Manish Anand and JC Pandey. Int. Res. J. Pharm.

2022, 13 (5)

RESEARCH ARTICLE

INTERNATIONAL RESEARCH JOURNAL OF PHARMACY

www.irjponline.com
ISSN 2230 – 8407

EVALUATION OF INTUBATING STATE USING TRAIN OF

FOUR STIMULATION WITH 0.6 MG/KG ROCURONIUM IN
SUBJECTS UNDERGOING ELECTIVE SURGERIES
Manish Anand1*, and JC Pandey2
1
Consultant, Department Of Anesthesiology, Jay Prabha Medanta Superspeciality Hospital, Patna, Bihar, India.
2
Department Of Anesthesiology, Jay Prabha Medanta Superspeciality Hospital, Patna, Bihar, India.
*Corresponding Author Email [email protected]

Article Received on: 10/04/22 Approved for publication: 21/05/22

DOI: 10.7897/2230-8407.1303182

ABSTRACT
Background: With the neuromuscular blocking agents, it is recommended to use TO (train of four) stimulation. The
assessment of intubating state using train of four and 0.6mg/kg rocuronium is scarce in the literature. Aims: The present
study was done for estimation of the subject's proportion with an excellent intubating state with the use of
0.6mg/kgrocuronium and train of four at adductor pollicislongus at different time intervals, immediately and 24 hours
after extubation, time to reach T0 and T1 and time to attain sore throat. Methods: 212 subjects were divided into 2 groups
namely T0 and T1 where the intubating state was evaluated following 0.6mg/kg rocuronium and monitoring by the train
of four. The data collected were statistically analyzed with a t-test and Chi-square test where p<0.05 was taken as the
level of statistical significance. Results: Intubating time was 132.58±30.73 seconds which was 142.96±27.06 seconds for
Group T0 and 122.36±30.78 seconds for T1 which was significantly higher for T0 with p<0.01. Intubating condition was
poor in 0.92% (n=1), good in 5.55% (n=6), and excellent in 93.51% (n=101) subjects respectively of group T0, whereas,
in Group T1, it was poor, good, and excellent in 1.92% (n=2), 8.65% (n=9), and 89.42% (n=93) subjects respectively.
Conclusion: Non-significantly higher proportion of subjects with excellent intubating conditions were seen at T0 after
0.6mg/kg rocuronium administration. 20 seconds more were taken to reach T0 compared to T1with less immediate and
late sore throat incidence.
KEYWORDS: General anesthesia, Intubating condition, Neuromuscular monitoring, Rocuronium, Sore throat, Train of four

INTRODUCTION injury, open eye injury, intracranial bleed, acute head injury,
burns, neuromuscular disorders, renal diseases, and/or
One of the most prominent advancements in the field of
cerebrovascular accidents. Hence, a non-depolarizing
anesthesiology is the neuromuscular blocking agent
muscle relaxant is needed for such conditions having a
introduction clinically. This advent has caused a
rapid onset of action. One such clinically acceptable
revolution in the anesthesia practice. The only available
alternative is Rocuronium which effectively substitutes
muscle relaxant causing speedy tracheal intubation is
succinylcholine. However, numerous ill-effects have been suxamethonium owing to its property of rapid action onset
linked to the use of succinylcholine including increased for both emergency and elective surgeries and intubation
intracranial tension, raised intra-ocular tension, with the added advantage of eliminating undesirable side
bradyarrhythmias, hyperkalemia, myalgia, fasciculation in effects associated with Suxamethonium.2
muscles, masseter spasm, malignant hyperthermia, Rocuronium is a non-depolarizing muscle relaxant having
anaphylaxis, and raised intragastric pressure.1 intermediate action duration and rapid onset. Rocuronium
With the associated undesirable effects of succinylcholine, is used in the two doses of 0.6mg/kg and 0.9mg/kg. The
its use is not desirable in conditions such as spinal cord most commonly used dose is 0.6mg/kg for 60 seconds

6
 Manish Anand and JC Pandey. Int. Res. J. Pharm. 2022, 13 (5)

duration. Previous literature data has shown that in 60 agent, opioid analgesia, and midazolam premedication. To
seconds of use, 0.9mg/kg provides excellent intubating attain 40-50 BIS, the agent was selected by a consultant
conditions, whereas, other studies conducted in the anesthesiologist. Neuromuscular transmission was
previous literature depict that better intubating conditions monitored using a digital monitor. After consciousness
are seen with 0.6mg/kg rocuronium compared to the dose loss, neuromuscular block monitoring was done by a train
of 0.9mg/kg. However, the dose of 0.6mg/kg remains the of four stimulation at APL (abductor pollicislongus). 4
most widely used dose in clinical practice.3 successive stimuli were delivered at 2Hz at 200µs pulse
duration for 0.5 sec which was repeated every 10 seconds.
In endotracheal intubation cases, rocuronium remains the
As a bolus, 0.6 mg/kg rocuronium was given over 5
most common and widely used non-depolarizing muscle
seconds. 90% of receptors were taken when one of 4
relaxant. With the use of rocuronium in a 0.6mg/kg dose
twitches was present (T1). 100% receptors were considered
for 90 seconds, clinically acceptable results have been
occupied after all 4 twitches were lost (T0).
reported in the previous literature data. However, the scarce
literature data assessed and quantitative proportion of After the disappearance of either three/four twitches,
subjects with excellent intubating conditions and the time tracheal intubation was done by the anesthesiologist.
needed to attain these. Also, after a train of four (TOF) Onset time was considered as rocuronium injection to T0
stimuli, a standard and observable endpoint, which is the or T1 attainment. TOF endpoint was blinded to the
disappearance of all twitches (T0) and three twitches (T1) intubating anesthesiologist. Intubating conditions were
are scarce in the literature. Also, the best intubating recorded as poor, good, or excellent. Target BIS of 40-60
conditions suggesting endpoint are not described well in was maintained with a volatile inhalational agent. After
the literature. 4Hence, the present study was done to surgery completion, the volatile agent was stopped, the
quantitively evaluate the proportion of subjects with trachea was extubated, and the residual neuromuscular
excellent intubating conditions following 0.6mg/kg block was reversed. Preoperatively, sore throat was
rocuronium administration in TOF stimulation-guided assessed 24 hours after surgery and immediately following
intubation in elective surgery. The study also assessed extubation. 212 study subjects were divided into 2 groups
the time to reach T0 or T1 after rocuronium, sore throat of trachea intubation at T0 and T1.
incidence immediately and after 24 hours, anesthetic agent
The collected data were subjected to statistical evaluation
effect on intubation, and intubating condition.
using SPSS version 20, Chicago Inc., USA. The data were
expressed in percentage and number, and mean and
MATERIALS AND METHODS
standard deviation. The level of significance was kept at
The present prospective clinical study was conducted at p<0.05. The tests used were Chi-square, student t-test,
an Indian health care center after clearance was taken from and ANOVA.
the concerned Ethical committee. The study population
was contributed by subjects undergoing elective surgical RESULTS
procedures at the Institute. The study included 212
The present study included 212 subjects divided into 2
subjects of both genders within the age range of 18-60
groups of trachea intubation at T0 and T1. The mean age
years and a mean age of 37.4±6.46 years. The inclusion
of the study subjects for groups T0 and T1 was37.52±12.36
criteria for the study were subjects in the age range of 18-
and35.76±11.43 years respectively. In T0 there were 68.51%
60 years, both males and females, ASA (American Society
(n=74) females and 31.48% (n=34) males, whereas in T1
of Anesthesiology) physical status I and II, and subjects
there were 70.19% (n=73) females and 29.80% (n=31) males.
undergoing elective dental surgery of > 1-hour duration
72% (n=) of the study subjects were ASA type I and 28%
under general anesthesia and endotracheal intubation. The
(n=) were ASA type II. The study results showed that
exclusion criteria were subjects with BMI <20 or >30,
intubating time was 132.58±30.73 seconds which was
anticipated difficult airway, and subjects with
142.96±27.06 seconds for Group T0 and 122.36±30.78
neuromuscular disease. After explaining the detailed study
seconds for T1 which was significantly higher for T0 with
design, informed consent was taken from all the subjects
p<0.01. Intubating condition was poor in 0.92% (n=1), good
in both written and verbal form.
in 5.55% (n=6), and excellent in 93.51% (n=101) subjects
After the final inclusion of the study subjects, vitals were respectively of group T0, whereas, in Group T1, it was
examined along with BIS (bispectral index), and the poor, good, and excellent in 1.92% (n=2), 8.65% (n=9), and
intravenous line was established. For induction, 89.42% (n=93) subjects respectively which was statistically
premedication was done with an inhalation agent, inducing non-significant with p=0.218 (Table 1).

7
 Manish Anand and JC Pandey. Int. Res. J. Pharm. 2022, 13 (5)

On assessing the excellent and non-excellent conditions in also seen with the use of propofol or thiopentone as an iv
the study subjects, for inhalation with sevoflurane excellent induction agent with p=0.05, among two groups, T0 and T1
condition was seen in 90.90% (n=140) subjects, with with p=0.09, and between genders with p=1.000. For onset
isoflurane in 76.92% (n=20) subjects, and none in 96.87% time, the area under the curve was 0.542 and was non-
(n=31) subjects. With nitrous oxide use, the excellent significant p=0.418. Concerning fentanyl and midazolam
condition was seen in 91.21% (n=135) subjects and without doses, the area under the curve was 0.564 and 0.536
nitrous oxide in 87.5% (n=56) subjects which were non- respectively with both showing statistically non-significant
significant with p=0.264. The non-significant difference was results with p=0.224 and 0.492 respectively (Table 2).

Table 1: Intubation Time and Conditions in the Study Subjects

S. No. Intubation and Group T0 Group T1 Total p-value

Related Conditions (n=108) (n=104)

1. Intubating time (seconds) 142.96±27.06 122.36±30.78 132.58±30.73 <0.01

2. Intubating condition % (n)

a) Poor 0.92 (1) 1.92 (2) 1.41 (3) 0.218

b) Good 5.55 (6) 8.65 (9) 7.07 (15)

c) Excellent 93.51 (101) 89.42 (93) 91.50 (194)

Table 2: Intubation Time and Conditions in the Study Subjects

S. No Factor Excellent % (n) Non-excellent % (n) p-value
1. Inhalation
a) Sevoflurane 90.90 (140) 9.09 (14) 0.132
b) Isoflurane 76.92 (20) 23.07 (6)
c) None 96.87 (31) 3.12 (1)
2. Nitrous oxide
a) Yes 91.21 (135) 8.78 (13) 0.264
b) No 87.5 (56) 12.5 (8)
3. IV induction agents
a) Propofol 91.35 (148) 8.64 (14) 0.05
b) Thiopentone 86 (43) 14 (7)
4. Groups
a) T0 95.19 (99) 4.80 (5) 0.09
b) T1 84.25 (91) 15.74 (17)
5. Gender
a) Females 87.82 (137) 12.17 (19) 1.000
b) Males 94.64 (53) 5.35 (3)
Variables Condition Area under curve p-value
1. Onset time Excellent (202) 0.542 0.418
2. Non-excellent (10)
3. Fentanyl Dose Excellent (202) 0.564 0.224
4. Non-excellent (10)
5. Midazolam Dose Excellent (202) 0.536 0.492
6. Non-excellent (10)

8
 Manish Anand and JC Pandey. Int. Res. J. Pharm. 2022, 13 (5)

For intubation attempts, in Group T0 one and two attempts 122.36±30.78 seconds for T1 which was significantly higher
were done in 95.37% (n=103) and 4.62% (n=5) subjects for T0 with p<0.01. Intubating condition was poor in 0.92%
respectively, whereas, in Group T1, one and two attempts (n=1), good in 5.55% (n=6), and excellent in 93.51% (n=101)
were done in 93.26% (n=97) and 6.73% (n=7) subjects subjects respectively of group T0, whereas, in Group T1,
respectively which was statistically non-significant with it was poor, good, and excellent in 1.92% (n=2), 8.65%
p=0.598. Cormack-Lehane grade of 1, 2, and 3 was seen in (n=9), and 89.42% (n=93) subjects respectively which was
66.6% (n=72), 31.48% (n=34), and 1.85% (n=2) subjects of statistically non-significant with p=0.218. These findings
group T0, and in 69.23% (n=72), 28.84% (n=30), and 1.92% were consistent with the results of Nakadate Y et al5 in
(n=2) subjects respectively of Group T1 which was 2021 and Wardhana A et al6 in 2019 where authors reported
statistically non-significant with p=0.766 (Table 3). similar intubating conditions in their studies.
On evaluating the incidence of sore throat in the two groups, For the assessment of the excellent and non-excellent
it was seen that immediate sore throat was seen in 3.70% conditions in the study subjects, for inhalation with
(n=4) subjects of Group T0, 13.46% (n=14) subjects of T1, sevoflurane excellent condition was seen in 90.90% (n=140)
and 8.49% (n=18) subjects in total which was significantly subjects, with isoflurane in 76.92% (n=20) subjects, and
higher in Group T 1 with p=0.02. Late report of sore throat with none in 96.87% (n=31) subjects. With nitrous oxide
was reported by no subject of Group T0 and in 4.80% (n=5) use, the excellent condition was seen in 91.21% (n=135)
subjects of T1, 4.80% (n=%) subjects of Group T1, and subjects and without nitrous oxide in 87.5% (n=56) subjects
2.35% (n=5) subjects in total which was significantly higher which were non-significant with p=0.264. The non-
for Group T1 with p-0.01 as shown in Table 4. significant difference was also seen with the use of
propofol or thiopentone as an iv induction agent with
DISCUSSION p=0.05, among two groups, T0 and T1 with p=0.09, and
Intubating time was 132.58±30.73 seconds in study between genders with p=1.000. For onset time, the area
subjects, 142.96±27.06 seconds for Group T0, and under the curve was 0.542 and was non-significant

Table 3: Intubation Attempts and Cormack-Lehane Grade in the Study Subjects

S. No. Parameter Group T0 Group T1 Total p-value

(n=108) (n=104) (n=212)

1. Intubation attempts (n)

a) One 95.37 (103) 93.26 (97) 94.33 (200) 0.598

b) Two 4.62 (5) 6.73 (7) 5.66 (12)

2. Cormack-Lehane Grade

a) 1 66.6 (72) 69.23 (72) 67.92 (144) 0.766

b) 2 31.48 (34) 28.84 (30) 30.18 (64)

c) 3 1.85 (2) 1.92 (2) 1.88 (4)

Table 4: Incidence of Immediate and Late Sore Throat in the Study Subjects

S. No. Sore Throat Group T0 Group T1 Total p-value

(n=108) (n=104)

1. Immediate

a) Yes 3.70 (4) 13.46 (14) 8.49 (18) 0.02

b) No 96.26 (104) 86.53 (90) 91.50 (194)

2. Late

a) Yes 0 (0) 4.80 (5) 2.35 (5) 0.01

b) No 100 (108) 95.19 (99) 97.64 (207)

9
 Manish Anand and JC Pandey. Int. Res. J. Pharm. 2022, 13 (5)

p=0.418. Concerning fentanyl and midazolam doses, the CONFLICTS OF INTEREST

area under the curve was 0.564 and 0.536 respectively with
Nil
both showing statistically non-significant results with
p=0.224 and 0.492 respectively. These results were in REFERENCES
agreement with the studies of Fuchs-Buder T et al7 in 2007
1. Shahnawaz M. M., Shahjahan B. and Sarwar S. S.
and Scheiber G et al8 in 2007 where factors and parameters
Evaluation of intubating conditions after rocuronium
o anesthesia showed a similar effect on excellent
bromide in adults induced with propofol or thiopentone
intubating conditions. sodium. J AnaesthesiolClinPharmacol. 2011; 27: 215-9.
Concerning intubation attempts, in Group T0 one and two 2. Adamus M., Koutna J., Gabrhelik T., Hubackova M.
attempts were done in 95.37% (n=103) and 4.62% (n=5) and Janaskova E. Influence of gender on the onset
subjects respectively, whereas, in Group T1, one and two and duration of rocuronium-induced neuromuscular
attempts were done in 93.26% (n=97) and 6.73% (n=7) block. Biomed Pap Med FacUnivPalacky Olomouc
subjects respectively which was statistically non- Czech Repub. 2007; 151: 301-5.
significant with p=0.598. Cormack-Lehane grade of 1, 2,
3. Mencke T., Echternach M., Plinkert P. K., Johann U.,
and 3 was seen in 66.6% (n=72), 31.48% (n=34), and 1.85% Afan N., Rensing H. et al. Does the timing of tracheal
(n=2) subjects of group T0, and in 69.23% (n=72), 28.84% intubation based on neuromuscular monitoring
(n=30), and 1.92% (n=2) subjects respectively of Group decrease laryngeal injury? A randomized, prospective,
T1 which was statistically non-significant with p=0.766. controlled trial. AnesthAnalg. 2006; 102: 306-12.
These results were similar to the findings of Patel DD et al9
4. Zhou T. J., White P. F., Chiu J. W., Joshi G. P., Dullye K.
in 2013 and Gupta N et al10 in 2015 where authors reported
K., Duffy L. L. et al. Onset/offset characteristics and
similar attempts and grading as in the subjects of the
intubating conditions of rapacuronium: A comparison
present study. with rocuronium. Br J Anaesth. 2000; 85: 246-50.
For evaluation of the incidence of sore throat in the two 5. Nakadate Y., Takamino A., Nakashige D. and Ikemoto
groups, it was seen that immediate sore throat was seen in K. Role of postoperative anesthesia visits in
3.70% (n=4) subjects of Group T0, 13.46% (n=14) subjects hoarseness following surgery. Indian J Anaesth. 2021;
of T1, and 8.49% (n=18) subjects in total which was 65: 901-5.
significantly higher in Group T 1 with p=0.02. Late report of
6. Wardhana A., Kurniawaty J. and Uyun Y. Optimised
sore throat was reported by no subject of Group T0 and in
reversal without a train of four monitoring versus reversal
4.80% (n=5) subjects of T1, 4.80% (n=%) subjects of Group using quantitative train of four monitoring. An
T1, and 2.35% (n=5) subjects in total which was significantly equivalence study. Indian J Anaesth. 2019; 63: 361-7.
higher for Group T1 with p-0.01. These results were in
7. Fuchs Buder T., Claudius C., Skovgaard L. T., Eriksson
agreement with the results of Khurshid H et al11 in 2015 and
L. I., Mirakhur R. K. and Viby Mogensen J. Good Clinical
Parikh K et al12 in 2014 where authors reported comparable
Research Practice in pharmacodynamic studies of
incidence of early and late sore throat in their subjects.
neuromuscular blocking agents II: The Stockholm
revision. ActaAnaesthesiolScand 2007; 51: 789-808.
CONCLUSION
8. Scheiber G., Riberio F. C., Marichal A., Bredendiek M.
Within its limitation, the present study concludes that the
and Renzing K. Intubating conditions and onset of
proportion of subjects with the excellent intubating
action after rocuronium, vecuronium and atracurium
condition was non-significantly higher at T0 compared to
in young children. AnesthAnalg. 1996; 83:.320-4.
T1 after the use of 0.6mg/kg rocuronium with lesser reports
of sore throat. The present study had a few limitations 9. Patel D. D. and Swadia V. N. Rocuronium Bromide
including a smaller sample size and a short monitoring versus vecuronium bromide: Comparison of onset,
period. Universal acceptance is not associated with intubating condition, and duration of action. Int J Res
Blumenthal incision owing to its large incision. Also, ease Med. 2013; 2: 137-41.
of performing and learning frown incision is low, however, 10. Gupta N., Sharma M., Gupta P. and Agarwal D.
SIA has made its choice among ophthalmic surgeons. Comparative evaluation of onset time intubating

10
 Manish Anand and JC Pandey. Int. Res. J. Pharm. 2022, 13 (5)

condition judged by clinical criteria and hemodynamic and two doses of rocuronium. Int J Adv Res 2015; 3:
response after the intubating dose of rocuronium 1152-9.
and vecuronium. Int J Basic Appl Med Sci 2015; 5: 12. Parikh K., Modh D. B. and Upadhyay M. R. Comparison
39-44. of rocuronium bromide with suxamethonium chloride
11. Khurshid H., Muneer K. and Wani S. A. A comparative for tracheal intubation. Int J Med Sci Public Health.
study of intubating conditions using succinylcholine 2014; 3: 610-5.

11