Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children.
Cheng CAY, Aun CST, Gin T. Paediatric Anaesthesia 2002; 12:140-145.
Review: This randomized, blinded study compared intubating conditions during rapid tracheal intubation in 120 ASA 1 children ranging in age from 1-10 years. Following intravenous induction of general anesthesia with alfentanil 10 ug/kg and thiopentone 5 mg/kg, patients received suxamethonium 1.5 mg/kg, rocuronium 0.6 mg/kg, or rocuronium 0.9 mg/kg. Cricoid pressure was not applied since patients were undergoing elective surgery and were not at risk for aspiration. One of the authors was blinded to the administration of muscle relaxant and performed all intubations and evaluated intubating conditions. Intubation was attempted 30 seconds after administration of muscle relaxant and was successfully completed in all patients by 60 seconds. For patients who received suxamethonium, intubating conditions were judged to be good (relaxed vocal cords, slight cough) in 3 (2.5%) patients and excellent (relaxed vocal cords, no cough) in 37 (92.5%) patients. For patients who received rocuronium 0.9 mg/kg, intubating conditions were poor in 1, good in 1 and excellent in 38 (95%). For patients who received rocuronium 0.6 mg/kg, intubating conditions were poor in 4 (10%), good in 7(17.5%) and excellent in 29(72.5%). The authors concluded that rocuronium 0.9 mg/kg provided similar intubating conditions to suxamethonium 1.5 mg/kg. Rocuronium 0.6 mg/kg did not provide adequate intubating conditions.
Comments: Efforts to find a satisfactory substitute for suxamethonium (succinylcholine) continue. Rapacuronium failed in it's bid to replace succinylcholine, primarily because of a clinically significant incidence of severe bronchospasm. Rocuronium has proven to be a useful alternative in some circumstances. Sixty seconds after administration of rocuronium 1-1.2mg/kg, intubating conditions are similar to those produced by succinylcholine. This dose produces an intermediate duration of neuromuscular blockade, however, so rocuronium in this dose is unsuitable for short cases. Furthermore, duration of blockade may be prolonged in young infants due to slower plasma clearance. The aim of this study was to determine if a lower dose of rocuronium could produce comparable intubating conditions within 30-60 seconds. The authors considered this interval to be desirable since children are more prone to oxygen desaturation than adults. (Infants, who are at even greater risk for hypoxia during rapid tracheal intubation, were excluded from the study, however.) Although intubating conditions were rated poor in one patient, the authors concluded that rocuronium 0.9 mg/kg was as effective as suxamethonium. Rocuronium 0.6 mg/kg provided inadequate intubating conditions. The authors did not attempt to correlate the subjective assessment of intubating conditions with the objective results of neuromuscular blockade monitoring. In addition, the duration of neuromuscular blockade with this dose of rocuronium was not reported. This study describes the efficacy of a somewhat reduced dose of rocuronium in children to facilitate rapid tracheal intubation. It left unanswered, however, the question of its efficacy and utility for patients less than one year of age.
Reviewed by: John T. Algren, MD
Vanderbilt Children's Hospital
Nashville, TN