Abstract | BACKGROUND:
Succinylcholine remains the muscle relaxant of choice for rapid sequence induction (RSI) but has many adverse effects. High-dose rocuronium bromide may be an alternative to succinylcholine for RSI but recovery times are nearly doubled compared with a standard intubating dose of rocuronium. Magnesium sulfate significantly shortens the onset time of a standard intubating dose of rocuronium. We set out to investigate whether intravenous (IV) pretreatment with MgSO4 followed by a standard intubating dose of rocuronium achieved superior intubation conditions compared with succinylcholine. METHODS: Adults were randomized to receive a 15-minute IV infusion of MgSO4 (60 mg·kg-1) immediately before RSI with propofol 2 mg·kg-1, sufentanil 0.2 μg·kg-1 and rocuronium 0.6 mg·kg-1, or a matching 15-minute IV infusion of saline immediately before an identical RSI, but with succinylcholine 1 mg·kg-1. Primary end point was the rate of excellent intubating conditions 60 seconds after administration of the neuromuscular blocking agent and compared between groups using multivariable log-binomial regression model. Secondary end points were blood pressure and heart rate before induction, before and after intubation, and adverse events up to 24 hours postoperatively. RESULTS: Among 280 randomized patients, intubating conditions could be analyzed in 259 (133 MgSO4- rocuronium and 126 saline- succinylcholine). The rate of excellent intubating conditions was 46% with MgSO4-rocuronium and 45% with saline- succinylcholine. The analysis adjusted for gender and center showed no superiority of MgSO4-rocuronium compared with saline- succinylcholine (relative risk [RR] 1.06, 95% confidence interval [CI], 0.81-1.39, P = .659). The rate of excellent intubating conditions was higher in women (54% [70 of 130]) compared with men (37% [48 of 129]; adjusted RR 1.42, 95% CI, 1.07-1.91, P = .017). No significant difference between groups was observed for systolic and diastolic blood pressures. Mean heart rate was significantly higher in the MgSO4-rocuronium group. The percentage of patients with at least 1 adverse event was lower with MgSO4-rocuronium (11%) compared with saline- succinylcholine (28%) (RR 0.38, 95% CI, 0.22-0.66, P < .001). With saline- succinylcholine, adverse events consisted mainly of postoperative muscle pain (n = 26 [19%]) and signs of histamine release (n = 13 [9%]). With MgSO4-rocuronium, few patients had pain on injection, nausea and vomiting, or skin rash during the MgSO4-infusion (n = 5 [4%]). CONCLUSIONS: IV pretreatment with MgSO4 followed by a standard intubating dose of rocuronium did not provide superior intubation conditions to succinylcholine but had fewer adverse effects.
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Authors | Christoph Czarnetzki, Eric Albrecht, Philippe Masouyé, Moira Baeriswyl, Antoine Poncet, Matthias Robin, Christian Kern, Martin R Tramèr |
Journal | Anesthesia and analgesia
(Anesth Analg)
Vol. 133
Issue 6
Pg. 1540-1549
(12 01 2021)
ISSN: 1526-7598 [Electronic] United States |
PMID | 33337797
(Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
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Copyright | Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society. |
Chemical References |
- Neuromuscular Depolarizing Agents
- Neuromuscular Nondepolarizing Agents
- Magnesium Sulfate
- Succinylcholine
- Rocuronium
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Topics |
- Adult
- Blood Pressure
(drug effects)
- Double-Blind Method
- Female
- Heart Rate
(drug effects)
- Humans
- Infusions, Intravenous
- Intubation, Intratracheal
(methods)
- Magnesium Sulfate
(administration & dosage, adverse effects)
- Male
- Middle Aged
- Neuromuscular Depolarizing Agents
(adverse effects)
- Neuromuscular Nondepolarizing Agents
(adverse effects)
- Pain, Postoperative
(epidemiology)
- Rapid Sequence Induction and Intubation
(methods)
- Rocuronium
(adverse effects)
- Sex Characteristics
- Succinylcholine
(adverse effects)
- Young Adult
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