Comparison of Succinylcholine and Rocuronium for Rapid Sequence Induction in Pediatrics Age Group
Dr Mansi Shukla *1, Dr Pauravi Bhatt 2, Dr Meet Patel 3
1.3rd Year Anaesthesiology resident doctor, SVP Hospital and Smt. NHL Medical college, Ellisbridge, Ahmedabad, Gujarat.
2.Associate Professor, SVP Hospital and Smt. NHL Medical college, Ellisbridge, Ahmedabad, Gujarat.
3. First Year Anaesthesiology resident doctor, SVP Hospital and Smt. NHL Medical college, Ellisbridge, Ahmedabad, Gujarat.
*Correspondence to: Dr Mansi Shukla, 3rd Year Anaesthesiology resident doctor, SVP Hospital and Smt. NHL Medical college, Ellisbridge, Ahmedabad, Gujarat.
© 2024: Dr Mansi Shukla. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 26 July 2024
Published: 06 August 2024
Abstract
Background: Succinylcholine has been the agent of choice for neuromuscular block when clinical conditions require emergency airway protection during a rapid-sequence induction of anaesthesia. Succinylcholine does have rapid onset but unfortunately there are many side-effects some of them are life threatening. Rocuronium bromide, non-depolarising muscle relaxants with a brief onset of action, but devoid of such side effects may be used as alternative to succinylcholine
Objective: The purpose of our study was to assess the onset and quality of muscle paralysis, the intubation condition of succinylcholine with Rocuronium.
Material and Method: Study was conducted in 80(n=80) ASA grade 1 children of age 5-10 years. Patients were given either Rocuronium 0.6mg/kg iv (n=40) or Succinylcholine 1 mg/kg (n=40). Neuromuscular blockade was quantified by assessing twitch response of adductor pollicis evoked after supramaximal stimulus of the ulnar nerve. Tracheal intubating conditions were assessed at 60 seconds by the Cooper scoring system for both groups. The neuromuscular block was assessed by using the single twitch stimulation. Onset of time was slightly more in Rocuronium (75.3±29.4sec) as compared to Succinylcholine (61.2±11.5sec). With Rocuronium 36 patients (95%) could have clinically acceptable intubating conditions at 60sec, while all were intubated at 60sec with Succinylcholine (100%).
Conclusion: We concluded that Rocuronium provides a good intubating condition at the same time as compared to succinylcholine. Thus its use is beneficial in patients requiring rapid tracheal intubation without any side effects.
Keywords: Neuromuscular relaxant: Rocuronium, Succinylcholine; Pediatric patients; neuromuscular monitoring, Rapid sequence induction.
Introduction
The anatomy and physiology of neonates and infants are different from those of adults, creating challenges for anesthesiologists. Among them, of particular concern is the airway. Pediatric airways can be classified as 'normal', 'impaired normal', and 'known abnormal'.[1] The incidence of unanticipated difficult airways is higher in pediatric age groups than adults due to different airway anatomy, difficulty in airway examination, and congenital malformations.[2] Securing the airway of a pediatric patient in the operating theater is a real challenge for anesthesiologists. Controlled rapid-sequence intubation without cricoid pressure is a safe alternative for pediatric patients to manage a difficult airway.3 Succinylcholine, with rapid onset time and good intubating condition is still the drug of choice for rapid sequence endotracheal intubation. However, it falls short of the ideal muscle relaxants due to its potentially hazardous side effects. [4,5]
The time interval between the suppression of the protective reflexes by induction of anesthesia and development of satisfactory intubating conditions is the critical period for anesthetists. It is desirable therefore, that this period should be as short as possible. Ever since the advent of anaesthesia, anaesthesiologists have been in search of an ideal muscle relaxant, which can provide ideal intubating conditions in an ultra short duration with minimal side effects.
Succinylcholine has been the drug of choice for intubation since its introduction; doses of 1-1.5mg/kg provide an excellent intubating condition with short duration of action. But its use is strongly opposed in children because of multiple complications like an increase in intra- gastric, intracranial and intraocular pressure, risk of malignant hyperthermia in susceptible individuals, risk of rhabdomyolysis, recent burns injury, upper motor neuron diseases, septicemia, hyperkalemia due to any cause.[6,7,8] There are reports of rare but life-threatening malignant hyperpyrexia, hyperkalaemia, and cardiac arrests in young boys with undiagnosed muscular dystrophy. Considering these side effects and contraindications, efforts were made to find out a newer neuromuscular blocking agent with a comparable fast onset and shorter duration of action but without associated side effects of Succinylcholine.[9] Thus, in search for a newer neuromuscular blocking agent with rapid onset, brief duration of action and minimal side effects lead to the discovery of Rocuronium.[10,11] The works carried out by various workers [12] have confirmed the long held belief that a rapid onset of action can by the compounds of relatively low potency.
Rocuronium bromide is a steroidal (ORG 9426) non-depolarizing neuromuscular blocking drug, related structurally to Vecuronium. It was introduced in 1988 at the 9th World Conference of Anaesthesiologists in Washington.[13]
The rapid onset of action of Rocuronium was subject of several investigations determining if this compound allows rapid sequence.
The purpose of our study was to compare the onset of times as well as intubating conditions of succinylcholine and Rocuronium for endotracheal intubation at 60 sec in pediatric patients aged 5-10 years for an elective surgery.
Material and Method
After informed consent of parents, and institutional approval, the present study was conducted in 80(n=80) patients who were scheduled for a planned surgery. The intubating conditions were assessed at 60 sec using Succinylcholine and Rocuronium bromide.
Accordingly, patients were divided into two groups.
GROUP-A (n=40): Succinylcholine 1.0mg/kg at 60 sec.
GROUP-B (n=40): Rocuronium 0.6mg/kg at 60 sec.
Inclusion criteria:
Patients between 5-10 years of age of ASA-1. The current study was conducted in patients who were supposed to undergo elective surgery.
Exclusion criteria:
Patients who were known to have neuromuscular diseases or receiving medications known to influence neuromuscular functions and anticipated airway problem
A day before the surgery, all the patients were thoroughly assessed and examined systematically. Weight and height of the patient were recorded. All routine investigations were done. Vital data were noted and the patient was kept nil by mouth 6 hours before the surgery.
In the operating theater, standard monitoring (ECG, non invasive blood pressure, pulse oximetry and capnography) surface electrode of TOF (peripheral nerve locator) was applied to the opposite forearm, to the one that was used for intravenous line, to stimulate ulnar nerve. The two surface electrodes were placed over the volar side of the wrist, 2-3 cm apart from each other. Baseline measurements were recorded and an intravenous line was secured.
Total Score for intubation condition:
|
Score |
|
|
|
8-9 |
Excellent |
clinically acceptable |
|
|