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Comparison of Rocuronium Bromide and Succinylcholine Chloride for Use During Rapid Sequence Intubation in Adult Patients

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Comparison of Rocuronium Bromide and Succinylcholine Chloride for Use During Rapid Sequence Intubation in Adult Patients Sasidharan Nair et al / International Journal of Biomedical Research 2016; 7(6): 365-371. 365 International Journal of Biomedical Research ISSN: 0976-9633 (Online); 2455-0566 (Print) Journal DOI: 10.7439/ijbr CODEN: IJBRFA Original Research Article Comparison of rocuronium bromide and succinylcholine chloride for use during rapid sequence intubation in adult patients * Sasidharan Nair M , Sweetline Subha M and Sreejith H Department of Anaesthesia, Dr. SMCSI Medical College, Karakonam, Trivanadrum, Kerala -695504 *Correspondence Info: Dr. Sasidharan Nair. M, M.D Assistant Professor Department of Anaesthesia, Dr. SMCSI Medical College, Karakonam, Trivandrum, Kerala -695504 E-mail: [email protected] Abstract The introduction of endotracheal intubation during First World War and introduction of balanced anaesthesia in 1926, urged the search for a drug which could cause Jaw relaxation to facilitate endotracheal intubation.Succinylcholine chloride introduced in 1951, was a synthetic depolarising muscle relaxant. It fulfilled both of the above requirements and soon became the drug of choice for endotracheal intubation especially in rapid sequence intubation in emergency cases. Because of its adverse effects like hyperkalemia, rise in intragastric, intraocular, intracranial pressures and cardiovascular effects, a quest began for a safer substitute for Succinylcholine chloride. The new non depolarising muscle relaxant drug rocuronium bromide introduced in 1994 became the first competitor for Succinylcholine chloride. Rocuronium bromide when given in two to three times the ED95 dose is said to produce excellent to good intubating conditions in 60 seconds. Further rocuronium bromide is said to be devoid of the adverse effects that are seen with Succinylcholine chloride. Hence the present study was undertaken to evaluate the intubating conditions with rocuronium bromide 1 mg/kg body weight and to compare the intubating conditions with that of Succinylcholine chloride 1.5 mg/kg body weight, for use during rapid sequence intubation in adult patients. Rocuronium bromide 1 mg/kg body weight produces excellent intubating conditions in 96.67% of patients and good to excellent intubating conditions in 100% of patients at 60 seonds with an average clinical duration of action of 49 minute and 10 seonds. Keywords: Intubation, Succinylcholine, Rocuronium bromide. 1. Introduction The introduction of endotracheal intubation during above requirements and soon became the drug of choice for First World War and introduction of balanced anaesthesia in endotracheal intubation specially in rapid sequence intubation 1926, urged the search for a drug which could cause Jaw in emergency cases. Because of its adverse effects like relaxation to facilitate endotracheal intubation. Most of the hyperkalemia, rise in intragastric, intraocular, intracranial intubations were done with inhalational technique which was pressures and cardiovascular effects, a quest began for a safer associated with problems like laryngospasm and substitute for Succinylcholine chloride. bronchospasm. Further there was a need to take the patient The aim of research on neuromuscular drugs was to sufficiently in deeper anaesthetic plane before intubation, have non depolarising muscle relaxant, which is like which lead to hemodynamic disturbances.[1] Succinylcholine chloride without its side effects. Though The skeletal muscle relaxant d-tubocurarine which many non depolarising muscle relaxant drugs like atracurium, was non-depolarising in nature was introduced in 1942 to vecuronium and mivacurium were introduced, none of them fulfill the need for jaw relaxation. Though this drug provided could challenge Succinylcholine chloride in terms of its onset. excellent muscle relaxation, it had additional ganglion The new non depolarising muscle relaxant drug blocking properties causing tachycardia, hypotension even in rocuronium bromide introduced in 1994 became the first clinical doses. Further it has delayed onset at jaw, making it competitor for Succinylcholine chloride. Rocuronium unsuitable for use during rapid sequence intubation in bromide when given in two to three times the ED95 dose is emergency cases. Hence a research began for a relaxant said to produce excellent to good intubating conditions in 60 which had rapid onset and short duration of action.[3] seconds. Further rocuronium bromide is said to be devoid of Succinylcholine chloride introduced in 1951, was a the adverse effects that are seen with Succinylcholine synthetic depolarising muscle relaxant. It fulfilled both of the chloride. IJBR (2016) 7 (06) www.ssjournals.com Sasidharan Nair et al / Comparison of rocuronium bromide and succinylcholine chloride for use during rapid sequence intubation 366 Hence the present study was undertaken to evaluate and EtCO2. The baseline heart rate, oxygen saturation and the intubating conditions with rocuronium bromide 1 mg/kg electrocardiogram, systolic, diastolic, mean arterial blood body weight and to compare the intubating conditions with pressure and EtCO2 were recorded. that of Succinylcholine chloride 1.5 mg/kg body weight, for Inj Pentazocine 30 mg, Inj Midazolam 1 mg and Inj use during rapid sequence intubation in adult patients. Glycopyrrolate 0.2 mg were given intravenousy to all patients 3 minutes prior to administering induction agents. All the 2. Methodology patient were preoxygeneated with 100%oxygen via a face A double blind clinical study comparing rocuronium mask for 3 minutes after administering Pentazocine, bromide 1 mg/kg and Succinylcholine chloride 1.5 mg/kg for Midazolam and Glycopyrrolate. They were induced with Inj. use during rapid sequence intubation of anaesthesia in adult Thiopentone sodium 5 mg/kg body weight intravenously. patients was undertaken at Vinayaka Mission’s Medical In all patients cricoid pressure was applied by an College and Hospital, Karaikal, Puducherry during the period assistant after induction as soon as patient became 15-11-2009 to 10-05-2011 after obtaining ethical committee unconscious and continued till the ETT was in place. In clearance. Group I Succinylcholine chloride 1.5 mg/kg body weight was The study population consisted of 60 adults patients given intravenously after the loss of eye lash reflex. Similarly of ASA grade I and II belonging to both sexes in the age in Group II rocuronium bromide 1 mg/kg body wieght was group of 18-60 years who were posted for various emergency given intravenously after the loss of eye lash reflex. No mask surgeries at Vinayaka Mission’s Medical College and ventilation was done in any patient after administration of Hospital. Informed written consent was obatained from relaxant. Laryngoscopy was attempted at 60 sec. by a senior patients before taking up for surgery. Exclusion criteria anasethesiologist (who was blinded to the drug group the consisted of patients with ischemic heart disease, medication patient belonged), the C & L grading and intubating with drugs that interact with neuromuscular transmission viz conditions were assessed and graded and appropriate sized Aminoglycosides, Calcium channel blockers etc, history of ETT was passed. Bilateral air entry was checked and the tube drug allergy, obesity, neuromuscular disorders and anticipated was firmly secured by inflating the cuff. Then the cricoids difficult airway. pressure was released. The study population was randomly divided into 2 The intubating conditions were graded using the groups, with 30 patients in each group. score adopted by Toni Magorian et al[8] (1993) as shown Group I consisting of 30 patients were to receive below. Succinylcholine chloride 1.5 mg/kg body weight and Excellent= Jaw relaxed, vocal cords apart and immobile, no intubation attempted at 60 seconds. diaphragmatic movements. Group II consisting of 30 patients were to receive Good= Jaw relaxed, vocal cords apart and immobile, some rocuronium bromide 1 mg/kg body weight and intubation diaphragmatic movements. Poor=Jaw relaxed vocal cords moving and bucking attempted at 60 seconds. Inadequate = Jaw not relaxed, vocal cords closed. Patient was assessed in the pre op holding room Manitenance of anasethesia was done with 40% regarding the general physical conditions, any existing oxygen and 60% nitrous oxide and halothane and intermittent systemic illness, the present cardiopulmonary status, airway positive pressure ventilation (IPPV) on Bain’s circuit. assessment including mallampatti grading, jaw movements, Monitoring of vital parameters like heart rate oxygen neck movements, thyromental distance and dentition. All the saturation, systolilc and mean arterial pressure, basic investigations like haemoglobin, total and differential electrocardiogram and Et CO2 were recorded at 1,3 and 5 blood count, bleeding and clotting time, random blood sugar, minutes following intubation. The clinical duration of action blood urea, serum creatinine, chest X-Ray and ECG were that is the time from administration of relaxant to first attempt done preoperatively. at respiration of initial bolus doses of Succinylcholine Patients were premedicated with Inj Ranitidine 50 chloride and rocuronium bromide was noted. Subsequently, mg IV and Inj Metaclopromide 10 mg IV half an hour before the muscle relaxation was maintained with intermittent dose surgery. All patients were practically considered to be full of rocuroium bromide 0.1 mg/kg body weight till the end of stomach anticipating the risk of pulmonary aspiration. the surgery. At the end of surgery all the patients were In the operating
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