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Quality of Laryngoscopic View and Rapidity of Development Of alenc uiv e & eq B io io B a f v o a Mitra et al., J Bioequiv Availab 2016, 8:3 i l l a a b n DOI: 10.4172/jbb.1000282 r i l i u t y o Journal of Bioequivalence & Bioavailability J ISSN: 0975-0851 Research Article OpenOpen Access Access Quality of Laryngoscopic View and Rapidity of Development of Intubating Conditions after Atracurium, Vecuronium and Rocuronium: A Randomized Controlled Study Manasij Mitra1, Abhishek Nag2, Tanmoy Ganguly3, Sandeep Kumar Kar3* and Santi Lahiri1 1Department of Anaesthesiology, MGM Medical College, Kishanganj, India 2Subham Hospital and Diagnostic Centre, Coochbehar, India 3Department of Cardiac Anesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, India Abstract Introduction: The choice of muscle relaxant for endotracheal intubation may be straightforward in selective cases, but in most patients, who are otherwise uncomplicated, poses a dilemma among anesthesiologists and intensivists. The authors examined the most commonly used muscle relaxants (Vecuronium, atracurium and rocuronium) in equipotent doses and compared the most vital parameters, i.e., rapidity of development of clinically acceptable intubating condition and quality of laryngoscopic view. Method: 150 adult patients of 18 to 50 y of age were recruited randomly into 3 equal groups having 50 patients (n=50) in each and equipotent dose of vecuronium, atracurium and rocuronium was administered. Endotracheal intubations were attempted every 30 seconds till excellent or good intubating conditions were achieved upto a maximum of 240 s. The available data were analyzed statistically. Results: The three study groups were comparable in terms of the demographic characteristics. The quality of intubating condition was rated significantly better with Rocuronium than with Vecuronium and Atracurium. Time required to achieve successful intubation was also significantly less with rocuronium than with Vecuronium (107.48 ± 1.98*6.583 s vs. 165.46 ± 1.98*6.790 s) and Atracurium (107.48 ± 1.98*6.583 s vs. 195.43 ± 1.98*6.583 s). Excellent laryngoscopic condition was found in more patients with rocuronium at 60 and 90 s and number of successful intubation was also higher. Conclusion: Therefore, the study confirms that rocuronium produces clinically acceptable intubating condition earlier than the other two drugs and the quality of intubating condition is better in terms of laryngoscopic view. Keywords: Muscle relaxants; Laryngoscopy; Intubating conditions; intubating conditions after administration of equipotent doses of Rocuronium; Atracurium; Vecuronium Vecuronium, Atracurium and Rocuronium and to compare the timing of achievement of successful intubation in adults after administration Introduction of equipotent doses of the three drugs. From time immemorial the quest for an ideal anesthetic agent Patients and Methods considered as the ultimate goal in anesthesia research. Scientists and chemists experimented over innumerable drugs and chemicals to After obtaining research approval from Institutional research find an agent which can provide sedation, analgesia, amnesia, muscle oversight committee and informed written consent from the patients, relaxation and loss of reflex response without any hemodynamic this randomized double blind study was conducted on 150 patients instability or undue adverse effect but failed to establish a single drug between 18 to 50 y of age (Table 1), ASA physical status I and II posted as a sole remedy of surgical stress. Modern anesthesia practice involves for surgery under general anesthesia. Patients with anticipated difficult use of multiple drugs, e.g., sedatives, neuromuscular blockers (NMBs), intubation, refused consent, contraindication to any drug under study analgesics etc., to achieve and maintain adequate plane of anesthesia (e.g., hepatic or renal insufficiency), any neuromuscular disorder, during surgery. Among NMBs currently three agents very commonly dyselectrolytemia, pregnancy or patients receiving drugs influencing used in the anesthesia practice, namely: atracurium, vecuronium neuromuscular transmission were sorted out in preoperative clinic and rocuronium. All these three drugs are intermediate acting non- and excluded. Patients were recruited to three groups according to depolarising neuromuscular blockers with unique advantages and disadvantages which guides their use in selective cases (Like atracurium or cisatracurium in renal or hepatic insufficiency owing to its liver or *Corresponding author: Dr. Sandeep Kumar Kar, Assistant Professor, Department of Cardiac Anaesthesiology, Institute of Postgraduate Medical kidney independent unique metabolism: Hofmann elimination and Education and Research, Kolkata, India, Tel: +919477234900; E-mail: sndpkar@ nonspecific ester hydrolysis) [1-5]. But for general purpose, the ideal yahoo.co.in and best neuromuscular blocker is still to be investigated. For surgery Received March 08, 2016; Accepted April 05, 2016; Published April 12, 2016 under general anesthesia, maximum muscle relaxation is required Citation: Mitra M, Nag A, Ganguly T, Kar SK, Lahiri S (2016) Quality of during laryngoscopy and intubation. Therefore the neuromuscular Laryngoscopic View and Rapidity of Development of Intubating Conditions after blockers are usually judged in terms of their ability to produce ideal Atracurium, Vecuronium and Rocuronium: A Randomized Controlled Study. J intubating conditions as well as quality of muscle relaxation after a Bioequiv Availab 8: 128-133. doi:10.4172/jbb.1000282 specified time period. Copyright: © 2016 Mitra M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted In this background, the aims of this study were aimed to evaluate use, distribution, and reproduction in any medium, provided the original author and the quality and speed of development of clinically acceptable tracheal source are credited. J Bioequiv Availab ISSN: 0975-0851 JBB, an open access journal Volume 8(3): 128-133 (2016) - 128 Citation: Mitra M, Nag A, Ganguly T, Kar SK, Lahiri S (2016) Quality of Laryngoscopic View and Rapidity of Development of Intubating Conditions after Atracurium, Vecuronium and Rocuronium: A Randomized Controlled Study. J Bioequiv Availab 8: 128-133. doi:10.4172/jbb.1000282 Drugs ED 95 Doses considered for intubation, i.e., Variables Excellent Good Poor 2 X ED95 Laryngoscopy Easy (Fully Fair (Not fully Difficult Vecuronium [7-12] 0.05 mg/kg 0.1 mg/kg (Jaw relaxation) relaxed) relaxed) (Resistance) Atracurium [12-15] 0.23 mg/kg 0.25 mg/kg Vocal cord position Abducted Intermediate Closed Rocuronium [7,16-20] 0.3 mg/kg 0.6 mg/kg Vocal cord movement None Moving Closing Table 1: Neuromuscular blockers: ED 95 values [6]. Reaction to intubation AND/ None Slight Vigorous OR Cuff Inflation a computer generated randomization chart. Each group included 50 Movements of limbs/ None Diaphragm* Sustained patients. Group A received 0.1 mg/kg vecuronium, group B received Coughing 0.5 mg/kg Atracurium and group C received 0.6 mg/kg rocuronium *‘diaphragm’ indicates slight diaphragmatic movements only intravenous bolus as equipotent intubating dose of neuromuscular Table 2: Endotracheal intubating condition score [21]. blocker. After the patient was received in operating room, documents were Airway Examination Component Anticipated difficult intubation checked, a brief examination was done and monitors were attached. Length of upper incisors Relatively long Before intubation, ECG, pulse oxymetry, non-invasive blood pressure Relationship of maxillary and Prominent “overbite” (maxillary incisors mandibular incisors during normal anterior to mandibular incisors) was monitored and after intubation end tidal carbon dioxide was also jaw closure monitored. All patients were preoxygenated for 5 min and received Relationship of maxillary and Patient cannot bring mandibular glycopyrrolate (0.2 mg), fentanyl (2 µg/kg), ondansetron (4 mg) 5 min mandibular incisors during voluntary incisors anterior to (in front of) maxillary before induction. Propofol (2 mg/kg) was used as induction agent. After protrusion of mandible incisors the patient was induced, equipotent dose of neuromuscular blocker Interincisor distance Less than 3 cm was introduced to the patients according to their randomization group Visibility of uvula Not visible when tongue is protruded with patient in sitting position (e.g., as described earlier Mallampati class>2) The time of administration of neuromuscular blockers were Shape of palate Highly arched or very narrow noted. Endotracheal intubations were attempted by experienced Compliance of mandibular space Stiff, indurated, occupied by mass, or anesthesiologist using cuffed polyvinylchloride endotracheal tubes non-resilient [sizes appropriate for the age and the body structure]. The first Thyromental distance Less than three ordinary finger breadths intubation attempt was made at 60 s, after administration of relaxant. Length of neck Short Intubation conditions were scored as excellent, good or poor based on Thickness of neck Thick Range of motion of head and neck Patient cannot touch tip of chin to chest laryngoscopy [jaw relaxation], vocal cords position and movements or cannot extend neck and movement of limbs and coughing in response to intubation and/ or cuff inflation using the scoring systems proposed by Viby-Mogensen Guided by Practice Guidelines for Management of the Difficult Airway; An Updated Report by the American Society of Anesthesiologists Task
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