rocuronium and Obesity

To conduct a meta-analysis to compare different dosing scalars of sugammadex in a morbidly obese population for reversal of neuromuscular blockade (NMB).. PubMed®, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were searched for relevant randomized controlled trials (RCTs) comparing lower-dose sugammadex using ideal body weight (IBW) or corrected body weight (CBW) as dosing scalars with standard-dose sugammadex based on total body weight (TBW) among morbidly obese people after NMB. Mean difference with SD was used to estimate the results.. The analysis included five RCT with a total of 444 morbidly obese patients. The reversal time was significantly longer in patients receiving sugammadex with dosing scalar based on IBW than in patients receiving sugammadex with dosing scalar based on TBW (mean difference 55.77 s, 95% confidence interval [CI] 32.01, 79.53 s), but it was not significantly different between patients receiving sugammadex with dosing scalars based on CBW versus TBW (mean difference 2.28 s, 95% CI -10.34, 14.89 s).. Compared with standard-dose sugammadex based on TBW, lower-dose sugammadex based on IBW had 56 s longer reversal time whereas lower-dose sugammadex based on CBW had a comparable reversal time.

Topics: Androstanols; Body Weight; gamma-Cyclodextrins; Humans; Muscle Relaxation; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity; Randomized Controlled Trials as Topic; Rocuronium; Sugammadex; Vecuronium Bromide

How to titrate rocuronium under the specific conditions such as hepatic/renal failure, hypothermia, acidosis, and baby/aged, obese, with antibiotics, type of anesthetics, operation site and continuous infusion was discussed.

Topics: Acidosis; Age Factors; Androstanols; Anesthetics; Anti-Bacterial Agents; Drug Interactions; Humans; Hypothermia; Liver Failure; Neuromuscular Nondepolarizing Agents; Obesity; Renal Insufficiency; Rocuronium; Time Factors

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.. We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events.. Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.. Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

Topics: Humans; Laparoscopy; Neuromuscular Blockade; Obesity; Rocuronium; Stomach Neoplasms

To compare onset time, duration of action, and tracheal intubation conditions in obese patients when the intubation dose of rocuronium was based on corrected body weight (CBW) versus lean body weight (LBW) for rapid sequence induction. . This prospective study was carried out at Numune Education and Research Hospital, Ankara, Turkey between August 2013 and May 2014. Forty female obese patients scheduled for laparoscopic surgery under general anesthesia were randomized into 2 groups. Group CBW (n=20) received 1.2 mg/kg rocuronium based on CBW, and group LBW (n=20) received 1.2 mg/kg rocuronium based on LBW. Endotracheal intubation was performed 60 seconds after injection of muscle relaxant, and intubating conditions were evaluated. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis. Onset time, defined as time to depression of the twitch tension to 95% of its control value, and duration of action, defined as time to achieve one response to train-of-four stimulation (T1) were recorded.. No significant differences were observed between the groups in intubation conditions or onset time (50-60 seconds median, 30-30 interquartile range [IQR]). Duration of action was significantly longer in the CBW group (60 minutes median, 12 IQR) than the LBW group (35 minutes median, 16 IQR; p less than 0.01).. In obese patients, dosing of 1.2 mg/kg rocuronium based on LBW provides excellent or good tracheal intubating conditions within 60 seconds after administration and does not lead to prolonged duration of action.

Topics: Adult; Androstanols; Anesthesia, General; Body Weight; Drug Dosage Calculations; Female; Humans; Intubation, Intratracheal; Laparoscopy; Middle Aged; Myography; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity; Rocuronium; Time Factors; Young Adult

We evaluated whether the effect of remifentanil treatment differs between normal weight (NW) patients with real body weight-based remifentanil and mildly obese (Ob) patients with ideal body weight based-remifentanil during short-term anesthetic induction. We enrolled 20 patients aged between 20 and 64 years in each group (NW group: 18.5 kg/m(2) ≤ BMI < 25 kg/m(2); Ob group: BMI ≥ 25 kg/m(2)). Tracheal intubation (TI) was performed after administration of 0.5 μg/kg/min remifentanil for 5 min, including 2 min of antecedent administration, with propofol and rocuronium. Hemodynamic parameters (SBP, DBP, and HR) were measured. Percent changes in hemodynamics resulting from anesthetic induction and TI were calculated, and effect-site concentration (ESC) in each patient was calculated by performing pharmacokinetic simulation. All hemodynamic values in the Ob group after TI were significantly higher than those in the NW group. Percent increases in SBP and HR in the Ob group were significantly higher than the corresponding values in the NW group. ESC of remifentanil at the time of TI in the NW group was higher than that in the Ob group. Remifentanil treatment with anesthetic induction based on the Japanese package insert might have insufficient effects in obese patients.

Topics: Adult; Androstanols; Anesthetics, Intravenous; Female; Humans; Ideal Body Weight; Infusions, Intravenous; Intubation, Intratracheal; Male; Middle Aged; Obesity; Piperidines; Propofol; Remifentanil; Rocuronium

Pharmacokinetic studies in obese patients suggest that dosing of rocuronium should be based on ideal body weight (IBW). This may, however, result in a prolonged onset time or compromised conditions for tracheal intubation. In this study, we compared onset time, conditions for tracheal intubation, and duration of action in obese patients when the intubation dose of rocuronium was based on three different weight corrections.. Fifty-one obese patients, with a median (range) body mass index of 44 (34-72) kg/m2, scheduled for laparoscopic gastric banding or gastric bypass under propofol-remifentanil anesthesia were randomized into three groups. The patients received rocuronium (0.6 mg/kg) based on IBW (IBW group, n = 17), IBW plus 20% of excess weight (corrected body weight [CBW]20% group, n = 17), or IBW plus 40% of excess weight (CBW40% group, n = 17). Propofol was administered as a bolus of 200 mg and an infusion at 5 mg x kg(-1) x h(-1) and remifentanil was administered at 1.0 microg x kg(-1) x min(-1), both according to CBW40%. Neuromuscular function was monitored with train-of-four nerve stimulation and acceleromyography. The primary end point was duration of action, defined as time to reappearance of the fourth twitch in train-of-four.. The median (range) duration of action was 32 (18-49), 38 (25-66), and 42 (24-66) min in the IBW, CBW20%, and CBW40% groups, respectively (P = 0.001 for comparison of the IBW and CBW40% group). There were no significant differences in onset time (85 vs 84 vs 80 s) or in intubation conditions 90 s after administration of rocuronium.. In obese patients undergoing gastric banding or gastric bypass, rocuronium dosed according to IBW provided a shorter duration of action without a significantly prolonged onset time or compromised conditions for tracheal intubation.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Anesthetics, Intravenous; Body Mass Index; Body Weight; Female; Gastric Bypass; Humans; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity; Piperidines; Propofol; Remifentanil; Rocuronium

Following administration of 0.6 mg kg-1 rocuronium, the pharmacokinetics and the pharmacodynamics were studied in six obese and six control (normal weight) patients receiving balanced anaesthesia. Twelve gynaecological patients were allocated into two groups, according to body mass index (normal weight: body mass index: 20-24, obese weight: body mass index > 28). Venous plasma concentrations were determined by high-pressure liquid chromatography before administration of rocuronium, at 1, 2, 4, 6, 8, 10, 15, 20, 25, 30, 35, 40, 48, 60, 75, 120, 180, 240, 300, 360 and 420 min after administration of rocuronium and at recovery of single twitch to 25% and 75% of control twitch height. Onset time was shorter (NS) in the obese compared with normal weight (obese weight: 65 +/- 16, normal weight: 100 +/- 39 s, mean +/- SD). Duration 25% (obese weight: 29.5 +/- 5.3, normal weight: 28.4 +/- 5.3 min) and spontaneous recovery time (obese weight: 12.6 +/- 2.7, normal weight: 12.5 +/- 2.3 min) did not show any differences between the two groups. The pharmacokinetics of rocuronium were comparable in the two groups. The volume of distribution at steady state Vss (mL kg-1) was 208 +/- 56 in normal weight and 169 +/- 37 in obese weight. Distribution (T1/2 alpha) and elimination half-life (T1/2 beta) as well as mean residence time were 15.6 +/- 3.7, 70.3 +/- 23.9 and 53.2 +/- 9.8 min in normal weight and 16.9 +/- 3.8, 75.5 +/- 25.5 and 51.1 +/- 18.9 min in obese weight, respectively. Also, no differences were observed in plasma clearance (3.89 +/- 0.58 in normal weight and 3.62 +/- 1.42 mL kg-1 min-1 obese weight). This study indicates that the pharmoacodynamics and pharmacokinetics of rocuronium are in female patients not altered by obesity.

Topics: Adult; Androstanols; Anesthesia; Body Height; Body Mass Index; Body Weight; Female; Gynecologic Surgical Procedures; Half-Life; Humans; Neuromuscular Nondepolarizing Agents; Obesity; Rocuronium; Skin Temperature; Synaptic Transmission

The duration of action and recovery of 0.6 mg kg-1 rocuronium in underweight, normal weight, overweight and obese patients were investigated. Forty-eight patients were divided into four groups, according to their body mass index, and were given 0.6 mg kg-1 rocuronium. The onset time, the duration 25% and either the spontaneous or induced recovery were measured according to the random assignment. The onset time in the obese group was shorter 60 (50-90) s compared to the other groups (underweight: 95 (40-320) s, normal: 95 (50-200) s, overweight: 90 (50-260) s, but the difference did not reach the level of statistical significance. The duration 25% was slightly prolonged in the obese patients (31.5 (21.0-61.0) min) when compared to the underweight (25.0 (15.0-37.0) min), normal weight (26.0 (20.0-36.0) min) and overweight (27.0 (19.0-35.0) min) patients. No differences were observed in spontaneous (9.5-12.5 min) and induced (2.5-3.5 min) recovery.

Topics: Androstanols; Anesthesia Recovery Period; Body Mass Index; Body Weight; Humans; Neuromuscular Nondepolarizing Agents; Obesity; Rocuronium

The observation that patients presenting for bariatric surgery had a high incidence of neuromuscular blocking agent (NMBA) anaphylaxis prompted this restricted case-control study to test the hypothesis that obesity is a risk factor for NMBA anaphylaxis, independent of differences in pholcodine consumption.. We compared 145 patients diagnosed with intraoperative NMBA anaphylaxis in Western Australia between 2012 and 2020 with 61 patients with cefazolin anaphylaxis with respect to BMI grade, history of pholcodine consumption, sex, age, comorbid disease, and NMBA type and dose. Confounding was assessed by stratification and binomial logistic regression.. Obesity (odds ratio [OR]=2.96, χ. Obesity is a risk factor for NMBA anaphylaxis, the risk increasing with BMI grade. Pholcodine consumption is also a risk factor, and this is consistent with the pholcodine hypothesis. Rocuronium use is associated with an increased risk of anaphylaxis compared with vecuronium in this population.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anaphylaxis; Bariatric Surgery; Case-Control Studies; Cefazolin; Codeine; Female; Humans; Incidence; Male; Middle Aged; Morpholines; Neuromuscular Blocking Agents; Obesity; Prospective Studies; Risk Factors; Rocuronium; Young Adult

Topics: Adult; Anesthesia; Depressive Disorder, Major; Electroconvulsive Therapy; Humans; Intubation, Intratracheal; Male; Neuromuscular Nondepolarizing Agents; Obesity; Rocuronium; Sleep Apnea, Obstructive; Sugammadex; Treatment Outcome

An unanticipated difficult airway during induction of anesthesia can be a vexing problem. In the setting of can't intubate, can't ventilate (CICV), rapid recovery of spontaneous ventilation is a reasonable goal. The urgency of restoring ventilation is a function of how quickly a patient's hemoglobin oxygen saturation decreases versus how much time is required for the effects of induction drugs to dissipate, namely the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade. It has been suggested that prompt reversal of rocuronium-induced neuromuscular blockade with sugammadex will allow respiratory activity to recover before significant arterial desaturation. Using pharmacologic simulation, we compared the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade in normal, obese, and morbidly obese body sizes in this life-threatening CICV scenario. We hypothesized that although neuromuscular function could be rapidly restored with sugammadex, significant arterial desaturation will occur before the recovery from unresponsiveness and/or central ventilatory depression in obese and morbidly obese body sizes.. We used published models to simulate the duration of unresponsiveness and ventilatory depression using a common induction technique with predicted rates of oxygen desaturation in various size patients and explored to what degree rapid reversal of rocuronium-induced neuromuscular blockade with sugammadex might improve the return of spontaneous ventilation in CICV situations.. Our simulations showed that the duration of neuromuscular blockade was longer with 1.0 mg/kg succinylcholine than with 1.2 mg/kg rocuronium followed 3 minutes later by 16 mg/kg sugammadex (10.0 vs 4.5 minutes). Once rocuronium neuromuscular blockade was completely reversed with sugammadex, the duration of hemoglobin oxygen saturation >90%, loss of responsiveness, and intolerable ventilatory depression (a respiratory rate of ≤4 breaths/min) were dependent on the body habitus and duration of oxygen administration. There is a high probability of intolerable ventilatory depression that extends well beyond the time when oxygen saturation decreases <90%, especially in obese and morbidly obese patients. If ventilatory rescue is inadequate, oxygen desaturation will persist in the latter groups, despite full reversal of neuromuscular blockade. Depending on body habitus, the duration of intolerable ventilatory depression after sugammadex reversal may be as long as 15 minutes in 5% of individuals.. The clinical management of CICV should focus primarily on restoration of airway patency, oxygenation, and ventilation consistent with the American Society of Anesthesiologist's practice guidelines for management of the difficult airway. Pharmacologic intervention cannot be relied upon to rescue patients in a CICV crisis.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Anesthesia, General; Biomarkers; Body Mass Index; Computer Simulation; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Lung; Male; Models, Theoretical; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Obesity; Obesity, Morbid; Oxyhemoglobins; Pulmonary Ventilation; Recovery of Function; Respiration, Artificial; Respiratory Center; Risk Factors; Rocuronium; Succinylcholine; Sugammadex; Time Factors

A 32-year-old pregnant woman (height 162 cm, weight 86 kg, age of fetus 25 weeks) without preoperative complications underwent an emergent cesarean section under general anesthesia. She was intubated with a 7.0-mm tracheal tube 40 s after receiving rocuronium 0.93 mg x kg(-1) and thiamilal 375 mg. Anesthesia was maintained with oxygen, air, sevoflurane 1.0-2.5%, and fentanyl 425 microg. Nine minutes after the end of surgery (operation time 71 minutes), a train-of-four count of 2 with 20 spontaneous breaths was noted, and sugammadex 2.3 mg x kg(-1) was administered. However, the train-of-four count was 3 even five minutes after sugammadex administration. Fifteen minutes after sugammadex administration (train-of-four ratio 14%), she received atropine 0.5 mg and neostigmine 1.0 mg. Ten minutes later, the train-of-four ratio increased to 89%, and the patient was successfully extubated with no respiratory suppression. We speculate that the rocuronium dose (0.93 mg x kg(-1)) was too high in this obese patient, and sugammadex dose at the end of the surgery was not enough for reversal of rocuronium-induced neuromuscular blockade.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Anesthesia, General; Anesthesia, Obstetrical; Cesarean Section; Dose-Response Relationship, Drug; Female; gamma-Cyclodextrins; Humans; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity; Postoperative Care; Pregnancy; Pregnancy Complications; Rocuronium; Sugammadex; Time Factors

Postoperative reintubation after planned extubation (RAP) following general anesthesia is a major anesthetic morbidity. A previous study on RAP identified the various risk factors for RAP, including chronic obstructive pulmonary disease (COPD), pneumonia, systemic inflammatory response syndrome (SIRS), and airway surgery. However, the prognosis and predictive risk index of RAP were not investigated.. Data on surgical patients who were reintubated after planned extubation at the end of surgery between January 1, 2005 and December 31, 2009 were retrospectively sorted out from the quality assurance database of the Department of Anesthesiology, Chang Gung Memorial Hospital. Risk factors and prognosis of RAP cases were compared with the control group (successful planned extubation) using descriptive statistics and logistic regression. The RAP predictive risk index was developed from multivariate logistic regression and the predictive accuracy was evaluated by goodness-of-fit test.. Of the 227,876 patients who were subjected to endotracheal intubation for general anesthesia, 130 (0.06%) sustained postoperative RAP. The control group consisted of 390 patients who were randomly selected from those who underwent endotracheal intubation without RAP. A total of 30 variables, including demographic, operative, anesthetic data, and prognosis were analyzed. We found that significant risk factors for RAP included COPD (odds ratio: 4.30), pneumonia (odds ratio: 6.60), ascites (odds ratio: 4.86), SIRS (odds ratio: 7.52), hypothermia (body temperature <35°C; odds ratio: 2.45), rocuronium as muscle relaxant (odds ratio: 1.90), inexperienced anesthetic service (odds ratio: 3.44), and airway surgery (odds ratio: 4.34). An RAP predictive risk index was developed and the predictive accuracy was confirmed by goodness-of-fit test as excellent discrimination (c statistic: 0.873). RAP significantly increased postoperative stay in hospital (odds ratio: 2.46) and intensive care unit, as well as tracheostomy and mortality (odds ratio: 58.52).. The RAP predictive risk index included higher American Society of Anesthesiologists classification, conscious disturbance, COPD, pneumonia, SIRS, room air SpO2 <95%, hypothermia, airway surgery, and head and neck surgeries. The RAP predictive risk index provides us an opportunity to take preventive measures including renewal of risk-reduction protocols for high-risk patients.

Topics: Adult; Aged; Airway Extubation; Androstanols; Anesthesia, General; Case-Control Studies; Female; Humans; Hypothermia; Intubation, Intratracheal; Logistic Models; Male; Middle Aged; Obesity; Prognosis; Retrospective Studies; Risk; Rocuronium; Taiwan; Time Factors

Rapid-onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysfunction is an increasingly common diagnosis in patients who are being seen at tertiary care children's hospitals. We present two cases of anesthetics from the authors' own experience in addition to a comprehensive review of the disorder and anesthetic implications.

Topics: Adjuvants, Anesthesia; Analgesics; Androstanols; Anesthesia, General; Anesthetics, Inhalation; Atropine; Autonomic Dysreflexia; Child; Child, Preschool; Colonoscopy; Dexmedetomidine; Female; Humans; Hypnotics and Sedatives; Hypothalamic Diseases; Hypoventilation; Intubation; Ketamine; Methyl Ethers; Neuromuscular Depolarizing Agents; Obesity; Rocuronium; Sevoflurane; Syndrome; Tracheostomy

We report a case that involved immediate postoperative respiratory failure necessitating tracheal intubation, which was possibly related to recurarization after sugammadex reversal.. A 54-yr-old woman weighing 115-kg was scheduled for laparoscopic repair of abdominal dehiscence under general anesthesia. Muscle relaxation was induced and maintained with rocuronium (170 mg iv total dose). At the end of the 170-min procedure, two twitches were visualized after supramaximal train-of-four (TOF) stimulation at the adductor pollicis muscle, and the patient's central core temperature was 35.6°C. Sugammadex 200 mg iv (1.74 mg·kg(-1)) was administered. With the patient fully awake, a TOF ratio 0.9 was obtained five minutes later. The tracheal tube was then removed, and the patient was transferred to the postanesthesia care unit. Ten minutes later, the patient presented respiratory failure necessitating tracheal intubation and sedation with propofol. One TOF response only was visualized at the adductor pollicis muscle. Another dose of sugammadex 200 mg iv was administered. Forty-five minutes later, the patient was fully awake and her trachea was extubated after repeated measures of the TOF ratio (≥ 0.9) at the adductor pollicis muscle. The patient fully recovered without sequelae, further complication, or prolonged hospital stay.. Shortly after tracheal extubation, an obese patient experienced respiratory failure necessitating tracheal intubation and an additional dose of sugammadex. This occurred despite initial reversal of neuromuscular blockade with an appropriate dose of sugammadex 2 mg·kg(-1) iv given at two responses to TOF stimulation.

Topics: Androstanols; Anesthesia, General; Female; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Laparoscopy; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity; Respiratory Insufficiency; Rocuronium; Sugammadex; Surgical Wound Dehiscence

We have developed a sensitive and specific capillary GC (cGC) assay for the quantification of the quarternary aminosteroidal compound rocuronium (roc), a neuromuscular blocking agent, and its putative metabolite 17-desacetylrocuronium (17OH-roc), using 3-desacetylvecuronium (3OH-vec) as an internal standard (I.S.). This novel method has been applied to a pharmacokinetic study with roc, monitoring sixty patients who were classified according to four different body mass index (BMI) groups. The isolation of these drugs from plasma was carried out using a dichloromethane liquid-liquid extraction after ion-pairing of the positively charged ammonium compounds with iodide. To achieve thermal stability, tert.-butyldimethylsilyl-ethers were formed at the 3OH- and 17OH-steroidal positions by reaction with N-methyl-N-(tert.-butyldimethylsilyl)-trifluoroacetamide at 70 degrees C overnight. An automated cGC system fitted with a nitrogen sensitive detector with a specially prepared glass phase bead and a computer controlled data handling system was used to analyze and quantify the compounds, which were separated on a DB1 capillary column with helium as the carrier gas and a temperature program ranging from 120 to 300 degrees C. The method is linear for 50-6400 ng/ml for roc and 80-6400 ng/ml for 17OH-roc. The detection limits were 10 ng/ml for roc and 50 ng/ml for 17OH-roc. The lower limit of quantification was 50 ng/ml for roc and 80 ng/ml for 17OH-roc. Intra-assay coefficients of variation (C.V.s) were 10% and 15% and the inter-assay C.V.s 8-18% and 16-21% for roc and 17OH-roc, respectively.

Topics: Androstanols; Anticoagulants; Asthenia; Chromatography, Gas; Circadian Rhythm; Female; Heparin; Humans; Infusions, Intravenous; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity; Reproducibility of Results; Rocuronium; Sensitivity and Specificity; Thinness; Time Factors