Rapid Sequence Induction: Succinyl Choline vs Rocuronium After Pretreatment With Dexmedetomidine

Comparison Between Standalone Succinyl Choline and Rocuronium After Pretreatment With Dexmedetomidine, in Rapid Sequence Induction.

Background: Rapid sequence induction is a well-established anesthetic procedure used in trauma setting and patients with full stomach. Succinyl choline has the been the drug of choice, however, it carries potential risk and sometimes fatal outcome. Aim of the study: to compare rocuronium after pre-treatment with Dexmedetomidine, to succinyl choline in providing excellent intubating conditions. Material and method: Patients were randomly allocated to one of two groups, of 120 each. Control (SS) group, patients received pretreatment with 10 ml 0.9% saline over 10 minutes, and succinyl choline 1mg/ kg was on induction. Experimental (DR) group, received pretreatment with Dex 1 µg / kg in 10 ml 0.9% saline over 10 minutes and rocuronium 0.6 mg/kg on induction.

Study Overview

• Status: Enrolling by invitation
• Conditions: Rapid Sequence Induction
• Intervention / Treatment: Drug: 0.9% saline and succinyl choline 1mg/ kg; Drug: dexemedetomidine and rocuronium

Detailed Description

Rapid sequence induction (RSI) is a well-established anesthetic procedure routinely used in emergency and trauma setting, and in elective situations when there is high risk of regurgitation/aspiration The ideal neuromuscular relaxant agent used for RSI should have a quick onset of action, which is a major advantage in trauma setting as it mitigates the risk of aspiration and desaturation when endotracheal intubation should be performed as early as possible. It also should have a quick offset to ensure that if trials at endotracheal intubation were unsuccessful, there would be quick neuromuscular recovery, with return to spontaneous breathing before the patient start desaturation. Moreover, it should have minimal cardiovascular or systemic side effects.

Typically, succinyl choline has been the neuromuscular agent of choice for RSI as it has the quickest onset and offset of action compared to other muscle relaxants. However, it has potentially risky- sometimes fatal- side effects that make it far from being ideal neuromuscular blocking agent in RSI.

Owing to its fast onset of action and stable hemodynamics Rocuronium, a non-depolarizing muscle blocker, has been suggested as possible alternative to succinyl choline in RSI. The standard rocuronium intubating dose of during routine anesthesia is 0.6 mg/ kg, which results in adequate intubation conditions within 60 seconds in nearly all patients.

The recommended rocuronium intubating dose during RSI anesthesia is 1.0-1.2 mg/kg, after which optimum tracheal intubation conditions are also achieved within 60 seconds in nearly all patients. If the standard dose of 0.6 mg/ kg is given on RSI of anesthesia, it is advised to wait 90 seconds before attempting to intubate the trachea.

Nevertheless, this high dose has long duration of action and may pose a risk in patients with unpredictable difficult intubation.

Dexmedetomidine (DEX), is a selective centrally acting α 2-adrenergic receptors agonist that has been used successfully as procedural adjuvant, e.g., to minimize the stress response to laryngoscopy during endotracheal intubation and has gained popularity in the peri-operative period, due to its unique action as anxiolytic, sedative with no respiratory depression, analgesic, opioid sparing effect, and Its ability to decrease overall anesthetic requirements.

The aim of our study is to compare a combination of standard intubating dose of DEX and rocuronium (0.6 mg /kg) to succinyl choline as regard endotracheal intubation condition during RSI.

Material and method

Patients will be randomly allocated to one of two groups, of 120 each. The Dex pretreatment/ rocuronium group (DR group), and saline pretreatment/succinyl group (SS group). In the DR group, patients shall receive pretreatment with Dex 1 µg / kg in 10 ml 0.9% saline over 10 minutes and rocuronium 0.6 mg/kg is the intubating muscle relaxant. In the SS group, patients receive pretreatment with 10 ml 0.9% saline over 10 minutes, and succinyl choline 1mg/ kg is the intubating muscle relaxant. Pretreatments will be given over 10 minutes using infusion pump.

As soon as the pretreatment is completed, intravenous (IV) fentanyl 0.1 μg / kg and preoxygenation for 3 minutes with a facemask, after which anesthesia is induced with IV propofol 2 mg/ kg. Standardized intubating procedure is carried out that on loss of consciousness, the neuromuscular relaxant drug is given per protocol, and 45 seconds later the intubating anesthetist will be called in the operating room, at 50 seconds laryngoscopy is introduced and at 60 seconds, the trachea would be expectedly successfully intubated. To minimize interobserver bias, all intubations will be conducted by two designated senior consultants. No ventilation will be carried out before orotracheal intubation. No cricoid pressure shall be performed.

• Study Type: Interventional
• Enrollment (Anticipated): 240
• Phase: Phase 3

Contacts and Locations

Study Locations

• Egypt
  • Qina
    • Qinā, Qina, Egypt, 85203
      • South Valley University Hospitals

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 56 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. American Society of Anesthesiologists (ASA) physical status I or II
2. scheduled for elective surgery of more than 60 minutes duration. -

Exclusion Criteria:

1. Mallampati score of III or IV
2. Neuromuscular disease
3. History of allergy to the studied drugs
4. Malignant hyperthermia
5. Patients taking anticonvulsants or aminoglycoside antibiotic
6. Hepatic dysfunction
7. Renal dysfunction
8. Cardiovascular dysfunction;
9. Electrolyte imbalance
10. Morbidly obese with a body mass index (BMI) more than 30 kg/m2
11. Pregnant or nursing mothers.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: saline pretreatment/succinyl group (SS group).; patients receive pretreatment with 10 ml 0.9% saline over 10 minutes, and succinyl choline 1mg/ kg is the intubating muscle relaxant.	Drug: 0.9% saline and succinyl choline 1mg/ kg; 0.9% saline over 10 minutes, and succinyl choline 1mg/ kg
Experimental: Dex pretreatment/ rocuronium group (DR group),; patients receive pretreatment with Dex 1 µg / kg in 10 ml 0.9% saline over 10 minutes and rocuronium 0.6 mg/kg is the intubating muscle relaxant.	Drug: dexemedetomidine and rocuronium; In the DR group, patients received pretreatment with Dex 1 µg / kg in 10 ml 0.9% saline over 10 minutes and rocuronium 0.6 mg/kg was the intubating muscle relaxant

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
number of patients with excellent intubating conditions	This score is based on triad of signs: how easy to insert the laryngoscope, the anatomical position of the vocal cords, and how patients react to the introduction of the laryngoscope	60 seconds after muscle relaxant has been given

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
heart rate	heart rate (beats/minute) were non invasively recorded	at induction of anesthesia, 4 and 5 minutes after intubation.
mean blood pressure	mean blood pressure were non invasively recorded.	at induction, 4 and 5 minutes after intubation

Collaborators and Investigators

• Sponsor: South Valley University
• Investigators: Principal Investigator: ossama salman, MD, South Valley University

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2020
• Primary Completion (Anticipated): January 1, 2021
• Study Completion (Anticipated): January 1, 2021

Study Registration Dates

• First Submitted: January 11, 2021
• First Submitted That Met QC Criteria: January 13, 2021
• First Posted (Actual): January 14, 2021

Study Record Updates

• Last Update Posted (Actual): January 14, 2021
• Last Update Submitted That Met QC Criteria: January 13, 2021
• Last Verified: January 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Antimetabolites; Gastrointestinal Agents; Hypolipidemic Agents; Lipid Regulating Agents; Neuromuscular Agents; Nootropic Agents; Lipotropic Agents; Neuromuscular Nondepolarizing Agents; Neuromuscular Blocking Agents; Neuromuscular Depolarizing Agents; Choline; Rocuronium; Succinylcholine
• Other Study ID Numbers: southvu7

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No