They found that of the 401 intubations, 333 (83%) were accomplished on the first, 57 (14.2%) on the second, 9 (2.2%) on the third, and 2 (0.5%) on the fourth attempt. No periprocedural death occurred.
More than one intubation attempt was required in 32/ 200 patients under Succinylcholine and in 36/201 patients under Rocuronium (P = 0.4). In 77/200 (39%) patients of the Succinylcholine group, fasciculations were not visible or had not ceased 45 sec after the injection of the drug.
The duration of the intubation sequence which was significantly shorter (P = 0.002) in the succinylcholine group (81 ± 38 sec) than in the Rocuronium group (95 ± 48 sec). Intubation was not completed within 90 sec in 50/200 patients under succinylcholine and 67/201 patients under Rocuronium (P = 0.048).
The numerical sub-scores for ease of laryngoscopy (succinylcholine 2.75 ± 0.45; Rocuronium 2.75 ± 0.46; P = 0.84) and conditions of the vocal cords (succinylcholine 2.61 ± 0.52; Rocuronium 2.67 ± 0.56; P = 0.32) did not differ between the groups while there was a small, but significant difference in the sub-score of the response to intubation (succinylcholine 2.97 ± 0.20; Rocuronium 2.86 ± 0.36; P = 0.001). The overall numerical score for intubation conditions (succinylcholine 8.3 ± 0.8; Rocuronium 8.2 ± 0.9; P = 0.7) did not differ between the groups.
The mean intubation sequence was 14 sec shorter after succinylcholine than after rocuronium. Succinylcholine and rocuronium resulted in similar intubation conditions and a similar incidence of intubation related complications.
In contrast to various other studies done in the elective operation, theatre settings, this study showed no significant difference in intubating conditions between Rocuronium and Succinylcholine
Abu-Halaweh SA et al8 in their study found that intubating conditions after 1 mg/kg of Rocuronium Bromide were found to be acceptable (good and excellent) in 95% of patients and were similar to the Succinylcholine group (97%). The endotracheal tube could be passed through the vocal cards of all patients enrolled in the study.
They concluded that Rocuronium Bromide 1mg/kg can be safely used for rapid sequence induction in cesarean section and the intubating conditions are similar to those of Succinylcholine.
Mencke et al did a randomised, prospective controlled trial in which they investigate the incidence and severity of Postoperative Hoarseness, Sore Throat, Vocal Cord Injury and Post Operative Myalgia in patients requiring a RSI after administration of rocuronium 0.6 mg/kg. These data were compared with those after the administration of succinylcholine 1.0 mg/kg.
Tracheal intubation was successful in all patients of both groups. Time of intubation, number of attempts, and Cormack and Lehane grades did not differ significantly between study groups.
The rate of excellent intubating conditions was significantly more frequent in the Succinylcholine group compared with the Rocuronium group: 42 (57%) versus 16 patients (21%), respectively (P 0.001). Similar results were noted for clinically acceptable (excellent and good) intubating conditions: 66 (89%) versus 45 patients (59%), respectively (P 0.001).
With the above graphs and values, this study concluded that the rate of excellent and clinically acceptable intubating conditions during a RSI was significantly more frequent in the succinylcholine group compared with the rocuronium group.
Larsen PB et al conducted a study to compare the overall intubating conditions of standard doses of rocuronium 0.6 mg/kg and succinylcholine 1.0 mg/kg during a strict rapid sequence induction regimen including propofol and alfentanil.
Intubation was performed by a blinded anaesthesiologist 60 seconds after injection of neuromuscular blocking drug.
During a one year prospective cohort study, 578 patients were intubated out of whom 521 underwent RSI. Of these, 382 received Succinylcholine as the neuromuscular blocking agent and 138 received Rocuronium as the neuromuscular blocking agent.
Three 10 point Numeric Descriptor Scales were used, similar to that used by Mencke et al.
The first was to grade the extent of body movement. The second was for vocal cord movement. The third was for the intubating physicians overall satisfaction with the environment provided by the neuromuscular agent used.
In this study, it was found that adequate intubating conditions were achieved with both the neuromuscular agents used in under one minute. A difference of five seconds to time of paralysis was found in the Succinylcholine group which is of statistical significance but has no clinical significance as such.
During a rapid-sequence induction with alfentanil and propofol, both rocuronium 0.6 mg/kg and succinylcholine 1.0 mg/kg provide clinically acceptable intubation conditions in 60 s in patients scheduled for emergency surgery.
Sluga et al5 in their prospective, randomised trial 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.
Using a 9-point grading system for intubation conditions (Table 1), a difference of at least 1.0 points was considered to be of clinical relevance. The grading system used was similar to the one used by Mencke et al.
Scores for endotracheal intubation conditions were significantly higher in the succinylcholine group than in the rocuronium group (8.6 1.1 versus 8.0 1.5; P 0.001). This difference resulted almost exclusively from a difference in the subscore rating the response to intubation (2.8 0.5 versus 2.3 1.0; P 0.0001), whereas there was no difference in the subscores for laryngoscopy (2.9 0.3 versus 2.9 0.3; P 0.91) and vocal cords (2.9 0.4 versus 2.8 0.6; P 0.23). Figure 3 depicts the scores for intubating conditions.
The figure below shows that compared to the rocuronium group, the succinylcholine group showed better intubating conditions.
They found that 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. Hence they concluded 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.
Lam AM et al Prospective, open-label, parallel group comparative, randomized study 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.
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.
Laurin et al did a one year prospective chort comparison study To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED).
They concluded that Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance.
.
Methodology
A clinical study comparing Rocuronium Bromide 0.9 mg/kg and 1.2 mg/kg with succinylcholine chloride 1.5 mg/kg for use in rapid sequence intubation of anaesthesia in adult patients was undertaken at KG Hospital, Coimbatore during the period from November 2015 to October 2017 after obtaining clearance from the ethical committee.
The study population consisted of 90 adult patients of ASA grade I and II belonging to both sexes in the age group of 18 to 60 years who were posted for various elective surgeries at KG Hospital. Informed consent was obtained from the patients before taking up for surgery. Exclusion criteria consisted of patients with hypertension, diabetes, bronchial asthma, ischaemic heart disease or anticipated difficult airway.
The study population was randomly divided using computer generated numbers into three groups with 30 patients in each group.
Group I consisting of 30 patients were to receive succinylcholine chloride
1.5 mg/kg body weight and intubation attempted at 60 seconds.
Group II consisting of 30 patients were to receive rocuronium bromide
0.9mg/kg body weight and intubation attempted at 60 seconds.
Group III consisting of 30 patients were to receive rocuronium bromide
1.2 mg/kg body weight and intubation attempted at 60 seconds.
A thorough preanaesthetic evaluation was done a day before surgery and all the necessary investigations were done to rule out any systemic disease. Tablet alprazolam 1 mg and Tablet pantoprazole 40 mg were administered to all patients on the night before surgery. Patients were maintained nil per oral for a duration of 6 hours prior to surgery for solids and two hours prior to surgery for clear liquids.
On the day of surgery, the patient was shifted to the operating room. An
intravenous line was secured with an appropriate sized intravenous cannula and the
patient was connected to multichannel monitor consisting of pulse oximeter,
3 lead electrocardiogram, non-invasive blood pressure and side stream capnography.
To test the efficacy of drugs for use during emergency surgeries, a technique
mimicking rapid sequence induction was employed in patients posted for elective
surgeries.
The baseline heart rate, oxygen saturation, electrocardiogram, systolic,
diastolic, mean arterial blood pressure and capnogram were recorded using Siemens
SC7000 monitor.
Injection pentazocin 15 mg and injection midazolam 1 mg were given to all
patients 3 minutes prior to administering induction agent.
All patients were preoxygenated with 100% oxygen via a face mask for 3 minutes
after administering pentazocin and midazolam. They were induced with injection
thiopentone sodium 5 mg kg-1 body weight intravenously.
In all patients, cricoid pressure was applied after the administration of induction agent when the patients become unconscious.
In group I, succinylcholine chloride 1.5 mg/kg body weight was given intravenously after the loss of eyelash reflex.
Similarly in group II and group III, rocuronium bromide 0.9 mg/kg and
1.2 mg/kg respectively was given intravenously after the loss of eyelash reflex. No mask
ventilation was done in any patient after administration of relaxant.
In all the three groups of patients, oral endotracheal intubation was attempted at
60 seconds following the administration of muscle relaxant and intubating conditions
were graded using the score.
Excellent = Jaw relaxed, vocal cords apart and immobile, no diaphragmatic
movements.
Good = Jaw relaxed, vocal cords apart and immobile, some diaphragmatic
movements.
Poor = Jaw relaxed, vocal cords moving and bucking.
Inadequate = Jaw not relaxed, vocal cords closed.
All the patients were intubated with well lubricated appropriate sized oral polyvinylchloride endotracheal tubes (cuffed), bilateral air entry was checked by five point auscultation and the tube was firmly secured.
Maintenance of anaesthesia was done with 50% oxygen and 50% nitrous oxide and IPPV on Bain’s circuit.
Monitoring of vital parameters like heart rate, oxygen saturation, systolic, diastolic and mean arterial blood pressures, electrocardiogram, capnogram were recorded 1, 3 and 5 minutes following intubation.
The clinical duration of action that is the time from administration of relaxant to first attempt at respiration of initial bolus doses of succinylcholine chloride and rocuronium bromide was noted. Subsequently, the muscle relaxation was maintained with vecuronium bromide 0.04 mg kg-1 body weight till the end of surgery.
At the end of surgery all the patients were reversed with injection neostigmine 0.05 mg kg-1 body weight and injection atropine 0.02 mg kg-1 body weight.
Other side effects like histamine releasing properly associated with administration of rocuronium bromide and succinylcholine chloride were also noted.
The haemodynamic parameters in the present study were compared statistically using p value obtained from student t-test.
RESULTS
Age distribution
The age distribution of all patients of all the three groups is as shown below.
Table 18
Age groups Group I % Group II % Group III %
(n = 30) (n = 30) (n = 30)
18-30 years 12 40 17 56.67 17 56.67
31-40 years 10 33.34 9 30 10 33.33
41-50 years 7 23.33 4 13.34 3 10
51-60 years 1 3.33 – – – –
Mean age 34.5 years 30.43 years 33.03 years
Maximum age 55 years 50 years 50 years
(case no. 19) (case no. 4) (case no. 22)
Minimum age 18 years 18 years 22 years
(case no. 30) (case nos. 9, 22) (case no. 5)
Sex distribution
The following table shows the sex distribution in the three groups.
Table 19
Sex Group I % Group II % Group III %
(n = 30) (n = 30) (n = 30)
Male 9 30 18 60 10 33.34
Female 21 70 12 40 20 66.66
FIGURE 4: GRAPH SHOWING INTUBATION SCORE
30 30 29
25
Number of 20 16
15 13
patients 10
5 1 1
0
t d r e
n o o t
e o o a
l u
l G P
e q
c e
x d
E a
n
I
Scores
Group I (n = 30)
Group II (n = 30)
Group III (n = 30)
Weight distribution
The following table shows the weight distribution of the three groups.
Table 20
Weight Group I % Group II % Group III %
(n = 30) (n = 30) (n = 30)
35-45 kg 9 30 4 13.33 10 33.33
46-55 kg 13 43.33 12 40 16 53.33
56-65 kg 6 20 12 40 4 13.34
66-75 kg 2 6.67 2 6.67 – –
Mean weight 51.34 kg 54.16 kg 49.13 kg
Maximum weight 68 kg 71 kg 63 kg
(case nos. 10, 12) (case no. 1) (case no. 24)
Minimum weight 41 kg 35 kg 40 kg
(case nos.15, (case no. 9) (case nos. 4, 8, 12,
18,23,27) 16)
Intubation Score
(based on the scale adopted by Toni Magorian et al. (1993))
Table 21
Scores Group I (n = 30) Group II (n = 30) Group III (n = 30)
No. of % No. of % No. of %
patients patients patients
Excellent 30 100 16 53.33 29 96.67
Good – – 13 43.33 1 3.33
Poor – – 1 3.34 – –
Inadequate – – – – – –
As it is seen in the table 21, in group I patients who received succinylcholine chloride 1.5 mg kg-1 body weight, all patients (30) had excellent intubating conditions with jaw relaxed, vocal cords apart and immobile and no diaphragmatic movements.
In group II, who received rocuronium bromide 0.9 mg kg-1 body weight 16 patients (53.33%) out of 30 had excellent intubating conditions, 13 (43.33%) patients had good intubating conditions with vocal cords apart and immobile and some diaphragmatic movements on intubation. One patient (3.34%) (case no. 4) in group II had poor intubating condition with vocal cords moving and bucking after intubation. Even in this patient who had poor intubating condition, intubation was possible at 60 seconds as the jaw was relaxed. Altogether in group II, 96.67% of patients, i.e. 29 patients out of 30 had excellent to good intubating conditions at 60 seconds.
In group III patients, who received rocuronium bromide 1.2 mg kg-1 body weight, 29 (96.67%) patients out of 30 had excellent intubating conditions with 1 (3.33%) patient (case no. 9) having good intubating condition. There was no case of failed intubation at 60 seconds in any of the three groups.
Duration of action of succinylcholine chloride
Table 22
Duration No. of patients Percentage
3-5 min 17 56.67
5.1-7 min 12 40
7.1-9.0 min 1 3.33
Mean duration 4.77 0.99 minutes
Maximum duration 8.25 minutes (case no. 11)
Minimum duration 3.5 minutes (case no. 3)
Duration of action of rocuronium bromide 0.9 mg kg-1 body weight
Table 23
Duration No. of patients Percentage
20-25 minutes 4 13.33
26-30 minutes 24 80
31-35 minutes 2 6.67
Mean duration 27.4 2.14 minutes
Maximum duration 32 minutes (case no. 6)
Minimum duration 22 minutes (case no. 4)
Duration of action of rocuronium bromide 1.2 mg kg-1 body weight
Table 24
Duration No. of patients Percentage
40-45 min 17 56.67
46-50 min 8 26.66
51-55 min 5 16.67
Mean duration 45.33 3.73 minutes
Maximum duration 52 minutes (case nos. 15, 30)
Minimum duration 40 minutes (case nos. 19, 27)
FIGURE 5: GRAPH SHOWING MEAN HEART
RATE
120 286. 9785. 4387. 3117. 37118. 67115. 03104. 23104. 53102. 8389. 7389. 2390.
100
Beats per 80
60
Group I
minute
40 Group II
Group III
20
0
Pre One minute Three Five minute
induction after minute after after
intubation intubation intubation
Mean Heart rate (beats/min)
Table 25
Group I Group II Group III
Succinylcholine Rocuronium bromide Rocuronium bromide
chloride 1.5 mg kg-1 0.9 mg kg-1 1.2 mg kg-1
Beats per % Beats per % Beats per %
minute minute minute
Pre induction 86.20 85.97 87.43
SD=9.539 SD=11.577 SD=10.109
SEm=1.742 SEm=2.114 SEm=1.846
One minute after 117.30 +36.07 118.37 +37.69 115.67 +32.28
intubation SD=11.721 SD=12.254 SD=8.770
SEm=2.140 SEm=2.237 SEm=1.601
Three minute 104.03 +20.68 104.23 + 21.25 102.53 +17.27
after intubation SD=10.156 SD=10.177 SD=8.513
SEm=1.854 SEm=1.858 SEm=1.554
Five minute after 89.83 +4.21 89.73 +4.38 90.23 +3.20
intubation SD=9.374 SD=10.279 SD=8.003
SEm=1.711 SEm=1.877 SEm=1.461
As shown in table, there was a significant (p < 0.05) rise in mean heart rate by 36.07%, 37.69% and 32.28% from preinduction value in Group I, II, III respectively. This increase in mean heart rate declined to 4.21%, 4.38% and 3.20% from base line at 5 minutes following intubation. There were no abnormal ECG findings noted in any of the cases following the administration of drugs.
FIGURE 6: GRAPH SHOWING MEAN ARTERIAL
PRESSURE
140
120
100
80
mmHg
60
40
20
0
890. 8390. 3792. 17119. 47121. 03122. 3106. 33108. 105.1 2391. 995. 93.17
Group I
Group II
Group III
Pre induction One minute Three minute Five minute after intubation after intubation after intubation
Mean Arterial pressure
Table 26
Group I Group II Group III
mm Hg % mm Hg % mm Hg %
Pre induction 90.8 90.83 92.37
SD=7.654 SD=6.849 SD=6.557
SEm=1.397 SEm=1.250 SEm=1.197
One minute after 119.17 +31.23 121.47 +33.72 122.03 +31.98
intubation SD=11.216 SD=9.183 SD=7.912
SEm=2.048 SEm=1.677 SEm=1.469
Three minute 106.30 +17.07 108.33 + 19.26 105.10 +13.79
after intubation SD=8.979 SD=10.159 SD=8.470
SEm=1.639 SEm=1.855 SEm=1.546
Five minute after 91.23 +0.47 95.9 +5.58 93.17 +0.86
intubation SD=11.041 SD=9.382 SD=5.908
SEm=2.016 SEm=1.713 SEm=1.079
As shown in table, there was a significant (p < 0.05) rise in mean arterial pressure by 31.23%, 33.72%, 31.98% from preinduction value at 1 minute following intubation in Group I, Group II, Group III respectively. This rise in mean arterial pressure declined to 0.47%, 5.58%, 0.86% from preinduction value at 5 minutes following intubation. In all three groups, there was a trend towards returning to baseline mean arterial pressure at 5 minute following intubation.
In one patient (case no. 28) in group II receiving rocuronium bromide 0.9 mg kg-1 body weight there was a fall in mean arterial pressure to 68 mmHg at 7 minutes following intubation (baseline 88 mmHg) with negligible change in heart rate. The blood pressure returned towards preinduction value at 8 minutes without any treatment. There was no bronchospasm or rash associated with fall in blood pressure. There were no clinical findings of histamine release in any of the patients in the present study.
DISCUSSION
Rapid sequence induction of anaesthesia and intubation (RSII) is a specialised method of intravenous induction and establishment of a definitive airway in a patient in whom the risk of regurgitation of acidic gastric contents and their pulmonary aspiration is present. Patients who are at risk are those with a full stomach (questionable NPO status), patients with diabetes mellitus and gastroparesis, GERD, pregnant females and patients with an intra-abdominal pathology causing an acute abdomen.
Methods to reduce the risk include measure to increase gastric emptying by using prokinetics. Reduction of gastric volume and acidity by using H2 receptor antagonists and proton pump inhibitors is also helpful. In terms of airway management and protection, rapid sequence induction and intubation of trachea entails adequate preoxygenation for 3 minutes and cricoid pressure of 10N in an awake patient, an induction dose of an IV anaesthetic rapidly followed by a fixed dose of neuromuscular blocking agent is administered. The trachea is then intubated after a period of one minute without any attempts at mask ventilation. Cricoid pressure is maintained till the cuff of the endotracheal tube is inflated and position is confirmed.
The above technique was first described in 1970. The use of succinylcholine as the gold standard muscle relaxant for RSI since its introduction in 1949 has been established.
But succinylcholine is contraindicated in patients in whom the side effects of the drug are undesired. These are as follows :
– Patients on drugs such as digitalis, tricyclic antidepressants, monoamine oxidase inhibitors, exogenous catecholamines (arrhythmogenic drugs)
– Patients with pre-existing hyperkalemia or patients prone to severe hyperkalemia such as those with severe metabolic acidosis and hypovolemia.
– Patients with severe intra-abdominal infections.
– Patients who have suffered a cerebrovascular accident with resultant paraplegia or hemiplegia; pre- existing muscular dystrophies and Guillain-Barre syndrome.
– Patients with extensive burns.
– In intra-ocular surgeries with an open anterior chamber, thus posing the risk of extrusion.
– Conditions in which the increase in intragastric pressure may cause incompetence at the gastroesophageal junction; ascites, bowel obstruction or a hiatus hernia.
– Intracranial procedures.
– Patients with previous anaphylaxis to the drug.
– Patients with malignant hyperthermia.
Due to the presence of such a vast number of contraindications of this very popularly used drug, the need for another muscle relaxant which provided the same pharmacological profile and intubating conditions as succinylcholine quickly arose.
It was found that RSI can be accomplished using non-depolarising NMBDs such as Rocuronium Bromide. The primary disadvantage of this drug is the prolonged duration of action. In such scenarios, modified RSI with its use of mask ventilation in conjunction with cricoid pressure comes into play.
Sugammadex, which is the reversal agent for Rocuronium, has also made it easier to use the drug. With its correct dosage, one can expect a quick return of neuromuscular tone. But the drug is still not widely and easily available, is expensive and it still does not guarantee good visualisation of cords in a cannot intubate/ cannot ventilate situation.
The only major contraindication to Rocuronium is the rare patient with previous allergy to the drug. No other contraindications have been observed, unlike Succinylcholine.
In view of the above observations, this study was carried out to compare and analyse the intubating conditions of the two drugs at different dosages at 60 seconds.
Dosage selected
The dosage of the neuromuscular blocking drug selected is usually based on the ED95 value which is the dose of relaxant needed to produce 95% suppression of the single twitch response in half of the patients. The ED95 of the drug also decides its potency. The higher it is, the lesser is the drug potency.
better technique of obtaining adequate relaxation than priming method for hastening the onset of action.36
DOSAGE
Chavan SG et al in 2016 in their study to compare rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries used Rocuronium at 0.6 mg/kg and 0.9 mg/kg and succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared.
Sørensen MK et al did a randomised trial in 2012 to compare RSI and intubation with rocuronium-sugammadex and succinylcholine. They used dosages of alfentanil (10 µg/kg, propofol (2 mg/kg), and either succinylcholine (1 mg/kg) or rocuronium (1 mg/kg).
Marsch SC et al in 2011 did a prospective randomised controlled trial comparing succinylcholine and rocuronium in RSI in the intensive care setup. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade.
Abu-Halaweh SA et al in 2007 did a study to demonstrate that Rocuronium Bromide can be used for rapid sequence induction in emergency conditions. They studied the efficacy and intubating conditions after administrating of Rocuronium Bromide 1 mg/kg at 60 second in group of 60 pregnant women undergoing elective or emergency cesarean section and compared the results with those obtained after giving Suxamethonium 1 mg/kg at 60 seconds in a group of patients similar to the Rocuronium group.
Mencke T et al in 2006 wanted to test their hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less post-operative hoarseness and vocal cord injury than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microgram/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI.
Larsen PB et al in 2005 decided to compare the overall intubating conditions of standard doses of rocuronium 0.6 mg/kg and succinylcholine 1.0 mg/kg during a strict rapid-sequence induction regimen including propofol and alfentanil.
Sluga et al in 2005 did a randomised prospective trial investigate 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. They chose dosages of 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)
Lam AM et al in 2000 did a Prospective, open-label, parallel group comparative, randomized study 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.
Laurin EG et al in 2000 did a one-year prospective cohort comparison study to compare the efficacy of succinylcholine and rocuronium in RSI of emergency department patients. The average dose of succinylcholine was 1.7mg/kg and that of rocuronium was 1mg/kg.
When comparing Succinylcholine and Rocuronium, laryngeal adductor muscles are realtively resistant to the effects of Rocuronium, and the plasma concentrations required for an equivalent blockade are greater at the larynx than at the adductor pollicis muscle.
Keeping all these study dosages and the recommended dosage (1-1.5mg/kg of Succinylcholine and 1-1.2mg/kg of Rocuronium ) in mind, we used two varying doses of rocuronium bromide and one dose of succinylcholine for the study. Succinylcholine was used at a dose of 1.5mg/kg; rocuronium at 0.9 mg/kg and 1.2 mg/kg were used. Millers 1655,1656
Intubation Time
Chavan SG et al used neuromuscular monitoring and performed Intubation when “train of four (TOF) count” was 0.
Sorensen MK et al in their study used neuromuscular monitoring with acceleromyography using the TOF-Watch SX (MSD,Glostrup, Denmark) connected to a computer.
Marsch SC et al performed laryngoscopy after cessation of fasciculations in the lower extremities,if any; or after 45 seconds, whichever was earlier (anticipated time of intubation was 60 seconds after the administration of neuromuscular blocking agent)
Abu Halaweh et al performed intubation 60 seconds after the administration of neuromuscular relaxant.
Mencke T et al chose to blind the anaesthesiologist performing the intubation; who was called to enter the room after 40 seconds; exactly 50 seconds after administration of the neuromuscular blocking drug. Intubation was done in 10 seconds. Hence the time till intubation was 60 seconds.
Larsen PB et al also followed suit and intubation was performed by a blinded anaesthesiologist 60 seconds after injection of neuromuscular blocking drug.
Sluga M et al in their study started intubation either after the cessation of fasciculations in the lower extremities, if any, the cessation of a visible motor response to continuous single-twitch nerve stimulation, or after 50 s (anticipated time of intubation 60 s after the injection of the neuromuscular blocking drug), whichever was earlier.
Lam AM et al in their study measured onset and offset time of the neuromuscular blocking drugs with evoked twitch response of the adductor pollicis muscle.
Laurin et al performed laryngoscopy after the injection of the neuromuscular blocking agent by serially gauging the relaxation of the jaw to assess the onset of paralysis. Once the jaw was fully relaxed and no breathing movement was seen, paralysis was assumed complete and laryngoscopy was performed.
Various authors have employed neuromuscular monitoring for assessing the time for intubation. They have defined the onset time as the time from injection of drug to 95% twitch height depression at the adductor pollicis muscle. However, as for nondepolarising agents like Rocuronium Bromide it has been found that the onset of paralysis is more rapid at the diaphragm and the adductor laryngeal muscles than at the adductor pollicis muscle. This is probably due the greater blood flow to centrally located muscles.(barash 539) Hence neuromuscular monitioring at the adductor pollicis muscle may not always give the correct onset time.
Hence in the present study clinical criteria were used instead of neuromuscular monitoring for scaling intubating conditions at 60 seconds.
Intubating conditions
The intubating conditions vary with the drug and the dosage used.
Chavan SG et al in their study assigned three different groups of 30 patients each.
They observed that that the onset time was considerably shorter with 0.9mg/kg Rocuronium than 0.6mg/kg rocuronium, but it was significantly longer than that of succinylcholine 2mg/kg.
Time taken to intubate was shortest with Succinylcholine 2 mg/kg. whereas for the two does of rocuronium it was found to be comparable.
Sorensen MK et al in their trial found that in the rocuronium group, the time taken to intubate was slightly shorter as compared to that of the Succinylcholine group.
The intubating conditions were found to be excellent in 76% of the patients in the Succinylcholine group whereas in the Rocuronium-Sugammadex group, 93% of patients achieved excellent conditions.
24% of the Succinylcholine group of patients had good conditions as compared to only 2% of patients in the Rocuronium-Sugammadex group.
None of the patients in either group had poor intubating conditions.
Marsch SC et al found that out of the 401 intubations, 333 (83%) were accomplished on the first, 57 (14.2%) on the second, 9 (2.2%) on the third and 2 (0.5%) on the fourth attempt.
The duration of the intubation sequence which was significantly shorter (P = 0.002) in the succinylcholine group (81 ± 38 sec) than in the Rocuronium group (95 ± 48 sec). Intubation was not completed within 90 sec in 50/200 patients under succinylcholine and 67/201 patients under Rocuronium (P = 0.048).
The numerical sub-scores for ease of laryngoscopy (succinylcholine 2.75 ± 0.45; Rocuronium 2.75 ± 0.46; P = 0.84) and conditions of the vocal cords (succinylcholine 2.61 ± 0.52; Rocuronium 2.67 ± 0.56; P = 0.32) did not differ between the groups while there was a small, but significant difference in the sub-score of the response to intubation (succinylcholine 2.97 ± 0.20; Rocuronium 2.86 ± 0.36; P = 0.001). The overall numerical score for intubation conditions (succinylcholine 8.3 ± 0.8; Rocuronium 8.2 ± 0.9; P = 0.7) did not differ between the groups.
The mean intubation sequence was 14 sec shorter after succinylcholine than after rocuronium. Succinylcholine and rocuronium resulted in similar intubation conditions and a similar incidence of intubation related complications.
In contrast to various other studies done in the elective operation theatre settings, this study showed no significant difference in intubating conditions between Rocuronium and Succinylcholine.
Abu-Halaweh SA et al found that intubating conditions after 1 mg /kg of Rocuronium Bromide were found to be acceptable (good and excellent) in 95% of patients and were similar to the Succinylcholine group (97%).
Mencke et al in their trial found that tracheal intubation was successful in all patients of both groups. Time of intubation, number of attempts, and Cormack and Lehane grades did not differ significantly between study groups.
The rate of excellent intubating conditions was significantly more frequent in the Succinylcholine group compared with the Rocuronium group: 42 (57%) versus 16 patients (21%), respectively (P 0.001). Similar results were noted for clinically acceptable (excellent and good) intubating conditions: 66 (89%) versus 45 patients (59%), respectively (P 0.001).
Larsen PB et al found that adequate intubating conditions were achieved with both the neuromuscular agents used in under one minute. A difference of five seconds to time of paralysis was found in the Succinylcholine group which is of statistical significance but has no clinical significance as such.
Sluga et al showed in their study that scores for endotracheal intubation conditions were significantly higher in the Succinylcholine group than in the Rocuronium group (8.6 1.1 versus 8.0 1.5; P 0.001). This difference resulted almost exclusively from a difference in the subscore rating the response to intubation (2.8 0.5 versus 2.3 1.0; P 0.0001), whereas there was no difference in the subscores for laryngoscopy (2.9 0.3 versus 2.9 0.3; P 0.91) and vocal cords (2.9 0.4 versus 2.8 0.6; P 0.23). Figure 3 depicts the scores for intubating conditions.
Hence they found that choosing rocuronium instead of succinylcholine for rapid sequence induction of anaesthesia prolongs the time of unprotected airway, i.e., the time interval from beginning of the induction until completion of endotracheal intubation, from a median time of 95 seconds to a median time of 130 seconds. But even so, Succinylcholine allowed for a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium.
Lam et al in their study found that Rocuronium at 0.6mg/kg with propofol and fentanyl induction creates intubating conditions similar to Succinylcholine at 1mg/kg in one minute.
Laurin et al in their study clinically acceptable intubating conditions were found in 93.5% of Succinylcholine group and96.1% of Rocuronium group.
In the present study, Succinylcholine at a dose of 1.5mg/kg provided excellent intubating conditions in 100% of the cases (n=30)
In terms of Rocuronium Bromide, at a dose of 0.9mg/kg; out of 30 patients,16 had excellent intubating conditions at 60 seconds (53.33%).
13 out of 30 patients had good intubating conditions, that is 43.33% of the group.
Only one patient had poor intubating conditions with jaw relaxed, movement of vocal cords and bucking after intubation. Even so, intubation was accomplished after 60 seconds.
In the third group which received Rocuronium Bromide at a dose of 1.2mg/kg; 96.7% of the patients had excellent intubating conditions at 60 seconds.
Only 1 patients had good intubating conditions and none had poor intubating conditions.
Thus increasing the dose of rocuronium bromide from 0.9 mg/kg to 1.2 mg/kg body weight increased the incidence of excellent intubating conditions but at the cost of increased duration of action.
(NDSs) were used to determine the degree of pa-
ralysis obtained by the NMBAs. The first scale de-
scribed the extent of body movement during intu-
bation, such as bucking, coughing, or limb
movement. A score of zero corresponded to severe
movement, and a score of ten corresponded to no
movement. Measurements for succinylcholine were
obtained for 367 patients (96%), with a median of
10 (IQR = 9–10, mean = 9.5 6 1.1). Measurements
for rocuronium were obtained for 136 patients
(99%), with a median of 10 (IQR = 9–10, mean =
9.1 6 1.5). Succinylcholine resulted in statistically
less body movement during intubation than rocu-
ronium (p = 0.01).
The second NDS was used to determine the de-
gree of vocal cord movement. A score of zero cor-
responded to laryngospasm, and a score of ten cor-
responded to wide-open and motionless vocal
cords. Measurements for succinylcholine were ob-
tained for 364 patients (95%), with a median of 10
(IQR = 9–10, mean = 9.2 6 1.6). Measurements for
rocuronium were obtained for 132 patients (96%),
with a median of 9 (IQR = 9–10, mean = 9.0 6
1.6). There was no significant difference between
these values (p = 0.15).
The third NDS was used to determine the phy-
sician’s overall satisfaction with the extent of pa-
ralysis. A score of zero corresponded to complete
dissatisfaction, and a score of ten corresponded to
extreme satisfaction. Measurements for succinyl-
choline were obtained for 365 patients (96%), with
a median of 10 (IQR = 9–10, mean = 9.4 6 1.3).
Measurements for rocuronium were obtained for
135 patients (98%), with a median of 10 (IQR = 9–
10, mean = 8.8 6 2.0). The overall satisfaction with
the extent of paralysis was higher for succinylcho-
line than for rocuronium (p < 0.01).
During the one-year study period, 578 patients
were intubated in the ED
The primary endpoint and other continuous variables were com- pared using the Mann–Wcompared using a x2 test or Fisher’
In the present study 16 patients (53.33%) had excellent intubating conditions with rocuronium bromide 0.6 mg kg-1 body weight at 60 seconds.
13 patients (43.33%) out of 30
had good intubating conditions. Only one patient (case no. 4) (3.33%) in the present study had poor intubating condition with jaw relaxed, vocal cords moving and bucking after intubation. However even in this patient intubation was accomplished at 60 seconds.
In the present study 96.67% of patients had excellent intubating conditions with rocuronium bromide 1.2 mg/kg body weight at 60 seconds.
Only 1 patient (3.33%) had good intubating condition. There was no case of poor intubating condition with rocuronium bromide 1.2 mg/kg body weight.
In the present study, succinylcholine chloride 1.5 mg/kg body weight produced excellent intubating conditions in 100% of patients at 60 seconds. Rocuronium bromide 0.9 mg/kg body weight produced good to excellent intubating conditions in 96.67% of patients.
The authors who have compared succinylcholine chloride 1.5 mg/kg body weight and rocuronium bromide 1.2 mg/kg body weight have noted that both drugs produce excellent intubating conditions in majority of patients and produce good to excellent intubating conditions in 100% of patients.
In the present study also succinylcholine chloride 1.5 mg/kg body weight produced excellent intubating conditions in 100% of patients. Rocuronium bromide 1.2 mg/kg body weight produced excellent intubating conditions in 96.67% of cases and good to excellent intubating conditions in 100% of patients.
In the present study with rocuronium bromide 0.9 mg/kg body weight, excellent intubating conditions were noted in 53.33% of patients with good intubating conditions in 43.33% of patients. Only one patient (3.33%) had poor intubating condition. With rocuronium bromide 1.2 mg/kg body weight excellent intubating conditions were noted in 96.67% of cases with good intubating condition in remaining 3.33% of cases.
The present study involved comparison of Succinylcholine Chloride 1 mg/kg body weight with Rocuronium Bromide 0.9 mg/kg body weight and 1.2 mg/kg body weight for rapid sequence intubation in adult patients. It was noted that succinylcholine chloride 1.5 mg/kg body weight produced excellent intubating conditions in 100% of patients. Rocuronium bromide 0.9 mg/kg body weight produced excellent intubating conditions in 53.33% of cases, good intubating conditions in 43.33% and poor intubating conditions in 3.34% of cases. Rocuronium bromide 1.2 mg/kg body weight produced excellent intubating conditions in 96.67% of cases and good intubating conditions in 3.33% of cases. Thus increasing the dose of rocuronium bromide from 0.9 mg/kg to
1.2 mg/kg body weight increased the incidence of excellent intubating conditions but at the cost of increased duration of action.
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