Abstract
BackgroundRocuronium is an acceptable alternative when succinylcholine is contraindicated for facilitating the endotracheal intubation. However, the onset time of rocuronium for good intubation condition is still slower than that condition of succinylcholine. This study systematically investigated the most efficacious pharmacological interventions for accelerating the onset time of rocuronium.MethodsMedline, Embase, Cochrane Library databases, www.clinicaltrials.gov, and hand searching from the reference lists of identified papers were searched for randomized controlled trials comparing drug interventions with placebo or another drug to shorten the onset time of rocuronium. Statistical analyses were performed using RevMan5.2 and ADDIS 1.16.5 softwares. Mean differences (MDs) with their 95% confidence intervals (95% CIs) were used to analyze the effects of drug interventions on the onset time of rocuronium.Results43 randomized controlled trials with 2,465 patients were analyzed. The average onset time of rocuronium was 102.4±24.9 s. Priming with rocuronium [Mean difference (MD) −21.0 s, 95% confidence interval (95% CI) (−27.6 to −14.3 s)], pretreatment with ephedrine [−22.3 s (−29.1 to −15.5 s)], pretreatment with magnesium sulphate [−28.2 s (−50.9 to −5.6 s)] were all effective in reducing the onset time of rocuronium. Statistical testing of indirect comparisons showed that rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate had the similar efficacy.ConclusionRocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and furthermore their efficacies were similar. Considering the convenience and efficacy, priming with rocuronium is recommended for accelerating the onset time of rocuronium. However, more strict clinical trials are still needed to reach a more solid conclusion due to the large heterogeneities exist among different studies.
Highlights
Succinylcholine was once considered to be the most appropriate muscle relaxant to facilitate the endotracheal intubation during induction of anesthesia
Intervention techniques mainly included non-depolarizing muscle relaxants priming, drug pretreatments, drugs mixed with rocuronium, and chronic anticonvulsant therapy
Sixteen drugs with different combinations of intervention techniques were studied to affect the onset time of rocuronium: non-depolarizing muscle relaxants priming [17,18,19,20,21,22,23,24,25,26,27,28,29,30]; ephedrine [31,32,33,34,35], phenylephrine [36], magnesium sulphate (MgSO4) [22, 37,38,39], suxamethonium [40, 41], lidocaine [42,43,44], midazolam [45] and esmolol [31, 35] pretreatments; rocuronium admixed with sodium bicarbonate [46, 47], mivacurium [48,49,50,51,52,53,54] and cisatracurium [55]; rocuronium priming with pretreatments of thiopentone [24], MgSO4 [22] and ketamine [29], effects of chronic anticonvulsant therapy [56,57,58] (Table 1)
Summary
Succinylcholine was once considered to be the most appropriate muscle relaxant to facilitate the endotracheal intubation during induction of anesthesia It can causes severe hyperkalemia in patients involving burns, denervation or fragile muscle membranes, severe bradycardia after a second dose of succinylcholine, increases in intracranial pressure, intragastric pressure or intraocular pressure, cardiac arrest, etc. We mainly focused on the effects of three pharmacological intervention techniques including pretreatment with drugs, non-depolarizing muscle relaxants priming techniques, and drugs admixed with rocuronium on the onset time of rocuronium. Conclusion: Rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and their efficacies were similar. More strict clinical trials are PLOS ONE | DOI:10.1371/journal.pone.0114231 December 2, 2014
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