Rocuronium for rapid sequence induction Presenters: Dr. Said Nawaz. Dr.Reem Al-safar. Dr.Ahmed Al-sharif. Dr.Abdulla Al-harbi.

Rocuronium Bromide pharmacology Chemistry: Chemistry:  Monoquaternary Amino-steroid compound of Non-depolarizing neuromuscular blocking agents.  It was introduced 1995 CH 53 BrN 2 O 4 CH 53 BrN 2 O 4

 Presentation - Rocuronium is supplied as a sterile, isotonic solution that is clear. - Rocuronium is supplied as a sterile, isotonic solution that is clear. - pH of 4. - pH of 4.  Indications and usage - used to facilitate both rapid sequence and routine tracheal intubation. - used to facilitate both rapid sequence and routine tracheal intubation. - to provide skeletal muscle relaxation during surgery or mechanical ventilation. - to provide skeletal muscle relaxation during surgery or mechanical ventilation. - is also indicated as an adjunct in the intensive care unit (ICU) to facilitate intubation and mechanical ventilation - is also indicated as an adjunct in the intensive care unit (ICU) to facilitate intubation and mechanical ventilation

 Mechanism of action: It acts by competitve inhibition of α-subunit of nicotinic receptors at the motor end-plate. It acts by competitve inhibition of α-subunit of nicotinic receptors at the motor end-plate.  Onset of action: (Dose dependant) -ED95 0.3mg/kg -ED95 0.3mg/kg - Intubating dose 0.6mg/kg,maximal block 1.5min - Intubating dose 0.6mg/kg,maximal block 1.5min -Dose of mg/kg, maximal block sec. -Dose of mg/kg, maximal block sec. -In children : dose of 0.6mg/kg,maximal block 1min -In children : dose of 0.6mg/kg,maximal block 1min dose of 1.2mg/kg,maximal block 40 sec dose of 1.2mg/kg,maximal block 40 sec -Intrmuscular injection 1mg/kg for infants and 2mg/kg for children,maximal block 3-6 min. -Intrmuscular injection 1mg/kg for infants and 2mg/kg for children,maximal block 3-6 min.

 Duration of action: - Duration of action is determined by redistribution. - Duration of action is determined by redistribution. after 0.6mg/kg is 31 min after 0.6mg/kg is 31 min after mg/kg 58-67min after mg/kg 58-67min  Like other Non-DNMBA :it is highly ionized in water compound at physiological PH, VD is limited and can not cross lipid membrane barrier.  Metabolism and execration: -No metabolism. -No metabolism. -Eliminated primarily by liver and slightly by kidneys -Eliminated primarily by liver and slightly by kidneys - Elimination half life is 1-2h. - Elimination half life is 1-2h. -No active metabolites. -No active metabolites.

 Rocuronium in special situations

 Hepatic impairment  Onset time is unchanged  Duration of action is increased. (1.5 times longer)  Larger or repeat doses may have prolonged effect  Renal failure  Onset time is unchanged  Also, Duration of action is unchanged at the dose of 0.6mg/kg.

 Rocuronium and obesity  Same onset time compared to Non obese  Same Duration  Dose should be given according to Actual Body Weight.

 Rocuronium in Obstetric anesthesia  The umbilical venous plasma concentrations were 18% of maternal concentrations at delivery. Apgar score>7 in 5m.  Rocuronium can be used for rapid intubation during cesarian section if succinylcholine is contraindicated.(Koroglu et al.)

 Age and Rocuronium ( 0.6mg/kg )  Pediatrics (3 mos. - 1 yr):  excellent to good intubating conditions within 1 minute, with 41 minutes of clinical relaxation (median)  Pediatrics (1 yr - 12 yrs):  excellent to good intubating conditions within 1 minute, with 27 minutes of clinical relaxation (median)  Geriatric (  65 yrs):  excellent to good intubating conditions within 2.3 minutes, with 46 minutes of clinical relaxation (median)

The case of Rocuronium versus Succinylcholine for RSI

A comparison of Succinylcholine and Rocuronium for rapid sequence intubation of ED patients. Erik Laurin et al, california, AEMJ 2003  360 patients Sch  1.5 mg/kg  Relaxation 39±13 sec  Body movements 9.2±1.2  Vocal cords movements 9.0±1.5  Physician satisfaction +++  6 patients bradycardia with wide QRS  182 patients RCR  0.9 mg/kg  Relaxation 44±2.0 sec  Body movements 9.5±1.1  Vocal cords movements 9.2±1.2  Physician satisfaction  ++  None

Rocronium versus Succinylcholine: are they equally effective during RSI of aneasthesia Mazeruka A J., Chicago Anaesthesia and Analgesia 1998  30 children  Thiopentone 5mg/kg  SUX 1.5 mg/kg  30 children  Thiopentone 5mg/kg  RCR 1.2 mg/kg

What is the message?  Rocuronium can do every thing, what Succinylcholine does, with the equal efficiency, but more safely.

Limitations Not suitable for difficult intubation situation Not suitable for difficult intubation situation

Thank you