|Year : 2008 | Volume
| Issue : 5 | Page : 551
Evaluation of Post Succinylcholine Myalgia and Intubation Conditions with Rocuronium Pretreatment: A Comparison with Vecuronium
V Abraham1, Arti Raj Kumar2, L Afzal3
1 Professor & Head, Department of Anaesthesia, CMC, Ludhiana, Punjab, India
2 Lecturer, Department of Anaesthesia, CMC, Ludhiana, Punjab, India
3 Professor, Department of Anaesthesia, CMC, Ludhiana, Punjab, India
|Date of Acceptance||08-Jul-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anesthesiology, Christian Medical College, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
We have studied 120 adult patients in the age group of 20-40 years belonging to ASA I or II. Patients were divided into two groups of 60 patients each, taking alternate patient for each group. Group R patients were given rocuronium 0.06mg.kg -1 and Group V patients were given vecuronium 0.01 mg.kg -1 intravenously 60 seconds before the administration of thiopentone followed by succinylcholine. Both groups did not have statistically significant myalgia on the 1 st post-operative day. On the 3rd postoperative day 3 patients in vecuronium group had moderate myalgia. There was no statistically significant rise in serum potassium, creatinine phosphokinase and urine myoglobin in both the two groups. Rocuronium provides better intubating conditions and effective precurarization within short interval.
Keywords: Succinylcholine, Intubation, Myalgia, Vecuronium , Pretreatment
|How to cite this article:|
Abraham V, Kumar AR, Afzal L. Evaluation of Post Succinylcholine Myalgia and Intubation Conditions with Rocuronium Pretreatment: A Comparison with Vecuronium. Indian J Anaesth 2008;52:551
|How to cite this URL:|
Abraham V, Kumar AR, Afzal L. Evaluation of Post Succinylcholine Myalgia and Intubation Conditions with Rocuronium Pretreatment: A Comparison with Vecuronium. Indian J Anaesth [serial online] 2008 [cited 2020 Oct 24];52:551. Available from: https://www.ijaweb.org/text.asp?2008/52/5/551/60673
| Introduction|| |
Succinylcholine is the best drug for rapidly providing ideal intubating conditions. Despite the recent introduction of short-acting, non-depolarizing neuromuscular blockers, succinylcholine with its rapid onset of action, short duration of effect, complete and predictable paralysis remains the best drug in providing ideal intubating condition for tracheal intubation. However the usefulness of succinylcholine is limited by the frequent occurrence of post-operative myalgia  .
Muscle pains following administration of succinylcholine have been recognized since its introduction into clinical practice  and there is often biochemical evidence of muscle damage with raised serum creatinine kinase concentration in many subjects after its administration  . It has been suggested that the underlying mechanism of muscle damage associated with administration of succinylcholine may involve calcium induced phospholipids degradation with release of damaging products of fatty acid metabolism  .
Various attempts have been made to prevent the muscle pain caused after the administration of succinylcholine. One of the most useful is the administration of a small dose of non-depolarising neuromuscular blocking drug before administration of succinylcholine  . True and carter  compared tubocurarine, rocuronium and cisatracurium in the prevention and reduction of succinylcholine induced muscle fasciculation and found rocuronium is a valid alternative to tubocurarine for defasciculation. Cisatracurium is inferior to rocuronium and tubocurarine for defasciculation.
Various factors influence the efficacy of pre-treatment including the choice of nondepolarizing agents  , degree of prejunctional receptor block, interval between administration of pretreatment agent and succinylcholine and the speed of onset of the non-depolarizing drug. Vecuronium which is a non-depolarizing drug has a short duration of action and the drug acts rapidly particularly regarding to intubating condition  .
Rocuronium which has a more rapid onset of action compared with established non-depolarising agents  provides good intubating conditions within 60 sec has not yet been evaluated widely for the purpose of reducing succinylcholine induced myalgia. Rocuronium pretreatment given just before induction of anaesthesia with propofol reduces fasciculations and succinylchoine induced myalgia. Subramaniam et al studied low dose and high dose of rocuronium and found that rocuronium is effective in the prevention of fasciculations in all doses and myalgia in higher doses. As the optimum time interval for pre-treatment with pre-existing drugs is approximately 3 min, this property of rocuronium may be relevant to its use in the prophylaxis of myalgia after succinylcholine Precurarization with rocuronium 90 seconds before succinylcholine administration reduces the incidence and severity of fasciculations and prevents increase in serum potassium and myoglobin concentrations . Schrieber et al did a meta analysis of randomized trial on prevention of succinylcholine induced fasciculation and myalgia and found that the best prevention of myalgia was with non-steroidal anti-inflammatory drugs and with rocuronium.
This study was undertaken with the aim of comparing the efficacy of rocuronium and vecuronium for intubation, succinylcholine induced myalgia and the levels of creatine phosphokinase and urine myoglobin after the pretreatment with rocuronium.
| Methods|| |
The study was conducted on 120 patients in the age group of 20-40 years of either sex belonging to ASA grade I or II. They were divided into two groups, Group R& V taking alternate patient for each group. All patients were premedicated with pethidine 1 mg.kg -1 , promethazine hydrochloride 25 mg and glycopyrrolate 0.2 mg intramuscularly 1 hour prior to surgery. Baseline recording of blood pressure, pulse rate and oxygen saturation were noted. Group R patients received 0.06 mg.kg1 of rocuronium and Group V patients received 0.01 mg.kg -1 of vecuronium intravenously. After sixty seconds all patients were given thiopentone sodium 5 mg.kg -1 and succinylcholine 1.5 mg.kg -1 intravenously.
The presence of post succinylcholine fasciculation, intubation conditions, post-operative myalgia on the 1st and the 3rd day were noted. Severity of fasciculation was assessed on a four point scale (Foster 1960)  i.e Nil-no visible fasciculations , Mild -very fine fingertip or facial muscle movement, Moderate- minimal fasciculations on trunk and extremities, Severe-vigorous fascicualtions on trunk and extremities. Intubation condition was assessed (Lund 1970)  . Myalgias was graded on a four point scale (White 1962)  Nil -no muscle pain or stiffness, Mild- muscle pain or stiffness at one site but not causing disability or limiting activities, Moderatemuscle pains or stiffness at more than one site but not causing disability or limiting activities. Severe-muscle pains or stiffness at one or more sites and causing disability or limiting activities eg; difficulty in getting out of bed or turning head. A urine sample was taken for urine myoglobin level 20 minutes after succinycholine administration. Urine sample was taken by introducing a red rubber tube that was removed after taking the urine. A blood sample was taken 24 hours after succinycholine administration for Se creatinine phosphokinase level. Another blood sample(venous) was taken for estimation of potassium levels before induction and 2 minutes after the administration of succinylcholine.
| Statistical analysis|| |
In order to compare the two proportions of subjects in the two groups, test of proportion i.e Z-test were applied. To assess the significance of difference in the mean values of a variables between the two groups, unpaired student's test was applied.
| Results|| |
The two groups were comparable regarding age, sex and weight (P > 0.10). 29 patients in group V and 41 patients in group R did not have fasciculations. 26 patients had mild fasciculation and 5 patients had moderate fascucualtion in Group V. 19 patient had mild fasciculation and none of the patients had moderate fasciculation in Group R. Statistical analysis showed that fasciculations seen after succinylcholine chloride were significantly less in Rocuronium than Vecuronium group(P< 0.01)[Table 2].
30 patient had excellent intubation condition, 30 patients had good intubation condition and none of the patients had poor intubation condition in Group R. In Group V 12 patients had excellent intubation condition, 47 patients had good intubation condition and 1 patient had poor intubation condition.
Statistical analysis showed that intubation conditions with Rocuronium group was significantly better (P < 0.01) than that of Vecuronium group P< 0.01. [Table 3].
In Group R 57 patients did not have myalgia, 3 patients had mild myalgia and none of the patient had moderate or severe myalgia on the first post-operative day. In Group V 54 patients did not have myalgia, 6 patients had mild myalgia and none of the patients had moderate or severe myalgia. On the third post-operative day 39 patients in group R did not have myalgia, 21 patients have mild myalgia and none of the patients had moderate or severe myalgia. In group V 37 patients didn't have myalgia, 21 patients had mild myalgia and 2 patients had moderate myalgia and none of the patients had severe myalgia[Table 4].
Both groups did not show statistically significant difference regarding the post-operative myalgia on 1st and 3r d day (P > 0.10).
Mild increase in potassium level(4.6-5 meq/L) was shown by 27(45%) patients of Group V and 18(30%) patients of Group R. 5(8.3%) patients in Group V and 3(5%) of Group R had more than 1050 CPK levels. Urine myoglobin level was >1.3 in 3(5%) and 9(15%) patients of Group R and V respectively.
Statistical analysis of SeK, CPK and urine myoglobin did not show any statistical significant difference (P < 0.10) between the two groups[Table 5].
| Discussion|| |
Succinylcholine is a depolarizing muscle relaxant having quick onset of action and is commonly used for endotracheal intubation. However post succinylcholine myalgia has lowered it popularity among the minor surgical procedures. Post succinylcholine pain and stiffness appear on the day following surgery may last 2-6 days and vary in intensity from mild malaise and tenderness to generalized and very severe pain  . The literatures reveal that the incidence of myalgia varies from 20% to 80%  . Pre treatment with a small dose of nondepolarising muscle relaxant has been considered almost a gold standard in the prevention of succnylcholine induced myalgia. The literatures revealed that vecuronium was probably being the best agent for prevention of post-operative myalgia  and for this reason we chose to compare rocuronium with vecuronium. In our study there was no statistical significant difference among the two groups regarding to age, sex and weight.
In our study statistical analysis showed that fascicualtions in Group R was significantly less ((P < 0.01) when compared to Group V. Findlay and Spittal  showed that fasciculation in the group precurarised with vecuronium was more when compared to rocuronium (P < 0.01).
Regarding intubation condition statistical analysis showed that Group R were significantly better (P < 0.01) than that of Group V. Findlay and Spittal  in their study showed that there was statistically significant difference in intubating conditions between the two groups. Rocuronium was better than vecuronium.
We have evaluated myalgia on the first and 3 rd postoperative day. In our study statistical analysis showed no significant difference (P > 0.10) in the myalgia between the two groups on the first postoperative day. Findlay and Spittal  did not find statistical significant difference in myalgia between the groups on the 1st post-operative day.
In our study on 3 rd post-operative day 2 patients in vecuronium group had moderate myalgia. This may be due to moderate fasciculations after succinylcholine in vecuronium group. The myalgia on 3 rd post-operative day did not show any statistical significant difference) P> 0.10) between the two groups.
Findlay and Spittal  compared the incidence of myalgia between rocuronium and vecuronium group on third post-operative day and found that there was no statistical significant difference between the groups. JaeHwan Kim et al  suggested that the myalgia may be due to irreversible changes on muscle spindles, unsynchronized contractions of muscle fibers resulting in a shearing of connective tissues, electrolyte imbalance, release of prostaglandins are among the various reasons proposed for post-operative myalgias.
Our study compared the serum potassium value at 2 min after the administration of succinylcholine with the basal K levels and found no statistical significant difference between the two groups.
Jae, Hwan Kim et al  also did not find any statistical significant rise in K level between basal and the 2 min interval after induction.
We studied CPK level after 24 hours post-operatively, and found that there was statistically significant rise in both the two groups. Jae-Hwan Kim et al  did not find significant rise in CPK level after 24 hour post-operatively in both the groups. In our study urine myoglobin after 24 hours showed mild increase in 44 patients in vecuronium group but this was not statistically significant.
Tammisto  reported myoglobinuria in a group of Ophthalmological patients predominantly in children after intermittent doses of succinylcholine chloride under halothane anaesthesia.
In our study it was seen that rocuronium is better drug than vecuronium in reducing succinylcholine induced fascicualtions. The potency of rocuronium is 15 to 20% than vecuronium this explains the effectiveness of rocuronium as defasciculant even if the interval between rocuronium pretreatment and succinylcholine is short. As precurarisation time is only sixty seconds it is a time saving technique and it minimizes the unpleasant experience of partial neuromuscular blockade from precurarization. Rocuronium provides good intubation conditions and effective precurarization within short interval.[Table 1]
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]