|Year : 2015 | Volume
| Issue : 3 | Page : 68-72
Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation
Shady M Hassan, Ahmed M Hegab, Eslam N Nada
Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||09-Sep-2015|
|Date of Acceptance||02-Nov-2015|
|Date of Web Publication||30-Dec-2015|
Eslam N Nada
MD, Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig 44519
Source of Support: None, Conflict of Interest: None
As it can be manually manipulated and facilitates visualization around corners, use of an awake flexible fiberoptic bronchoscope has been established as the gold standard for difficult intubation since the 1960s. It is advisable to use conscious sedation to make the procedure easier and more tolerable. The aim of this study was to evaluate the safety and efficacy of using low-dose rocuronium in awake fiberoptic intubation.
Patients and methods
In an experimental prospective study, 90 patients of ASA grades I and II scheduled for elective surgery, with age range of 18-60 years, received sedation for awake fiberoptic intubation. The patients were divided into three groups of 30 patients each: group I received 1 mg/kg fentanyl and 0.05 mg/kg midazolam; group II received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.05 mg/kg rocuronium; and group III received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.1 mg/kg rocuronium. Hemodynamic changes, hypoxia, hypercapnia, sedation score, position of vocal cords, time taken for intubation, cough, sore throat, vomiting, bleeding in airways, bronchospasm, patient discomfort, and any other side effects were noticed and recorded.
Sedation score in group III was significantly higher than in the other two groups (P = 0.04). There was significant decrease in time taken to intubate in group III when compared with group I or group II (P = 0.041). Patient satisfaction in group III was significantly higher than in group I (P = 0.02). Incidence of cough in group I was significantly high when compared with groups II and III (P = 0.001). No significant differences were seen between groups regarding hemodynamic changes, hypoxia, hypercapnia, position of vocal cords, cough, sore throat, bleeding, bronchospasm, vomiting, and vagal faint.
Addition of low-dose rocuronium at 0.1 mg/kg to fentanyl and midazolam during awake fiberoptic intubation is more efficient, safer, and better than addition of 0.05 mg/kg rocuronium or usage of fentanyl and midazolam alone with regard to sedation score, time taken for intubation, and patient satisfaction.
Keywords: Awake fiberoptic intubation, rocuronium, sedation
|How to cite this article:|
Hassan SM, Hegab AM, Nada EN. Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation. Res Opin Anesth Intensive Care 2015;2:68-72
|How to cite this URL:|
Hassan SM, Hegab AM, Nada EN. Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2020 Feb 19];2:68-72. Available from: http://www.roaic.eg.net/text.asp?2015/2/3/68/172788
| Introduction|| |
The importance of airway management strategies comes from catastrophic outcomes such as death, brain damage, and aspiration resulting from interruption of oxygenation .
As it can be manually manipulated and facilitates visualization around corners, an awake flexible fiberoptic bronchoscope has been established as the gold standard for difficult intubation since the 1960s . Awake fiberoptic intubation without sedation is associated with complications, especially those of airway trauma, infection, and lidocaine side effects . It is advisable to use conscious sedation to make the procedure easier and more tolerable . Midazolam, fentanyl, remifentanil, propofol, etomidate, and ketamine were described for conscious sedation in previous studies ,,,. The best sedative agent is that which causes the least degree of respiratory depression and, at the same time, provides adequate degree of sedation and analgesia . Rocuronium bromide is an aiminosteroid muscle relaxant of rapid onset and intermediate duration . Rocuronium-induced muscle blockade can be completely and safely reversed in less than 2 min by the action of sugammadex, a synthetic γ-cyclodextrin . The aim of this study was to evaluate the safety and efficacy of using low-dose rocuronium in awake fiberoptic intubation.
| Patients and methods|| |
This study was an experimental prospective study conducted in Zagazig University Hospitals. After obtaining approval from the hospital ethics committee, written informed consent was taken from 90 patients of ASA grades I and II who were scheduled for elective surgery. These patients were all scheduled for elective surgery on Tuesdays and Wednesdays for 2 consecutive months. These 2 days were selected by the simple random sampling technique method. Because of the risk of using a muscle relaxant during awake intubation, only patients with Simplified Airway Risk Index  4 or more were included in this study, with preservation of spontaneous breathing. Age, height, and weight were documented. Exclusion criteria were patient refusal, pregnancy, history of allergy to lidocaine, age under 18 years, ASA grades IV and V, severe hepatic or renal disease, history of any muscle disease, mouth opening less than 15 mm, and any contraindication to transcricoid injection (tumor or infection at the site of injection and inability to recognize the cricothyroid membrane).
One hour before operation, all patients received 0.01 mg/kg atropine intramuscularly After explanation of the technique and on arrival at the anesthetic room, intravenous access, nasal oxygenation (2 l/min), and routine monitoring in the form of ECG, noninvasive arterial blood pressure, and oxygen saturation were established in all patients. A capnography sensor was attached immediately after endotracheal tube insertion. Patients were divided into three groups: group I received 1 mg/kg fentanyl and 0.05 mg/kg midazolam; group II received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.05 mg/kg rocuronium; and group III received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.1 mg/kg rocuronium. All patients were subjected to spraying of oral cavity with lidocaine 10% (each puff = 10 mg), transcricoid injection of 7 ml 2% lidocaine for local anesthesia of the larynx and proximal trachea, introduction of the fiberoptic endoscope (3.7 mm; Karl Storz GmbH & Co. KG, Tuttlingen, Germany) through the mouth opening into the trachea with continuous insufflation of oxygen (4 l/min) through the working channel of the fiberoptic instrument, and then advancement of a polyvinyl chloride tracheal tube (ID 7.0 mm) over the fiberoptic endoscope. After securing the endotracheal tube, general anesthesia was administered and surgery was allowed to proceed. A postoperative interview was conducted within 24 h.
The following parameters were assessed
- Hypotension or bradycardia: considered when there was a decrease in mean blood pressure or heart rate more than 20% from the baseline.
- Five readings were taken: at baseline, after sedation, after transcricoid injection, during intubation, and after intubation.
- Hypoxia: considered if arterial oxygen saturation (SpO2) was below 90% during the procedure.
- Hypercapnia: considered if end tidal carbon dioxide (EtCO2) was above 50 immediately after intubation.
- Sedation score using the Ramsay sedation score.
- Vocal cords position (cadaveric or moving).
- Time taken for intubation.
- Recording of any side effects such as
- Vagal faint.
- Patient discomfort in the form of verbal rating score (1-10), with 1 indicating the least comfort and 10 indicating maximum satisfaction.
The collected data were handled using a database software program (version 14.0; SPSS Inc., Chicago, Illinois, USA). Data were expressed as mean ± SD or as number and percentage. Analysis of variance, the χ2 -test, and the paired t-test were performed. P value less than 0.05 was considered statistically significant.
| Results|| |
The three groups were comparable regarding patient characteristics in the term of demographic data of the patients [Table 1].
- Awake fiberoptic intubation was successfully performed in all patients.
- There were no statistically significant differences in heart rate among groups [Figure 1], nor were there statistically significant differences in mean arterial pressure [Figure 2]. There were no significant changes in heart rate or mean arterial pressure between time intervals within each group [Figure 1] and [Figure 2].
- There were no statistically significant differences between groups regarding hypoxia (P < 0.05) [Table 2].
- There were no statistically significant differences between groups regarding hypercapnia (P < 0.05) [Table 2].
- Significant increase was noticed in sedation score in group III when compared with groups I and II (P = 0.04) [Table 3].
- There were no statistically significant differences between groups regarding the position of vocal cords (P < 0.05) [Table 4].
- As regards time taken to intubate, there was significant decrease in time in group III when compared with groups I and II (P = 0.041) [Table 5].
- There was no statistically significant difference between group I and group II or between group II and group III with regard to patient satisfaction. However, there was significant increase in patient satisfaction in group III when compared with group I (P = 0.02) [Table 6].
|Figure 1: Changes in heart rate (beats/min) in the three studied groups.|
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|Figure 2: Changes in mean blood pressure (mmHg) in the three studied groups.|
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- There was statistically significant increase in the incidence of cough in group I (30%) when compared with group II (6.66%) and group III (0%) (P = 0.001).
- The incidence of sore throat was 20% in group I, 13.33% in group II, and 6.66% in group III. The incidence of bronchospasm was 3.33% in group I and 0% in group II and group III. No patient developed bleeding, arrhythmia, vomiting, or vagal faint in the three studied groups.
- There were no statistically significant differences between the three studied groups regarding sore throat, bronchospasm, vomiting, and vagal faint.
| Discussion|| |
To our knowledge there are no previous studies on the use of rocuronium in awake fiberoptic intubation.
The use of rocuronium for conscious sedation may be considered difficult because of the fear of interruption of spontaneous ventilation and occurrence of hypoxia.
Fortunately, actions of all drugs used in this study can be reversed by flumazenil for midazolam, naloxone for fentanyl, and sugammadex for rocuronium.
However, there are limitations in this study. Because of the risk of using a muscle relaxant in awake intubation, all our patients were prepared for elective procedures, excluding patients with upper airway emergencies and patients with expected difficulty in airway management (only patients with Simplified Airway Risk Index 4 or more were included in this study). Other future studies are needed to cover these groups of patients.
The results of this study demonstrate that awake fiberoptic intubation can be performed with the use of rocuronium with considerable hemodynamic stability. Previous studies have reported that awake intubation can be achieved with considerable hemodynamic stability under local anesthetic when combined with sedation ,,.
Woodall et al.  demonstrated that absence of sedation in awake intubation causes greater variability and instability in heart rate and systolic blood pressure.
This study demonstrated that there were no statistically significant differences between groups regarding hypoxia or hypercarbia. Only one patient in the third group suffered from hypoxia and two suffered from hypercapnia. This was attributed to breath-holding and displacement of nasal cannulae.
There was significant increase in sedation score in group III when compared with group I or group II. Lapisatepun et al.  found that rocuronium combined with lidocaine may result in a quicker onset of action of lidocaine and improve the quality of intravenous regional anesthesia without significant side effects. This may lead to much better block of lidocaine and may reflect on increasing the sedation score. Another cause is the minimal neuromuscular blocking effect of the low-dose rocuronium, which may lead to sluggishness in response.
As a result of increasing sedation score in group III, time taken to intubate in group III was significantly less than that in the other two groups, and patient satisfaction in group III was significantly higher than in group I.
There were no statistically significant differences between groups regarding the position of vocal cords.
Nine cases in group I suffered from cough. The increased incidence of cough in this group, when compared with the other groups, is understandable. The use of rocuronium in group II and group III suppressed coughing.
As regards other side effects such as sore throat, bronchospasm, bleeding, vomiting, and vagal faint, there was no statistically significant difference in their incidence rates between the three groups. Preoperative atropinization probably prevented any cases of vagal faint, and the good anesthesia of the airways prevented the occurrence of other complications.
| Conclusion|| |
This study concluded that addition of low-dose rocuronium at 0.1 mg/kg to fentanyl and midazolam during awake fiberoptic intubation is more efficient, safer, and better than addition of 0.05 mg/kg rocuronium or usage of fentanyl and midazolam alone in terms of sedation score, time taken for intubation, and patient satisfaction. Our recommendation is to perform future studies to test the use of low dose of rocuronium in awake fiberoptic intubation in difficult intubation cases.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]