Rocuronium Injection Pain Research Articles

The effect of orally administered metoprolol on the frequency and severity of rocuronium injection pain

Objectives: This study aimed to examine the effects of orally administered metoprolol on the frequency and severity of pain caused by rocuronium injection in patients who started to use and were currently using oral metoprolol for any reason such as ischemic heart disease, hypertension, and arrhythmias. Methods: Patients were evaluated in four groups. Group M: patients currently using metoprolol and who did not receive lidocaine before the application of rocuronium. Group ML: patients currently using metoprolol and who received lidocaine before rocuronium application. Group L: patients currently not using metoprolol and received lidocaine before rocuronium application. Group C: patients currently not using metoprolol and who did not receive lidocaine before rocuronium application. Following the induction of general anesthesia with thiopental sodium, a researcher blind to the groups observed the pain during rocuronium injection based on the following scale: (1) no reaction, (2) movement only in the ankle, (3) movement or withdrawal only in the arm (shoulder and ankle), and (4) diffuse reaction (movement or withdrawal in more than one extremity, coughing and holding breath). Results: Two hundred patients with 50 in each of four groups were included. The incidence of pain was statistically significantly lower in Group ML compared to Groups M and C (p = 0.001). The correlations between pain caused by rocuronium injection and duration of metoprolol usage and the time since the last dose were not statistically significant (for all, p > 0.05). Conclusions: Oral metoprolol combined with lidocaine reduced pain and withdrawal reflex caused by rocuronium injection. No significant difference was observed between the last dose and the duration of metoprolol usage.

Effects of COX 1-2 Inhibitors on Prevention of Rocuronium Injection Pain: Controlled, Randomised, Double Blind Study

Aim: Rocuronium bromide is a painful agent during induction of general anaesthesia. The aim of the study is to investigate the effects of Cyclooxygenase (COX) inhibitors as a resque agent against the rocuronium pain.
 Material and Methods: Sixty patients of either sex scheduled for under general anesthesia were enrolled in this study. Patients were allocated into two groups (Group 1: Dexkethoprofen group, Group 2: Control group). Pain was evaluated by during rocuronium injection, patients were scored by a scale showed below. 0; No movement response to injection, 1; Mild movement response to injection, 2; Hand withdrawal response to injection, 3; Arm withdrawal response to injection. We also evaluated the pain with 2 questions when the patient was in the recovery room. Question 1. What was the last feeling before you fall into sleep? and question 2. Did you feel any pain on your hand during medication injection for anesthesia?
 Results: There were differences between the groups in terms of total pain score for example in group 1 there were 16 (53%) patients who did not make any movement during rocuronium injection while there were 22 (73%) patients in group 2.There was significant difference in injection rocuronium bromide pain between group 1: dexkethoprofen group, Group 2: control group in terms of the answer to the second question. Patients felt less pain than the control group. In the second question, 16% in group 2 stated that they felt pain, while this rate was observed as 3% in group 1.
 Conclusion: The effect of cox inhibitors on rocuronium pain was seen in our study but control group is also effective in reducing pain in vascular width.

Median Effective Dose of Remifentanil for the Prevention of Pain Caused by the Injection of Rocuronium: An Age-Stratified Study.

Rocuronium intravenous pain is common in induction of general anesthesia. The aim of our study was to determine the median effective dose (ED50) of prophylactic intravenous remifentanil for the prevention of rocuronium injection pain and to explore the effect of age on the ED50. Eighty-nine adult patients undergoing elective general anesthesia, ASA I or II, regardless of gender or weight, were stratified according to age: group R1 18-44years, group R2 45-59years, and group R3 60-80years. The initial dose of prophylactic remifentanil before rocuronium injection was set at 1μg/kg lean body weight (LBW). The remifentanil doses were adjusted according to the degree of injection pain using the Dixon sequential method, with a ratio of 1.1 between adjacent doses. Injection pain was graded, and the occurrence of injection pain and adverse reactions were recorded. The ED50 and 95% confidence intervals (CIs) of remifentanil were calculated using the Dixon-Massey formula. Patients were asked whether they recalled feeling any injection pain in the post-anesthesia care unit (PACU). The ED50 (95% CIs) of prophylactic remifentanil for the prevention of rocuronium injection pain were 1.266μg/kg (1.186-1.351μg/kg), 1.188μg/kg (1.065-1.324μg/kg), and 1.070μg/kg (1.014-1.129μg/kg) LBW in group R1, group R2, and group R3, respectively. No adverse reactions to remifentanil occurred in any group. In PACU, 84.6, 86.7, and 85.7% of patients who experienced injection pain had memories of the pain in group R1, group R2, and group R3, respectively. Prophylactic intravenous remifentanil can prevent rocuronium injection pain, and its ED50 decreases with age, with 1.266μg/kg (18-44years), 1.188μg/kg (45-59years), and 1.070μg/kg LBW (60-80years), respectively. ClinicalTrials.gov: NCT05217238 (registration date 18 Dec 2021).

Propofol ve Rokuronyum Enjeksiyon Ağrısı İçin Vibrasyon Anestezisi

ABSTRACT Objective: Despite numerous strategies for preventing or alleviating pain associated with propofol and rocuronium injections, it remains common and distressing for patients. Application of vibration is an effective method of reducing pain during facial cosmetic injections and some venipuncture procedures. But it has been studied in limited trials for the context of propofol or rocuronium injection pain. This randomized study aims to evaluate the effect of vibration anesthesia on the incidence and severity of propofol and rocuronium injection pain. Methods: Fifty-one patients who underwent elective gynecologic operations under general anesthesia, were randomized, into two groups. On the dorsal side of the hand, a 20 G intravenous cannula was inserted. In Group V (n=25), propofol and rocuronium was administered following 1 minute of pre-treatment with the vibration device on the intravenous catheter trace. In Group C (n=26) vibration was not applied before drug administration. Propofol pain was recorded according to McCrirrick and Hunter scale and rocuronium injection pain response was evaluated with a four-point scale. Results: The number of patients who experienced propofol injection pain, in the vibration group was significantly lower than in the control group (p=0.007). The percentage of pain free patients in Group V was 88%, whereas 46% in Group C. The incidence of withdrawal movements associated with rocuronium injection pain was also significantly lower in Group V (p=0.043). Percentage of pain free patients in Group V was 28% whereas 3.8% in Group C. Conclusion: Vibration anesthesia before propofol and rocuronium injection significantly reduced the injection pain. Keywords: Injection pain, propofol, rocuronium, vibration

Effect of injection pain and withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery: a prospective observational study.

The experience and perception of pain may vary among individuals.This prospective cohort study aimed to determine the impact of injection pain/withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery. A total of 100 patients aged 19-60 years received propofol and rocuronium injections for the induction of anaesthesia. The incidence of propofol injection pain (PIP) and rocuronium-induced withdrawal movement (RIWM), postoperative pain scores and total opioid consumption were evaluated, and the associations between PIP/RIWM and postoperative pain outcomes were determined. Visual analogue scale (VAS) for pain after surgery and total opioid consumption after surgery were significantly higher in patients with PIP or RIWM than in patients without PIP or RIWM. The correlations of PIP/RIWM with VAS at 1 h, VAS at 24 h and total opioid consumption were significant and weakly positive ( r = 0.249, r = 0.234, r = 0.22 and r = 0.234, respectively). The RIWM correlated more positively with pain score compared to PIP at 1 h ( r = 0.408 vs. r = 0.234), PIP at 24 h ( r = 0.398 vs. r = 0.227) and with total opioid consumption for 48 h after surgery ( r = 0.457 vs. r = 0.234). During anaesthesia induction, the occurrence of PIP and RIWM may predict the severity of postoperative pain and total opioid consumption, with RIWM emerging as a stronger predictor than PIP.

Effect of nalbuphine on rocuronium injection pain

ObjectiveRocuronium-associated intravenous injection pain occurs frequently in children during induction of anesthesia. The aim of this study was to systematically evaluate the benefits of nalbuphine in patients with rocuronium-associated injection...

Comparison of lignocaine and nitrous oxide in reducing pain due to Rocuronium injection: A prospective observational study

Background and Objectives: Rocuronium bromide is used in anaesthesia to endotracheal intubation and skeletal muscle relaxation. Rocuronium causes pain on parenteral injection as a common adverse effect. In this prospective observational study pre-treatment with lignocaine and nitrous oxide used to reducing the adverse effect i.e pain of Rocuronium injection.Methodology: A prospective observational study was conducted on 200 patients those underwent modified radical mastectomy and thyroidectomy under general anesthesia were randomly assigned in to two groups (Group L and Group N). Group L (n-100) received 4ml of 1% intravenous preservative free Lignocaine followed by a sub-paralysing dose of intravenous Rocuronium 0.06 mg/kg, diluted with normal saline to an injection volume of 5ml over 10 seconds. Group N received 50% Nitrous oxide in oxygen for 2 minutes followed by a sub-paralysing dose of intravenous Rocuronium 0.06 mg/kg, diluted with normal saline to an injection volume of 5ml over 10 seconds. Pain in the arm, and their response was assessed according to McCrirrick and Hunter scale).Results: It was observed that both lignocaine (Group L) and Nitrous oxide (Group N) reduced Rocuronium injection pain similarly (82% vs 91%; P >0.05).Conclusion: In our study we had compared the effect of 40mg 1% Intravenous preservative free lignocaine and Inhalational 50% Nitrous oxide in reducing pain due to Rocuronium injection and found that both were equally effective in reducing pain of Rocuronium injection.

Gabapentin pretreatment for propofol and rocuronium injection pain: A randomized, double-blind, placebo-controlled study.

This prospectively-planned, randomized, double-blind and placebo-controlled study aims to evaluate the effect of 1200 mg gabapentin premedication on the incidence and severity of propofol and rocuronium injection pain. One hundred patients, between 18-60 years of age and ASA I-II for elective surgery planned under general anaesthetic, were randomized and divided into two groups. Two hours before the operation, the patients were given either a placebo tablet (Group P, n = 50) or 1200 mg gabapentin tablet (Group G, n = 50). On the back of the non-dominant hand, a vein was opened using a 20 G cannula , 0.9% NaCl was begun and preoxygenation was provided. For anaesthesia induction, 1% propofol at 800 ml/hr infusion rate was administered for 20 s. Propofol injection pain was evaluated up to the 20th second and recorded using a scale between 0 and 3 developed by McCrirrick and HunteR The remaining propofol dose (2.5 mg/kg), 5 ml saline and 0.6 mg/kg rocuronium were injected in that order over 10 seconds and rocuronium injection pain response was evaluated with a four point scale. Pain after propofol infusion average score (degree ≥ 1) (Group G = 0.5; Group P = 1.0) and incidence (Group G = 46%; Group P = 68%); and average withdrawal movements response score linked to rocuronium injection pain (≥ 1 response) (Group G = 0.3; Group P = 1.2) and incidence (Group G = 20%; Group P = 80%) were detected to be significantly lower in the gabapentin group compared to the placebo group (p < 0.001). Premedication with 1200 mg gabapentin 2 hours before propofol and rocuronium injection reduced the incidence and severity of injection pain.

Prediction of emergence agitation using withdrawal reaction following rocuronium injection in preschool-aged patients undergoing inguinal herniorrhaphy: a preliminary exploratory observational trial.

PurposeThe development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA.MethodsA total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale.ResultsThere was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU.ConclusionThe findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated.

Effect of Sevoflurane–Nitrous Oxide Induction on the Incidence of Rocuronium Injection Pain in Adults

Effect of Sevoflurane–Nitrous Oxide Induction on the Incidence of Rocuronium Injection Pain in Adults

Effect of rocuronium administration rate and remifentanil on prevention of rocuronium injection pain in pediatric cases

In this study, we aimed to determine the effect of remifentanil administration prior to slow and fast rocuronium infusion on hemodynamic changes and rocuronium injection pain in pediatric patients. In total, 120 5-15-year-old ASA score I/II pediatric patients were included in the study. Group A: slow rocuronium injection-saline; group B: slow rocuronium injection (0.6 mg/kg IV)-remifentanyl; group C: fast rocuronium injection-saline; and group D: fast rocuronium injection-remifentanyl. Withdrawal movement after rocuronium injection was recorded based on a 3-point response to withdrawal score. Hemodynamic parameters were recorded. One minute after rocuronium injection, HR values were found to be lower in remifentanil groups (p: 0.0001; 101.4±22.1, p: 0.003; 99.8±18.3 in group B and D, respectively) compared with those in placebo groups (p: 0.025; 107.4±21.7, p: 0.012; 114.0±16.4 in group A and C, respectively). With respect to the response to withdrawal scores, unresponsiveness rates were the highest in group B (66.7%) and group D (70%). The number of non-responder patients was 9 in saline-administered groups (group A and C), whereas it was 20 and 21 in remifentanil-administered groups (group B and D, respectively). Generalized responses were observed predominantly in groups A (20%) and C (20%). Generalized responses were highest in groups A (20%, n=6) and C (20%, n=6). There was no impact of infusion speed on rocuronium injection pain in pediatric cases, whereas it is concluded that remifentanil administration prior to rocuronium injection considerably reduced rocuronium injection pain regardless of injection speed and without serious hemodynamic changes.

Efficacy of pretreatment with intravenous paracetamol and lidocaine on rocuronium injection pain: A randomized, double-blinded, placebo-controlled study

Background: Pain and withdrawal movement during rocuronium injection are common. The present study was conducted to compare the effect of paracetamol and lidocaine in ameliorating rocuronium injection pain and withdrawal movements. Materials and Methods: With approval of the Institutional Ethics Committee, 135 adult patients of both sexes aged 18–65 years with American Society of Anesthesiologists I or II, undergoing general anesthesia, were recruited to this randomized, double-blinded, placebo-controlled study, and patients were randomly divided into three equal groups. A rubber tourniquet was applied to the arm with intravenous line to occlude the venous drainage. Then, one of the pretreatment solutions was given, Group P received 50 mg paracetamol, Group L received 40 mg lidocaine, and Group S received 5 ml normal saline. After 2-min, tourniquet was released, and subparalyzing dose of rocuronium bromide 0.06 mg/kg was given and pain assessed using a 4-point verbal rating scale. Anesthesia was induced using 2.5% thiopentone sodium, followed by giving the remainder of calculated dose of rocuronium. During and after injection of rocuronium, withdrawal movements were observed and graded on a 4-point scale. Results: The incidence of pain on injection of subparalyzing dose of rocuronium in paracetamol, lidocaine and saline groups was 35.5%, 20%, and 55.5%, respectively (P < 0.05). The incidence of withdrawal movements while giving the bolus dose of rocuronium in paracetamol, lidocaine, and saline was 35.6%, 28.8%, and 59.9%, respectively (P < 0.05). Conclusion: Both paracetamol and lidocaine were effective in reducing rocuronium injection pain and withdrawal movements, but lidocaine is more effective than paracetamol.

Fentanyl or ketamine pre-treatment to prevent withdrawal response to rocuronium.

Fentanyl or ketamine pre-treatment to prevent withdrawal response to rocuronium.

English

English

A comparative study of lignocaine and nitrous oxide for rocuronium injection pain

Background: Pain is a common side effect of rocuronium bromide and this study has been undertaken to compare the effect of nitrous oxide and lignocaine in reducing the rocuronium injection pain in adult patients. Materials and Methods: After ethical committee approval, 80 adult patients of age 18-65 years and ASA I and II who underwent elective surgery from October 2011 and September 2013 in the Regional Institute of Medical Sciences, Imphal were randomly assigned into one of the two groups: Group O ( n = 40) received 100% oxygen for 2 min as preoxygenation; Group N ( n = 40) received 50% nitrous oxide and 50% oxygen mixture for 2 min as preoxygenation. After 2 min., 2 ml of 2% lignocaine was given with the forearm occluded and then released after 1 min. followed by the injection of subparalyzing dose of rocuronium (0.06 mg/kg) and the patients were enquired about the degree of pain. Anaesthesia was then induced with injection thiopentone sodium (2.5%) 5 mg/kg and then a paralyzing dose of rocuronium (0.6 mg/kg) was given to facilitate intubation. The airway was secured and any withdrawal movements were noted. Results: It was observed that the combination of nitrous oxide and lignocaine (Group N) reduced rocuronium injection pain more than lignocaine alone (Group O) (5% vs. 25%; P P Conclusion: It may be concluded that two different analgesic modalities nitrous and lignocaine effectively prevent pain and withdrawal movements associated with rocuronium injection.

The effect of intravenous paracetamol for the prevention of rocuronium injection pain

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50–80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I–II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).

Dexmedetomidine reduces pain associated with rocuronium injection without causing a decrease in BIS values: a dose-response study

Study ObjectivesTo examine whether dexmedetomidine reduces the injection pain of propofol and rocuronium and to investigate whether the decrease in injection pain is associated with the known sedative action of dexmedetomidine. DesignRandomized, double-blind, placebo-controlled clinical comparison study. InterventionsPatients undergoing general anesthesia with intubation received 40 mg of 1% lidocaine (lidocaine group; n = 28), 0.25 μg/kg of dexmedetomidine (low-dose group; n = 27), 0.5 μg/kg of dexmedetomidine (subclinical dose group; n = 28), 1.0 μg/kg of dexmedetomidine (clinical dose group, n = 27), or normal saline (saline group; n = 28) before anesthetic induction. MeasurementsPain associated with propofol and rocuronium injection was assessed using a 10-point verbal analog scale (VAS) and a 4-point withdrawal movement scale, respectively. The BIS value was measured 60 seconds after administration of the study drug, and at the time of rocuronium injection and intubation. Main ResultsThe overall incidence of withdrawal movements due to rocuronium decreased significantly as the dose of dexmedetomidine increased (92.8%, 85.2%, 78.6%, and 51.9% in the saline, low-dose, subclinical dose, and clinical dose groups, respectively; P = 0.001). There was no significant difference in BIS values among the groups 60 seconds after study drug administration or at the time of rocuronium injection. ConclusionsDexmedetomidine reduced pain associated with rocuronium injection in a dose-dependent manner. This effect was not associated with the decrease in BIS value.

Effects of pretreatment with different doses of dexmedetomidine and lidocaine on rocuronium injection associated pain

Objective To compare the efficacy of pretreatment with dexmedetomidine (Dex) and lidocaine to prevent rocuronium injection pain.Methods One hundred and sixty patients (ASA Ⅰ-Ⅱ) scheduled for elective surgery were randomly divided into 4 groups(n=40):control group(Group C),Dex 0.2 μg/kg group(Group D1),Dex 0.4 μg/kg group(Group D2) and lidocaine 0.5 mg/kg group (Group L).Patients in Group D1,Group D2 and Group L received intravenous Dex 0.2,0.4 μg/kg and lidocaine 0.5 mg/kg respectively,while patients in Group C received intravenous normal saline with the same volume(10 ml) within 10 min.Then all patients are intravenously injected rocuronium 10 mg (1 ml) within 2 s.The pain score,sedation and side effects were recorded.Results Demographic parameters were similar among groups.Comparing to Group C,the incidence of pain in Group C (82.5％) was significantly higher than that in Group D1 (60.0％),Group D2 (40.0％) and Group L(32.5％)(P＜0.05).The frequency and intensity of rocuronium injection pain were statistically similar between Group D2 and Group L.The frequency of pain in the Group D2 and Group L was significantly less than the Group D1 (P＜0.05).Sendation score in the Group D2 was significantly higher than the other three groups (P＜0.05).Hypotension,bradycardia and side effects of injection were similar among groups.Conclusions Pretreatment with Dex and lidocaine was effective in reducing the frequency and severity of pain with rocuronium injection but pretreatment with Dex 0.4 μg/kg and lidocaine 0.5 mg/kg proved to be the most effective treatments. Key words: Dexmedetomidine; Lidocaine; Rocuronium; Injection pain

Two birds with one stone: palonosetron pretreatment

CC Recently introduced anesthetic drugs have a common problem: drug-injection pain. The main disadvantage of propofol, etomidate, and rocuronium is pain on injection, which is very stressful to patients and anesthetic providers. Among 33 clinical problems, propofol-injection pain has been positioned as the seventh most frequently occurring clinical anesthetic outcome which expect to avoid [1]. Numerous types of drugs [2,3] and doses of drugs [4] have been tested to solve the problem of intravenous injection pain of rocuronium. However, there is no definitive single therapy. Many investigations have been performed to elucidate the mechanism of injection pain. However, the mechanism remains obscure. In this month’s Korean Journal of Anesthesiologists, Cho et al. [5] evaluated the effect of palonosetron on the injection pain of rocuronium. The authors suggest that palonosetron is effec tive in reducing intravenous injection pain due to rocuronium. Palonosetron is a second-generation 5-HT3 receptor antagonist with a high receptor-binding affinity. It is mainly used to prevent nausea and vomiting related to surgery and chemotherapy. Ondansetron effectively reduces intravenous injection pain from rocuronium [6]. Ondansetron has an action similar to that of lidocaine in terms of blocking sodium channel. We hesitate to use ondansetron during induction because of its short duration. Ondansetron has a plasma half-life of 4 hours because of genetic polymorphisms of the P450 enzyme which lead to decreased efficacy by ultrarapid metabolism [7]. Ondansetron seems to be more effective when given at the end of surgery rather than immediately after induction of anesthesia because of these poly morphisms [8]. While most serotonin antagonists have similar effects, palonosetron might be an exception. Palonosetron has a long half-life of about 40 hours. Therefore, it can be used during induction. If these beneficial properties are established, palonosetron will be a first choice drug to prevent injection pain of rocuronium. Many surgeries are currently performed on an outpatient basis. Postoperative nausea and vomiting is a major cause of delayed discharge and unanticipated readmission. To date, the incidence of postdischarge nausea and vomiting has not been studied on a large scale. Note that shorter-acting drugs are not as effective and antiemetics with a longer duration of action ap pear to be favorable. Palonosetron may be a reasonable choice for postdischarge nausea and vomiting. However, proof for this has not yet been reported. The manufacturer recommends that palonosetron be used with caution in patients with prolongation of cardiac conduction intervals, particularly QTc. Such patients include those with electrolyte abnormalities and those taking antiarrhythmic drugs [9]. Although the prescribing information recommends caution in patients at risk of QTc prolongation, palonosetron has been safely used to patients with cardiac problems [10]. None of the currently used drugs for prophylaxis of injection pain are capable of completely eliminating the incidence of rocuronium injection pain. When considering a multimodal approach, palonosetron can be recommended as an essential component. Palonosetron might relieve injection pain and postoperative nausea and vomiting in one treatment.

Prevention of rocuronium injection pain.

The introduction of rocuronium bromide to the anesthetic field has led to its replacement of succinylcholine for rapidsequence intubation because of its rapid onset time and intermediate duration. Rocuronium is an especially good choice for children because it avoids the complications of succinylcholine; however, injection pain or withdrawal movement (IPWM) has been reported [1]. IPWM is characterized by sudden flexion of the wrist and arm after rocuronium infusion, lasting 10-20 seconds [2]. The incidence of rocuronium-induced IPWM is reportedly 50-80%. Some authors have argued against the necessity of alleviating IPWM based on the lack of convincing data regarding negative patient outcomes caused by IPWM [3]. However, pain on injection and other stressful stimulation during anesthetic induction may cause bronchospasm or myocardial infarction [4,5]. Additionally, a case of pulmonary aspiration caused by rocuronium-induced generalized spontaneous movements has been reported [6]. These findings highlight the importance of alleviating IPWM caused by rocuronium. In an article published in this issue of the Korean Journal of Anesthesiology, Na et al. [7] demonstrate the efficacy of sevoflurane combined with remifentanil against withdrawal movement associated with rocuronium injection in children. The incidence and severity of IPWM are higher in children than in adults [8]. The high incidence of generalized movements in children could cause injury or dislodgement of the venous catheter. Thus, it is more important to prevent IPWM in children than in adults. According to Na et al. [7], 54 and 20% of children who received 2.0 vol% sevoflurane exhibited withdrawal movement and generalized movement respectively; these rates were similar among children who received remifentanil (57 and 17%, respectively). However, when 2.0 vol% sevoflurane was combined with remifentanil at 0.5 µg/kg, the incidence of withdrawal movement decreased to 17% while all generalized movement ceased. In two recently published studies [9,10], the 50% effective end-tidal concentration of sevoflurane (ETsev) was 2.4 vol% in adults and 2.9 vol% in children. In those same studies, the 95% effective ETsev was 3.0-3.5 vol% in adults and 4.3 vol% in children. The 2.0 vol% sevoflurane reported by Na et al. [7] was relatively lower concentration to prevention of IPWM. The remifentanil dose used by Na et al. [7] was also relatively lower than that used in other studies. There was no withdrawal movement in 77% of patients treated with 1 µg/kg of remifentanil [11]. Kim et al. [12] reported that remifentanil at 1.0 µg/kg prevented IPWM after rocuronium more effectively than did remifentanil at 0.5 µg/kg. O'Hare et al. [13] reported that remifentanil at 0.5 µg/kg did not adequately control the hemodynamic changes that occurred after intubation. However, higher doses could result in side effects. Remifentanil at 1.0 µg/kg caused coughing in 14% of patients [11]. Many types of drugs have been investigated for the prevention of IPWM [14,15]; however, few studies have attempted to evaluate the combined effects of more than two drugs on IPWM after rocuronium administration. Na et al. [7] evaluated the effect of a combination of sevoflurane and remifentanil. Separately administered low doses of sevoflurane and remifentanil did not prevent IPWM effectively after rocuronium administration. However, when these drugs were combined the effect was comparable with that of higher doses. Additionally, combined treatment could minimize the side effects of higher doses of sevoflurane or remifentanil. In conclusion, the combination of an inhalation agent with an intravenous agent to prevent IPWM caused by rocuronium is a proper approach, especially for children, who require rapid airway management.