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Pharmacological interventions for acceleration of the onset time of rocuronium: a meta-analysis.

Dong J, Gao L, Lu W, Xu Z, Zheng J - PLoS ONE (2014)

Bottom Line: Priming with rocuronium [Mean difference (MD) -21.0 s, 95% confidence interval (95% CI) (-27.6 to -14.3 s)], pretreatment with ephedrine [-22.3 s (-29.1 to -15.5 s)], pretreatment with magnesium sulphate [-28.2 s (-50.9 to -5.6 s)] were all effective in reducing the onset time of rocuronium.Rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and furthermore their efficacies were similar.Considering the convenience and efficacy, priming with rocuronium is recommended for accelerating the onset time of rocuronium.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

ABSTRACT

Background: Rocuronium is an acceptable alternative when succinylcholine is contraindicated for facilitating the endotracheal intubation. However, the onset time of rocuronium for good intubation condition is still slower than that condition of succinylcholine. This study systematically investigated the most efficacious pharmacological interventions for accelerating the onset time of rocuronium.

Methods: Medline, Embase, Cochrane Library databases, www.clinicaltrials.gov, and hand searching from the reference lists of identified papers were searched for randomized controlled trials comparing drug interventions with placebo or another drug to shorten the onset time of rocuronium. Statistical analyses were performed using RevMan5.2 and ADDIS 1.16.5 softwares. Mean differences (MDs) with their 95% confidence intervals (95% CIs) were used to analyze the effects of drug interventions on the onset time of rocuronium.

Results: 43 randomized controlled trials with 2,465 patients were analyzed. The average onset time of rocuronium was 102.4±24.9 s. Priming with rocuronium [Mean difference (MD) -21.0 s, 95% confidence interval (95% CI) (-27.6 to -14.3 s)], pretreatment with ephedrine [-22.3 s (-29.1 to -15.5 s)], pretreatment with magnesium sulphate [-28.2 s (-50.9 to -5.6 s)] were all effective in reducing the onset time of rocuronium. Statistical testing of indirect comparisons showed that rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate had the similar efficacy.

Conclusion: Rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and furthermore their efficacies were similar. Considering the convenience and efficacy, priming with rocuronium is recommended for accelerating the onset time of rocuronium. However, more strict clinical trials are still needed to reach a more solid conclusion due to the large heterogeneities exist among different studies.

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Funnel plot of studies based on rocuronium priming.AMG: acceleromyography; MMG: mechanomyography; EMG: electromyography; Administration protocol of rocuronium priming: 0.06 mg/kg rocuronium was first intravenously administrated as priming dose, then 0.54 mg/kg rocuronium i.v.
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pone-0114231-g003: Funnel plot of studies based on rocuronium priming.AMG: acceleromyography; MMG: mechanomyography; EMG: electromyography; Administration protocol of rocuronium priming: 0.06 mg/kg rocuronium was first intravenously administrated as priming dose, then 0.54 mg/kg rocuronium i.v.

Mentions: Non-depolarizing muscle relaxant priming is the most commonly used intervention to study the onset time of rocuronium, and rocuronium itself is the most commonly used priming agent with 13 studies, other studied non-depolarizing muscle relaxant priming agents include mivacurium (1 trial) and pancuronium (1 trial). The pooled mean difference of non-depolarizing muscle relaxant priming in the onset time of rocuronium was −20.9 s (95% CI: −27.0 to −14.7 s, p<0.01), indicating that non-depolarizing muscle relaxants priming can shorten the onset time of rocuronium. However, the I2 value of heterogeneous test was much higher (about 90%) (Table.1). In order to reduce the possible bias of our conclusion caused by large heterogeneity, subgroup analyses were performed. We focused on the effects of rocuronium priming on the onset time of rocuronium in 13 RCTs with 792 patients since there was only one study for mivacuronium priming and one for pancuronium priming. 11 out of 13 RCTs with rocuronium priming used the protocol of 0.06 mg/kg rocuronium priming followed by 0.54 mg/kg rocuronium injection. We next performed subgroup analysis on these 11 RCTs according to the different methods of neuromuscular monitoring [electronmyography (EMG), mechanomyography (MMG) and acceromyograph (AMG)]. The mean differences with rocuronium priming were −40.0 s (−47.6 to −32.4 s, p<0.01) measured by EMG, −17.9 s (−30.6 to −5.2 s, p<0.01) by AMG, and −16.5 s (−23.4 to −9.7 s, p<0.01) by MMG, and the mean difference of overall effect of rocuronium priming was −21.0 s (−27.6 to −14.3 s, p<0.01) (Fig.2). Statistical heterogeneity I2 in MMG, AMG and EMG subgroups were about 72% (p = 0.01), 83% and (p<0.01) and 12% (p = 0.03), indicating the heterogeneity of different datasets in MMG and AMG subgroups. The funnel plot of subgroups demonstrated asymmetry, suggesting the existence of small studies effect or publication bias for this intervention (Fig. 3), so fixed and random-models were compared, and the result of meta-analysis did not show any difference. Sensitivity analysis indicated that the meta-analysis results were not changed if only studies with Oxford score ≥4 were included.


Pharmacological interventions for acceleration of the onset time of rocuronium: a meta-analysis.

Dong J, Gao L, Lu W, Xu Z, Zheng J - PLoS ONE (2014)

Funnel plot of studies based on rocuronium priming.AMG: acceleromyography; MMG: mechanomyography; EMG: electromyography; Administration protocol of rocuronium priming: 0.06 mg/kg rocuronium was first intravenously administrated as priming dose, then 0.54 mg/kg rocuronium i.v.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4252114&req=5

pone-0114231-g003: Funnel plot of studies based on rocuronium priming.AMG: acceleromyography; MMG: mechanomyography; EMG: electromyography; Administration protocol of rocuronium priming: 0.06 mg/kg rocuronium was first intravenously administrated as priming dose, then 0.54 mg/kg rocuronium i.v.
Mentions: Non-depolarizing muscle relaxant priming is the most commonly used intervention to study the onset time of rocuronium, and rocuronium itself is the most commonly used priming agent with 13 studies, other studied non-depolarizing muscle relaxant priming agents include mivacurium (1 trial) and pancuronium (1 trial). The pooled mean difference of non-depolarizing muscle relaxant priming in the onset time of rocuronium was −20.9 s (95% CI: −27.0 to −14.7 s, p<0.01), indicating that non-depolarizing muscle relaxants priming can shorten the onset time of rocuronium. However, the I2 value of heterogeneous test was much higher (about 90%) (Table.1). In order to reduce the possible bias of our conclusion caused by large heterogeneity, subgroup analyses were performed. We focused on the effects of rocuronium priming on the onset time of rocuronium in 13 RCTs with 792 patients since there was only one study for mivacuronium priming and one for pancuronium priming. 11 out of 13 RCTs with rocuronium priming used the protocol of 0.06 mg/kg rocuronium priming followed by 0.54 mg/kg rocuronium injection. We next performed subgroup analysis on these 11 RCTs according to the different methods of neuromuscular monitoring [electronmyography (EMG), mechanomyography (MMG) and acceromyograph (AMG)]. The mean differences with rocuronium priming were −40.0 s (−47.6 to −32.4 s, p<0.01) measured by EMG, −17.9 s (−30.6 to −5.2 s, p<0.01) by AMG, and −16.5 s (−23.4 to −9.7 s, p<0.01) by MMG, and the mean difference of overall effect of rocuronium priming was −21.0 s (−27.6 to −14.3 s, p<0.01) (Fig.2). Statistical heterogeneity I2 in MMG, AMG and EMG subgroups were about 72% (p = 0.01), 83% and (p<0.01) and 12% (p = 0.03), indicating the heterogeneity of different datasets in MMG and AMG subgroups. The funnel plot of subgroups demonstrated asymmetry, suggesting the existence of small studies effect or publication bias for this intervention (Fig. 3), so fixed and random-models were compared, and the result of meta-analysis did not show any difference. Sensitivity analysis indicated that the meta-analysis results were not changed if only studies with Oxford score ≥4 were included.

Bottom Line: Priming with rocuronium [Mean difference (MD) -21.0 s, 95% confidence interval (95% CI) (-27.6 to -14.3 s)], pretreatment with ephedrine [-22.3 s (-29.1 to -15.5 s)], pretreatment with magnesium sulphate [-28.2 s (-50.9 to -5.6 s)] were all effective in reducing the onset time of rocuronium.Rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and furthermore their efficacies were similar.Considering the convenience and efficacy, priming with rocuronium is recommended for accelerating the onset time of rocuronium.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.

ABSTRACT

Background: Rocuronium is an acceptable alternative when succinylcholine is contraindicated for facilitating the endotracheal intubation. However, the onset time of rocuronium for good intubation condition is still slower than that condition of succinylcholine. This study systematically investigated the most efficacious pharmacological interventions for accelerating the onset time of rocuronium.

Methods: Medline, Embase, Cochrane Library databases, www.clinicaltrials.gov, and hand searching from the reference lists of identified papers were searched for randomized controlled trials comparing drug interventions with placebo or another drug to shorten the onset time of rocuronium. Statistical analyses were performed using RevMan5.2 and ADDIS 1.16.5 softwares. Mean differences (MDs) with their 95% confidence intervals (95% CIs) were used to analyze the effects of drug interventions on the onset time of rocuronium.

Results: 43 randomized controlled trials with 2,465 patients were analyzed. The average onset time of rocuronium was 102.4±24.9 s. Priming with rocuronium [Mean difference (MD) -21.0 s, 95% confidence interval (95% CI) (-27.6 to -14.3 s)], pretreatment with ephedrine [-22.3 s (-29.1 to -15.5 s)], pretreatment with magnesium sulphate [-28.2 s (-50.9 to -5.6 s)] were all effective in reducing the onset time of rocuronium. Statistical testing of indirect comparisons showed that rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate had the similar efficacy.

Conclusion: Rocuronium priming, pretreatment with ephedrine, and pretreatment with magnesium sulphate were all effective in accelerating the onset time of rocuronium, and furthermore their efficacies were similar. Considering the convenience and efficacy, priming with rocuronium is recommended for accelerating the onset time of rocuronium. However, more strict clinical trials are still needed to reach a more solid conclusion due to the large heterogeneities exist among different studies.

Show MeSH
Related in: MedlinePlus