Rocuronium Succinylcholine

Clinically important, potentially hazardous interactions with adefovir, aldesleukin, aminoglycosides, atracurium, bumetanide, carbenicillin, cephalexin, cephalothin, doxacurium, ethacrynic acid, furosemide, methoxyflurane, non-polarizing muscle relaxants, pancuronium, pipecuronium, polypeptide antibiotics, rocuronium, succinylcholine, teicoplanin, torsemide, tubocurarine, vecuronium... 

Clinically important, potentially hazardous interactions with rocuronium, succinylcholine, teicoplanin... 

Table 27-2 Comparison of a Typical Nondepolarizing Muscle Relaxant (Rocuronium) and a Depolarizing Muscle Relaxant (Succinylcholine). ...

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. 

Demers-Pelletier J, Drolet P, Girard M, Donati F. Comparison of rocuronium and d-tubocurarine for prevention of succinylcholine-induced fasciculations and myalgia. Can J Anaesth 1997 44(ll) 1144-7. 

Motamed C, Choquette R, Donati F. Rocuronium prevents succinylcholine-induced fasciculations. Can J Anaesth 1997 44(12) 1262-8. 

NMBAs are further differentiated by their duration of action during anesthesia. Succinylcholine and mivacurium are common ultra-short-acting competitive NMBAs (5-10 min). An intermediate duration of action (30-45 min) is maintained with the use of atracurium, cisatracurium, rocuronium and vecuronium. A long-lasting duration of action (90-100 min) is observed with d-tubocurarine, doxacurium, metocurine, pancuronium and pipecuronium. 

The onset of rocuronium is similar to that of succinylcholine. but rocuronium s duration of action is significantly longer. 

Laurin EG, Sakles JC, Panacek EA, et al A comparison of succinylcholine and rocuronium for rapid-se-... 

If the patient is not fuiiy relaxed (eg, if the jaw is not flaccid or neck mobility Is restricted), induce neuromuscular paralysis with succinyl-choline (1-1.5 mg/kg intravenously [IV]), rocuronium (0.6-1.2 mg/kg IV) or pancuronium (0.1 mg/kg IV), or another neuromuscular blocking agent (see p 472). Caution In children, succinylcholine may induce excessive vagal tone, resulting in bradycardia or asystole. Patients with digitalis intoxication (see p 155) may have a similar response to succinylcholine. Pretreat with atropine (0.01 mg/kg IV),... 

Ventilate the patient manually with 100% oxygen while awaiting full paralysis (1-2 minutes tor succinylcholine or rocuronium, 3-5 minutes for pancuronium). 

C. Succinylcholine produces the most rapid onset of effects, with total paralysis within 30-60 seconds after intravenous administration. It is rapidly hydrolyzed by plasma cholinesterases, and its effects dissipate in 10-20 minutes. Rocuronium, a nondepolarizing agent, also offers a rapid onset for rapid sequence intubations. Onset and duration of several other neuromuscular blockers are described in Table III-9. 

B. Neuromuscular blockers provide prompt flaccid paralysis to facilitate orotracheal intubation. The preferred agents for this purpose are rapid-onset agents such as succinylcholine, rapacurium, mivacurium, rocuronium, and vecuronium. They also are used to treat laryngospasm. 

C. Known hypersensitivity or anaphylactic reaction (non-dose-related) to agent or presenrative (eg, benzyl alcohol). Succinylcholine is most commonly implicated, but anaphylaxis has been reported with rocuronium, atracurium, mi-vacurium, and cisatracurium. 

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. 

A study of 16 patients who had been taking various beta blockers (propranolol 5, atenolol 5, metoprolol 2, bisoprolol 2, oxprenolol 1, celiprolol 1) for longer than one month found no difference in the onset and duration of action of rocuronium, when compared with a control group. Similarly, intra-operative esmolol did not affect the onset and recovery time from suxamethonium (succinylcholine) blockade in patients with normal plasma cholinesterase (pseudocholinesterase) activity, but see also (b) above. 

Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs succinylcholine... 

Category 2. Antibodies with recognition profiles confined to the ammonium groups but which cross-react with, and are inhibited almost equally well by, each of the NMBDs with the same or similar groups linked to the nitrogens. Examples include succinylcholine and decamethonium rf-mbocurarine and atracurium and pancuronium and vecuronium. However, since differences occur in the structures attached to the nitrogens in some NMBDs, antibodies to one NMBD, for example, succinylcholine, may not readily cross-react with, and be inhibited by, some other NMBDs, for example, rocuronium. 

Succinylcholine accounts for about one-third of the reactions. Reactions to rocuronium are significantly higher in Europe than in Australia. 

Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs succinylcholine in the emergency department a critical appraisal. J Emerg Med 2009 37(2) 183-8. 

Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2008 (2) CD002788. 

Comparative studies The impact of rocuronium versus succinylcholine neuromuscular blocking drug choice for laparoscopic pyloromyotomy was studied retrospectively in 246 infant patients and it was concluded that despite the potential side effects of suxamethonium, this agent remains the best choice of neuromuscular blocking drug [1. ... 

Ghazal E, Amin A, Wu A, Edema B, Applegate II RL. Impact of rocuronium vs succinylcholine nevtromuscular blocking drug choice for laparoscopic pyloromyotomy is there a difference in tune to transport to recovery Paediatr Anaesth 2013 4 316-21. 

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