Rocuronium for Tracheal Intubation

Laura S. Willets, Pharm.D.

Disclosures

Pediatr Pharm. 2000;6(10) 

In This Article

Use in Children

Since rocuronium was approved by the FDA in 1994, there have been numerous trials evaluating its use in children.[6,7,8,9,10,11] Scheiber and colleagues[6] evaluated 60 children aged 18 to 72 months undergoing elective surgical procedures requiring intubation. The children were randomized to receive rocuronium 0.6 mg/kg, vecuronium 0.1 mg/kg, or atracurium 0.5 mg/kg after induction of anesthesia with etomidate and fentanyl. Endotracheal intubation was attempted every 30 seconds, beginning 30 seconds after administration of the neuromuscular blocker, until intubation was achieved under good or excellent conditions. Intubating condition grades were based on jaw relaxation, closing of the vocal cords, and diaphragmatic response.

Rocuronium produced acceptable intubating conditions significantly faster than vecuronium or atracurium. All children in the rocuronium group were intubated by 60 seconds (60% intubated at 30 seconds), compared to 120 seconds for complete intubation of the vecuronium group and 180 seconds for the atracurium group. The adductor pollicus muscle was electrically stimulated in order to assess a train-of-four every twenty seconds. Onset of 95% blockade at the adducter pollicis muscle was not significantly different between the groups and the peripheral muscle block was not complete in all groups at the time of successful intubation. Based on these results, the authors speculated that rocuronium may have a faster onset at laryngeal muscle compared with peripheral muscle.

Woolf and colleagues[7] completed a two-part study to evaluate the potency of rocuronium in children. They compared the time course of action at doses up to three times the effective dose for 95% neuromuscular block (ED95) with that of succinylcholine. Forty-eight children aged 2 to 10 years were randomized to intravenous rocuronium 120, 160, 200 or 240 mcg/kg after being anesthetized with nitrous oxide, fentanyl, and propofol. Neuromuscular block was assessed by monitoring train-of-four stimulation of the ulnar nerve every 2 seconds for 10 seconds. This initial study yielded ED50 and ED95 values of 210±24 and 404±135 mcg/kg, respectively.

In the second part of the study, 30 children were randomized to receive 2.0 mg/kg of succinylcholine, 0.8 mg/kg, or 1.2 mg/kg of rocuronium (two and three times the ED95). Time to 90 and 100% block was not significantly different between succinylcholine (30±7 seconds) and 1.2 mg/kg of rocuronium (33±5 seconds); both were significantly less than the 0.8 mg/kg group (46±8 seconds). Time to 25% recovery from 1.2 mg/kg of rocuronium was nearly 8 times longer than after succinylcholine (41±13 compared to 5.2±1.9 minutes).

Another study by Mazurek and coworkers[8] compared 1.2 mg/kg of rocuronium with 1.5 mg/kg of succinylcholine in 26 children aged 2 to 15 years. All children received 5 mg/kg of thiopental. Intubation was attempted after 30 seconds. No difference was noted in time to completion of intubation (41.8±2.9 seconds for rocuronium compared to 40.2±4 seconds for succinylcholine) or in the number of patients receiving excellent intubating scores. Time to recovery of 25% of train-of-four was significantly longer for patients receiving rocuronium, 46.3±23.4 compared to 5.8±3.3 minutes for succinylcholine.

Rocuronium appears to be an acceptable alternative to succinylcholine in providing adequate intubating conditions within 60 seconds of administration. The use of rocuronium is limited by its long duration of action. It should only be used when a rapid return to spontaneous respiration is not required.

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