|Year : 2015 | Volume
| Issue : 2 | Page : 57-61
Comparative study between succinylcholine, rocuronium and magnesium sulphate with rocuronium in rapid sequence induction
Nagwa M El-Kobbia, Maher M Doghaim, Moustafa Abdelaziz Moustafa, Ahmed M Deifallah
Department of Anaethesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||01-Feb-2014|
|Date of Acceptance||01-May-2014|
|Date of Web Publication||30-Dec-2016|
Moustafa Abdelaziz Moustafa
Alnasrst, Smouha, Alboroug buildings, Building 5, Alexandria
Source of Support: None, Conflict of Interest: None
Rapid sequence induction usually applies when tracheal intubation must be performed in a patient who is suspected of having a full stomach and who is at risk of pulmonary aspiration of gastric contents. Succinylcholine is the traditional depolarizing neuromuscular-blocking agent used in rapid sequence induction. However, it has a number of undesirable side effects. Magnesium may have a role in potentiation of neuromuscular blockade produced by neuromuscular blockers such as rocuronium.
The aim of this study was to investigate the effects of magnesium sulphate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI).
Patients and methods
A total of 60 adult patients were randomly allocated to three groups: the succinylcholine group, which received 1 mg/kg succinylcholine; the rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 500 ml normal saline; and the magnesium rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 60 mg/kg magnesium sulphate in 500 ml normal saline infusion. Anaesthesia was induced with fentanyl, propofol and a neuromuscular-blocking drug on the basis of the studied group. An anaesthesiologist, blinded to the rocuronium group assignments, performed RSI and assessed the onset time, intubating conditions and clinical duration of neuromuscular block in the different groups. Haemodynamics were recorded before magnesium sulphate or normal saline infusion, after anaesthesia induction and every minute after intubation for 5 min.
The onset time was shortest in the succinylcholine and magnesium groups. The intubating conditions were significantly better in the magnesium group (P < 0.001) compared with the other two groups. Significant increases in heart rate and blood pressure were observed at 1 min after intubation in the succinylcholine and rocuronium groups relative to stable haemodynamics in the magnesium group (P < 0.05).
Magnesium sulphate administered before RSI using fentanyl, propofol and rocuronium may shorten the onset time and improve the intubating conditions comparable to those of succinylcholine and suppress the haemodynamic stress response to intubation.
Keywords: Induction, magnesium, rapid sequence, rocuronium, succinylcholine
|How to cite this article:|
El-Kobbia NM, Doghaim MM, Moustafa MA, Deifallah AM. Comparative study between succinylcholine, rocuronium and magnesium sulphate with rocuronium in rapid sequence induction. Res Opin Anesth Intensive Care 2015;2:57-61
|How to cite this URL:|
El-Kobbia NM, Doghaim MM, Moustafa MA, Deifallah AM. Comparative study between succinylcholine, rocuronium and magnesium sulphate with rocuronium in rapid sequence induction. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2017 Dec 14];2:57-61. Available from: http://www.roaic.eg.net/text.asp?2015/2/2/57/161335
| Introduction|| |
Rapid sequence induction usually applies when tracheal intubation must be performed in a patient who is suspected of having a full stomach and who is at risk of pulmonary aspiration of gastric contents. The goal is to secure the airway without producing any regurgitation or vomiting. The second objective involves minimization of induction-intubation interval, which means that a short-acting hypnotic agent should be administered with a rapidly acting neuromuscular-blocking agent. Finally, the chance of aspiration is to be diminished by applying cricoid pressure without positive pressure ventilation before tracheal intubation is accomplished, and by waiting until neuromuscular blockade is complete to perform tracheal intubation .
Succinylcholine is the traditional depolarizing neuromuscular-blocking agent used in rapid sequence induction. However, it has a number of undesirable side effects. Hence, it is not suitable in many situations, such as neuromuscular disorders, burn, acute head injury, intracranial bleeding, open eye injury, spinal cord injury, cerebrovascular accidents and renal diseases. The above side effects and contraindications of succinylcholine had prompted the use of nondepolarizing muscle relaxants using various techniques for rapid sequence intubation .
Rocuronium, a nondepolarizing muscle relaxant, has been shown to provide adequate intubating conditions with rapid onset, an intermediate duration and no obvious side effects. Rocuronium produces faster neuromuscular blockade compared with other nondepolarizing neuromuscular-blocking drugs. It produces comparable intubating conditions to that of succinylcholine, but does not have the short intubation time of the latter .
Magnesium potentiates neuromuscular blockade through the inhibition of calcium-mediated release of acetylcholine from the presynaptic nerve terminals at the neuromuscular junction and also a decrease in postsynaptic sensitivity to acetylcholine and direct effects on the membrane potential of myocytes, thus augmenting the effect of nondepolarizing neuromuscular blockers .
| Aim of the study|| |
The primary aim of the work was to compare succinylcholine with rocuronium with and without the addition of magnesium sulphate as regards onset time. Duration of intubation, adequacy of intubating conditions and haemodynamic stability came as secondary aims.
| Patients and methods|| |
This study was conducted on 60 adult patients of either sexes, ASA I physical status, scheduled for long elective surgeries. They were randomly categorized using the sealed envelope method into three equal groups (20 each) on the basis of the muscle relaxant used in rapid sequence induction: 1 mg/kg succinylcholine in group I (the S group), 1.2 mg/kg rocuronium in group II (the R group) and 60 mg/kg magnesium sulphate 15 min before 1.2 mg/kg rocuronium in group III (the Mg.R group).
All patients were assessed preoperatively by detailed history taking, complete clinical examination, airway assessment and routine laboratory investigations. On arrival to the operating room, an intravenous access was established. Patients were connected to the standard monitoring, including ECG, noninvasive arterial blood pressure, pulse oximeter and end-tidal carbon dioxide using multichannel monitor (Viesta; Drager, Draeger Medical Systems, Inc. Telford, USA). Neuromuscular monitoring was carried out using a peripheral nerve stimulator (Tristim Tm Model NS-3a). Induction of anaesthesia was carried out with propofol 2.5-3 mg/kg intravenously, and after loss of verbal response, muscle relaxant was administered on the basis of the studied group:
- S group: patients received 1 mg/kg succinylcholine, and intubation was performed after disappearance of response to Train of Four (TOF).
- R group: patients received 1.2 mg/kg rocuronium preceded by 500 ml 0.9% sodium chloride as a placebo, and intubation was performed after loss of three twitches of TOF.
- Mg.R group: patients received 1.2 mg/kg rocuronium preceded by 60 mg/kg magnesium sulphate in 500 ml 0.9% sodium chloride infusion, and intubation was performed after loss of three twitches of TOF.
Maintenance of anaesthesia was carried out in the three groups with isoflurane and increments of rocuronium based on peripheral nerve stimulation.
| Results and statistical analysis|| |
Qualitative data were described using number and percentage. Association between categorical variables was tested using the χ2 -test. When more than 20% of the cells have an expected count less than 5, correction for χ2 -was conducted using Monte Carlo correction.
For normally distributed data, comparison between more than two populations was made using the F-test (analysis of variance). Post-hoc test (Scheffe) with adjusted Bonferroni P value was used for analysis of variants with repeated measures.
Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level.
All patients completed the study. Duration of surgery ranged from 90 to 120 min. Patients of the three groups were comparable as regards the demographic data, as well as the surgical procedure.
Heart rate and mean arterial blood pressure were statistically significantly lower in the Mg.R group compared with the S and R groups during the different times of measurement. When comparing the S and R groups, heart rate was statistically significantly lower in the S group [Figure 1] and [Figure 2].
|Figure 2: Follow-up of mean arterial blood pressure during the different study|
Click here to view
Onset time of neuromuscular blockade was comparable in the S and Mg.R groups (45 and 50 s, respectively) [Figure 3] and [Table 1]. Compared with the Mg.R group, it was statistically significantly shorter relative to the R group (70 s) (with P < 0.001, P < 0.001, respectively) [Figure 3] and [Table 1]. Intubating conditions were statistically significantly better in the S and Mg.R groups compared with the R group (P1 = 0.046, P3 < 0.014), whereas there was no statistically significant difference when comparing the S and Mg.R groups [Figure 4] and [Table 1]. The clinical duration of the muscle relaxant effect was statistically significantly longer in the Mg.R group (80 min) compared with the S group (8 min) and the R group (57 min), with P values of less than 0.001 [Figure 3] and [Table 1].
|Figure 3: Comparison between the three studied groups as regards onset time|
in seconds and clinical duration in minutes
Click here to view
|Figure 4: Comparison between the three studied groups as regards intubation|
Click here to view
|Table 1 Comparison between the three studied groups based|
on onset time (seconds), intubating conditions and clinical
Click here to view
| Discussion|| |
The present study showed that the addition of magnesium sulphate to rocuronium may shorten the onset of action and improve the intubating conditions when compared with rocuronium alone. It seems to provide comparable onset of action and intubating conditions to that of succinylcholine. In addition, magnesium may have a role in suppressing the haemodynamic response to endotracheal intubation manifested by the stable haemodynamics in response to intubation in the Mg.R group in comparison with the significant rise in the rocuronium group.
A few previous studies have been carried out to evaluate the effect of adding magnesium sulphate to rocuronium, especially the 1.2 mg/kg. In accordance with the present study, Park et al.  concluded that pretreatment of 0.6 mg rocuronium with magnesium sulphate suppresses the haemodynamic stress response to endotracheal intubation. Concomittantly, Robertson et al. and Verma et al.  studied the haemodynamic response to intubation under muscle relaxation, with varying doses of rocuronium ranging from 0.6 to 0.9 mg/kg, and reported a significant rise in heart rate and mean arterial blood pressure. In contrast to the present study, Nitschman et al.  studied the cardiovascular parameters after receiving rocuronium (1 mg/kg), in which heart rate, arterial pressure and cardiac output were not altered to a clinically relevant degree.
Several previous studies have been performed to assess the onset of action of different doses of rocuronium. Verma et al. concluded that the onset of intubation with 0.9 mg/kg rocuronium was much more delayed than that of succinylcholine. Misra et al.  noticed that the mean onset time of 0.6 mg/kg rocuronium was 53.67 ± 11.87 s. In this study, assessment of the onset of action of neuromuscular-blocking agents was carried out with clinical methods in the form of the onset of apnoea and cessation of chest movements, which may explain the short onset time of a small dose of rocuronium compared with the present results. Williamson et al. , Perry et al.  and Magorion et al.  reported in agreement with the present results that the onset of action of neuromuscular blockade of 1.2 mg/kg rocuronium was still longer than that of succinylcholine.
In agreement with the present study, McCourt et al.  and Perry et al.  compared the tracheal intubating conditions during a rapid sequence induction of anaesthesia using rocuronium 1.0 and 1.2 mg/kg, respectively, or suxamethonium 1.0 mg/kg, and they observed better intubation conditions with suxamothonium.
Park et al.  combined magnesium sulphate with rocuronium 0.6 and 0.9 mg/kg and found that the intubating conditions were improved significantly in the magnesium group compared with the rocuronium-only group, in addition to preservation of stable postintubation haemodynamics.
Czarnetzki et al.  evaluated the effect of the pretreatment of rocuronium with magnesium sulphate on the onset of neuromuscular blockade using a nerve stimulator. The onset of action in the Mg group was shorter (77 s) and the duration was longer (44.7 min) than that in the rocuronium-only group. The effect of Mg was consistent with the results of the current study; yet, the onset was shorter and the duration of action was longer compared with ours. This may be attributed to the lower dose of rocuronium (0.6 mg/kg) evaluated in that study.
The effect of magnesium as regards potentiation of neuromuscular blockade may be explained by the inhibition of calcium-mediated release of acetylcholine from the presynaptic nerve terminals at the neuromuscular junction and also a decrease in postsynaptic sensitivity to acetylcholine and direct effects on the membrane potential of myocytes that may augment the effect of nondepolarizing neuromuscular blockers .
We concluded from the present study that magnesium sulphate administered before rapid sequence induction using fentanyl, propofol and rocuronium may shorten the onset time, improve the intubating conditions comparable to those of succinylcholine and suppress the haemodynamic stress response to intubation.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Murdoch H. Induction for rapid sequence induction: a tri-deanery survey. Anaesthesia 2012; 67:1047-8.
Naguib M, Brull SJ. Update on neuromuscular pharmacology. Curr Opin Anaesthesiol 2009; 22:483-90.
Rao MH, Venkatraman A, Mallleswari R. Comparison of intubating conditions between rocuronium with priming and without priming: randomized and double-blind study. Indian J Anaesth 2011; 55:494-8.
Czarnetzki C, Lysakowski C, Elia N, Tramèr MR. Time course of rocuronium-induced neuromuscular block after pre-treatment with magnesium sulphate: a randomised study. Acta Anaesthesiol Scand 2010; 54:299-306.
Park SJ, Cho YJ, Oh JH, Hwang JW, Do SH, Na HS. Pretreatment of magnesium sulphate improves intubating conditions of rapid sequence tracheal intubation using alfentanil, propofol, and rocuronium - a randomized trial. Korean J Anesthesiol 2013; 65:221-7.
Robertson EN, Hull JM, Verbeek AM, Booij LH. A comparison of rocuronium and vecuronium: the pharmacodynamic, cardiovascular and intra-ocular effects. Eur J Anaesthesiol Suppl 1994; 9:116-21.
Verma RK, Goordayal R, Jaiswal S, Sinha G. A comparative study of the intubating conditions and cardiovascular effects following succinylcholine and rocuronium in adult elective surgical patients. Internet J Anesthesiol 2007; 14:11-16.
Nitschmann P, Oberkogler W, Hertsig M, Schwarz S. Comparison of haemodynamic effects of rocuronium bromide with those of vecuronium in patients undergoing CABG surgery. Eur J Anaesthesiol Suppl 1994; 9:113-5.
Misra MN, Agarwal M, Pandey RP, Gupta A. A comparative study of rocuronium, vecuronium and succinylcholine for rapid sequence induction of anaesthesia. Indian J Anaesth 2005; 49:469 -73.
Williamson RM, Mallaiah S, Barclay P. Rocuronium and sugammadex for rapid sequence induction of obstetric general anaesthesia. Acta Anaesthesiol Scand 2011; 55:694-9.
Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2008; 2:CD002788.
Magorion T, Wood P, JE Caldwell. Pharmacokinetics, onset and duration of action of rocuronium in humans: normal v/s hepatic dysfunction. Anesthesiology 1991; 75:A1069.
McCourt KC, Salmela L, Mirakhur RK, Carroll M, Mäkinen MT, Kansanaho M, et al
.. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998; 53:867-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]