Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial

Article Article scientifique Article Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial eng 2020-12-17 2021-12 author Czarnetzki Christoph 45273 author Albrecht Eric author Masouye Philippe Charles 84906 author Baeriswyl Moira author Poncet Antoine 814032 author Robin Matthias author Kern Christian author Tramer Martin 124140 1540-1549 10.1213/ANE.0000000000005324 33337797 0003-2999 PMC8568325 https://journals.lww.com/10.1213/ANE.0000000000005324 Background: Succinylcholine remains the muscle relaxant of choice for rapid sequence induction (RSI) but has many adverse effects. High-dose rocuronium bromide may be an alternative to succinylcholine for RSI but recovery times are nearly doubled compared with a standard intubating dose of rocuronium. Magnesium sulfate significantly shortens the onset time of a standard intubating dose of rocuronium. We set out to investigate whether intravenous (IV) pretreatment with MgSO4 followed by a standard intubating dose of rocuronium achieved superior intubation conditions compared with succinylcholine. Methods: Adults were randomized to receive a 15-minute IV infusion of MgSO4 (60 mg·kg-1) immediately before RSI with propofol 2 mg·kg-1, sufentanil 0.2 μg·kg-1 and rocuronium 0.6 mg·kg-1, or a matching 15-minute IV infusion of saline immediately before an identical RSI, but with succinylcholine 1 mg·kg-1. Primary end point was the rate of excellent intubating conditions 60 seconds after administration of the neuromuscular blocking agent and compared between groups using multivariable log-binomial regression model. Secondary end points were blood pressure and heart rate before induction, before and after intubation, and adverse events up to 24 hours postoperatively. Results: Among 280 randomized patients, intubating conditions could be analyzed in 259 (133 MgSO4-rocuronium and 126 saline-succinylcholine). The rate of excellent intubating conditions was 46% with MgSO4-rocuronium and 45% with saline-succinylcholine. The analysis adjusted for gender and center showed no superiority of MgSO4-rocuronium compared with saline-succinylcholine (relative risk [RR] 1.06, 95% confidence interval [CI], 0.81-1.39, P = .659). The rate of excellent intubating conditions was higher in women (54% [70 of 130]) compared with men (37% [48 of 129]; adjusted RR 1.42, 95% CI, 1.07-1.91, P = .017). No significant difference between groups was observed for systolic and diastolic blood pressures. Mean heart rate was significantly higher in the MgSO4-rocuronium group. The percentage of patients with at least 1 adverse event was lower with MgSO4-rocuronium (11%) compared with saline-succinylcholine (28%) (RR 0.38, 95% CI, 0.22-0.66, P < .001). With saline-succinylcholine, adverse events consisted mainly of postoperative muscle pain (n = 26 [19%]) and signs of histamine release (n = 13 [9%]). With MgSO4-rocuronium, few patients had pain on injection, nausea and vomiting, or skin rash during the MgSO4-infusion (n = 5 [4%]). Conclusions: IV pretreatment with MgSO4 followed by a standard intubating dose of rocuronium did not provide superior intubation conditions to succinylcholine but had fewer adverse effects. Trial registration: ClinicalTrials.gov <a href="http://clinicaltrials.gov/show/NCT01571908" rel="noopener noreferrer" target="_blank">NCT01571908</a>. Adult Blood Pressure / drug effects Double-Blind Method Female Heart Rate / drug effects Humans Infusions, Intravenous Intubation, Intratracheal / methods Magnesium Sulfate / administration & dosage Magnesium Sulfate / adverse effects Male Middle Aged Neuromuscular Depolarizing Agents / adverse effects Neuromuscular Nondepolarizing Agents / adverse effects Pain, Postoperative / epidemiology Rapid Sequence Induction and Intubation / methods Rocuronium / adverse effects Sex Characteristics Succinylcholine / adverse effects Young Adult Neuromuscular Depolarizing Agents Neuromuscular Nondepolarizing Agents Magnesium Sulfate Succinylcholine Rocuronium Dewey 617 Dewey 618 63 Département d'anesthésiologie, pharmacologie, soins intensifs et urgences 229 217 Centre de recherche clinique 201 false 47 La médecine périopératoire et l'anesthésie 70 88 Epidémiologie clinique et biostatistique 115 https://clinicaltrials.gov/ct2/show/NCT01571908 Anesthesia and analgesia 133 6 622e85d9-6884-4656-98f6-f6fa55127b49 Article (Published version) Public Czarnetzki-RSI ROC vs Succi Anesth .pdf 548372 application/pdf CC BY-NC-ND-4.0 ef378d00-3ff8-45e7-be0a-85bf0debd134 Supplemental data Public aa_2020_11_06_czarnetzki_aa-d-20-01.docx 19925 application/vnd.openxmlformats-officedocument.wordprocessingml.document Supplemental Table 1. Hemodynamic measurements according to study treatment 6c9c9894-5d99-415f-8d21-07fdeedd87e6 Supplemental data Public aa_2020_11_06_czarnetzki_aa-d-20-011.docx 27173 application/vnd.openxmlformats-officedocument.wordprocessingml.document Supplemental Table 2. Adverse events openAccess Faculté de médecine / Section de médecine clinique / Département d'anesthésiologie, pharmacologie, soins intensifs et urgences Faculté de médecine / Centre de recherche clinique

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Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial	Anesthesia and analgesia			2021	463	77

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Masouye, Philippe Charles