Prevention of rocuronium-induced withdrawal movement in children: A comparison of remifentanil with alfentanil

Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine, Suwon, Korea.
Pediatric Anesthesia (Impact Factor: 1.85). 04/2008; 18(3):245-50. DOI: 10.1111/j.1460-9592.2007.02390.x
Source: PubMed


This study was designed to compare the efficacy of remifentanil and alfentanil without the venous occlusion technique in preventing the withdrawal response associated with rocuronium injection in children.
One hundred and twenty children aged between 3 and 10 years were randomly allocated into one of four groups to receive either i.v. remifentanil 0.5 (remi 0.5 group), remifentanil 1 (remi 1.0 group), alfentanil 15 (alfentanil group) or saline 5 ml (saline group). Anesthesia was induced with 2.5% thiopental sodium 5 and the test drug was injected over 30 s. One minute later, 1% rocuronium 0.6 was injected over 5 s and the response was recorded. Mean arterial pressure (MAP) and heart rate (HR) were recorded on arrival in the operating room, before and 1 min after tracheal intubation.
The incidence of withdrawal movement in the saline group (93%) was significantly higher than that in the remi 0.5, remi 1.0, and alfentanil groups (53%, 17%, and 20%, respectively) (P < 0.05). The incidence in the remi 1.0 and alfentanil groups was significantly less than that in the remi 0.5 group (P < 0.05). After intubation, MAP and HR were significantly higher in the saline group than that in remi 1.0 and alfentanil groups.
Both remifentanil 1 and alfentanil 15 can be used to prevent rocuronium-associated withdrawal movement in children because they are equally effective and attenuate the increase in MAP and HR after intubation.

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    • "Thirteen studies mentioned the method of random sequence generation [11,12,13,14,15,16,17,18,19,20,21,22,23], and 10 studies used allocation concealment [11,14,23,24,25,26,27,28,29,30]. Patients were blinded in 39 studies [11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49], whereas outcome assessors were blinded in 25 studies [11,12,13,16,17,18,19,20,21,22,23,24,25,27,28,29,30,31,34,35,36,37,38,40,42]. "
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    ABSTRACT: Background We purposed to systemically review studies investigating the prophylactic effect of both pharmacological and non-pharmacological modalities against rocuronium induced withdrawal movement (RIWM) in the Korean population. Methods Literature search was performed using MEDLINE, EMBASE, CENTRAL, Koreamed, KMBASE, KISS and RISS up to March 2014. Randomized controlled trials (RCTs) comparing pharmacological and non-pharmacological interventions with placebo aimed for the Korean population were included. Outcome measures were the incidence and severity of RIWM. We conducted subgroup analyses according to each intervention method. Results Data were analyzed from 41 RCTs totaling 4,742 subjects. The overall incidence of RIWM was about 80% (range 56-100%). Incidence and severity of RIWM were significantly reduced with lidocaine (risk ratio [RR] 0.60, 95% CI 0.49-0.74; standardized mean difference [SMD] -0.74, 95% CI -1.05 to -0.44), opioids (RR 0.28, 95% CI 0.18-0.44; SMD -1.71, 95% CI -2.09 to -1.34) and hypnotics (RR 0.36, 95% CI 0.25-0.52; SMD -2.20, 95% CI -2.62 to -1.79). Regardless of tourniquet use, lidocaine showed a prophylactic effect against incidence and severity of RIWM: tourniquet (RR 0.36, 95% CI 0.21-0.62; SMD -1.51, 95% CI -2.15 to -0.86); non-tourniquet (RR 0.58, 95% CI 0.47-0.71; SMD -0.74, 95% CI -1.05 to -0.44). Dilution and slow injection of rocuronium decreased incidence and severity of RIWM: dilution (RR 0.47, 95% CI 0.39-0.56; SMD -1.64, 95% CI -2.47 to -0.81); slow injection (RR 0.34, 95% CI 0.17-0.70; SMD -2.13, 95% CI -2.74 to -1.51). Conclusions The greater part of pharmacological and non-pharmacological interventions showed prophylactic effect against the incidence and severity of RIWM in the Korean population.
    Korean journal of anesthesiology 06/2014; 66(6):419-32. DOI:10.4097/kjae.2014.66.6.419
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    • "Remifentnil is known to have a dose-dependent effect. Kim et al. [7] reported that remifentanil 1 µg/kg was more effective in preventing rocuronium induced withdrawal movements than remifentanil 0.5 µg/kg. A few studies have reported the EC50 and EC95 of remifentanil to prevent rocuronium withdrawal movements in children [10] and adults [4,10] using the Dixon's up-and down method and by probit analysis. "
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    ABSTRACT: Background Intravenous administration of rocuronium induces intense pain in most patients (60-100%). This could be harmful during anesthesia induction because of the unintended reflex movement of an unconscious patient in response to the pain. Previous studies have reported that remifentanil effectively reduces rocuronium-induced pain and withdrawal movements. This study was designed to evaluate the EC50 and EC95 of remifentanil to prevent withdrawal movements in children. Methods We enrolled a total of 171 pediatric patients scheduled for general anesthesia in this study. Remifentanil was administrated by target-controlled infusion. Effect-site target concentrations ranged from 0.5 to 3.0 ng/ml. At each concentration, experiments were repeated in 10-20 patients. Propofol 2 mg/kg and rocuronium 0.9 mg/kg were administrated after equilibration of plasma and effect-site target remifentanil concentration. The withdrawal movements were graded on a 4-point scale. The EC50 and EC95 of remifentanil to prevent rocuronium-induced withdrawal movements were determined by using a logistic regression model. Results The logistic regression model showed that the probability of preventing rocuronium-induced withdrawal movement was as follows: exp (-3.49 + 2.07 × remifentanil concentration) / (1 + exp [-3.49 + 2.07 × remifentanil concentration]). EC50 and EC95 were 1.69 ng/ml (95% confidence intervals [CIs], 1.42-1.87) and 3.11 ng/ml (95% CIs, 2.79-3.72), respectively. Conclusions Administration of remifentanil at an effect-site target concentration of 3.1 ng/ml could effectively prevent rocuronium-induced withdrawal movements.
    Korean journal of anesthesiology 06/2014; 66(6):433-8. DOI:10.4097/kjae.2014.66.6.433
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    ABSTRACT: A prospective, randomised, double-blind, placebo-controlled study was carried out to determine the effect of nitrous oxide (N(2)O) on the frequency and severity of pain and withdrawal reactions after injection of rocuronium. Eighty ASA physical status I and II patients undergoing general anaesthesia for elective surgery were enrolled. The patients were randomised to receive 100% oxygen (O(2)), or 50% N(2)O in O(2) for 3 minutes followed by a subparalysing dose of rocuronium 0.06 mg/kg. After induction of anaesthesia with thiopentone 5 mg/kg, an intubating dose of rocuronium 0.6 mg/kg was given. The patients were observed after injection of rocuronium 0.06 mg/kg, and asked to rate pain in the arm on a 4-point (0-3) verbal rating scale (none, mild, moderate or severe). After the intubating dose of rocuronium, withdrawal reactions were recorded. Thirty-six patients (90%) in the group N(2)O and 15 patients (37.5%) in the group O(2) reported no pain (P < 0.001). The pain was mild in 1 (2.5%) and 9 (22.5%) patients in N(2)O and O(2) groups, respectively (P = 0.006). Moderate pain occurred in 2 (5%) patients in group N(2)O and 15 (37.5%) patients in group O(2) (P = 0.001). Severe pain was reported by one patient in each group (P = 0.47). Withdrawal response after an intubating dose of rocuronium was observed in 6 (15%) and 18 (45%) patients in the N(2)O and O(2) groups, respectively (P < 0.05). Inhalation of 50% N(2)O in O(2) reduces the incidence and severity of pain and the withdrawal reactions associated with rocuronium injection.
    Indian journal of anaesthesia 03/2010; 54(2):142-6. DOI:10.4103/0019-5049.63660
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