Rocuronium for rapid Rocuronium for rapid sequence inductionsequence induction

Presenters:Presenters:

Dr. Said Nawaz.Dr. Said Nawaz.

Dr.Reem Al-safar.Dr.Reem Al-safar.

Dr.Ahmed Al-sharif.Dr.Ahmed Al-sharif.

Dr.Abdulla Al-harbi.Dr.Abdulla Al-harbi.

Rocuronium Bromide Rocuronium Bromide pharmacologypharmacology

Chemistry:Chemistry: Monoquaternary Amino-steroid compound of Monoquaternary Amino-steroid compound of

Non-depolarizing neuromuscular blocking Non-depolarizing neuromuscular blocking agents.agents.

It was introduced 1995It was introduced 1995

CHCH5353BrNBrN22OO44

PresentationPresentation

- - Rocuronium is supplied as a sterile, isotonic Rocuronium is supplied as a sterile, isotonic solution that is clear .solution that is clear .

- pH of 4.- pH of 4. Indications and usageIndications and usage - used to facilitate both rapid sequence and - used to facilitate both rapid sequence and

routine tracheal intubation.routine tracheal intubation. - to provide skeletal muscle relaxation during - to provide skeletal muscle relaxation during

surgery or mechanical ventilation.surgery or mechanical ventilation. - is also indicated as an adjunct in the - is also indicated as an adjunct in the

intensive care unit (ICU) to facilitate intensive care unit (ICU) to facilitate intubation and mechanical ventilation intubation and mechanical ventilation

Mechanism of actionMechanism of action: : It acts by competitve inhibition of It acts by competitve inhibition of αα-subunit -subunit

ofof nicotinic receptors at nicotinic receptors at the motor end-plate.the motor end-plate.

Onset of action: (Onset of action: (Dose dependant)Dose dependant) -ED95 0.3mg/kg-ED95 0.3mg/kg --Intubating dose 0.6mg/kg ,maximal block 1.5minIntubating dose 0.6mg/kg ,maximal block 1.5min -Dose of 0.9-1.2mg/kg , maximal block 60-90 sec.-Dose of 0.9-1.2mg/kg , maximal block 60-90 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 secdose of 1.2mg/kg ,maximal block 40 sec -Intrmuscular injection 1mg/kg for infants and 2mg/kg for -Intrmuscular injection 1mg/kg for infants and 2mg/kg for

children ,maximal block 3-6 min.children ,maximal block 3-6 min.

Duration of actionDuration 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 0.9-1.2mg/kg 58-67min after 0.9-1.2mg/kg 58-67min Like other Non-DNMBA :it is highly ionized in water Like other Non-DNMBA :it is highly ionized in water

compound at physiological PH, VD is limited and can not compound at physiological PH, VD is limited and can not cross lipid membrane barrier.cross lipid membrane barrier.

Metabolism and execrationMetabolism 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 situationsRocuronium in special situations

Hepatic impairmentHepatic impairment Onset time is unchangedOnset time is unchanged Duration of action is increased. Duration of action is increased.

(1.5 times longer)(1.5 times longer) Larger or repeat doses may have prolonged effectLarger or repeat doses may have prolonged effect

Renal failureRenal failure Onset time is unchangedOnset time is unchanged Also, Duration of action is unchanged at the dose of Also, Duration of action is unchanged at the dose of

0.6mg/kg.0.6mg/kg.

Rocuronium and obesityRocuronium and obesity Same onset time compared to Non obeseSame onset time compared to Non obese Same Duration Same Duration

Dose should be given according to Actual Dose should be given according to Actual Body Weight.Body Weight.

Rocuronium in Obstetric anesthesiaRocuronium in Obstetric anesthesia The umbilical venous plasma concentrations The umbilical venous plasma concentrations

were 18% of maternal concentrations at were 18% of maternal concentrations at delivery. Apgar score>7 in 5m.delivery. Apgar score>7 in 5m.

Rocuronium can be used Rocuronium can be used forfor rapidrapid intubationintubation during during cesariancesarian sectionsection if if succinylcholine is contraindicated succinylcholine is contraindicated .(Koroglu et al.).(Koroglu et al.)

Age and Rocuronium Age and Rocuronium ((0.6mg/kg0.6mg/kg)) Pediatrics (3 mos. - 1 yr):Pediatrics (3 mos. - 1 yr):

excellent to good intubating conditions within 1 minute, excellent to good intubating conditions within 1 minute, with 41 minutes of clinical relaxation (median)with 41 minutes of clinical relaxation (median)

Pediatrics (1 yr - 12 yrs): Pediatrics (1 yr - 12 yrs): excellent to good intubating conditions within 1 minute, excellent to good intubating conditions within 1 minute,

with 27 minutes of clinical relaxation (median)with 27 minutes of clinical relaxation (median)

Geriatric (Geriatric ( 65 yrs): 65 yrs): excellent to good intubating conditions within excellent to good intubating conditions within 2.3 2.3

minutes, with 46 minutes of clinical relaxation (median)minutes, with 46 minutes of clinical relaxation (median)

The case of Rocuronium The case of Rocuronium

versus Succinylcholine for RSIversus Succinylcholine for RSI

A comparison of Succinylcholine and A comparison of Succinylcholine and Rocuronium for rapid sequence intubation of Rocuronium for rapid sequence intubation of ED patients.ED patients.Erik Laurin et al, california , AEMJ 2003Erik Laurin et al, california , AEMJ 2003

360 patients Sch360 patients Sch 1.5 mg/kg1.5 mg/kg Relaxation 39±13 secRelaxation 39±13 sec Body movements 9.2±1.2 Body movements 9.2±1.2 Vocal cords movements Vocal cords movements

9.0±1.59.0±1.5 Physician satisfaction +++Physician satisfaction +++ 6 patients bradycardia with 6 patients bradycardia with

wide QRSwide QRS

182 patients RCR182 patients RCR 0.9 mg/kg0.9 mg/kg Relaxation 44±2.0 secRelaxation 44±2.0 sec Body movements 9.5±1.1 Body movements 9.5±1.1 Vocal cords movements Vocal cords movements

9.2±1.29.2±1.2 Physician satisfaction Physician satisfaction ++++ None None

Rocronium versus Succinylcholine: Rocronium versus Succinylcholine: are they equally effective during RSI are they equally effective during RSI of aneasthesiaof aneasthesiaMazeruka A J. , ChicagoMazeruka A J. , ChicagoAnaesthesia and Analgesia 1998Anaesthesia and Analgesia 1998

30 children30 children Thiopentone 5mg/kg Thiopentone 5mg/kg SUX 1.5 mg/kg SUX 1.5 mg/kg

30 children30 children Thiopentone 5mg/kgThiopentone 5mg/kg RCR 1.2 mg/kgRCR 1.2 mg/kg

What is the message?What is the message?

Rocuronium can do every thing, Rocuronium can do every thing, what Succinylcholine does, with the what Succinylcholine does, with the equal efficiency, but more safely.equal efficiency, but more safely.

LimitationsLimitations

Not suitable for difficult Not suitable for difficult intubation situationintubation situation

Thank youThank you