in this study. In all patients the procedure in the study began with i.v. injection of fentanyl 2 micrograms/kg, followed by preoxygenation with 100% O2 for 2 min. Afterward, the patients were randomly allocated to 3 groups with each group consisting of 30 patients. In Rocuronium-thiopental (Ro-Th) group the patients received rocuronium 0.6 mg/kg and then thiopental 5 mg/kg; in Th-Ro group the patients received thiopental 5 mg/kg and then rocuronium 0.6 mg/kg; and in Thiopental-Succinylcholine (Th-Sx) group, the control group, the patients received thiopental 5 mg/kg and then succinylcholine 1 mg/kg. Laryngoscopy and endotracheal intubation were performed 60 s after the injection of the muscle relaxant. The intubation condition, the apneal time before laryngoscopy, the intubation time, and total apneal time were investigated and compared. Presence of injection pain, sense of paralysis, SpO2 less than 95% during induction, and any unexpected adverse event were also recorded.
                Six patients (1 in Ro-Th group, 2 in Th-Ro group, and 3 in Th-Sx group, respectively) were excluded from the study. The intubation conditions were acceptable in all patients of three groups who completed the study, and as to excellent intubation condition there was no difference between the three groups. In Ro-Th group both the apneal time before laryngoscopy (32.4 +/- 5.4 s) and total apneal time (48.5 +/- 11.0 s) were the shortest. Th-Ro group (53.2 +/- 5.8 and 67.5 +/- 8.3 s, respectively) and Th-Sx group (54.4 +/- 5.8 and 68.4 +/- 7.7 s, respectively) were similar in both aspects. With respect to intubation time there was no significant difference among the three groups. Five patients in Ro-Th group and one patient in Th-Sx group felt mild injection pain. Three patients in Ro-Th group were noted to have diminished breathing during induction, which was not recalled during enquiry in the postoperative visit. One patient in Ro-Th group saw a fall of SpO2 down below 95% (94% the minimal) during the apnea period.
                Compared with traditional hypnotic-rocuronium or hypnotic-succinylcholine sequence, rocuronium (0.6 mg)-thiopental sequence can provide a similar intubation condition but cause a much shorter apneal period in rapid-sequence induction. In carrying out recuronium-thiopental sequence induction, maintaining a patent infusion line is essential to avoid drug precipitation and awareness of muscular weakness as a result of ill-timed action of thiopental. Rocuronium is a new non-depolarising steroidal muscle relaxant with a short onset time. The present study was undertaken to compare intubating conditions as well as onset and clinical duration of a single dose of 0.6 mg/kg (2 x ED95) with a single dose of 1 mg/kg suxamethonium (3 x ED95).
                After obtaining informed consent and approval of the Ethics Committee, 40 adult patients (ASA I-III) participated in this study. After premedication with oxazepam, anaesthesia was induced with fentanyl and propofol and maintained with propofol, N2O and supplements of fentanyl as needed. Muscular relaxation was assessed by EMG recording of adductor pollicis muscle after supramaximal single twitch stimulation of the ulnar nerve every 10 s. Patients were allocated randomly to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg. The following parameters were measured: intubating conditions 60 s after injection, onset time and clinical duration of neuromuscular block, % block at intubation, heart rate, blood pressure and arterial oxygen saturation.
                (mean +/- SD). Intubating conditions after rocuronium and suxamethonium were found to be clinically acceptable (excellent or good) in 90% of patients, though there was only a partial blockade of the adductor pollicis muscle with rocuronium (71 +/- 23%) compared to suxamethonium (95 +/- 14%) (p < 0.05). The onset time and clinical duration of relaxation was shorter after suxamethonium (p < 0.05) and occurred at 0.8 +/- 0.2, 7 +/- 2.1 and 3.2 +/- 1.3, 29 +/- 11 min after suxamethonium and rocuronium respectively.
                At a dosage of 0.6 mg/kg, rocuronium has an onset time of about 3 min and a clinical duration of relaxation of nearly half an hour. These data are supported by various studies, while others show shorter times, probably due to different monitoring techniques. In spite of the pharmacodynamic differences between suxamethonium and rocuronium, the intubating conditions after administration of both compounds are comparable and develop at the same rate. Different priming sequences of equipotent doses of rocuronium and mivacurium on the onset of maximum neuromuscular block and intubating conditions were compared with those obtained after succinylcholine. During thiopentone-fentanylnitrous oxide anaesthesia, 70 patients were randomly assigned into seven groups. Group I received mivacurium 0.15 mg.kg-1 as a single bolus dose. Group II received a priming dose of mivacurium 0.015 mg.kg-1 followed three minutes later by mivacurium 0.135 mg.kg-1. Group III received rocuronium 0.6 mg.kg-1 as a single bolus dose, and Group IV received an initial dose of rocuronium 0.06 mg.kg-1 followed by rocuronium 0.54 mg.kg-1. Group V received a priming dose of mivacurium 0.015 mg.kg-1 followed by rocuronium 0.54 mg.kg-1. Group VI received an initial dose of rocuronium 0.06 mg.kg-1 followed by mivacurium 0.135 mg.kg-1. Group VII received succinylcholine 1.0 mg.kg-1. Groups I, III, and VII received a placebo injection before the administration of the neuromuscular blocking drug. Additional thiopentone 2 mg.kg-1 iv was given 30 sec before intubation. Onset times (mean (95% confidence interval)) after priming a rocuronium block with either rocuronium (73 (57-90) sec) or mivacurium (58 (47-69) sec) were similar to those after succinylcholine (54 (40-68) sec), and were shorter (P < 0.01) than that observed in other groups. Intubating conditions were not different between the groups. The duration of neuromuscular block was shortest with succinylcholine. It is concluded that priming a rocuronium block with either mivacurium or rocuronium resulted in a neuromuscular block comparable to that of succinylcholine in both the onset of action and intubating conditions. Rocuronium (Org 9426) was shown to have the fastest onset of action of all currently available non-depolarizing neuromuscular blocking drugs and to provide intubating conditions similar to those of suxamethonium 60 to 90 s after administration. We compared the intubating conditions after rocuronium and suxamethonium following rapid-sequence induction of anaesthesia.
                Fifty unpremedicated patients of ASA physical status I or II, scheduled for elective surgery were studied. Anaesthesia was induced with thiopentone 6 mg kg-1 followed randomly by suxamethonium 1 mg kg-1 or rocuronium 0.6 mg kg-1 and, 45 s later, intubation was commenced. Muscle fasciculations, intubating conditions and intubation time, haemodynamic variables and oxygenation were assessed.
                Intubation time did not differ between suxamethonium (9.8 +/- 2.2 s) (mean +/- SD) and rocuronium (10.5 +/- 2.9 s), respectively. Intubating conditions were clinically acceptable (good or excellent) in all patients given suxamethonium and in 96% of the patients given rocuronium. However, the condition of the vocal cords was better (P < 0.05) and diaphragmatic response to intubation was less pronounced with suxamethonium (P < 0.05). Changes in heart rate and arterial blood pressure were similar in both groups.
                The authors conclude that rocuronium is a suitable alternative to suxamethonium for rapid tracheal intubation even under unsupplemented thiopentone anaesthesia, at least in elective, otherwise healthy patients. Its use for rapid-sequence induction under emergency conditions, however, needs further investigation. This study was designed to compare the tracheal intubating conditions during a rapid sequence induction of anaesthesia using rocuronium 0.6 (n = 61) or 1.0 mg.kg-1 (n = 130) or suxamethonium 1.0 mg.kg-1 (n = 127) as the neuromuscular blocking drugs. Anaesthesia was induced with fentanyl 1-2 micrograms.kg-1 and thiopentone 5 mg.kg-1 (median dose) and intubating conditions were assessed 60s after the administration of the neuromuscular blocking drug by an observer unaware of which drug had been given. Intubating conditions were graded on a three-point scale as excellent, good or poor, the first two being considered clinically acceptable. The study was carried out in two parts. At the end of the first part a comparison between the two doses of rocuronium was carried out when at least 50 patients had been enrolled in each group. The results showed the intubating conditions to be significantly superior with the 1.0 mg.kg-1 dose of rocuronium (p < 0.01). Final comparison between the 1.0 mg.kg-1 doses of rocuronium and suxamethonium showed no significant difference in the incidence of acceptable intubations (96 and 97%, respectively). The incidence of excellent grade of intubations was, however, significantly higher with suxamethonium (80% vs. 65%; p = 0.02). It is concluded that rocuronium 1.0 mg.kg-1 can be used as an alternative to suxamethonium 1.0 mg.kg-1 as part of a rapid sequence induction provided there is no anticipated difficulty in intubation. The clinical duration of this dose of rocuronium is, however, 50-60 min. In a blinded randomized study intubating conditions were compared at one min following intravenous induction with propofol and either suxamethonium 1.0 mg.kg-1, or rocuronium 0.6 mg.kg-1. Onset time to maximal twitch depression, % block at one minute and clinical duration (time to 25% recovery) were measured. Sixty children undergoing elective tonsillectomy were recruited. Onset time [42s (SD 11s)] and clinical duration [3.3 min (SD 1.0 min)] in the suxamethonium group was significantly (P < 0.001) less than in the rocuronium group [92s (41s)] and [24.2 min (6.6 min)] respectively. The median twitch height at one minute for suxamethonium was 0% (range 0-8%) and significantly greater (P < 0.001) at 5% (range 0-22%) for rocuronium. Despite this there was no difference in the intubating conditions at one minute with 25 excellent/5 good in the suxamethonium group and 27 excellent/3 good in the rocuronium group. We conclude that rocuronium 0.6 mg.kg-1 gives optimal intubating conditions at one minute in children. We have assessed the effect of anaesthetic technique on intubating conditions after rocuronium 0.6 mg kg-1 in four groups (n = 25 each) of unpremedicated patients in whom anaesthesia was induced with either thiopentone 5 mg kg-1 or propofol 2.5 mg kg-1 alone, or supplemented with alfentanil 20 micrograms kg-1. Fifty control patients were anaesthetized with thiopentone followed by suxamethonium. Laryngoscopy was commenced at 45 s. Overall intubating conditions after rocuronium were similar to those after suxamethonium (good and excellent > or = 96%) only when alfentanil was part of the induction regimen. However, intubation time was similar in all five groups and averaged 55 (SD 3.2) s, and the tube could be passed through open vocal cords within 70 s. After rocuronium the response of the diaphragm to intubation was more pronounced in the two groups of patients not receiving alfentanil (P < 0.0001) and in patients anaesthetized using propofol with alfentanil (P < 0.01) than in the control group. Opioids (in doses equivalent to alfentanil 20 micrograms kg-1) constitute an integral part of an induction regimen containing rocuronium 0.6 mg kg-1, regardless of whether or not thiopentone or propofol is used, in order to achieve overall intubating conditions similar to those after suxamethonium. nan To evaluate the effects of priming doses of rocuronium on the duration of priming interval and on the outcome of priming sequence using rocuronium-atracurium combination.
                Three phase, randomized, controlled study.
                Inpatient anesthesia in a university hospital.
                144 ASA physical status I and II patients, 19 to 57 years of age, weighing 50 to 90 kg, and undergoing low-risk elective surgery.
                Phase I, two equal groups (n = 12) of adult patients anesthetized with propofol, fentanyl, and nitrous oxide (N2O), received a priming dose of rocuronium 0.1 mg/kg or vecuronium 0.015 mg/kg. Phase II included six equal groups (n = 12): Groups 1, 2, and 3 received a priming dose of rocuronium 0.1 mg/kg and atracurium 0.42 mg/kg for intubation. The priming intervals were, respectively, 1, 1.5, or 2 minutes in Groups 1, 2, and 3. Groups 4, 5, and 6 received, respectively, a bolus dose of rocuronium 0.6 mg/kg, atracurium 0.5 mg/kg, or succinylcholine 1 mg/kg. Intubation was performed at maximum block. Phase III included four equal groups (n = 12). A priming dose of rocuronium 0.1 mg/kg (Group 1) or a placebo (Groups 2, 3, and 4) was given to awake patients. Anesthesia was induced during the one-minute priming interval. Intubating doses of atracurium 0.42 mg/kg, rocuronium 0.6 mg/kg, atracurium 0.5 mg/kg, or succinylcholine 1 mg/kg were given to Groups 1, 2, 3, and 4, respectively. Intubation was attempted 1 minute after intubating doses were administered.
                Adductor pollicis response to train-of-four stimulation was recorded mechanically in Phases I and II only. The priming interval after rocuronium 0.1 mg/kg was in the range of 1 to 2 minutes. Priming doses of rocuronium resulted in significant acceleration in the onset time of intubating doses of atracurium, irrespective of the duration of the priming interval. The onset times [mean (SD)] following rocuronium-atracurium sequence in Groups 1, 2, and 3 were, respectively, 67 (17), 73 (14), and 66 (18) seconds and were comparable with the onset of bolus doses of rocuronium and succinylcholine. In Phase II, good to excellent intubating conditions were obtained in 41% to 58% of patients included in Groups 1 through 5. Excellent to good intubating conditions were obtained in all patients (100%) who received succinylcholine. In Phase III, good to excellent intubating conditions were obtained in 91% of patients who received recuronium-atracurium sequence. Symptoms of muscle weakness were not reported.
                Priming doses of recuroniums 0.1 mg/kg reduce the priming interval to 1 minute, allow early induction of anesthesia, eliminate patient discomfort, and accelerate the onset time of altracurium with intubating conditions comparable with succinylcholine and rocuronium. The onset time of neuromuscular blockade at the adductor pollicis (AP) is different among neuromuscular blocking drugs, but these discrepancies had never been studied at the orbicularis oculi (OO). The purpose of this study was to verify if the differences in onset time observed at the AP still existed at the OO and to score the intubating conditions using monitoring at the OO after five muscle relaxants. The study included 172 adults aged 18-75 yr. Anesthesia was induced with fentanyl and propofol. Atracurium (0.5 mg/kg), mivacurium (0.20 mg/kg), rocuronium (0.6 mg/kg), succinylcholine (1.0 mg/kg), or vecuronium (0.08 mg/kg) was injected by random allocation. Time to complete disappearance of the response at the OO was assessed visually after train-of-four stimulation of the facial nerve. Laryngoscopy was then performed, and intubating conditions were determined on a scale of 1-4. Results were based on 150 patients. Onset time at the OO was (mean +/- SD): succinylcholine (57 +/- 17 s) < mivacurium (99 +/-19 s) = rocuronium (99 +/- 47 s) < atracurium (129 +/-33 s) = vecuronium (135 +/- 38 s) (P < 0.05). Overall intubating conditions were excellent (84%), good (14%), poor (1.3%), impossible (0.7%), and were similar among the five groups. We conclude that differences in onset time of muscle relaxants observed at the AP were also found at the OO. Visual estimation of the response at the OO correctly predicted good-to-excellent intubating conditions in more than 90% of cases for all the currently available muscle relaxants.
                Onset time of neuromuscular blockade, as estimated visually at the orbicularis oculi, depends on the muscle relaxants given. Regardless of the relaxant used, intubating conditions at loss of orbicularis oculi are acceptable. The use of suxamethonium in children is associated with undesirable side effects. The synergistic effect of a rocuronium-mivacurium combination can be considered as an acceptable alternative to suxamethonium in clinical practice. The calculated ED50 of the rocuronium-mivacurium mixture was only 62% of the predicted value assuming a purely additive interaction. The use of this combination has not been evaluated in children. In this two-part study, we assessed the intubating conditions and pharmacodynamics of suxamethonium, rocuronium, mivacurium or a rocuronium-mivacurium combinations in children. We studied 120 ASA I children of both sexes, aged 3-10 yr. Children were premedicated with trimeprazine 2 mg kg-1 orally, and received fentanyl 2 micrograms kg-1 and propofol 2 mg kg-1 for induction of anaesthesia. They were allocated randomly to receive one of the following drugs or drug combinations: suxamethonium 1.0 mg kg-1, mivacurium 0.2 mg kg-1, rocuronium 0.6 or 0.9 mg kg-1, mivacurium 0.1 mg kg-1 with rocuronium 0.3 mg kg-1 or mivacurium 0.15 mg kg-1 with rocuronium 0.45 mg kg-1. In part 1, 60 s after administration of the neuromuscular blocking drug or drug combination, tracheal intubation was performed in 60 children by mimicking rapid sequence induction, and intubating conditions were evaluated by a blinded investigator according to a standard score. In part 2, neuromuscular monitoring was established before administration of neuromuscular blocking agent(s) and the time from injection of drug or drug combination until complete ablation of T1 (onset) and recovery of T1 to 25% (duration) were recorded in another 60 children. The frequency of distribution of excellent or good intubating conditions in the higher dose of rocuronium and the combination groups were similar to those in the suxamethonium group, but significantly different (P < 0.05) from those in the mivacurium group. Mean onset time was faster in the suxamethonium (55.1 (SD 11.4) s), rocuronium 0.9 mg kg-1 (70.5 (37.7) s), mivacurium 0.1 mg kg-1 with rocuronium 0.3 mg kg-1 (67 (35.9) s) and mivacurium 0.15 mg kg-1 with rocuronium 0.45 mg kg-1 (55 (26.7) s) groups compared with the mivacurium 0.2 mg kg-1 (116 (26.8) s) and rocuronium 0.6 mg kg-1 (97.9 (29) s) groups. This study demonstrated that the combination of rocuronium 0.45 mg kg-1 and mivacurium 0.15 mg kg-1 could possibly be considered as an acceptable alternative to suxamethonium when rapid sequence induction of anaesthesia is indicated in children because it provides uniform excellent intubating conditions and complete neuromuscular block in < 60 s. 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. To compare 4 different anesthesia induction protocols, in a simulated model of rapid-sequence induction, in controlled hypertensive patients.
                Prospective, randomized, double-blind, clinical investigation.
                Large metropolitan university hospital.
                120 ASA II-III adult hypertensive patients.
                Patients were allocated to 4 groups at random. After preoxygenation for 3 minutes, induction and tracheal intubation was performed in a 30 degrees head-up position. Thiopental (5-7 mg/kg) was the induction agent. Study groups were as follows: group LS (n = 30), lidocaine (1.5 mg/kg) and succinylcholine (1 mg/kg); group LR (n = 30), lidocaine (1.5 mg/kg) and rocuronium (1 mg/kg); group RS (n = 30), remifentanil (1 microg/kg) and succinylcholine (1 mg/kg); group RR (n = 30), remifentanil (1 microg/kg) and rocuronium (1 mg/kg). Patients were intubated 60 seconds after administration of muscle relaxant.
                Hemodynamic data were obtained before induction (baseline), after induction, at intubation, and at 1, 3, 5, and 10 minutes after intubation. More than 20% change in blood pressure and heart rate was considered significant.
                Systolic and mean arterial blood pressures at intubation and 1 and 3 minutes after intubation were higher in group LS compared with groups RS and RR (P < 0.01). Mean arterial blood pressure decreased after induction in groups LS, LR, and RR, but increased at intubation and 1 minute after intubation in groups LS and LR (P < 0.01). Mean arterial blood pressure was similar at all measurement intervals in group RS. The median area under the systolic, mean, and diastolic blood pressure time curves was higher in groups LS and LR compared with groups RS and RR (P < 0.05 and P < 0.01).
                Remifentanil is a better adjunct for attenuation of the response to laryngoscopy and intubation compared with lidocaine, whereas remifentanil-succinylcholine combination appears to be more beneficial in terms of hemodynamic stability in hypertensive patients.
Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent and clinically acceptable intubating conditions.