Comparison of succinylcholine and rocuronium for rapid sequence intubation in cesarean section

Almas Ahad1, Muhammad Saleh Khaskheli, FCPS2, Imtiaz Ali Langah3, Munazzah Meraj, M Phil, PhD4, Rao Irfan5
1Clinical lecturer; 2Professor & Chairman,

Department of Anesthesiology, SICU & Pain Center, Peoples University of Medical & Health Sciences for Women (PUMHSW), Nawabshah (Pakistan)

3Senior Registrar, Surgical Unit 3, Peoples University of Medical & Health Sciences for Women (PUMHSW), Nawabshah (Pakistan); langahimtiaznova@gmail.com
4Assistant professor, Department of Biochemistry, Peoples University of Medical & Health Sciences for Women (PUMHSW), Nawabshah (Pakistan); munazzahmeraj@yahoo.com
5Lecturer (Phar.D., PhD), Department of Pharmaceutical Sciences, Peoples University of Medical & Health Sciences for Women (PUMHSW), Nawabshah (Pakistan); raoirfan1@yahoo.com
Correspondence: Professor Muhammad Saleh Khaskheli, Department of Anesthesiology, SICU & Pain Center, Peoples University of Medical & Health Sciences for Women (PUMHSW), Nawabshah (Pakistan); Cell: 003360868593; E-mail: beesaleh@hotmail.com
ABSTRACT

Objectives: To compare efficacy in term of intubating condition between
rocuronium and succinylcholine for rapid sequence induction in cesarean section
Methodology: This randomized controlled trial was conducted at anesthesia department of our hospital at Nawabshah from January to December 2016. A total of 124 full term patients with Mallampati I & II and American Society of Anesthesiologists (ASA) physical status class I and II were randomly allocated into two groups. Group A (62 patients), was treated with succinylcholine chloride and Group B (62 patients) received rocuronium bromide for intubation. Intubating conditions were assessed by jaw relaxation, movement of vocal cords and bucking. Efficacy was labeled as ‘Yes’ when score 8 and 9 (excellent) otherwise ‘No’ if score was less than 8 “good and poor”. Blood pressure, heart rate, and SpO2 were monitored.
Results: - The average age of the patients was 32.37 ± 1.98 y. Overall rate of excellent intubating conditions at one min was observed in 103 (83.1%) patients, good in 17 (13.7%) and poor in 4 (3.2%).  The frequency of clinically acceptable intubating conditions (i.e. excellent) was 87.1% in group A and 79.03% in group B which is not statistically significant.
Conclusion: Rocuronium can be safely used for rapid sequence induction in caesarean sections and the intubating conditions are similar to those of
succinylcholine.
Key words: Endotracheal intubation; Succinylcholine; Rocuronium; Cesarean section
Citation: Ahad A, Khaskheli MS, Langah IA, Meraj M, Irfan R. Comparison of
succinylcholine and rocuronium for rapid sequence intubation in cesarean section. Anaesth Pain & Intensive Care 2018;22(4):­­488-491
Received: 8 Mar 2018, Reviewed: 23, 27 May 2018, Corrected: 18 Jul 2018, Accepted: 31 Aug 2018

INTRODUCTION

Succinylcholine is the most commonly used and a cost effective neuromuscular blocking agent available in Pakistan for endotracheal intubation. It has been in the core anesthetic practice for more than 60 y and is usually preferred if there is a fear of prolonged or failed intubation.1,2 No other drug can compete with it in quality of muscle relaxation, rapidity of onset and short duration of action; that is why despite its limitations and side effects, succinylcholine is still being used for endotracheal intubation.3 However, since its introduction into clinical practice, its side effects related to skeletal muscular activity and biochemically manifested in the form of a rise in serum creatine kinase and serum potassium have been recognized.4,5 Although many relaxant agents can be used for this intubation;6 succinylcholine is still the most popularly used agent in our setup.1,7,8
This study was designed to compare efficacy in term of intubating condition between rocuronium and succinylcholine for rapid sequence induction in cesarean section. The rationale of this study was to find out whether rocuronium produces equally good intubating conditions when compared to succinylcholine in RSI in elective caesarean sections.

Methodology

This randomized controlled trial was conducted at Department of Anesthesia, SICU & Pain Center, People’s Medical College Hospital Nawabshah from January 2016 to December 2016         
A sample size was calculated by using the Rao software to be 124 patients. All full term parturients, ages between 30-35 years of Mallampati I & II and ASA physical status class I and II were included while patients with cervical spine abnormalities were excluded from the study. This study was performed after the permission of ethical committee of hospital and written informed consent for the study was obtained from every patient. Patients were randomly divided into 2 groups of 62 patients each group. All patients received aspiration prophylaxis like inj dexamethasone 8 mg IV, inj metoclopramide 10 mg and inj ranitidine 50 mg IV diluted slowly. Pre-operative vital parameters including pulse rate, systolic and diastolic blood pressures, mean arterial pressure and oxygen saturation was recorded. Venous access was established and connected to IV fluid. After pre-oxygenation with 100% oxygen for 5 min anesthesia was induced with inj propofol 1.5 mg/kg and suxamethonium 1 mg/kg or rocuronium 1 mg/kg to patients of Group I and II respectively.

Intubating conditions were assessed after one minute by jaw relaxation, movement of vocal cords and any bucking, and graded by awarding points to each parameter as excellent (3 points), good (2 points) or poor (1 point). A score of 8-9 was considered Excellent, 6-7 as good and 3-5 as Poor. Pre-operative vital parameters including pulse rate, systolic, diastolic and mean arterial pressures and pulse oxygen saturation were monitored. The data was analyzed by using Statistical Package for Social Science (SPSS) software, version 16. Chi-square test was applied to compare the efficacy in term of intubating condition between groups. p ≤ 0.05 was considered as significant.

RESULTS

The average age of the patients was 32.37 ± 1.98 y. Mean age of the patients was significantly higher in Group B than Group A (Table 1).

Table 1: Comparison of mean age and ASA status between groups
Parameter Group A
(n = 62)		 Group B
(n = 62)		 p-value
Age (Mean ± SD) 32.87 ± 1.94 31.87 ± 1.91 0.005
ASA-I 39 (62.9%) 34 (54.84%) 0.36
ASA-II 23 (37.10%) 28 (45.16%) 0.36
Regarding ASA status, 73(58.9%) was in ASA-I and 51(41.1%) in ASA-II collectively. ASA-I and II status were equivalent in two groups.

Overall rate of excellent intubating condition was observed in 83.1% (103/124) patients, was good in 13.7% (17/124) and poor in 3.2% (4/124). Comparative intubating conditions in group A and B are given in Table 2.

Table 2: Comparison of intubation conditions between two groups
Intubation condition Group A
n = 62		 Group B
n = 62		 Total
Excellent 54 (87.1%) 49 (79%) 103 (83.1%)
Good 7 (11.3%) 10 (16.1%) 17 (13.7%)
Poor 1 (1.6%) 3 (4.8%) 4 (3.2%)
Chi-Square = 1.77 p = 0.41

The frequency of clinically acceptable intubating conditions (i.e. excellent) was 87.1% in group A and 79.03% in group B; the difference not being statistically significant (p = 0.23) (Table 2).The results of our study showed that both drugs produced equivalent intubating conditions.

The hemodynamic parameters were found to be equivalent in both groups without any statistically difference.

DISCUSSION

In this study the average age of the patients was 32.37 ± 1.98 y. Mean age of the patients in group B and Group A being 32.87 ± 1.94 vs. 31.87 ± 1.91 y (p = 0.005) respectively. In Farhat et al. study the mean age of Group A patients was 39.97 ± 1.833 y and of Group B was 36.63 ± 1.791 y.8
Succinylcholine has been for a long time the NMBA of choice for rapid intubation, because of quick onset along with excellent intubation conditions.9 As an alternative to succinylcholine, the non-depolarizing NMBA rocuronium can be used for RSI.1,4 In present study the difference between frequency of clinically acceptable intubating condition (i.e. excellent) was not statistically significant in both drugs. Similar study was also reported by Lauren EG, et al. They concluded that both succinylcholine and rocuronium produced a faster onset and reliable paralysis for rapid sequence intubation.10.
Studies comparing rocuronium and succinylcholine in the onset time and quality of intubation have yielded varying results.1,4,9 Williamson et al. had shown that with rocuronium (0.6 mg/kg) and succinylcholine (1.5 mg/kg), the time to achieve maximum blockade was 87.94 and 65.59s, respectively11 Jones et al. concluded that priming rocuronium with either rocuronium or mivacurium resulted in neuromuscular blockade comparable to that of succinylcholine in both the onset of action and intubating conditions.12
Ishigaki et al. found that the priming interval of 4 min allowed the fastest onset time compared with the 2- and 6-min priming intervals.13 de Caen et al. has proved that priming with the 3-min priming interval was more effective than the 2-min priming interval when rapid tracheal intubation with rocuronium was necessary. 14 Several previous studies have been performed to assess the onset of action of different doses of rocuronium.15-18 In this study, assessment of the onset of action of neuromuscular-blocking agents was carried out with clinical methods in the form of the onset of apnea and cessation of chest movements, which may explain the short onset time of a small dose of rocuronium. Several scientists reported in agreement with the present results that the onset of action of neuromuscular blockade of 1.2 mg/kg rocuronium was still longer than that of succinylcholine.19,20,21 In contrary to the results of these studies, our study shows that the at one min after injection of NMBA, both drugs produced equivalent drugs in the stated doses, even when no priming was done for rocuronium. Although most of the cesarean sections are being carried out under spinal anesthesia the world over, parturients belonging to certain sectors of our population still insist that they should be put to sleep during surgery. Many other patients have to be operated under general anesthesia due to various reasons. Hence, we tested both drugs in full term parturients, at our hospital.

CONCLUSION

Rocuronium can be safely used for rapid sequence induction in cesarean sections and the intubating conditions are similar to those of succinylcholine at one minute. It produces equally good intubating conditions when compared to succinylcholine. Careful consideration should go into the use of a drug such as succinylcholine in the ICU, and rocuronium is a very attractive alternative.

Conflict of interest: None declared by the authors
Authors’contribution:
AA: Conduction of study, data collection
MSK: Concept, Manuscript editing
IL: Statistical analysis
MM: Manuscript writing
RI: Manuscript editing

References
  1. Tran DT, Newton EK, Mount VA, Lee JS, Mansour C, Wells GA, et al. Rocuronium vs. succinylcholine for rapid sequence intubation: A cochrane systematic review. Anaesthia. 2017 Jun;72(6):765-77. [PubMed] DOI: 1111/anae.13903
  2. Ahmad M, Khan NA, Furqan A. Comparing the functional outcome of different dose regimes of Succinylcholine when used for rapid induction and intubation. J Ayub Med Col Abbottabad. 2018 Jun 18;30(3):401-4. [PubMed]
  3. Kosinova M, Stourac P, Adamus M, Seidlova D, Pavlik T, Janku P, et al. Rocuronium versus suxamethonium for rapid sequence induction of general anaesthesia for caesarean section: influence on neonatal outcomes. Int J Obstet Anesth. 2017 Nov 1;32:4-10. [PubMed] DOI: 1016/j.ijoa.2017.05.001
  4. April MD, Arana A, Pallin DJ, Schauer SG, Fantegrossi A, Fernandez J, et al. Emergency department intubation success with succinylcholine versus rocuronium: a national emergency airway registry study. Ann Emerg Med. 2018 May 7;72(6):645-53. [PubMed] DOI: 1016/j.annemergmed.2018.03.042
  5. Nafie MH. Rocuronium for rapid sequence induction in elective caesarean section. Int J Sci Res Pub. 2015 Dec 4;5(12):440-3. [Free Full Text]
  6. Sajayan A, Wicker J, Ungureanu N, Mendonca C, Kimani PK. Current practice of rapid sequence induction of anaesthesia in the UK-a national survey. Br J Anaesth. 2016 Feb 24;117(1):69-74. [PubMed] DOI: 1093/bja/aew017
  7. Li P, Luo L, Wang J, Huang W. Assessment of tracheal intubation in adults after induction with sevoflurane and different doses of propofol: a randomly controlled trial. Int J Clin Exp Med. 2015;8(8):140-2. [PubMed]
  8. Farhat K, Waheed A, Bakhtiar S, Pasha AK. Comparative study of succinylcholine and precurarization with rocuronium on muscular effects in patients undergoing surgery under general Anesthesia. Pak J Pharm. 2011;28(1):33-41.
  9. Ellison M, Grose B, Howell S, Wilson C, Lenz J, Driver R. Prolonged paralysis following emergent cesarean section with succinylcholine despite normal dibucaine number. W V Med J. 2016 Mar;112(2):44-6. [PubMed]
  10. Misra MN, Agarwal M, Pandey RP, Gupta A. A comparative study of rocuronium, vecuronium and succinylcholine for rapid sequence induction of anesthesia. Indian J Anaesth. 2005;49(6):469-73. [Free Full Text]
  11. Williamson RM, Mallaiah S, Barclay P. Rocuronium and sugammadex for rapid sequence induction of obstetric general anaesthesia. Acta Anaesthesiol Scand. 2011;55(6):694–9. [PubMed] DOI: 1111/j.1399-6576.2011.02431.x
  12. Jones P. The therapeutic value of atropine for critical care intubation. Arch Dis Child. 2016;101(1):77-80. [PubMed] DOI: 10.1136/archdischild-2014-308137
  13. Ishigaki S, Masui K, Kazama T. Saline flush after rocuronium bolus reduces onset time and prolongs duration of effect: a randomized clinical trial. Anesth Analg. 2016;122:706-11. [PubMed] DOI: 1213/ANE.0000000000001094
  14. de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, et al. Part 12: pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:526-9. [PubMed] DOI: 10.1161/CIR.0000000000000266
  15. Abou‐Arab MH, Feiner JR, Spigset O, Heier T. Alfentanil during rapid sequence induction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg: tracheal intubation conditions. Acta Anaesth Scand. 2015 Nov;59(10):1278-86. [PubMed] DOI: 1111/aas.12584
  16. Stourac P, Adamus M, Seidlova D, Pavlik T, Janku P, Krikava I, et al. Low-dose or high-dose rocuronium reversed with neostigmine or sugammadex for cesarean delivery anesthesia: a randomized controlled noninferiority trial of time to tracheal intubation and extubation. Anesth 2016 May 1;122(5):1536-45. [PubMed] DOI: 10.1213/ANE.0000000000001197
  17. Kosinova M, Klucka J, Stourac P. Re: Influence on neonatal outcomes of rocuronium for rapid sequence induction of general anaesthesia for caesarean section. Int J Obs anesth. 2018 Aug 1;35:113-4.
  18. Abou-Arab MH, Rostrup M, Heier T. Dose requirements of alfentanil to eliminate autonomic responses during rapid-sequence induction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg. J Clin Anesth. 2016;35:465-74. [PubMed] DOI: 1016/j.jclinane.2016.09.026
  19. Cohen L, Athaide V, Wickham ME , Doyle-Waters MM, Rose NG, Hohl CM. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Ann Emerg Med. 2015;65(1):43-51. [PubMed] DOI: 10.1016/j.annemergmed.2014.06.018
  20. Zafirova Z, Dalton A. Neuromuscular blockers and reversal agents and their impact on anesthesia practice. Best Prac Res Clin Anaesthesiol. 2018;32(2):203-11. [PubMed] DOI: 1016/j.bpa.2018.06.004
  21. Kulkarni M, Chuchendra LS, Bhavya PJ. The role of bolus injection of saline with arm elevation on rocuronium onset time: a randomized control study. Anesth Essays Res. 2018 Jan;12(1):55. [PubMed] DOI: 4103/aer.AER_212_17