Time interval between alfentanil and rocuronium administration necessary to prevent rocuronium-induced withdrawal movement.

BACKGROUND: We aimed to determine the time interval between alfentanil and rocuronium administration, at a 50% probability of preventing pain-induced withdrawal movement from rocuronium injection (TimeAR50). METHODS: A total of 64 patients scheduled for general anesthesia were enrolled in this study (33 men and 31 women). Anesthesia was induced with target-controlled infusion of propofol, at an effect-site target concentration of 3 µg/mL. Then, alfentanil 15 µg/kg was injected for 30 s. After 60 s, rocuronium 0.6 mg/kg was administered to the first patient. The Dixon's up-and-down method was used to determine the time interval for each subsequent patient (interval of 5 s). Mean arterial pressure (MAP) and heart rate (HR) were recorded at three time points: T0, pre-induction; T1, before rocuronium injection; and T2, 1 min after rocuronium injection. RESULTS: The TimeAR50 ± standard deviation (SD) was 5.6 ± 3.7 s and 21.9 ± 5.6 s in the male and female patients, respectively. Based on the probit regression, the TimeAR50 was 4.7 s (95% confidence interval [CI], 1.2-7.6 s) and 20.3 s (95% CI, 7.7-26.1 s) in the male and female patients, respectively. The TimeAR95 was 10.6 s (95% CI, 7.7-25.3 s) and 35.0 s (95% CI, 28.1-95.5 s) in the male and female patients, respectively, with significantly higher values in females than in males (P < 0.001). Compared with the T0, MAP and HR decreased significantly at T1 and T2 in both groups. CONCLUSION: The TimeAR50 required for preventing rocuronium-induced withdrawal movement were 4.7 s and 20.3 s in male and female patients, respectively. TRIAL REGISTRATION: This study was registered with the Chinese Clinical Trials Registry on April 7, 2021 (URL: http://www.chictr.org.cn . Registry number: ChiCTR2100045137 ) .

Rocuronium Bromide Intravenous Solution Maruishi® is more suitable than ESLAX Intravenous® during rapid-sequence induction of anesthesia.

PURPOSE: Rocuronium Bromide Intravenous Solution® (Maruishi Pharmaceutical Co., Ltd, Osaka, Japan) is a newly developed generic drug and we have noticed that compared with conventional rocuronium formulations [e.g. Esmeron (Eslax), MSD Co. Ltd., Tokyo, Japan], rocuronium Maruishi appeared to cause less pain or withdrawal movement. The aim of this study was to assess the hypothesis that the injection of rocuronium Maruishi causes less body movement than rocuronium MSD does, during rapid-sequence induction of anesthesia. METHODS: Sixty patients were allocated randomly to one of two groups. In one group, rocuronium MSD was used and in the other group, rocuronium Maruishi was used. After induction of general anesthesia, a test drug (containing rocuronium) 0.9 mg/kg was injected. Patient's withdrawal movement was graded with the scale. Primary outcome measure was the incidence of moderate or severe movement after the injection of rocuronium. Secondary outcome measure was the degree of movement between the groups. RESULTS: Moderate or severe withdrawal movement was observed after the injection of rocuronium MSD in 11 of 30 patients (37%) and after the injection of rocuronium Maruishi in 3 of 30 patients (10%). There was a significant difference in the incidence between the groups (P = 0.013, 95% CI for difference 26-28%). The degree of movement was also significantly greater for rocuronium MSD than for rocuronium Maruishi (P = 0.015). CONCLUSION: Compared with rocuronium MSD, rocuronium Maruishi is more suitable than conventional rocuronium formulations, for rapid-sequence induction of anesthesia.

Prediction of emergence agitation using withdrawal reaction following rocuronium injection in preschool-aged patients undergoing inguinal herniorrhaphy: a preliminary exploratory observational trial.

PURPOSE: The development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA. METHODS: A total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale. RESULTS: There was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU. CONCLUSION: The findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated.

The effect of palonosetron on rocuronium-induced withdrawal movement / O efeito de palonosetron sobre o movimento de retração induzido por rocurônio

Abstract Background: Rocuronium causes pain and withdrawal movement during induction of anesthesia. In this study, palonosetron was investigated to have analgesic effect on the reduction of rocuronium-induced withdrawal movement. Methods: 120 patients were randomly assigned to one of three groups to receive either saline, lidocaine 20 mg, or palonosetron 0.075 mg with a tourniquet applied two minutes before thiopental sodium (5 mg.kg-1) was given intravenously. After loss of consciousness, rocuronium (0.6 mg.kg-1) was injected and the withdrawal movement was estimated by 4-point scale in a double-blind manner. Results: The overall incidence of rocuronium withdrawal movement was 50% with lidocaine (p = 0.038), 38% with palonosetron (p = 0.006) compared with 75% for saline. The incidence of no pain to mild pain was significantly lower in the lidocaine and palonosetron groups (85% and 92% respectively) than in the saline group (58%). However, there was no significant difference in withdrawal movement between the lidocaine and palonosetron groups. There was no severe movement with palonosetron. Conclusion: Pretreatment of palonosetron with venous occlusion may attenuate rocuronium-induced withdrawal movement as effective as the use of lidocaine. It suggested that peripheral action of palonosetron was effective to reduce rocuronium-induced withdrawal movement.

Resumo Justificativa: Rocurônio provoca dor e reflexo de retirada durante a indução da anestesia. Neste estudo, avaliamos se palonosetron tem efeito analgésico para reduzir esse movimento induzido por rocurónio. Métodos: Cento e vinte pacientes foram randomicamente designados para um de três grupos para receber solução salina, lidocaína (20 mg) ou palonosetron (0.075 mg), com aplicação de torniquete dois minutos antes da administração intravenosa de tiopental sódico (5 mg.kg-1). Após a perda de consciência, rocurônio (0.6 mg.kg-1) foi injetado e o reflexo de retirada foi avaliado com o uso de uma escala de quatro pontos, de modo duplo-cego. Resultados: A incidência global do reflexo de retirada induzido por rocurônio foi de 50% para lidocaína (p = 0,038), 38% para palonosetron (p = 0,006), em comparação com 75% para solução salina. A incidência de dor ausente ou leve foi significativamente menor nos grupos lidocaína e palonosetron (85% e 92%, respectivamente) que no grupo solução salina (58%). Porém, não houve diferença significativa no reflexo de retirada entre os grupos lidocaína e palonosetron. Não houve movimento grave com palonosetron. Conclusão: O pré-tratamento com palonosetron com oclusão venosa pode atenuar o reflexo de retirada induzido por rocurônio de modo tão eficaz como o uso de lidocaína. Sugeriu-se que a ação periférica de palonosetron foi eficaz para reduzir o reflexo de retirada induzido por rocurônio.

[The effect of palonosetron on rocuronium-induced withdrawal movement]. / O efeito de palonosetron sobre o movimento de retração induzido por rocurônio.

BACKGROUND: Rocuronium causes pain and withdrawal movement during induction of anesthesia. In this study, palonosetron was investigated to have analgesic effect on the reduction of rocuronium-induced withdrawal movement. METHODS: 120 patients were randomly assigned to one of three groups to receive either saline, lidocaine 20mg, or palonosetron 0.075mg with a tourniquet applied two minutes before thiopental sodium (5mg.kg-1) was given intravenously. After loss of consciousness, rocuronium (0.6mg.kg-1) was injected and the withdrawal movement was estimated by 4-point scale in a double-blind manner. RESULTS: The overall incidence of rocuronium withdrawal movement was 50% with lidocaine (p=0.038), 38% with palonosetron (p=0.006) compared with 75% for saline. The incidence of no pain to mild pain was significantly lower in the lidocaine and palonosetron groups (85% and 92% respectively) than in the saline group (58%). However, there was no significant difference in withdrawal movement between the lidocaine and palonosetron groups. There was no severe movement with palonosetron. CONCLUSION: Pretreatment of palonosetron with venous occlusion may attenuate rocuronium-induced withdrawal movement as effective as the use of lidocaine. It suggested that peripheral action of palonosetron was effective to reduce rocuronium-induced withdrawal movement.

Prevention of Withdrawal Movement Associated with the Injection of Rocuronium in Children: Comparison of Paracetamol and Lidocaine.

OBJECTIVE: Pain from rocuronium injection is observed in 50%-80 % of patients. This study aimed to compare the effectiveness of pretreatment with paracetamol and lidocaine in preventing pain-induced withdrawal caused by the intravenous injection of rocuronium during the induction of general anaesthesia in paediatric patients. METHODS: Ninety children were randomized into two groups using a simple drawing from the box method: a paracetamol group (Group P, n=45) and a lidocaine group (Group L, n=45). After anaesthesia induction, venous occlusion was applied by a paediatric cuff inflated to a pressure of 75 mmHg and by 50 mg paracetamol and 0.5 mg kg(-1) lidocaine was injected in Groups P and L, respectively. Venous occlusion was then released, followed by rocuronium injection (0.6 mg kg(-1)). Withdrawal was evaluated using a 4-point scale (1, no response; 2, movement at the wrist only; 3, movement/withdrawal involving arm only (elbow/shoulder) and 4, generalized response, movement/withdrawal in more than one extremity). RESULTS: The incidence of withdrawal movement was 42% and 26% in the Groups P and L, respectively (p=0.120). Although no significant differences were noted in the number of patients who had no withdrawal movement and mild withdrawal movement in Groups P and L, compared with Group L, the incidences of moderate withdrawal movement were significantly higher in Group P (p<0.05). No patient in either group revealed generalized movement. CONCLUSION: Using a venous occlusion technique, pretreatment with 50 mg paracetamol can prevent withdrawal movement caused by rocuronium injection in children but is not as effective as lidocaine to prevent moderate withdrawal movement.

Effect of pretreatment with gabapentin on withdrawal movement associated with intravenous rocuronium injection.

BACKGROUND: The major disadvantage of rocuronium is the withdrawal movement associated with its injection. The analgesic effect of perioperative gabapentin has been evaluated. We investigated the effects of gabapentin on the withdrawal movement induced by rocuronium injection. METHODS: 86 ASA physical status I or II patients, aged 18-69 years who were scheduled to undergo elective surgery with general anesthesia were enrolled. Patients were randomly allocated into two groups to receive either gabapentin 600 mg or placebo 2 hours prior to surgery. The patient's response to rocuronium injection was graded using a 4-point scale. RESULTS: The incidence of withdrawal movement after rocuronium administration was significantly lower in the gabapentin group (55.0% in the control group vs 28.6% in the gabapentin group). The number of patients with generalized response indicating severe pain, was 9 (22.5%) in the control group and 3 (7.1%) in the gabapentin group. CONCLUSIONS: Pretreatment with a single oral dose of gabapentin 600 mg reduced the incidence and severity of withdrawal movement after rocuronium administration.

Novel Use of Hydromorphone as a Pretreatment Agent: A Double-blind, Randomized, Controlled Study in Adult Korean Surgical Patients.

BACKGROUND: Hydromorphone is a potent µ-opioid selective agonist that has an onset time within 5 minutes and reaches peak effect between 10 and 20 minutes. However, it may show immediate analgesic effect to rocuronium-induced pain because of its peripheral analgesic property and also may attenuate noxious stimuli from tracheal intubation during induction. The opioid receptors are known to be present in peripheral sensory nerve terminals as well as in the dorsal root ganglion and the central terminal of primary afferent nerves. Therefore, we hypothesized that hydromorphone may be considered a potent pretreatment or adjuvant drug during the induction of anesthesia with its peripherally and centrally mediated analgesia. OBJECTIVE: The aim of this study was to compare the effects of pretreatment with hydromorphone in reducing rocuronium-induced withdrawal movements and hemodynamic changes during tracheal intubation with the effects of fentanyl and normal saline. METHODS: In this double-blind, randomized, controlled study, consecutive adult patients aged 20 to 70 years who were scheduled to undergo general anesthesia for elective gastric or colorectal surgery at the Samsung Seoul Hospital (Seoul, Republic of Korea) were randomly assigned to receive 5 mL hydromorphone 0.03 mg/kg or fentanyl 2 µg/kg or normal saline. Thirty seconds after administering the study drug, anesthesia was induced with 2.5% thiopental sodium 5 mg/kg. After loss of consciousness, rocuronium 0.6 mg/kg was injected and immediate withdrawal movements were recorded. Two minutes after rocuronium injection, tracheal intubation was performed and hemodynamic changes were observed. RESULTS: A total of 194 patients were enrolled, with 65 in the hydromorphone group, 67 in the fentanyl group, and 62 in the saline group. The overall incidence of withdrawal movements was significantly lower in the hydromorphone group (2 patients; 3.1%) and the fentanyl group (5 patients; 7.5%) (both, P < 0.001) than in the saline group (36 patients; 58.1%). The mean arterial pressure (MAP) and heart rate (HR) after intubation (median [interquartile range]) in the fentanyl group (101.5 [84-115] mm Hg; 93.5 [82-102] beats per minute [bpm]) and the hydromorphone group (93.0 [83-106] mm Hg; 90.0 [86.3-93.6] bpm) were significantly lower than these measures in the saline group (111.5 [105-123] mm Hg; 103.5 [96-113] bpm) (fentanyl group MAP and HR, P < 0.001; hydromorphone group MAP and HR, P < 0.001). CONCLUSIONS: Pretreatment with hydromorphone and fentanyl may have similar effectiveness in reducing withdrawal movements in response to rocuronium injection pain and inducing immediate general anesthesia.

Effect of pretreatment with gabapentin on withdrawal movement associated with intravenous rocuronium injection / 대한마취과학회지

BACKGROUND: The major disadvantage of rocuronium is the withdrawal movement associated with its injection. The analgesic effect of perioperative gabapentin has been evaluated. We investigated the effects of gabapentin on the withdrawal movement induced by rocuronium injection. METHODS: 86 ASA physical status I or II patients, aged 18-69 years who were scheduled to undergo elective surgery with general anesthesia were enrolled. Patients were randomly allocated into two groups to receive either gabapentin 600 mg or placebo 2 hours prior to surgery. The patient's response to rocuronium injection was graded using a 4-point scale. RESULTS: The incidence of withdrawal movement after rocuronium administration was significantly lower in the gabapentin group (55.0% in the control group vs 28.6% in the gabapentin group). The number of patients with generalized response indicating severe pain, was 9 (22.5%) in the control group and 3 (7.1%) in the gabapentin group. CONCLUSIONS: Pretreatment with a single oral dose of gabapentin 600 mg reduced the incidence and severity of withdrawal movement after rocuronium administration.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study.

BACKGROUND: Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. METHODS: This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. RESULTS: The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). CONCLUSIONS: Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study / 대한마취과학회지

BACKGROUND: Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. METHODS: This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. RESULTS: The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). CONCLUSIONS: Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.

Hemodynamic Responses of Pretreatments Designed to Reduce Withdrawal Movements Following Rocuronium Injection: A Comparison of Alfentanil with Lidocaine / 대한마취과학회지

BACKGROUND: This study was conducted to compare the efficacy of intravenous alfentanil and lidocaine as a pretreatment for the prevention of withdrawal movements following a rocuronium injection and hemodynamic change following tracheal intubation. METHODS: This study evaluated 180 patients that were divided into the following 3 pretreatment groups: group C: normal saline, group L: lidocaine 1 mg/kg, group A: alfentanil 10microgram/kg. Anesthesia was induced using 5 mg/kg thiopental sodium, after which the test drug was injected. Rocuronium (1 mg/kg) was then administered 1 minute after the test drug was injected over 5 seconds and the response was characterized as one of the following: no movement, movement limited to the wrist, to the elbow or to the shoulder. Intubation was performed 1 minute later. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were then recorded at each of the following points: T1: preinduction, T2: immediately prior to rocuronium injection, T3: immediately after rocuronium injection, T4: immediately prior to intubation, T5: immediately after intubation, T6: 1 minute after intubation, T7: 5 minutes after intubation. RESULTS: The incidence of withdrawal movement was significantly lower in group A than groups C and L (P < 0.05). In addition, SBP, DBP and HR following intubation were significantly lower in group A than group C and group L (P < 0.05). CONCLUSIONS: Pretreatment with 10microgram/kg of alfentanil effectively reduced the incidence of withdrawal movement in response of rocuronium injection and caused minimal hemodynamic changes following intubation.

Dilution of Rocuronium with 0.9% NaCl Reduces Withdrawal Movement during Anesthetic Induction

BACKGROUND: After induction of anesthesia with propofol or thiopental, rocuronium causes hand or limb withdrawal or generalized movements, suggesting the presence of intense pain even under anaesthesia. We evaluated the effect of diluting rocuronium 10 mg/ml solution to 5 mg/ml or 3.3 mg/ml with 0.9% NaCl solution on the withdrawal movements associated with IV administration of rocuronium given at intubating doses after thiopental administration. METHODS: Sixty three patients undergoing surgical procedures that required general anesthesia were randomized into three groups. Group 1 received rocuronium 0.9 mg/kg in 10 mg/ml solution, while Group 2 and 3 received the same dose of rocuronium in 5 mg/ml and 3.3 mg/ml solutions with 0.9% NaCl solution after thiopental IV administration, respectively. RESULTS: We observed that the incidence of withdrawal movements was 71.4% in the Group 1, 47.6% in the Group 2 and 14.3% in the Group 3. Intense withdrawal movements involving elbow or shoulder and generalized movements were observed in 42.8% of patients in Group 1, but they were seen in 23.8% of patients in Group 2 and 4.8% of patients in Group 3. There were significant differences in incidence and degree of withdrawal movements between Group 1 and 3 (P < 0.05). The pH values and osmolalities of study solutions were not significantly different between the groups. CONCLUSIONS: Dilution of rocuronium with 0.9% NaCl solution given at intubating doses after thiopental administration is a simple and cost-effective strategy for preventing withdrawal movements during IV rocuronium injection.

The Effect of Dilution with 0.9% Normal Saline on Reducing Withdrawal Movement Induced by Rocuronium Injection

BACKGROUND: The intravenous injection of rocuronium after loss of consciousness during induction of general anesthesia can cause a withdrawal movement of hand, arm or more than one extremity. We designed this study to examine diluted rocuronium (2 mg/ml) with 0.9% normal saline can reduce withdrawal movement. METHODS: Eighty healthy female patients (aged 19-63) scheduled for general anesthesia were randomly assigned to one of two groups; Group 1 (rocuronium 10 mg/ml) and Group 2 (rocuronium diluted to 2 mg/ml with 0.9% normal saline). After loss of consciousness and eyelid reflex by intravenous injection of thiopental sodium 5 mg/kg, rocuronium (0.6 mg/kg) was injected at the speed of 1 ml/sec in both groups. The incidence and severity of withdrawal movements were assessed by using four-point scales. RESULTS: The incidence and severity of withdrawal movement in response to rocuronium injection were significantly reduced in Group 2 compared to Group 1 (P < 0.05). CONCLUSIONS: Dilution of rocuronium 10 mg/ml to 2 mg/ml with 0.9% normal saline was significantly effective for reducing withdrawal movement during induction of general anesthesia. This is a simple and effective strategy for preventing rocuronium-induced withdrawal movement.

The Effect of Rocuronium Diluted with 0.9% NaCl on Withdrawal Response during Injection in Pediatric Patients / 대한마취과학회지

BACKGROUND: Rocuronium is suitable for short operations and rapidly controlling the airway on account of its rapid onset and intermediate action. However, the intravenous administration of rocuronium can cause pain and withdrawal movement in children. This study evaluated the effect of diluting rocuronium from 10 mg/ml to 1 or 0.67 mg/ml with 0.9% NaCl on the withdrawal response associated with the intravenous administration of rocuronium with the intubation dose. METHODS: Ninety pediatric patients undergoing general anesthesia were randomized into one of three groups; Group OR (only rocuronium 0.6 mg/kg, n = 30), Group SR10 (rocuronium 0.6 mg/kg diluted with 0.9% NaCl to 1 mg/ml, n = 30), Group SR15 (rocuronium 0.6 mg/kg diluted with 0.9% NaCl to 0.67 mg/ml, n = 30). After the loss of consciousness by a thiopental sodium 5 mg/kg injection, the patients from each group received the 0.6 mg/kg premixed rocuronium, respectively. Patients' withdrawal response to the injection were graded using a 4-point scale (Grade 0, 1, 2, 3). RESULTS: The incidence and the intensity of the withdrawal response were significantly lower in the SR10 and SR15 groups than in the OR group (P < 0.05). In the SR15 group, the intensity of the withdrawal response was under grade 2 in all patients. CONCLUSIONS: Diluting rocuronium to 0.67 mg/ml is a simple and effective method for preventing withdrawal movements during an intravenous rocuronium injection.

Comparison of Premixed NaHCO3 and Lidocaine on Rocuronium Injection Pain / 대한마취과학회지

BACKGROUND: Rocuronium administration is associated with a severe burning pain during injection in 50-80% patients. The purpose of this study was to evaluate mixtures of saline, lidocaine, sodium bicarbonate (NaHCO3) and lidocaine-NaHCO3 with rocuronium to reduce injection pain and withdrawal movement. METHODS: One hundred and twenty patients were randomly assigned to one of four groups in a double blinded, prospective study; Group S (0.9% normal saline 5 ml mixed with rocuronium 50 mg/5 ml, n = 30), Group L (2% lidocaine 5 ml mixed with rocuronium 50 mg/5 ml, n = 30), Group B (8.4% NaHCO3 5 ml mixed with rocuronium 50 mg/5 ml, n = 30) and Group LB (4% lidocaine 2.5 ml and 8.4% NaHCO3 2.5 ml mixed with rocuronium 50 mg/5 ml, n = 30). After all patients had received an intubating dose (0.6 mg/kg) of premixed rocuronium over 5 seconds, we investigated the incidence and severity of pain and withdrawal movement. We measured the onset and duration of muscle relaxation using train-of-four (TOF) and the pH values and osmolalities of each mixture. RESULTS: The incidence and severity of pain during injection were significantly reduced in Groups B and LB compared with Group S. The withdrawal movement was observed 8 patients (26.7%) in Group S, but in no patient in Groups B or LB. No significant difference in the incidence of pain or withdrawal response was observed between Groups S and L. CONCLUSIONS: We conclude that premixed NaHCO3 with rocuronium is effective at reducing injection pain and withdrawal movement whereas the addition of lidocaine has little effect.

The Effect of Sodium Bicarbonate or Lidocaine Mixed with Rocuronium on Withdrawal Movement in Pediatric Patients / 대한마취과학회지

BACKGROUND: Rocuronium administration after the induction of general anesthesia is associated with localized withdrawal of limbs or generalized movements in children and adolescents. The purpose of this study was to evaluate the effect of normal saline, lidocaine, sodium bicarbonate (NaHCO3), and lidocaine-NaHCO3 mixed with rocuronium reduces withdrawal response. METHODS: Eighty-five pediatric patients (aged 5-15 years) were randomly assigned to one of four groups in a double blinded, prospective study; Group S (0.9% normal saline 5 ml mixed with rocuronium 50 mg/5 ml, n = 21), Group L (2% lidocaine 5 ml mixed with rocuronium 50 mg/5 ml, n = 22), group B (8.4% NaHCO3 5 ml mixed with rocuronium 50 mg/5 ml, n = 22) and Group LB (4% lidocaine 2.5 ml and 8.4% NaHCO3 2.5 ml mixed with rocuronium 50 mg/5 ml, n = 20). After loss of consciousness by sevoflurane inhalation, all patients received 0.6 mg/kg premixed rocuronium over 5 seconds. We investigated the incidence and severity of withdrawal movement using 4-point scales. We also measured pH values and the osmolalities of each mixture. RESULTS: The incidence and degree of withdrawal reaction in response to rocuronium injection were significantly reduced in Groups B (18.1%) and LB (15.0%) versus Group S (57.1%). The addition of lidocaine failed to reduce withdrawal response compared with saline. CONCLUSIONS: NaHCO3 mixed with rocuronium is more effective than lidocaine addition with suspect to preventing withdrawal movement in pediatric patients.

The Efficacy of BIS Monitoring for the Preventing of Withdrawal Movement on the Intravenous Injection of Rocuronium / 대한마취과학회지

BACKGROUND: Arm withdrawal movements are often observed on the administration of rocuronium. This study used the BIS to predict the depth of sedation and the prevention of withdrawal movements. METHODS: With the approval of the institutional review board and the informed consent of the subjects, sixty patients, with ASA physical stati of 1 to 2, were randomized into four groups. After the induction of anesthesia using 0.5 mg/kg of thiopental sodium, each group received 0.6 mg/kg of rocuronium when their BIS values were 85 (Group I), 75 (Group II), 65 (Group III), or 55 (Group IV). The blood pressure, heart rate, BIS value at the time of loss of eyelash reflex, incidence of withdrawal movement and grade, and the correlation between the BIS value and loss of eyelash reflex were observed. RESULTS: No difference were observed in the incidence of withdrawal movement and grade between the four groups. The correlation coefficients of the BIS value and time of loss of eyelash reflex were both 0.33 (P<0.05). CONCLUSIONS: It may be impossible to rely solely on the BIS value to insure patients reach a deep anesthetic state after induction of anesthesia with thiopental. The withdrawal movement on injection of rocuronium can not be prevented with BIS monitoring.

The Preventive Effect of Lidocaine on the Withdrawal Associated with the Injection of Rocuronium in Children / 대한마취과학회지

BACKGROUND: For pediatric anesthesia we frequently use rocuronium bromide, which is often associated with a localized withdrawal of the arm or generalized movements, that may cause harm to the patient. Lidocaine is said to be one of the better agents and reduce the incidence of movement associated with rocuronium injection in adults. The purpose of this study was to compare the effects on movement associated with rocuronium injection according to the method of lidocaine administration in children. METHODS: Two hundreds and four pediatric patients undergoing general anesthesia were randomly assigned to one of six groups (each group n = 34). Fifty seconds after the injection of thiopental sodium 5 mg/kg, the SM group was given mixture of rocuronium bromide 0.6 mg/kg and normal saline 0.05 ml/kg (same amount of 2% lidocaine 1 mg/kg) for 5-10 seconds. The LM 1.0 and LM 2.0 groups were given a mixture of rocuronium bromide 0.6 mg/kg and 2% lidocaine 1 mg/kg or 2 mg/kg, respectively. The LS 1.0, LS 1.5 and the LS 2.0 groups were given 2% lidocaine 1.0 mg/kg, 1.5 mg/kg, and 2.0 mg/kg respectively, 50 seconds after the injection of thiopental sodium, and rocuronium was given 5 seconds after the administration of lidocaine. Withdrawal movements after the injection of rocuronium were investigated. RESULTS: All of the SM group showed withdrawal movement and the LM 2.0, LS 1.0, LS 1.5, and LS 2.0 groups showed less withdrawal movement than the SM group. And the LS 1.0, LS 1.5, and LS 2.0 groups showed less movement than the LM 1.0 group. LS 2.0 group showed less withdrawal movement than LM 2.0 group. CONCLUSIONS: The sequential administration of lidocaine and rocuronium produced a better result than the administration of a mixture in terms of reducing withdrawal movement on rocuronium injection.

Effect of Sodium Bicarbonate or Lidocaine Mixed with Rocuronium on Withdrawal Movement during Rocuronium Injection / 대한마취과학회지

BACKGROUND:We have often observed arm withdrawal on administering rocuronium. This study was performed to determine the cause and to prevent this movement by mixing rocuronium with lidocaine or sodium bicarbonate. METHODS: Sixty-two patients, ASA I-II, were randomized into three groups for this blind, prospective study. After induction of anesthesia by thiopental sodium 0.5 mg/kg, each group received rocuronium 0.6 mg/kg alone (group R), with 2% (2 ml) lidocaine (group L), or rocuronium with an equivalent volume of 8.4% sodium bicarbonate (group S). Patients' responses to the injection were graded using a 4-point scale and the pHs of the mixtures were measured. RESULTS: The incidence rate of arm withdrawal was more reduced in groups L (47%) and S (45%) than in group R (80%) (P < 0.05). Severe withdrawal movement (grade 3) did not occur in group S (0%). CONCLUSIONS: The incidence and the degree of withdrawal movement in response to the injection of rocuronium were significantly reduced by mixing an equivalent volume of 8.4% sodium bicarbonate with rocuronium.