Optimal Dose of Combination of Rocuronium and Cisatracurium

Summary

BACKGROUND: The combinations of rocuronium and cisatracurium have a synergic effect. The investigators studied whether the prediction is possible to have a sufficient effect of reducing the dose when combining the two neuromuscular blocking agents through monitoring neuromuscular relaxation during surgery. METHODS: Each group were intubating dose group (Group I, n=27) combined Effective Dose (ED)95 rocuronium and ED95 cisatracurium, small amount reducing group (Group S, n=27) reduced 10% of each ED95 and large amount reducing group (Group L, n=27) reduced 20% of each ED95. Before patients arrived in the operating room, rocuronium and cisatracurium were prepared by a nurse who was not involved in this study. Each study drug was administrated to the patient and timer was started with TOF-Watch® monitoring. Train-of-four (TOF) of the ulnar nerve was used as setting of 2 Hz per 12 sec. The investigators checked time to TOF ratio=0 (Onset), time to 1st TOF ratio\>25% (Duration 25%) and TOF 25-75% (recovery index) under total i.v. anesthesia (TIVA). One way ANOVA was used for statistical analysis (α=0.05, β=0.2).

Timeline

Start

2014-03

Primary completion

2015-02

Completion

2015-02

Publications

• Background Naguib M, Samarkandi AH, Ammar A, Elfaqih SR, Al-Zahrani S, Turkistani A. Comparative clinical pharmacology of rocuronium, cisatracurium, and their combination. Anesthesiology. 1998 Nov;89(5):1116-24. doi: 10.1097/00000542-199811000-00011.
• Background Donati F, Plaud B. Rocuronium-cisatracurium combinations. Anesthesiology. 1999 Aug;91(2):587-8. doi: 10.1097/00000542-199908000-00054. No abstract available.
• Background Miller DR, Wherrett C, Hull K, Watson J, Legault S. Cumulation characteristics of cisatracurium and rocuronium during continuous infusion. Can J Anaesth. 2000 Oct;47(10):943-9. doi: 10.1007/BF03024863.
• Background Cammu G, de Baerdemaeker L, den Blauwen N, de Mey JC, Struys M, Mortier E. Postoperative residual curarization with cisatracurium and rocuronium infusions. Eur J Anaesthesiol. 2002 Feb;19(2):129-34. doi: 10.1017/s0265021502000236.
• Background Hans P, Welter P, Dewandre PY, Brichant JF, Bonhomme V. Recovery from neuromuscular block after an intubation dose of cisatracurium and rocuronium in lumbar disc surgery. Acta Anaesthesiol Belg. 2004;55(2):129-33.
• Background Mak PH, Irwin MG. The effect of cisatracurium and rocuronium on cisatracurium precurarization and the priming principle. J Clin Anesth. 2004 Mar;16(2):83-7. doi: 10.1016/j.jclinane.2003.05.004.
• Background Kopman AF, Zank LM, Ng J, Neuman GG. Antagonism of cisatracurium and rocuronium block at a tactile train-of-four count of 2: should quantitative assessment of neuromuscular function be mandatory? Anesth Analg. 2004 Jan;98(1):102-106. doi: 10.1213/01.ANE.0000094985.19305.E9.
• Background de Morais BS, de Castro CH, Teixeira VC, Pinto AS. Residual neuromuscular block after rocuronium or cisatracurium. Rev Bras Anestesiol. 2005 Dec;55(6):622-30. doi: 10.1590/s0034-70942005000600005. English, Portuguese.
• Background Kopman AF, Kopman DJ, Ng J, Zank LM. Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function. J Clin Anesth. 2005 Feb;17(1):30-5. doi: 10.1016/j.jclinane.2004.03.009.
• Background Flockton EA, Mastronardi P, Hunter JM, Gomar C, Mirakhur RK, Aguilera L, Giunta FG, Meistelman C, Prins ME. Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine. Br J Anaesth. 2008 May;100(5):622-30. doi: 10.1093/bja/aen037. Epub 2008 Apr 2.
• Background Adamus M, Gabrhelik T, Marek O. Influence of gender on the course of neuromuscular block following a single bolus dose of cisatracurium or rocuronium. Eur J Anaesthesiol. 2008 Jul;25(7):589-95. doi: 10.1017/S026502150800402X. Epub 2008 Apr 11.
• Background Lin SP, Chang KY, Chen YJ, Lin SM, Chang WK, Chan KH, Ting CK. Priming with rocuronium to accelerate the onset time of cisatracurium during intubation. J Chin Med Assoc. 2009 Jan;72(1):15-9. doi: 10.1016/S1726-4901(09)70014-0.
• Background Amin AM, Mohammad MY, Ibrahim MF. Comparative study of neuromuscular blocking and hemodynamic effects of rocuronium and cisatracurium under sevoflurane or total intravenous anesthesia. Middle East J Anaesthesiol. 2009 Feb;20(1):39-51.
• Background Fassbender P, Geldner G, Blobner M, Hofmockel R, Rex C, Gautam S, Malhotra A, Eikermann M. Clinical predictors of duration of action of cisatracurium and rocuronium administered long-term. Am J Crit Care. 2009 Sep;18(5):439-45. doi: 10.4037/ajcc2009883.
• Background Lee H, Jeong S, Choi C, Jeong H, Lee S, Jeong S. Anesthesiologist's satisfaction using between cisatracurium and rocuronium for the intubation in the anesthesia induced by remifentanil and propofol. Korean J Anesthesiol. 2013 Jan;64(1):34-9. doi: 10.4097/kjae.2013.64.1.34. Epub 2013 Jan 21.
• Results Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients. Anesth Analg. 2004 Oct;99(4):1086-1089. doi: 10.1213/01.ANE.0000120081.99080.C2.
• Results Breslin DS, Jiao K, Habib AS, Schultz J, Gan TJ. Pharmacodynamic interactions between cisatracurium and rocuronium. Anesth Analg. 2004 Jan;98(1):107-110. doi: 10.1213/01.ANE.0000093387.15263.48.
• Results Leykin Y, Pellis T, Lucca M, Gullo A. Intubation conditions following rocuronium: influence of induction agent and priming. Anaesth Intensive Care. 2005 Aug;33(4):462-8. doi: 10.1177/0310057X0503300407.
• Results Kim KS, Chun YS, Chon SU, Suh JK. Neuromuscular interaction between cisatracurium and mivacurium, atracurium, vecuronium or rocuronium administered in combination. Anaesthesia. 1998 Sep;53(9):872-8. doi: 10.1046/j.1365-2044.1998.00492.x.
• Results Liu M, Dilger JP. Synergy between pairs of competitive antagonists at adult human muscle acetylcholine receptors. Anesth Analg. 2008 Aug;107(2):525-33. doi: 10.1213/ane.0b013e31817b4469.
• Results Zeidan A, Nahle N, Maaliki H, Baraka A. Cisatracurium or rocuronium versus rocuronium-cisatracurium combination. Middle East J Anaesthesiol. 2006 Jun;18(5):879-86.
• Results Lighthall GK, Jamieson MA, Katolik J, Brock-Utne JG. A comparison of the onset and clinical duration of high doses of cisatracurium and rocuronium. J Clin Anesth. 1999 May;11(3):220-5. doi: 10.1016/s0952-8180(99)00030-6.
• Park WY, Choi JC, Yun HJ, Jeon YG, Park G, Choi JB. Optimal dose of combined rocuronium and cisatracurium during minor surgery: A randomized trial. Medicine (Baltimore). 2018 Mar;97(10):e9779. doi: 10.1097/MD.0000000000009779.

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