| Abstract|| |
Introduction: Rapid sequence induction and intubation is the method of choice for anesthesia induction in nonfasted, full stomach patients in the operating room. The aim of rapid sequence induction is to quickly secure the airway to reduce the risk of regurgitation and aspiration of gastric contents. Succinylcholine, which is the most commonly used neuromuscular blocker in rapid sequence induction, has several side effects. The aim of this study is to compare the effects of succinylcholine and atracurium on muscular relaxation quality in rapid sequence induction and intubation. Materials and Methods: In this blinded, controlled clinical trial, seventy patients undergoing elective herniorrhaphy or orthopedic limb surgery randomly received one of the drug combinations, fentanyl/remifentanil/atracurium/nesdonal or fentanyl/nesdonal/succinylcholine and were evaluated for relaxation of the jaw muscles, vocal cord condition, and muscular response to intubation. Results: There was no significant difference in jaw relaxation, vocal cord condition, and muscular response to intubation between groups. Mean systolic and diastolic blood pressure and pulse rate were significantly lower in remifentanil-atracurium group compared to the succinylcholine group. Conclusion: Keeping the side effects of succinylcholine in mind, it seems that using remifentanil-atracurium combination for rapid sequence induction and intubation of the trachea produces results comparable to succinylcholine and consequently can be used as an alternative approach.
Keywords: Atracurium, rapid sequence induction, succinylcholine
|How to cite this article:|
Khalili M, Moshiri E, Modir H. Comparison of muscular relaxation quality between the combination of remifentanil-atracurium and succinylcholine in rapid sequence induction and intubation. Ann Trop Med Public Health 2017;10:1627-30
|How to cite this URL:|
Khalili M, Moshiri E, Modir H. Comparison of muscular relaxation quality between the combination of remifentanil-atracurium and succinylcholine in rapid sequence induction and intubation. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Aug 4];10:1627-30. Available from: http://www.atmph.org/text.asp?2017/10/6/1627/222685
| Introduction|| |
Endotracheal intubation in nonfasted patients is a risky procedure that is associated with the risk of regurgitation and aspiration of gastric contents and hypoxia. The selected method for tracheal intubation in these conditions is called rapid sequence induction and intubation. It aims to intubate the trachea and secure the airway as fast as possible to reduce the chance of regurgitation and aspiration of gastric contents. The procedure is used in emergency conditions when the patient's stomach is full or there is high risk for aspiration. Due to its rapid action, succinylcholine is the most common neuromuscular blocker in rapid sequence induction method. However, this drug has numerous side effects such as cardiac arrhythmias, increased intraocular pressure, increased intragastric pressure, muscle fasciculation, and muscle pain after the operation., In addition, succinylcholine administration is prohibited in patients with a family history of malignant hyperthermia. Atracurium is a nondepolarizing muscle relaxant drug. Clinical studies have shown that the drug has an average onset of action of about 3–5 min. Its effects are cleared by anticholinesterase drugs and have few side effects.,,, In emergency situataions when the patient with a full stomach is sent to the operating room as quickly as possible, lack of conciousness and disappearance of laryngeal reflexes following induction of anesthesia, if lasting too long can be associated with aspiration of gastric contents and death. It seems logical to assess various pharmaceutical combinations to shorten the period of defenseless airway (i.e., the time span between the loss of consciousness until securing the airway using a tracheal tube). Yet, numerous studies searching for the ideal drug combination have failed to reach a consensus. Therefore, this study tries to compare two drug combinations of fentanyl + remifentanil + atracurium + thiopental with and fentanyl + thiopental + succinylcholine in terms of the quality of intubating conditions.
| Materials and Methods|| |
The study was a double-blinded clinical trial. Seventy patients in the range of 15–65 years old who were admitted for elective herniorrhaphy or orthopedic limb surgery were enrolled in the study. Other criteria were American Society of Anesthesiologists Class I or II, body mass index <26, and Mallampati score of I or II. Patients with a history of neuromuscular disease, family history of malignant hyperthermia or plasma cholinesterase deficiency, administration of known drugs that interfere with neuromuscular blockers, pregnancy, and history of allergy to the drugs used in this study were not included in the study.
The research proposal was approved by the Research Ethics Committee of Arak University of Medical Sciences under the number of 3-90-112.
At first, demographic data were recorded, and 1 min before induction of anesthesia, the patient's hemodynamic parameters including systolic and diastolic blood pressure and heart rate were recorded and then patients were randomly divided into two groups. The first group received 1 mcg/kg fentanyl, 1 mcg/kg remifentanil, 0.5 mg/kg atracurium, and finally 6 mg/kg thiopental for induction of anesthesia. In the second group, 1 mcg/kg fentanyl and then 6 mg/kg thiopental and finally 1.5 mg/kg succinylcholine were injected for induction of anesthesia. Then, 50 s after the injection of the last medication, the intubating person who was not informed of the group was assessed for muscle relaxation and laryngoscopy condition using Cooper scoring system [Table 1]. Based on these criteria, total scores of 8 and 9 mean high scores, 6 and 7 mean good scores, 3–5 were relatively good, and 0-2 mean poor. The patient's hemodynamic parameters including systolic and diastolic blood pressure and heart rate were also recorded 1 min after tracheal intubation. Data obtained were analyzed using the statistical software IBM SPSS Statistics V20.0.0 (IBM Co., Armonk, NY, USA) and t-independent and Chi-square tests.
| Results|| |
Seventy patients were studied on the basis of inclusion criteria. The average age of the patients was 43.65 ± 15.5 and 42.6 ± 14 years in the first and second groups, respectively. In terms of age, no statistically significant difference was observed between the two groups (P = 0.766). In both groups, 22 patients were male (62.9%) and 13 were female (37.1%) and there was no difference between groups in this regard (P = 1.00). Furthermore, there was no significant difference between two groups in terms of the weight, systolic and diastolic blood pressure, and heart rate 1 min before induction of anesthesia [Table 2].
|Table 2: Average systolic and diastolic blood pressure and heart rate before intubation|
Click here to view
In jaw relaxation score during intubation, 13 patients scored 2 and 22 patients scored 3 in the first group. In the second group, 10 patients scored 2 and 25 patients scored 3 in this regard. There were no statistically significant differences between groups regarding jaw relaxation (P = 0.61).
In vocal cord situation, 11 patients scored 2 and 24 patients scored 3 in the first group. In the second group, 6 patients scored 2 and 29 patients scored 3. Again there was no statistically significant difference between the groups regarding vocal cord situation (P = 0.26).
In response to intubation in the first group, 10 patients scored 2 and 25 patients scored 3. In the second group, 1 patient scored 1 and 8 whereas 26 patients scored 2 and 3, respectively. Again, in this item, the groups were not statistically different (P = 0.53). Furthermore, there was no significant difference between two groups in total score [Table 3].
Average systolic blood pressure before and after intubation in the first group showed a reduction of 8.06 ± 0.85 mmHg and in the second group showed an increase of 9.12 ± 2.68 mmHg. There was no significant difference between two groups (P = 0.09). The mean diastolic blood pressure before and after intubation in the first group showed a decrease of 6.56 ± 0.28 mm Hg and in the second group showed an increase of 6.25 ± 3.42 mmHg which was significant (P = 0.044).
The average heart rate before and after intubation was another parameter that was evaluated in this study. Based on the results, the value in the first group increased by 40.38 ± 37.42 bpm, and in the second group, it increased by 44.21 ± 43.34 bpm which was not significantly different between two groups (P = 0.561).
| Discussion|| |
The results showed that, despite the use of two different types of muscle relaxants for rapid sequence induction and intubation, atracurium and succinylcholine had no significant difference in providing ideal intubating conditions. In this study like other studies to assess the overall score for intubation, three factors of jaw relaxation, vocal cord position, and the response to intubation were used (Cooper's scoring system). There was no difference in demographic and basic hemodynamic factors between our groups.
To date, there have been numerous studies in this area for comparison of succinylcholine and nondepolarizing muscle relaxants, yet most of the studies have compared rocuronium and succinylcholine. Due to the similar efficacy and family, we refer to studies on rocuronium.
Various studies comparing nondepolarizing muscle relaxants and succinylcholine have ended into controversial results. Some studies including this study showed no significant difference between two classes of medications in that none of them are superior to the other. Koh et al. stated that the duration of intubation using atracurium is similar to succinylcholine and no severe hemodynamic changes were observed with the use of these drugs in patients undergoing elective surgery. The authors concluded that atracurium can be considered as a proper substitute for succinylcholine. On the other hand, Marsch et al., who investigated intubation in critically ill patients using rapid induction, stated that there is no difference between succinylcholine and rocuronium as muscle relaxants in terms of incidence and severity of decreased O2 saturation, quality of intubating conditions, and failed intubation. Despite the above discussions, there are studies addressing the higher efficacy of succinylcholine compared to nondepolarizing muscle relaxants.
In the study by Vinik, although both drugs cause an appropriate muscle relaxation, the score of intubation in patients who received succinylcholine was higher than patients who received atracurium as muscle relaxant. Although, in this study, a dose of received medications was identical and all patients were undergoing elective surgery, the results were not in line with our study.
The comparison of intubating conditions after rapid sequence induction using succinylcholine and rapacuronium showed that, after 50 s, clinically acceptable intubating conditions were achieved less frequently after rapacuronium 1.5 mg/kg than after succinylcholine. Furthermore, Mencke et al. stated that intubating conditions in succinylcholine group are significantly better than rocuronium group although there was no difference in airway adverse effects between two drugs.
Yusuf et al. in a study conducted in 2006 compared suxamethonium and priming with atracurium for rapid sequence orotracheal intubation in ninety Nigerian adult patients. In their study, intubating conditions were significantly better in suxamethonium group compared to atracurium group both in terms of the time required for intubation and intubating conditions.
Some studies suggest that the effect of nondepolarizing muscle relaxants is better than that of succinylcholine. Gyasi et al. showed that a single dose of atracurium (400 μg/kg) is ideal for intubation and maintaining muscle relaxation in minor surgeries although the onset of effect of this drug is slower than succinylcholine. Sparr et al. also compared rocuronium and succinylcholine for rapid intubation in patients with elective surgery and found that, in the intubation by rapid induction technique, rocuronium is a suitable alternative to succinylcholine. Although he stated that the use of this drug in emergency conditions requires further studies. In a recent study published by Reddy et al., it was found that the risk of anaphylaxis during anesthesia and surgery using succinylcholine is about ten times more than atracurium.
In the study by McCourt, it was found that between 96% and 98% of the cases had high scores, i.e., good to excellent  and in the study by Vinik, about 98% of cases were rated good to excellent for intubation score. In our study, 91.4%–94.2% of patients had good or excellent scores (Groups 1 and 2, respectively).
One of the limitations of our study is the lack of measurement of intubation time in patients and comparison between two groups. On the other hand, using different doses of atracurium or other nondepolarizing neuromuscular agents might cause different results. Using a larger sample size and measuring pain and hoarseness after surgery could also add credibility to our study.
| Conclusion|| |
Given the lack of significant difference between the variables measured in this study and also due to the effects of succinylcholine for intubation with rapid induction method, it seems that the use of remifentanil-atracurium combination has some characteristics comparable with succinylcholine and thus can be used as an alternative approach. On the other hand, there are conflicting studies comparing succinylcholine and nondepolarizing muscle relaxants indicating that further studies should be conducted using larger sample sizes and variable doses of the drugs.
We wish to express our thanks for moral and material support of Arak University of Medical Sciences and all anesthesia staff in Valiasr hospital.
Financial support and sponsorship
The researchers would like to thank the Deputy of Research of Arak University of Medical Sciences for assistance in developing this research.
Conflicts of interest
There are no conflicts of interest.
| References|| |
McCourt KC, Salmela L, Mirakhur RK, Carroll M, Mäkinen MT, Kansanaho M, et al.
Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia 1998;53:867-71.
Booij LH. Is succinylcholine appropriate or obsolete in the intensive care unit? Crit Care 2001;5:245-6.
Lee C. Succinylcholine: Its past, present and future. In: Katz R, editor. Neuromuscular Blocking Drugs, Seminars in Anesthesia. Orlando: Grune and Stratton; 1984. p. 293-302.
Donati F, Bevan DR. Succinylcholine-Current status. In: Norman J, editor. Neuromuscular Blockade Clinics in Anesthesiology. London: Saunders; 1985. p. 371-85.
Stenlake JB, Waigh RD, Urwin J, Dewar GH, Coker GG. Atracurium: Conception and inception. Br J Anaesth 1983;55 Suppl 1:3S-10S.
Hughes R, Payne JP. Clinical assessment of atracurium using the single twitch and tetanic responses of the adductor pollicis muscles. Br J Anaesth 1983;55 Suppl 1:47S-52S.
Hughes R, Chapple DJ. The pharmacology of atracurium: A new competitive neuromuscular blocking agent. Br J Anaesth 1981;53:31-44.
Basta SJ, Ali HH, Savarese JJ, Sunder N, Gionfriddo M, Cloutier G, et al.
Clinical pharmacology of atracurium besylate (BW 33A): A new non-depolarizing muscle relaxant. Anesth Analg 1982;61:723-9.
Njoku DB, Lenox WC. Use care when injecting rocuronium and thiopental for rapid sequence induction and tracheal intubation. Anesthesiology 1995;83:222.
Koh KF, Chen FG. Rapid tracheal intubation with atracurium: The timing principle. Can J Anaesth 1994;41:688-93.
Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, et al.
Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: A prospective, randomized controlled trial. Crit Care 2011;15:R199.
Vinik HR. Intraocular pressure changes during rapid sequence induction and intubation: A comparison of rocuronium, atracurium, and succinylcholine. J Clin Anesth 1999;11:95-100.
Sparr HJ, Mellinghoff H, Blobner M, Nöldge-Schomburg G. Comparison of intubating conditions after rapacuronium (Org 9487) and succinylcholine following rapid sequence induction in adult patients. Br J Anaesth 1999;82:537-41.
Mencke T, Knoll H, Schreiber JU, Echternach M, Klein S, Noeldge-Schomburg G, et al.
Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: A randomized, prospective, controlled trial. Anesth Analg 2006;102:943-9.
Yusuf AH, Okeke CI, Merah NA, Olatosi JO, Desalu IS, Kushimo OT, et al.
Comparison of suxamethonium and priming with atracurium for rapid sequence orotracheal intubation in a Nigerian adult population. Niger Postgrad Med J 2006;13:313-8.
Gyasi HK, Naguib M, Adu-Gyamfi Y. Atracurium for short surgical procedures: A comparison with succinylcholine. Can Anaesth Soc J 1985;32:613-7.
Sparr HJ, Luger TJ, Heidegger T, Putensen-Himmer G. Comparison of intubating conditions after rocuronium and suxamethonium following “rapid-sequence induction” with thiopentone in elective cases. Acta Anaesthesiol Scand 1996;40:425-30.
Reddy JI, Cooke PJ, van Schalkwyk JM, Hannam JA, Fitzharris P, Mitchell SJ, et al.
Anaphylaxis is more common with rocuronium and succinylcholine than with atracurium. Anesthesiology 2015;122:39-45.
Department of Anesthesiology, Valiasr Hospital, Arak University of Medical Sciences, Arak
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]