Rocuronium Propofol

Two LC methods have been reported for determining rocuronium bromide in pharmaceutical dosage forms [12,13]. The first method reported was used to examine the stability of a propofol-rocuronium mixture, a mixture employed for the rapid induction of anesthesia. In this method, a /iBondapak CN column (150 mm x 3.9 mm i.d.) was used as the stationary phase. A standard mixture of rocuronium bromide and propofol was prepared in acetonitrile, having 5 3 proportion of rocuronium bromide and propofol, respectively. The mobile phase consisted of 60 40 (v/v) acetonitrile/water, and the wavelength detection was set at 220 nm. It was found that in this mixture, rocuronium bromide was stable up to 48 h after mixing [13]. 

A 35-year-old man developed recurrent respiratory depression after being given alfentanil 0.0125 mg/kg for vitreoretinal surgery (5). General anesthesia was induced with a combination of propofol, rocuronium, and alfentanil, subsequent inhalation of isoflurane, and three additional doses of alfentanil (total 0.04 mg/kg over 2 hours). The pulse oxygen saturation fluctuated and was as low as 89% 180 minutes after extubation. 

In addition to the medicines mentioned above, a number of opiate- and non-opiate-based analgesics, including COX-2 inhibitors, anaesthetics (e.g. propofol, desflurane, sevoflurane, ropivacaine, levobupivacaine and remifentanil), neuromuscular blockers (e.g. rocuronium bromid, zemuron, cisatracuiium, doxacurium. 

Clinical use of muscle relaxants. Among the available neuromuscular blockers, succinylcholine displays the fastest onset of action. The patient can be intubated as early as 30-60 seconds after intravenous injection ( rapid sequence intubation ), which is important in emergency situations with an increased risk of aspiration (e.g., ileus, full stomach, head trauma). Postoperative muscle pain due to succinylcholine can be prevented by preinjection of a small dose of a nondepolarizing blocker ( precurarization ). In combination with propofol p. 218), rocuronium (p.184) creates intubation conditions comparable to those obtained with succinylcholine. 

In 113 patients undergoing general anesthesia, intravenous midazolam 15 mg slowed recovery of the twitch height after vecuronium and atracurium compared with diazepam. The recovery index was not altered (162). However, in another study in 20 patients, midazolam 0.3 mg/kg did not affect the duration of blockade, recovery time, intensity of fasciculations, or adequacy of relaxation for tracheal intubation produced by suxamethonium 1 mg/kg, nor the duration of blockade and adequacy of relaxation for tracheal intubation produced by pancuronium 0.025 mg/kg in incremental doses until 99% depression of muscle-twitch tension was obtained (161). Furthermore, in 60 patients undergoing maintenance anesthesia randomly assigned to one of six regimens (etomidate, fentanyl, midazolam, propofol, thiopental plus nitrous oxide, or isoflurane plus nitrous oxide), midazolam did not alter rocuronium dosage requirements (165). 

Olkkola KT, Tammisto T. Quantifying the interaction of rocuronium (Org 9426) with etomidate, fentanyl, midazolam, propofol, thiopental, and isoflurane using closed-loop... 

Both desflurane and sevoflurane significantly increase the neuromuscular blocking effects of rocuronium compared with isoflurane or propofol (20,21). 

Both desflurane and sevoflurane significantly increase the neuromuscular blocking effects of rocuronium compared with isoflurane or propofol (41,42). The effective doses of rocuronium for 50% depression of single twitch height were 95,120,130, and 150 pg/kg for desflurane, sevoflurane, isoflurane, and propofol respectively. There were no differences in recovery profiles between the four drugs using equieffective doses. Desflurane, sevoflurane, and to a lesser extent isoflurane, also potentiated the neuromuscular blocking effect of cisatracurium by 30% compared with propofol (43,44). 

There are several reports of pain during injection of rocuronium (5,6). Eight of 10 patients complained of severe pain, one complained of moderate pain, and another reported an unpleasant sensation (5). This suggests that rocuronium will almost invariably cause pain. The mechanism of this phenomenon is not clear, but there appear to be some similarities to propofol injection pain. Several authors have suggested that rocuronium should not be given to awake patients (5,6). On the other hand, small doses of rocuronium have been used, with some success, to prevent fasciculations and myalgia after suxamethonium (7-10). With regard to the severity of injection pain, rocuronium pretreatment in awake patients does not seem advisable. 

A 64-year-old obese man, scheduled for a hernia repair, had had previous episodes of venous thromboembolism, for which he was still taking an oral anticoagulant. Previous general anesthesia had been uneventful. General anesthesia was induced with sufentanil 15 xg and propofol 400 mg. He was given rocuronium 50 mg to facilitate endotracheal intubation, and shortly after... 

Inhalation anaesthetics may impair the efficacy of anticholinesterases in reversing neuromuscular blockade. Propofol does not affect the reversal of rocuronium block by neostigmine. Physostigmine pre-treatment increased propofol requirements by 20% in one study. 

Reid JE, Breslin DS, Mirakhur RK, Hayes AH. Neostigmine antagonism of rocuronium block during anesthesia with sevoflurane, isoflurane or propofol. Can JAnaesth (2001) 48, 351-5. 

The inhalational anaesthetics increase the effects of the neuromuscular blockers to differing extents, but nitrous oxide appears not to interact significantly. Ketamine has been reported to potentiate the effects of atracurium. Propofol does not appear to interact with mivacurium or vecuronium. Xenon is reported not to interact with mivacurium or rocuronium, and has less effect than sevoflurane on vecuronium neuromuscular blockade. Bradycardia has been seen in patients given vecuronium with eto-midate or thiopental. Propofol can cause serious bradycardia if it is given with suxamethonium (succinylcholine) without adequate antimuscarinic premedication, and asystole has been seen when fentanyl, propofol and suxamethonium were given sequentially. 

In animals, ketamine and thiopental potentiated the neuromuscular blocking effects of rocuronium, whereas propofol had no effect."... 

Bock M, Klippel K, Nitsche B, Bach A, Martin E, Motsch J. Rocuronium potency and recovery characteristics during steady-state desflurane, sevoflurane, isoflurane or propofol anaes-diesia. BrJ Anaesth (2000) 84, 43-7. 

In a double-blind, multicenter, randomized study in 20 ASA I-III patients aged 18-69 years and scheduled for elective surgery lasting at least 120 minutes, anesthesia was induced with remifentanil and rocuronium and maintained with sevoflurane or propofol remifentanil was used for... 

A 35-year-old woman, scheduled for an emergency cesarean section, was anesthetized with propofol 2 mg/kg and rocuronium 0.9 mg/kg and maintained with sevoflurane. About 15 minutes before the end of the operation she became tachycardic, difficult to ventilate, and hypoxic despite 70% oxygen. After a second dose of propofol for reintubation, she again became hypotensive and profoundly hypoxic and required inotropic support. Pulmonary edema was diagnosed. Afterwards, a skin test showed a strong weal and flare reaction to propofol. 

Cardiovascular In 176 adults who were randomized to sugammadex (2, 4, 8, 12, or 16 mg/kg) or placebo at 3 or 15 minutes after high-dose rocuronium (1.0 or 1.2 mg/ kg) during propofol anesthesia, there was no evidence of recurrent neuromuscular... 

Na HS, Hwang JW, Park SH, Oh AY, Park HP, Jeon YT, et al. IJrug-adrriinistration sequence of target-controUed propofol and remifentanil influences the onset of rocuronium. A double-blind, randomized trial. Acta Anaesthesiol Scand 2012 56 558-64. 

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