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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 68-72

Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation


Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission09-Sep-2015
Date of Acceptance02-Nov-2015
Date of Web Publication30-Dec-2015

Correspondence Address:
Eslam N Nada
MD, Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.172788

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  Abstract 

Background
As it can be manually manipulated and facilitates visualization around corners, use of an awake flexible fiberoptic bronchoscope has been established as the gold standard for difficult intubation since the 1960s. It is advisable to use conscious sedation to make the procedure easier and more tolerable. The aim of this study was to evaluate the safety and efficacy of using low-dose rocuronium in awake fiberoptic intubation.
Patients and methods
In an experimental prospective study, 90 patients of ASA grades I and II scheduled for elective surgery, with age range of 18-60 years, received sedation for awake fiberoptic intubation. The patients were divided into three groups of 30 patients each: group I received 1 mg/kg fentanyl and 0.05 mg/kg midazolam; group II received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.05 mg/kg rocuronium; and group III received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.1 mg/kg rocuronium. Hemodynamic changes, hypoxia, hypercapnia, sedation score, position of vocal cords, time taken for intubation, cough, sore throat, vomiting, bleeding in airways, bronchospasm, patient discomfort, and any other side effects were noticed and recorded.
Results
Sedation score in group III was significantly higher than in the other two groups (P = 0.04). There was significant decrease in time taken to intubate in group III when compared with group I or group II (P = 0.041). Patient satisfaction in group III was significantly higher than in group I (P = 0.02). Incidence of cough in group I was significantly high when compared with groups II and III (P = 0.001). No significant differences were seen between groups regarding hemodynamic changes, hypoxia, hypercapnia, position of vocal cords, cough, sore throat, bleeding, bronchospasm, vomiting, and vagal faint.
Conclusion
Addition of low-dose rocuronium at 0.1 mg/kg to fentanyl and midazolam during awake fiberoptic intubation is more efficient, safer, and better than addition of 0.05 mg/kg rocuronium or usage of fentanyl and midazolam alone with regard to sedation score, time taken for intubation, and patient satisfaction.

Keywords: Awake fiberoptic intubation, rocuronium, sedation


How to cite this article:
Hassan SM, Hegab AM, Nada EN. Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation. Res Opin Anesth Intensive Care 2015;2:68-72

How to cite this URL:
Hassan SM, Hegab AM, Nada EN. Safety and efficacy of low-dose rocuronium in awake fiberoptic intubation. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2020 May 31];2:68-72. Available from: http://www.roaic.eg.net/text.asp?2015/2/3/68/172788


  Introduction Top


The importance of airway management strategies comes from catastrophic outcomes such as death, brain damage, and aspiration resulting from interruption of oxygenation [1].

As it can be manually manipulated and facilitates visualization around corners, an awake flexible fiberoptic bronchoscope has been established as the gold standard for difficult intubation since the 1960s [2]. Awake fiberoptic intubation without sedation is associated with complications, especially those of airway trauma, infection, and lidocaine side effects [3]. It is advisable to use conscious sedation to make the procedure easier and more tolerable [4]. Midazolam, fentanyl, remifentanil, propofol, etomidate, and ketamine were described for conscious sedation in previous studies [5],[6],[7],[8]. The best sedative agent is that which causes the least degree of respiratory depression and, at the same time, provides adequate degree of sedation and analgesia [9]. Rocuronium bromide is an aiminosteroid muscle relaxant of rapid onset and intermediate duration [10]. Rocuronium-induced muscle blockade can be completely and safely reversed in less than 2 min by the action of sugammadex, a synthetic γ-cyclodextrin [11]. The aim of this study was to evaluate the safety and efficacy of using low-dose rocuronium in awake fiberoptic intubation.


  Patients and methods Top


This study was an experimental prospective study conducted in Zagazig University Hospitals. After obtaining approval from the hospital ethics committee, written informed consent was taken from 90 patients of ASA grades I and II who were scheduled for elective surgery. These patients were all scheduled for elective surgery on Tuesdays and Wednesdays for 2 consecutive months. These 2 days were selected by the simple random sampling technique method. Because of the risk of using a muscle relaxant during awake intubation, only patients with Simplified Airway Risk Index [12] 4 or more were included in this study, with preservation of spontaneous breathing. Age, height, and weight were documented. Exclusion criteria were patient refusal, pregnancy, history of allergy to lidocaine, age under 18 years, ASA grades IV and V, severe hepatic or renal disease, history of any muscle disease, mouth opening less than 15 mm, and any contraindication to transcricoid injection (tumor or infection at the site of injection and inability to recognize the cricothyroid membrane).

One hour before operation, all patients received 0.01 mg/kg atropine intramuscularly After explanation of the technique and on arrival at the anesthetic room, intravenous access, nasal oxygenation (2 l/min), and routine monitoring in the form of ECG, noninvasive arterial blood pressure, and oxygen saturation were established in all patients. A capnography sensor was attached immediately after endotracheal tube insertion. Patients were divided into three groups: group I received 1 mg/kg fentanyl and 0.05 mg/kg midazolam; group II received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.05 mg/kg rocuronium; and group III received 1 mg/kg fentanyl, 0.05 mg/kg midazolam, and 0.1 mg/kg rocuronium. All patients were subjected to spraying of oral cavity with lidocaine 10% (each puff = 10 mg), transcricoid injection of 7 ml 2% lidocaine for local anesthesia of the larynx and proximal trachea, introduction of the fiberoptic endoscope (3.7 mm; Karl Storz GmbH & Co. KG, Tuttlingen, Germany) through the mouth opening into the trachea with continuous insufflation of oxygen (4 l/min) through the working channel of the fiberoptic instrument, and then advancement of a polyvinyl chloride tracheal tube (ID 7.0 mm) over the fiberoptic endoscope. After securing the endotracheal tube, general anesthesia was administered and surgery was allowed to proceed. A postoperative interview was conducted within 24 h.

The following parameters were assessed

  1. Hypotension or bradycardia: considered when there was a decrease in mean blood pressure or heart rate more than 20% from the baseline.
  2. Five readings were taken: at baseline, after sedation, after transcricoid injection, during intubation, and after intubation.
  3. Hypoxia: considered if arterial oxygen saturation (SpO2) was below 90% during the procedure.
  4. Hypercapnia: considered if end tidal carbon dioxide (EtCO2) was above 50 immediately after intubation.
  5. Sedation score using the Ramsay sedation score.
  6. Vocal cords position (cadaveric or moving).
  7. Time taken for intubation.
  8. Recording of any side effects such as
    1. Bleeding.
    2. Arrhythmia.
    3. Cough.
    4. Bronchospasm.
    5. Vomiting.
    6. Vagal faint.
  9. Patient discomfort in the form of verbal rating score (1-10), with 1 indicating the least comfort and 10 indicating maximum satisfaction.


Statistical analysis

The collected data were handled using a database software program (version 14.0; SPSS Inc., Chicago, Illinois, USA). Data were expressed as mean ± SD or as number and percentage. Analysis of variance, the χ2 -test, and the paired t-test were performed. P value less than 0.05 was considered statistically significant.


  Results Top


The three groups were comparable regarding patient characteristics in the term of demographic data of the patients [Table 1].
Table 1: Patient characteristics

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  1. Awake fiberoptic intubation was successfully performed in all patients.
  2. There were no statistically significant differences in heart rate among groups [Figure 1], nor were there statistically significant differences in mean arterial pressure [Figure 2]. There were no significant changes in heart rate or mean arterial pressure between time intervals within each group [Figure 1] and [Figure 2].
  3. There were no statistically significant differences between groups regarding hypoxia (P < 0.05) [Table 2].
  4. There were no statistically significant differences between groups regarding hypercapnia (P < 0.05) [Table 2].
  5. Significant increase was noticed in sedation score in group III when compared with groups I and II (P = 0.04) [Table 3].
  6. There were no statistically significant differences between groups regarding the position of vocal cords (P < 0.05) [Table 4].
  7. As regards time taken to intubate, there was significant decrease in time in group III when compared with groups I and II (P = 0.041) [Table 5].
  8. There was no statistically significant difference between group I and group II or between group II and group III with regard to patient satisfaction. However, there was significant increase in patient satisfaction in group III when compared with group I (P = 0.02) [Table 6].
Figure 1: Changes in heart rate (beats/min) in the three studied groups.

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Figure 2: Changes in mean blood pressure (mmHg) in the three studied groups.

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Table 2: Patients suffering from hypoxia and hypercapnia (%)

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Table 3: Sedation score

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Table 4: Position of vocal cords

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Table 5: Time taken for intubation (min)

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Table 6: Patient satisfaction

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Side effects

[Table 7]

  1. There was statistically significant increase in the incidence of cough in group I (30%) when compared with group II (6.66%) and group III (0%) (P = 0.001).
  2. The incidence of sore throat was 20% in group I, 13.33% in group II, and 6.66% in group III. The incidence of bronchospasm was 3.33% in group I and 0% in group II and group III. No patient developed bleeding, arrhythmia, vomiting, or vagal faint in the three studied groups.
  3. There were no statistically significant differences between the three studied groups regarding sore throat, bronchospasm, vomiting, and vagal faint.
Table 7: Frequency of side effect (%)

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  Discussion Top


To our knowledge there are no previous studies on the use of rocuronium in awake fiberoptic intubation.

The use of rocuronium for conscious sedation may be considered difficult because of the fear of interruption of spontaneous ventilation and occurrence of hypoxia.

Fortunately, actions of all drugs used in this study can be reversed by flumazenil for midazolam, naloxone for fentanyl, and sugammadex for rocuronium.

However, there are limitations in this study. Because of the risk of using a muscle relaxant in awake intubation, all our patients were prepared for elective procedures, excluding patients with upper airway emergencies and patients with expected difficulty in airway management (only patients with Simplified Airway Risk Index 4 or more were included in this study). Other future studies are needed to cover these groups of patients.

The results of this study demonstrate that awake fiberoptic intubation can be performed with the use of rocuronium with considerable hemodynamic stability. Previous studies have reported that awake intubation can be achieved with considerable hemodynamic stability under local anesthetic when combined with sedation [13],[14],[15].

Woodall et al. [3] demonstrated that absence of sedation in awake intubation causes greater variability and instability in heart rate and systolic blood pressure.

This study demonstrated that there were no statistically significant differences between groups regarding hypoxia or hypercarbia. Only one patient in the third group suffered from hypoxia and two suffered from hypercapnia. This was attributed to breath-holding and displacement of nasal cannulae.

There was significant increase in sedation score in group III when compared with group I or group II. Lapisatepun et al. [16] found that rocuronium combined with lidocaine may result in a quicker onset of action of lidocaine and improve the quality of intravenous regional anesthesia without significant side effects. This may lead to much better block of lidocaine and may reflect on increasing the sedation score. Another cause is the minimal neuromuscular blocking effect of the low-dose rocuronium, which may lead to sluggishness in response.

As a result of increasing sedation score in group III, time taken to intubate in group III was significantly less than that in the other two groups, and patient satisfaction in group III was significantly higher than in group I.

There were no statistically significant differences between groups regarding the position of vocal cords.

Nine cases in group I suffered from cough. The increased incidence of cough in this group, when compared with the other groups, is understandable. The use of rocuronium in group II and group III suppressed coughing.

As regards other side effects such as sore throat, bronchospasm, bleeding, vomiting, and vagal faint, there was no statistically significant difference in their incidence rates between the three groups. Preoperative atropinization probably prevented any cases of vagal faint, and the good anesthesia of the airways prevented the occurrence of other complications.


  Conclusion Top


This study concluded that addition of low-dose rocuronium at 0.1 mg/kg to fentanyl and midazolam during awake fiberoptic intubation is more efficient, safer, and better than addition of 0.05 mg/kg rocuronium or usage of fentanyl and midazolam alone in terms of sedation score, time taken for intubation, and patient satisfaction. Our recommendation is to perform future studies to test the use of low dose of rocuronium in awake fiberoptic intubation in difficult intubation cases.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005; 103:33-39.  Back to cited text no. 1
    
2.
Rosenstock CV, Thøgersen B, Afshari A, Christensen A, Eriksen C, Gätke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management, a randomized clinical trial. Anesthesiology 2012; 116:1210-1216.  Back to cited text no. 2
    
3.
Woodall NM, Harwood RJ, Barker GL. Complications of awake fibreoptic intubation without sedation in 200 healthy anesthetists attending a training course. BJA 2008; 100:850-855.  Back to cited text no. 3
    
4.
Ovassapian A. Fibreoptic endoscopy and the difficult airway. 2nd ed. New York: Lippincott-Raven; 1996.  Back to cited text no. 4
    
5.
Rai MR, Parry TM, Dombrovskis A, Warner OJ. Remifentanil target-controlled infusion vs propofol target controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial. BJA 2008; 100:125-130.  Back to cited text no. 5
    
6.
Dhar P, Osborn I, Brimacombe J, Meenan M, Linton P. Blind orotracheal intubation with the intubating laryngeal mask versus fibreoptic guided orotracheal with the Ovassapian airway. A pilot study of awake patients. Anaesth Intensive Care 2001; 29: 252-254.  Back to cited text no. 6
    
7.
Schaeuble J, Heidegger T, Gerig HJ, Ulrich B, Schnider TW. Comparison of etomidate and propofol for fibreoptic intubation as part of an airway management algorithm: a prospective, randomized, double-blind study. Eur J Anaesthesiol 2005; 22:762-767.  Back to cited text no. 7
    
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Scher C, Gitlin M. Dexmedetomidine and low-dose ketamine provide adequate sedation for awake fibreoptic intubation. Can J Anesth 2003; 50:607-610.  Back to cited text no. 8
    
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Pani N, Rath SK, Pani N, Rath SK. Regional and topical anaesthesia of upper airways. Indian J Anaesth 2009; 53:641-648.  Back to cited text no. 9
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Wierda JMKH, De Wit APM, Kuizenga K, Agoston S. Clinical observations on the neuromuscular blocking action of ORG 9426, a new steroidal non depolarizing agen trial. BJA 1990; 64:521-523.  Back to cited text no. 10
    
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Veiga-Ruiz G, Domínguez N, Orozco J, Janda M, Hofmockel R, Alvarez-Gómez JA. Efficacy of sugammadex in the reversal of neuromuscular blockade induced by rocuronium in long-duration surgery: under inhaled vs. intravenous anesthesia. Rev Esp Anestesiol Reanim 2009; 56:349-354.  Back to cited text no. 11
    
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El-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996; 82:1197-1204.  Back to cited text no. 12
    
13.
Hawkyard SJ, Morrison A, Doyle LA, Croton RS, Wake PN. Attenuating the hypertensive response to laryngoscopy and endotracheal intubation using awake fibreoptic intubation. Acta Anaesthesiol Scan 1992; 36: 1-4.  Back to cited text no. 13
    
14.
Ovassapian A, Yelich SJ, Dykes MHM, Brunner EE. Blood pressure and heart rate changes during awake fibreoptic nasotracheal intubation. Anesth Analg 1983; 62:951-954.  Back to cited text no. 14
    
15.
Sutherland AD, Williams RT. Cardiovascular responses and lidocaine absorption in fiberoptic-assisted awake intubation. Anesth Analg 1986; 65:389-391.  Back to cited text no. 15
    
16.
Lapisatepun W, Bunchungmongkol N, Ruangtananon S. The effect of rocuronium added to lidocaine for upper limb intravenous regional anesthesia. Chiang Mai Med J 2012; 51:15-20.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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Abstract
Introduction
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