Recurarization with magnesium sulfate administered after two minutes sugammadex reversal: A randomized, double-blind, controlled trial.

STUDY OBJECTIVE: The current study tested the hypothesis that magnesium sulfate after reversal with sugammadex causes recurarization. DESIGN: A single-center, prospective, randomized, double-blind, controlled trial. SETTING: Terciary care hospital in Rio de Janeiro, Brazil. PATIENTS: Included 60 patients undergoing for elective otolaryngological surgery. INTERVENTIONS: All patients received total intravenous anesthesia and a single dose of rocuronium (0.6 mg/kg). In 30 patients, the neuromuscular blockade was reversed with sugammadex (4 mg/kg) at the reappearance of one or two posttetanic counts (deep-blockade series). In 30 other patients, sugammadex (2 mg/kg) was administered at the reappearance of the second twitch of the train-of-four (moderate-blockade series). After the normalized train-of-four ratio recovered to ≥0.9, the patients in each series were randomized to receive intravenous magnesium sulfate (60 mg/kg) or placebo for 10 min. Neuromuscular function was measured by acceleromyography. MEASUREMENTS: The primary outcome was the number of patients who exhibited recurarization (normalized train-of-four ratio < 0.9). The secondary outcome was rescue with an additional dose of sugammadex after 60 min. MAIN RESULTS: In the deep-blockade series, a normalized train-of-four ratio < 0.9 occurred in 9/14 (64%) patients receiving magnesium sulfate and 1/14 (7%) receiving placebo, RR 9.0 (95% CI: 62-1.30), and (p = 0.002), with four rescues with sugammadex. In the moderate-blockade series, neuromuscular blockade recurred in 11/15 (73%) patients receiving magnesium sulfate and in 0/14 (0%) receiving placebo (p < 0.001), with two rescues. The absolute differences in recurarization were 57% and 73% in the deep-blockade and moderate-blockade, respectively. CONCLUSIONS: Single-dose magnesium sulfate led to a normalized train-of-four ratio < 0.9, 2 min after recovery from rocuronium-induced deep and moderate neuromuscular blockade using sugammadex. Additional sugammadex reversed prolonged recurarization.

Rocuronium-Induced Dilated Nonreactive Pupils in a Patient With Coronavirus Disease 2019: A Case Report.

We report the clinical case of a patient with coronavirus disease 2019 (COVID-19) who had recently undergone neurosurgery and presented with dilated nonreactive pupils during continuous rocuronium infusion, which was reversible with the suspension of the drug. Both the neurosurgical procedure and possible disruption of the blood-brain barrier due to COVID-19 infection may have led to the action of rocuronium in the central nervous system (CNS). Thus, clinicians must remember that neuromuscular blocking agents (NMBAs) can cause dilated nonreactive pupils in patients with COVID-19.

Effect of body mass index and rocuronium on serum tryptase concentration during volatile general anesthesia: an observational study.

OBJECTIVE: Female sex, body mass index (BMI), and neuromuscular blocking agents are risk factors of perioperative hypersensitivity reactions. This study aimed to investigate the effect of rocuronium on serum tryptase concentrations during general anesthesia in overweight and obese women. METHODS: The study was conducted in two groups: Group I (n=66) underwent volatile anesthesia with rocuronium and group II (n=60) underwent volatile anesthesia without any muscle relaxant. Serum tryptase concentration (STC) measurements were performed at baseline (STC 0) and postoperatively (STC 1). ClinicalTrials.gov: NCT04035707 RESULTS: The highest median value of STC 0 was seen in obese patients (3.44 µg L-1) and it was significantly higher than in overweight (p=0.01) and underweight patients (p=0.03). The maximum STC 0 was observed in overweight patients (20.4 µg L-1). In group I, STC 0 in obese patients presented the highest median value (4.49 µg L-1), and was significantly higher than in overweight patients (p=0.03), and had significantly higher STC 1 than patients with normal BMI (p=0.04). STC 0 and STC 1 in overweight and obese female patients did not differ significantly between groups. STC 1 did not correlate with rocuronium doses. In group I, BMI positively correlated with the duration of rocuronium infusion (rho=0.37) and STC 1 positively correlated with BMI (rho=0.32). CONCLUSION: Excess weight and obesity predispose to higher preoperative serum tryptase values. Postoperative STC is not linked to rocuronium doses. BMI is the main determinant factor of STC during combined volatile general anesthesia.

Effect of body mass index and rocuronium on serum tryptase concentration during volatile general anesthesia: an observational study

OBJECTIVE: Female sex, body mass index (BMI), and neuromuscular blocking agents are risk factors of perioperative hypersensitivity reactions. This study aimed to investigate the effect of rocuronium on serum tryptase concentrations during general anesthesia in overweight and obese women. METHODS: The study was conducted in two groups: Group I (n=66) underwent volatile anesthesia with rocuronium and group II (n=60) underwent volatile anesthesia without any muscle relaxant. Serum tryptase concentration (STC) measurements were performed at baseline (STC 0) and postoperatively (STC 1). ClinicalTrials.gov: NCT04035707 RESULTS: The highest median value of STC 0 was seen in obese patients (3.44 μg L-1) and it was significantly higher than in overweight (p=0.01) and underweight patients (p=0.03). The maximum STC 0 was observed in overweight patients (20.4 μg L-1). In group I, STC 0 in obese patients presented the highest median value (4.49 μg L-1), and was significantly higher than in overweight patients (p=0.03), and had significantly higher STC 1 than patients with normal BMI (p=0.04). STC 0 and STC 1 in overweight and obese female patients did not differ significantly between groups. STC 1 did not correlate with rocuronium doses. In group I, BMI positively correlated with the duration of rocuronium infusion (rho=0.37) and STC 1 positively correlated with BMI (rho=0.32). CONCLUSION: Excess weight and obesity predispose to higher preoperative serum tryptase values. Postoperative STC is not linked to rocuronium doses. BMI is the main determinant factor of STC during combined volatile general anesthesia.

Albumin dialysis with MARS for the treatment of anabolic steroid-induced cholestasis.

 Background and aims. Steroid-related hepatotoxicity has become one of the most relevant causes of drug induced liver cholestasis. Some patients do not improve after standard medical treatment (SMT) and may therefore require other approaches, like extracorporeal liver support. MATERIAL AND METHODS: We report four cases of patients with pruritus, abnormal liver function tests and biopsy-proven anabolic steroid-induced cholestasis who were unresponsive to SMT. They underwent treatment with albumin dialysis (Molecular Adsorbent Recirculating System -MARS®-). A minimum of two MARS sessions were performed. RESULTS: After MARS® procedure, patients' symptoms improved, as well as liver function tests, thus avoiding liver transplantation. CONCLUSION: Albumin dialysis appears as a valuable therapeutic option for the management of anabolic steroid-induced cholestasis in patients that are unresponsive to SMT.

Intraoperative "Kounis syndrome" that improved electrocardiography changes and hemodynamic situation after administering nitroglycerine.

A 58-year-old female without cardiovascular risk factors, was going to be operated to repair the rotator cuff. Induction and interscalene brachial plexus block were uneventful, but after her placement for surgery the patient started with severe bronchospasm, hypotension, cutaneous allergic reaction and ST elevation on the electrocardiogram. An anaphylactic shock was suspected and treated but until the perfusion of nitroglycerina was started no electrocardiographic changes resolved. After necessary diagnostic test the final diagnosis was variant I of Kounis syndrome due to cefazolin and rocuronium. Ephinephrine is the cornerstone of treatment for anaphylaxis but should we use it if the anaphylactic reaction is also accompanied by myocardial ischemia? The answer is that we should not use it because myocardial ischemia in this syndrome is caused by vasospasm, so it would be more useful drugs such as nitroglycerin. But what if we do not know if it is a Kounis syndrome or not? In this article we report our experience that maybe could help you in a similar situation.

Intraoperative "Kounis syndrome" that improved electrocardiography changes and hemodynamic situation afteradministering nitroglycerine / Síndrome de Kounis intraoperatória com melhoria das alterações eletrocardiográficas e da situação hemodinâmica após a administração de nitroglicerina / Síndrome de Kounis intraoperatorio con mejoría de las alteraciones electrocardiográficas y de la situación hemodinámica después de la administración de nitroglicerina

A 58-year-old female without cardiovascular risk factors, was going to be operated to repair the rotator cuff. Induction and interscalene brachial plexus block were uneventful, but after her placement for surgery the patient started with severe bronchospasm, hypotension, cutaneous allergic reaction and ST elevation on the electrocardiogram. An anaphylactic shock was suspected and treated but until the perfusion of nitroglycerina was started no electrocardiographic changes resolved. After necessary diagnostic test the final diagnosis was variant I of Kounis syndrome due to cefazolin and rocuronium. Ephinephrine is the cornerstone of treatment for anaphylaxis but should we use it if the anaphylactic reaction is also accompanied by myocardial ischemia? The answer is that we should not use it because myocardial ischemia in this syndrome is caused by vasospasm, so it would be more useful drugs such as nitroglycerin. But what if we do not know if it is a Kounis syndrome or not? In this article we report our experience that maybe could help you in a similar situation.

Paciente do sexo feminino, 58 anos, sem fator de risco cardiovascular, submetida a cirurgia para reparação do manguito rotador. A indução do bloqueio do plexo braquial interescalênico foi feita sem intercorrência, mas, após seu posicionamento para a cirurgia, a paciente apresentou broncoespasmo grave, hipotensão, reação alérgica cutânea e elevação do segmento ST ao eletrocardiograma. Houve suspeita de choque anafilático que foi tratado, mas até que a perfusão de nitroglicerina fosse iniciada não houve resolução das alterações eletrocardiográficas. Após teste diagnóstico necessário, o diagnóstico final foi de variante tipo I da síndrome de Kounis por causa de cefazolina e rocurônio. Epinefrina é a base sólida do tratamento para anafilaxia, mas devemos usá-la se a reação anafilática também for acompanhada de isquemia miocárdica? A resposta é que não devemos usá-la, porque a isquemia miocárdica nessa síndrome é causada por vasoespasmo; portanto, drogas como a nitroglicerina seriam mais úteis. Porém, e quando não sabemos se é ou não uma síndrome de Kounis? Neste artigo relatamos nossa experiência que, talvez, possa ajudar em uma situação similar.

Paciente del sexo femenino, 58 años de edad, sin factor de riesgo cardiovascular, sometida a cirugía para la reparación del manguito rotador. La inducción del bloqueo del plexo braquial interescalénico fue realizada sin intercurrencias, pero después de su posicionamiento para la cirugía, la paciente presentó broncoespasmo grave, hipotensión, reacción alérgica cutánea y elevación del segmento ST al electrocardiograma. Hubo sospecha de choque anafiláctico que fue tratado, pero hasta que la perfusión de nitroglicerina se iniciase no hubo resolución de las alteraciones electrocardiográficas. Después del test diagnóstico necesario, el diagnóstico final fue de variante tipo i del síndrome de Kounis debido a la cefazolina y al rocuronio. La epinefrina es la base sólida del tratamiento para la anafilaxia, pero ¿debemos usarla si la reacción anafiláctica también viene seguida de isquemia miocárdica? La respuesta es que no debemos usarla porque la isquemia miocárdica en ese síndrome está causada por el vasoespasmo; por tanto, fármacos como la nitroglicerina serían más útiles. Sin embargo, ¿y cuando no sabemos si es o no un síndrome de Kounis? En este artículo, relatamos nuestra experiencia que, tal vez, pueda ayudarle a usted a hacer frente a una situación similar.

Effects of magnesium sulphate on the pharmacodynamics of rocuronium in patients aged 60 years and older: A randomised trial.

BACKGROUND: There is little information on the interaction between magnesium sulphate (MgSO4) and rocuronium in elderly patients. With a growing number of older patients who need surgical procedures, it is increasingly important to study this age group. OBJECTIVE: To evaluate the effects of MgSO4 administration on the pharmacodynamics of rocuronium in patients aged 60 years or older. DESIGN: A randomised controlled trial. SETTING: A tertiary care hospital. PATIENTS: Sixty-four patients, aged 60 years or older, American Society of Anesthesiologists (ASA) physical status classes I to III, scheduled for elective oncological head and neck surgery. Exclusion criteria were severe renal insufficiency (calculated creatinine clearance <30 ml min(-1)), preoperatorive serum magnesium concentration of more than 1.25 mmol l(-1) and patients receiving drugs known to affect neuromuscular function. INTERVENTIONS: Patients were randomly allocated to one of two groups: in the magnesium group, patients received MgSO4 30 mg kg(-1) intravenously, for 10 min, and then a continuous intravenous infusion at a rate of 1 g h(-1). The control group received the same volume of physiological saline. Neuromuscular function was evaluated continuously in both groups. MAIN OUTCOME MEASURES: Total recovery time was the primary outcome. Onset time, clinical duration, recovery index and recovery time were considered as secondary endpoints. Values are given as mean [SD]. RESULTS: Total recovery time from neuromuscular block (NMB) was 113 [36] min in the magnesium group and 101 [39] min in the control group. Clinical duration was 69 [23] min in the magnesium group and 59 [28] min in the control group. Recovery index was 19 [36] min in the magnesium group and 17 [6] min in the control group. Recovery time was 44 [22] min in the magnesium group and 42 [18] min in the control group. There were no statistically significant differences between the groups in any of the recovery indices. In the magnesium group, the mean onset time was 144 [58] s, significantly shorter than the onset time in the group that received physiological saline, which was 187 [90] s (P = 0.03). Group variances were compared using an F test: onset time varied significantly less in the magnesium group (P = 0.02). CONCLUSION: In oncology patients of 60 or more years of age, preadministration of MgSO4, with the doses used in this study, significantly reduced the onset time of NMB induced by rocuronium. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01804205.

Caso de anafilaxia induzida por rocurônio tratado com o auxílio de sugamadex / Case of anaphylaxis induced by rocuronium treated with sugammadex / Caso de anafilaxia inducida por rocuronio tratado con la ayuda del sugamadex

JUSTIFICATIVA E OBJETIVOS: A anafilaxia durante a anestesia é um evento raro que pode ocorrer em até 1:20.000 casos sendo que aproximadamente 60% a 70% destes casos são secundários ao uso de ralaxantes musculares onde os mais implicados a succinilcolina e o rocurônio. O objetivo deste relato foi descrever o tratamento de um caso de anafilaxia induzida por rocurônio com resposta inadequada a terapia tradicional e resolução do caso após o uso do sugamadex. RELATO DO CASO: Paciente do sexo feminino, com 62 anos de idade, 72 kg, foi encaminhada ao centro cirúrgico para tratamento de hematoma extradural após acidente em domicílio. Foi monitorada com oxímetro de pulso, cardioscópio e tensiômetro para medida da pressão anterial não invasiva (PA). Seus dados basais foram: PA de 138/80 mm Hg, frequência cardíaca (FC) de 80 bpm e saturação arterial (SaO2) de 100% em ar ambiente. A indução da anestesia se processou com propofol 70 mg, fentanil 200 µg e rocurônio 45 mg. Após a intubação traqueal, diagnosticou-se quadro de anafilaxia que não respondeu ao tratamento convencional. Optou-se pelo uso de sugamadex 700 mg por via venosa como agente coadjuvante. A paciente apresentou reversão do quadro com melhora do perfil hemodinâmico sendo operada e conduzida à unidade de terapia intensiva. CONCLUSÃO: Neste caso, o sugamadex foi utilizado para reverter quadro hemodinâmico induzido pela anafilaxia por rocurônio, entretanto não foi possível esclarecer qual o mecanismo exato para a reversão do quadro hemodinâmico.

BACKGROUND AND OBJECTIVES: Anaphylaxis during anesthesia is a rare event that may occur in up to 1:20,000 cases and approximately 60% to 70% of these cases are secondary to the use of muscle relaxants, particularly succinylcholine and rocuronium. The aim of this report is to describe the treatment of a case of rocuronium-induced anaphylaxis with inadequate response to traditional therapy, and the case resolution after using sugammadex. CASE REPORT: A female patient, 62 years old, 72 kg, was referred to the surgical center for treatment of epidural hematoma following an accident at home. She was monitored with pulse oximetry, cardioscope, and blood pressure meter for non-invasive blood pressure (BP) measurement. The baseline data were: BP 138/80 mm Hg, heart rate (HR) 80 bpm, and oxygen saturation (SaO2) 100% on room air. Anesthesia was induced with propofol 70 mg, fentanyl 200 mg, and rocuronium 45 mg. After tracheal intubation, anaphylaxis non-responsive to conventional treatment was diagnosed. We chose the use of sugammadex 700 mg intravenously as an adjuvant agent. The patient had reversal of the anaphylactic reactions with improvement of hemodynamic profile and was operated and conducted to the intensive care unit. CONCLUSION: In this case, sugammadex was used to reverse the hemodynamic picture caused by rocuronium-induced anaphylaxis. However, it was not possible to identify the exact mechanism for the reversal.

JUSTIFICATIVA Y OBJETIVOS: La anafilaxia durante la anestesia es un evento raro que puede ocurrir hasta en 1: 20.000 casos siendo que aproximadamente entre un 60% a un 70% de ellos son secundarios al uso de relajantes musculares donde los más implicados son la succinilcolina y el Rocuronio. El objetivo de este relato, fue describir el tratamiento de un caso de anafilaxia inducida por Rocuronio con una respuesta inadecuada a la terapia tradicional y la solución del caso después del uso del sugamadex. RELATO DEL CASO: Paciente del sexo femenino, 62 años, 72 kg, derivada al quirófano para tratamiento de hematoma extradural posterior a accidente en domicilio. Fue monitorizada con oxímetro de pulso, cardioscopio y tensiómetro para la medida de la presión arterial no invasiva (PA). Sus datos basales fueron los siguientes: PA de 138/80 mm Hg, frecuencia cardíaca (FC) de 80 lpm y saturación arterial (SaO2) de 100% en aire ambiente. La inducción de la anestesia fue procesada con propofol 70 mg, fentanil 200 µg y Rocuronio 45 mg. Después de la intubación traqueal se diagnosticó un cuadro de anafilaxia que no respondió al tratamiento convencional. Optamos entonces por el uso del sugamadex 700 mg por vía venosa como agente coadyuvante. La paciente presentó una reversión del cuadro con una mejoría del perfil hemodinámico siendo operada y derivada a la unidad de cuidados intensivos. CONCLUSIONES: En este caso, el sugamadex fue utilizado para revertir el cuadro hemodinámico inducido por la anafilaxia por Rocuronio, pero no se pudo aclarar cuál sería el mecanismo exacto para la reversión del cuadro hemodinámico.

Case of anaphylaxis induced by rocuronium treated with sugammadex.

BACKGROUND AND OBJECTIVES: Anaphylaxis during anesthesia is a rare event that may occur in up to 1:20,000 cases and approximately 60% to 70% of these cases are secondary to the use of muscle relaxants, particularly succinylcholine and rocuronium. The aim of this report is to describe the treatment of a case of rocuronium-induced anaphylaxis with inadequate response to traditional therapy, and the case resolution after using sugammadex. CASE REPORT: A female patient, 62 years old, 72kg, was referred to the surgical center for treatment of epidural hematoma following an accident at home. She was monitored with pulse oximetry, cardioscope, and blood pressure meter for non-invasive blood pressure (BP) measurement. The baseline data were: BP 138/80 mm Hg, heart rate (HR) 80 bpm, and oxygen saturation (SaO(2)) 100% on room air. Anesthesia was induced with propofol 70 mg, fentanyl 200mg, and rocuronium 45 mg. After tracheal intubation, anaphylaxis non-responsive to conventional treatment was diagnosed. We chose the use of sugammadex 700 mg intravenously as an adjuvant agent. The patient had reversal of the anaphylactic reactions with improvement of hemodynamic profile and was operated and conducted to the intensive care unit. CONCLUSION: In this case, sugammadex was used to reverse the hemodynamic picture caused by rocuronium-induced anaphylaxis. However, it was not possible to identify the exact mechanism for the reversal.

The use of rocuronium in giant Amazon turtle Podocnemis expansa (Schweigger, 1812) (Testudines, Podocnemididae).

PURPOSE: To determine whether rocuronium would provide safe, short-term immobilization in Podocnemis expansa. METHODS: Twenty P. expansa, weighing on average 1.59 +/- 0.28 kg, were subjected to two protocols: G1 0.25 mg/kg IM of rocuronium and 0.07 mg/kg IM of neostigmine, while G2 received 0.50 mg/kg IM of rocuronium and 0.07 mg/kg IM of neostigmine. The drugs were applied, respectively, in the left and right thoracic members. Assessments were made of the anesthetic parameters of respiratory frequency, heartbeat, righting reflex, cloacal relaxation, palpebral and pupilar reflexes, easy handling, muscle relaxation, locomotion, response to pain stimuli in the right thoracic members, pelvic members and tail, ambient humidity and temperature. RESULTS: They were not found statistical differences between the dosages for the majority of the assessments. G1 was as efficient as G2. A consistent neuromuscular blockade effect was recorded 12 +/- 4.21 minutes in G1 and G2. All the animals were recovered in 150 minutes. CONCLUSIONS: Administration of rocuronium at dose of 0.25 to 0.5 mg/kg IM is a safe and effective adjunct to clinical proceedings or pre-anesthetics in P. expansa. Because rocuronium does not provide any analgesic or sedative effects, the duration of neuromuscular blockade without anesthesia should be minimized to avoid undue stress.

The use of rocuronium in giant Amazon turtle Podocnemis expansa (Schweigger, 1812) (Testudines, Podocnemididae) / Uso do rocurônio em tartaruga da Amazônia Podocnemis expansa (Schweigger, 1812) (Testudines, Podocnemididae)

PURPOSE: To determine whether rocuronium would provide safe, short-term immobilization in Podocnemis expansa. METHODS: Twenty P. expansa, weighing on average 1.59 ± 0.28 kg, were subjected to two protocols: G1 0.25 mg/kg IM of rocuronium and 0.07 mg/kg IM of neostigmine, while G2 received 0.50 mg/kg IM of rocuronium and 0.07 mg/kg IM of neostigmine. The drugs were applied, respectively, in the left and right thoracic members. Assessments were made of the anesthetic parameters of respiratory frequency, heartbeat, righting reflex, cloacal relaxation, palpebral and pupilar reflexes, easy handling, muscle relaxation, locomotion, response to pain stimuli in the right thoracic members, pelvic members and tail, ambient humidity and temperature. RESULTS: They were not found statistical differences between the dosages for the majority of the assessments. G1 was as efficient as G2. A consistent neuromuscular blockade effect was recorded 12 ± 4.21 minutes in G1 and G2. All the animals were recovered in 150 minutes. CONCLUSIONS: Administration of rocuronium at dose of 0.25 to 0.5 mg/kg IM is a safe and effective adjunct to clinical proceedings or pre-anesthetics in P. expansa. Because rocuronium does not provide any analgesic or sedative effects, the duration of neuromuscular blockade without anesthesia should be minimized to avoid undue stress.

OBJETIVO: Determinar se o rocurônio promove imobilização segura e de curta duração em Podocnemis expansa. MÉTODOS: Vinte P. expansa com média de peso 1,59 ± 0,28 kg, foram submetidas a dois protocolos: G1 recebeu rocurônio 0,25 mg/kg IM e neostigmina 0,07 mg/kg IM enquanto G2 rocurônio 0,50 mg/kg IM e neostigmina 0,07 mg/kg IM, aplicados no membro torácico esquerdo e direito, respectivamente. Observaram-se os parâmetros anestésicos: freqüência respiratória e cardíaca, reflexo de endireitamento, relaxamento do esfíncter da cloaca, reflexo palpebral e pupilar, facilidade de manipulação, relaxamento muscular, locomoção, resposta aos estímulos dolorosos no membro torácico direito, nos membros pelvinos e na cauda, temperatura e umidade ambiental. RESULTADOS: Não foram encontradas diferenças estatísticas entre as doses para a maioria dos parâmetros e o G1 foi tão eficiente quanto o G2. Um bloqueio neuromuscular consistente foi observado aos 12 ± 4,21 minutos tanto no G1 como no G2. A recuperação de todos os animais ocorreu em até 150 minutos. CONCLUSÕES: Administração de rocurônio nas doses 0,25 e 0,50 mg/kg IM é segura e efetiva para os procedimentos clínicos ou pré-anestésicos em P. expansa. Como o rocurônio não produz efeitos sedativos ou analgésicos, a duração do bloqueio neuromuscular sem anestesia deverá ser minimizado para evitar estresse.

Rocuronio / Rocuronium

Se trata de un relajante muscular no despolarizante de tiempo más corto de todos los disponibles en clínica en la actualidad. El maximo bloqueo despúes de la administración endovenosa de una dosis de intubación ocurre en promedio a los 90 segundos, separándolosólo 30 segundos de la succinilcolina. La evaluación final de si el rocuronio reemplazára a la succinilcolina en situaciones de urgencia, y específicamente en el estómago lleno, está por verse. La valoración debe hacerse teniendo presente que no siempre concuerdan la clínica con pequeñas varaciones estadísticass. Es necesario hacer un balance costo beneficio de las ventajas de aislar la tráquea 30 segundos antes con la succinilcolina y sus riesgos, o 30 segundos despúes con una droga carente de toda complicación. El rocuronio es un relante muscular de amplio margen de seguridad que puede ser usado en el caso diario, con la excepción de los pacientes con antecedentes de hipersensibilidad y en pacientes con patología hepática severa. No está contraindicado en pacientes con patología renal, aunque se recomienda adecuar la dosis y monitorizar la relajación. Dependiendo de su costo, el rocuronio está destinado a reemplazar a otros bloqueadores neuromusculares de duración intermedia