COMPARATIVE STUDY OF DIFFERENT DOSES OF

ROCURONIUM BROMIDE FOR ENDOTRACHEAL INTUBATION

-Dr. Priyam A. Shah(Anaesthesia Resident ,SVP)

-Dr. Sonal A. Shah( Assistant Professor- Anaesthesia
department , SVP)
TITLE :COMPARATIVE
STUDY OF DIFFERENT
DOSES OF ROCURONIUM BROMIDE FOR
ENDOTRACHEAL INTUBATION

PRINCIPAL AUTHOR :Dr. Priyam A. Shah(Anaesthesia Resident ,SVP)

CO-AUTHOR/
PG GUIDE:Dr. Sonal A. Shah( Assistant Professor- Anaesthesia

department , SVP)

AFFILIATION INSTITUTE : SMT NHL MUNICIPAL MEDICAL COLLEGE

CONFERENCE REGISTRATION NO.: PGV0552

CITY: AHMEDABAD
Aims and Objectives
The present study was designed to compare the effect of three different doses
(0.6mg/kg, 0.9mg/kg, 1.2mg/kg) of Rocuronium bromide in facilitating tracheal
intubation at 60 seconds in various elective surgeries, divided in three groups of 20
patients each.

Aims of study :
• To compare the intubating conditions of different doses (0.6 mg/kg, 0.9
mg/kg, 1.2 mg/kg) of Rocuronium bromide at 60 seconds in adults.
• To observe haemodynamic changes after administration of different doses.
Introduction

● Endotracheal intubation is of paramount importance in general anesthesia requiring

relaxation of laryngeal musculature leading to total inactivity of vocal cords.

● Anesthesiologists have been in search of an ideal muscle relaxant which can provide
ideal intubating conditions in ultrashort duration with minimal side effects.

● Suxamethonium chloride in the dose of 1-1.5mg/kg provide excellent intubating

condition in 60-90 seconds with short duration of action on the diaphragm and
adductor muscles of the larynx involved in respiration and airway protection.
 Unfortunately, Suxamethonium chloride has many side effects like

● Increase in intragastric, intracranial and intraocular pressure. - Rhabdomyolysis

with hyperkalemia.

● Changes in cardiac rhythm including bradycardia and cardiac arrest. - Malignant

hyperthermia in susceptible individuals.

● Life threatening increase in serum potassium levels seen in patients with burns,
massive trauma, denervating injuries and upper motor neuron lesions.

Therefore it is contraindicated in patients with-

● head injury
● eye injury
● patients having recent history of burns and
● patients with denervating injuries.
ROCURONIUM BROMIDE

Rocuronium bromide, introduced in 1994 , a new aminosteroidal nondepolarizing neuromuscular

blocking agent with rapid onset of action, became the first competitor for Suxamethonium chloride.
Molecular formula - C32H53BrN2O4
Molecular weight - 609.7.
Commercial preparation is sterile, non-pyrogenic and isotonic solution for intravenous injection,
Each milliliter containing 10 mg Rocuronium bromide and 2 mg sodium acetate.
Absorption - Poorly absorbed from GI Tract.
Distribution Half-life -Rapid distribution half-life is 1 to 2 minutes.
-Slow distribution half-life is 14 to 18 minutes.
Elimination Half-life - 73 (66-80) minutes.
Excretion - Mainly bile, 30-35 % via kidneys.
Onset of Action:
After intravenous administration: 1-2 minutes
Duration of Action:
After intravenous Administration: 20-35 minutes.

DOSAGE
• In adults:
For tracheal intubation -0.6-1.2 mg/kg
Maintenance dose -0.15 mg/kg
Continuous infusion -10-12 mcg/kg/min

REVERSAL
Neuromuscular blocking effect of Rocuronium bromide can be reversed with usual muscle relaxant
antagonist such as Neostigmine.
Sugammadex is a newer reversal agent.
Methodology

● The clinical study was carried out by randomly selecting 60 patients aged 18-60
years of either sex, ASA physical status I/II and Mallampatti Grade I/II, who were
scheduled for various elective surgeries under general anaesthesia. Informed
consent was taken. Patients were divided into 3 groups of 20 patients each.
Group-A:Rocuronium bromide 0.6 mg/kg i.v. (2x ED95)

Group-B:Rocuronium bromide 0.9 mg/kg i.v. (3 x ED95)

Group-C: Rocuronium bromide 1.2 mg/kg i.v. (4 x ED95)

All patients were kept nil by mouth for 6 hours. All vital parameters were noted and
considered as control baseline values.
● PREMEDICATION-

● Injection Glycopyrrolate 0.004 mg/kg i.v. and Injection Fentanyl 1 μg/kg i.v. 5
minutes before induction of anaesthesia.

● Patients were preoxygenated with 100% O2 by facemask for 3 minutes and were induced with
Injection Thiopentone sodium 5 mg/kg i.v. slowly and Injection Rocuronium bromide according to
group allocation and the time of Injection of Rocuronium bromide was noted.

In Group A - 0.6 mg/kg of Rocuronium bromide

In Group B - 0.9 mg/kg of Rocuronium bromide

In Group C - 1.2 mg/kg of Rocuronium bromide

● Patients were ventilated with 100 % oxygen with facemask.
● At 60 seconds after completion of Rocuronium bromide injection, laryngoscopy and tracheal intubation
was done.

● Laryngoscopy and endotracheal intubation were accessed and graded according to Cooper et al
criteria.
Cooper et al criteria

Score Jaw relaxation Vocal cords Response to Intubation

positions

0 Poor (Impossible) Closed Severe bucking or

coughing Score
8-9 = Excellent

1 Minimal Closing Mild coughing 6-7 = Good

(Difficult)
3-5 = Poor

2 Moderate (Fair) Moving Slight diaphragmatic 0-2 = Bad

movement

3 Good (Early) Open None

The vital parameters like pulse rate, systolic, diastolic and mean
arterial blood pressure were recorded at fixed time intervals i.e.

IB- Before Induction

IA- After Induction

T1 - l min after Intubation

T3- 3 min after Intubation

T5 - 5 min after Intubation

Observation and results
Intubating conditions in percentage were as follows-

The table shows that 60%, 85%, 100% patients had excellent intubating conditions in group A, B, C
respectively. 25% and 15% patients had good intubating condition in group A and B respectively, while
only group A had poor intubating condition in 15% of patient.

Condition Score Group A Group B Group C

Excellent 8-9 60% 85% 100%

Good 6-7 25% 15% 0%

Poor 3-5 15% 0% 0%

Bad 0-2 0% 0% 0%
The graph shows that 60%,
85%, 100% patients had
excellent intubating conditions
in group A, B, C respectively.
25% and 15% patients had good
intubating condition in group
A and B respectively, while only
group A had poor intubating
condition in 15% of patient.
 Heart Rate Variation (Mean)
This table shows that there was no significant difference in heart rate variation among
the three groups as per the times in table.

TIME GROUP A GROUP B GROUP C P VALUE INFERENCE

BEFORE 86.5 ± 4.49 85.6±7.15 85.5±6.32 0.927 NS

INDUCTION

AFTER 94.1±5.05 91.3±7.26 90.5±6.42 0.169 NS

INDUCTION

1 MIN AFTER 103±5.97 99.2±6.11 97.8±7.51 0.130 NS

INTUBATION

3 MIN AFTER 94.8±5.72 92.2±6.15 91.3±6.32 0.168 NS

INTUBATION

5 MIN AFTER 90.7±4.33 89.2±5.99 88.5±5.97 0.432 NS

INTUBATION
This graph shows that there was no significant difference in heart rate variation
among the three groups .
 Mean arterial Pressure (Mean) mmHg

This table shows that there was no significant difference in mean arterial pressure
variation among the three groups as per the times in table.

Time Group A Group B Group C P VALUE Inference

BEFORE 93.4±5.21 92.3±5.36 91.7±4.82 0.557 NS

INDUCTION

AFTER 88.8±5.13 86.1±5.23 85.3±4.93 0.093 NS

INDUCTION

1 MIN AFTER 106.5±4.92 101.6±5.60 101.4±4.41 0.182 NS

INTUBATION

3 MIN AFTER 99.9±5.49 98.4±5.07 98±4.49 0.292 NS

INTUBATION

5 MIN AFTER 95.6±5.32 94.3±5.15 92.7±4.56 0.342 NS

INTUBATION
This graph shows that there was no significant difference in diastolic blood
pressure variation among the three groups .
 DISCUSSION
●There was no significant difference in heart rate, systolic and diastolic blood pressure and
mean arterial pressure variation among the three groups .

●Changes in heart rate and mean arterial pressure following intubation with Rocuronium bromide with
all three doses is minimal.

●Cooper et al (1992) assessed intubating conditions by using Cooper et al criteria and intubating
condition in Rocuronium bromide (0.6 mg/kg) were found to be clinically acceptable (good and
excellent) in 95% of patients at 60 seconds and in 100% ofpatients at 90 seconds.

●Schultz P et al (2001) compared intubating condition at 60 seconds after one hundred and eight
patients were randomized to one of three doses of Rocuronium 0.6,0.9 and 1.2 mg/kg. The intubating
conditions are graded as excellent or good in allpatients except in two patients following 0.6 mg/kg
dose of Rocuronium. They concluded that there is no further improvement in intubating conditions of
60 seconds by increasing the Rocuronium dose from 0.9 mg/kg to 1.2 mg/kg.
● Statistical analysis revealed that there was no statistically significant difference
with regard to mean heart rate and mean arterial pressure during intubation
among all the three groups.

● No allergic or adverse reactions were noted in all groups.

● Raghavan L et al (2016)observed that there was no statistically significant

difference with regard to mean heart rate and mean arterial pressure during
intubation.

● Levy et al (1994) concluded that between three dose groups, there was no
significant difference with respect to these hemodynamic parameters with
Rocuronium bromide 0.6,0.9 and 1.2 mg/kg.
Conclusion

● Rocuronium bromide in the dose of 0.9 mg/kg and 1.2 mg/kg provides better clinically
acceptable intubating conditions at 60 seconds than 0.6 mg/kg.

● No further improvement in intubating conditions at 60 seconds was evident by

increasing dose from 0.9 mg/kg to 1.2 mg/kg.

● Rocuronium bromide is a hemodynamically stable neuromuscular blocking agent with

all the three doses 0.6 mg/kg, 0.9 mg/kg and 1.2 mg/kg.
References
● Cooper R, Mirakhur RK., Clarke RSJ, Bombs Z : Comparison for intubating conditions after
administration of ORG 9426 (Rocuronium) and Suxamethonium, Br.J. Anaesthesia1992; 69: (3), 269-
73.
● Schultz P; Ibsan M, Ostergaaed D, Skovgaard L.T; Onset and duration of action of Rocuronium from
tracheal intubation through intense block to complete recovery.ActaAnaesthesiologicaScandinavica
vol.45; No.5, May 2001, pp.612-617.
● Raghavan L, Venkatesan G, Padmanabhan KR. A prospective randomised clinical trial of three
different doses of rocuronium for intubation in adults. J. Evolution Med. Dent. Sci. 2016;5(88):6560-
6564, DOI:10.14260/Jemds/2016/1483
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Analog 1994; 78: 318-321.
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1994; 41: 3-6

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Intubating conditions after three different doses of rocuronium in the elderly. J Med Assoc Thai
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