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CLINICAL INVESTIGATION
Year : 2008  |  Volume : 52  |  Issue : 5  |  Page : 551 Table of Contents     

Evaluation of Post Succinylcholine Myalgia and Intubation Conditions with Rocuronium Pretreatment: A Comparison with Vecuronium


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 Acceptance08-Jul-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
V Abraham
Department of Anesthesiology, Christian Medical College, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


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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 Top


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 [1] .

Muscle pains following administration of succi­nylcholine have been recognized since its introduction into clinical practice [1] and there is often biochemical evidence of muscle damage with raised serum creati­nine kinase concentration in many subjects after its ad­ministration [2] . 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 [3] .

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 [4] . True and carter [5] 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 [6] , 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 [7] .

Rocuronium which has a more rapid onset of ac­tion compared with established non-depolarising agents [8] 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[10] 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[11] . Schrieber et al[12] 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 Top


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) [13] 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) [14] . Myalgias was graded on a four point scale (White 1962) [15] 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 Top


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 Top


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 Top


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 [16] . The literatures re­veal that the incidence of myalgia varies from 20% to 80% [17] . 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 [18] 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 [19] 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 [19] 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 [19] 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 [19] 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 [16] 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 [20] 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 [20] 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 [21] 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]

 
   References Top

1.Bourne JG, Collier HOJ, Somers GF. Succinyl choline , muscle relaxant of short action. Lancet 1952; 1:1225-1229.  Back to cited text no. 1      
2.Charak DS, Dhar CL. Suxamethonium induced changes in serum creatine phosphokinase. British Journal of Anaesthesia 1981; 53:955-7.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.McLoughin C, Neshitt GA, Howe JP. Suxamethonium induced myalgia and the effect of preoperative administration of oral aspiration. Anaesthesia 1988; 43: 565.  Back to cited text no. 3      
4.Broad T, Larujami GE, Marr AT. Comparison of atracurium and de-tubocurarine for prevention of succinylcholine myalgia. Anaesthesia and Analgesia 1987; 66: 657-659.  Back to cited text no. 4      
5.True CA, Carter PJ. A comparison of tubocurarine, rocuronium and cisatracurium in the prevention and reduction of succinylcholine induced muscle fascicualtions. AANA J 2003; 71: 23-28.  Back to cited text no. 5  [PUBMED]    
6.Eakola O. Effects of precurarisation on suxamethonium induced postoperative myalgia during the first trimester of pregnancy. Acta Anaesthesiologia Scandivania 1990; 34:63­-67.  Back to cited text no. 6      
7.Agoston S, Salt P, Newton Detal . The neuromuscular blocking action of Org NC 45, a new pancuronium derivative in anaesthetized patients. Br J Anaesth 1980; 52-335.  Back to cited text no. 7      
8.LHDL, Knape HTA. The neuromuscular blocking effect of ORG 9426. Anaesthesia 1991; 46: 341-343.  Back to cited text no. 8      
9.Tsui BC, Reid S, Gupta S, Kearney R, Mayson T, Finucane B. A rapid precurarization technique using rocuronium. Can J Anaesth 1998; 45: 397-401.  Back to cited text no. 9  [PUBMED]    
10.Kathivel Subramaniam, Balachundhar Subramaniam, Samir K Patel. Precurarization with Rocuronium- A systematic review. Anesthesiology 2002; 96: A 992.  Back to cited text no. 10      
11.Hernamdez - Palazon J, Noguera Velasco J Falcon Aran LF, Domenech Asensi P, Burguillos Lopez S, Nuno de la Rosa, Carillo V. Precurarization with rocuronium prevents fasciculations and biochemical changes after succinyl­choline administration. Rev Esp Anaesthesiol Reanim 2004;51:184-9.  Back to cited text no. 11      
12.Schoideber, Jan-UWE MD, Lysakowski, Christopher MD et al. Prevention of succinylcholine-induced-fas­ciculation and myalgia. A meta-analysis of randomized trial. Anesthsiology 2005; 103: 877-884.  Back to cited text no. 12      
13.Foster CA. Muscle pains that follow administration of suxamethonium Br Med J 1960; 2: 24-24.  Back to cited text no. 13      
14.Lund I, Stovner J. Dose response curve for tubocurarine, atracurium and pancuronium. Anaesthesiol Scan 1970; 178: 238-242.  Back to cited text no. 14      
15.White DC. Observation on the prevention of muscle pain after suxamethonium. Br J Anaesth 1962; 34: 332-335.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Bryson THL and Ormston, T.O.G. Muscle pains follow­ing the use of suxamethonium in caesarean section. Br J Anaesth 1962;43:467.  Back to cited text no. 16      
17.Hegarty P. Postoperative muscle pains. Br J Anaesth 1956: 28: 209-12.  Back to cited text no. 17      
18.Ferres CJ, Mirakhur RK. Craig HJL, Browne ES, Clarke RJS. Pretreatment with vecuronium as a prophylactic agent against post-suxamethonium muscle pain. British Journal of Anaesthesia 1983; 55: 735-740.  Back to cited text no. 18      
19.Findlay GP, Spittal MJ. Rocuronium pretreatment re­duces suxamethonium induced myalgia: comparison with vecuronium. Br J Anaesth 1996; 76: 526-529.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Jae-Hwan Kim Hun Cho, Hye-won Lee, Hye-Ja Lim, Seok-Min Yoon. Comparison of rocuronium and vecuronium pretreatment for prevention of fascicualtions. Myalgia and biochemical changes fol­lowing succinylcholine administration. Acta anaesth Scand 1999; 37: 173-178.  Back to cited text no. 20      
21.Tammesto T, Airaksineri MM. Suxamethonium induced myoglobinuria. Br J Anaesth 1965; 37:464-466.  Back to cited text no. 21      



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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