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• W2110494059 abstract "EDITOR: Succinylcholine provides excellent intubating conditions and thus remains the muscle relaxant of choice in nonfasting patients. However, it produces an undesirable rise in intraocular pressure (IOP) [1], which may prove disastrous in patients with penetrating eye injuries. Rocuronium (ORG-9426), a nondepolarizing muscle relaxant, has been shown to provide adequate intubating conditions with rapid onset, an intermediate duration and no obvious side-effects [2]. The present study was conducted to compare the effects of rocuronium and succinylcholine on IOP during rapid sequence induction of anaesthesia in patients undergoing nonophthalmic surgery. After obtaining local ethics committee approval and informed consent from patients, we conducted a randomized, double-blind, controlled study on 40 adult patients of ASA status I and II undergoing elective nonophthalmic surgery. Patients with ocular diseases with or without raised IOP and those with anticipated difficult intubation belonging to Mallampati classes 3 or 4 were excluded. Patients were randomly allocated to one of the two groups (n =20 each) to receive either succinylcholine (S group) or rocuronium (R group). All patients received diazepam 5 mg orally the night before surgery and 1 h before operation. In the operating room, the baseline IOP, heart rate (HR), noninvasive arterial pressure (NIBP), arterial oxygen saturation (SPO2) and end-tidal carbon dioxide (ETCO2) were recorded. After the patient had been preoxygenated for 3 min, anaesthesia was induced in a rapid sequence manner (without applying cricoid pressure) with i.v. morphine 0.1 mg kg–1 and propofol 2 mg kg–1. This was followed by either succinylcholine 1.5 mg kg–1 or rocuronium 0.6 mg kg–1 diluted to 10 mL with 0.9% saline. All drugs were administered into a rapidly running i.v. infusion by one anaesthetist who was unaware of the drug administered. Laryngoscopy and tracheal intubation were performed 60 s after administration of the muscle relaxant and was completed within 30 s in all patients. During this period and after tracheal intubation, the patients’ lungs were ventilated via a Bain system with 66% N2O in oxygen with a fresh gas inflow to maintain the ETCO2 in the range 3.3–4.7 kPa. Throughout the study period all patients were monitored for SPO2, NIBP, ETCO2 and HR (electrocardiograph Tramscope 12, Marquette, USA). IOP was measured using a Schiotz tonometer (technique accurate to within ± 2 mmHg). All readings of IOP including the baseline were taken in both eyes after topical instillation of 4% local anaesthetic. Measurements of IOP, mean arterial pressure (MAP), HR, SPO2 and ETCO2 were obtained at baseline, at induction (immediately after propofol administration), at 1 min after muscle relaxation before intubation and thereafter every 1 min after intubation for 4 min. A simple 4-point scoring system (‘excellent, good, poor, inadequate’) was used to grade intubation [3]. Experienced anaesthetists performed the tracheal intubation. All IOP measurements were made by one anaesthetist who was unaware of the type of relaxant administered. The investigator who measured IOP and the intubating anaesthetist were not allowed to observe the injection of the neuromuscular blocking drug or the presence of fasciculation by making them stand with their back to the patient for 45 s after injection of the drug; by then the fasciculation had subsided in all patients who had received succinylcholine. All patients were in a horizontal supine position while IOP was measured and care was taken to avoid any external compression of neck veins. Results are expressed as the mean (SD). Two-way analysis of variance for repeated measurements (ANOVA with treatment group and time as between and within-group factors, respectively) were performed to analyse the changes in IOP, MAP and HR using Statistical Package for Social Sciences (SPSS) for Windows computer software. For comparing IOP values at different times with that of the baseline value, Student’s paired t-test was used with Bonferroni correction, setting α at 0.05. Correlation coefficients were worked out between systolic blood pressure (SBP) and diastolic blood pressure (DBP) with IOP. The characteristics of the patients (eight males, 32 females) were: mean age 40 (SD 14.5) year; mean body weight 59.6 (SD 9.7) kg; 33 were ASA I; baseline IOP 12.3 (SD 3.3) mmHg. The two groups did not differ significantly on any baseline variables or patient characteristics. Figure 1 depicts the changes in IOP values during induction sequence in the two groups for the right eye. The IOP values decreased at induction with propofol and morphine in both groups. After laryngoscopy and intubation, the IOP values in group S showed a significant rise above baseline (mean difference from baseline 4 mmHg, 95% CI 2.2–5.8; Bonferroni-corrected P < 0.01). Later, values returned to being comparable with baseline.Figure 1 .: Intraocular pressure changes (mean values) in two groups (right eye). Vertical bars represent ± SD. ▮ rocuronium group, ▵ succinylcholine group. B, baseline; time (min) after induction at 1-min intervals. * Bonferroni-corrected P < 0.05 compared with baseline.In contrast, IOP never exceeded baseline values in group R (mean peak value 11.4 mmHg; 95% CI of difference from baseline: –1.3–2.7;P > 0.05). Indeed, for group R, IOP values remained significantly below the baseline at 1, 4 and 5 min after induction (Bonferroni-corrected P < 0.01). In order to test the significance of IOP between the two groups across time, a two-way repeated-measure ANOVA was conducted. The main effects for both groups as well as time were highly significant (F =1051.70 and 21.71, respectively). Group × time interaction was not significant, implying that the patterns of IOP changes in the two groups over time were similar. Although the mean values of arterial pressure and HR in the two groups often fluctuated at different time intervals, differences from baseline values for both groups were not significant after applying the Bonferroni correction. Differences between the two groups also were not significant. Correlation coefficients between SBP and DBP with IOP values at the various time intervals were also not significant. Intubating conditions in both the groups were similar. All patients in group S and 18 in group R achieved excellent intubating conditions; two patients in group R achieved good intubating condition (P > 0.05). Thus, in the present study the use of rocuronium during rapid sequence induction did not cause a rise in IOP when compared with succinylcholine. However, the differences in the haemodynamic variables were not significant. The few other available studies on this issue [4,5], despite differing in certain methodological aspects such as premedication, induction agents, dose of rocuronium, setting and patient characteristics, also showed similar findings. The increase in IOP due to succinylcholine is caused by contraction of extraocular muscles, although dilatation of choroidal vessels is a contributory factor. Rocuronium reduces the tone of extraocular muscles and produces decrease in arterial and venous pressure due to paralysis. Indeed, as found in our study, it may significantly lower IOP when used with propofol and morphine. Cricoid pressure, a part of rapid sequence induction, was not applied in this study for technical reasons. Inappropriate addition of cricoid pressure can not only distort the laryngoscopic view, but may also cause congestion of neck veins and hence give a fallacious rise in IOP [4]. In conclusion, rocuronium 0.6 mg kg–1 when used with propofol and narcotics, does not cause a rise in IOP. Thus, it may be a suitable alternative to succinylcholine in the emergency situation, especially in cases of penetrating eye injury. However, owing to the small sample size of our present study, more randomized controlled trials in the emergency situation are required." @default.
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• W2110494059 date "2001-12-01" @default.
• W2110494059 modified "2023-09-26" @default.
• W2110494059 title "The effect of rocuronium on intraocular pressure: a comparison with succinylcholine" @default.
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