Rocuronium Vs Cisatracurium
Rocuronium versus Cisatracurium as Adjuvants to Local Anesthetic in Peribulbar Induced Akinesia Abstract:
Background and Objectives: Peribulbar anesthesia is widely used in cataract surgeries; but, the onset of akinesia is way behind and slower in comparison to that for the retrobulbar technique. The effect of using adjuvant to the peribulbar block in developing ameliorated conditions in absence of any adverse effects, and in accelerating the onset of akinesia have been implicated. We investigate the effect of using rocuronium, cisatracourium and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar induced akinesia as regards the degree of akinesia. …show more content…
Methods: 135 women scheduled for cataract surgery were divided into three groups of patients (45 patients in each group) who received peribulbar local eye anesthesia of a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% containing hyaluronidase 15 IU/ml plus 0.5 ml saline 0.9% (group C), a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml cisatracurium 1 mg.
(group A) and a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml rocuronium 5 mg (group R). Lid akinesia, globe akinesia, hemodynamics and side effects were evaluated between
groups.
Results: One minute after the injection, the number of individuals reaching to the total akinesia was 15 (33%) with rocuronium, 9 (20%) with cisatracurium, and 0 (0%) in control group. Three minutes after the injection, the number of subjects reaching to total akinesia was 21 (46%) with rocuronium, 15 (33%) with cisatracurium and 6 (13%) in control group. Five minutes after injection, the number of subjects reaching to total akinesia was 33 (73%) with rocuronium, 27 (60%) with cisatracurium, and 21 (46%) with control group. Also; in the 10th minute after the injection, the number of subjects reaching to total akinesia was 39 (86%) with rocuronium, 33(73%) with cisatracurium, and 30 (66%) with control. Total akinesia is comparatively more frequent in group of rocuronium and cisatracurium than in the control group. Number of individuals with complete lid akinesia was higher in rocuronium group after 10 minutes is more than cisatracurium and control groups but there was no statistically significant difference among the three groups regarding lid akinesia. We did not observe any side effects during the study related to the peribulbar block or the used drugs.
Conclusions: this study demonstrated that addition of low-dose cisatracourium and rocuronium to the anesthetic drug is recommended in order to enhance the quality of akinesia especially when hyaluronidase is not added.
INTRODUCTION: Local anesthesia has been developed greatly in recent years. Surgeons have been using the local anesthesia for ophthalmological procedures since 1884. (1) Nowadays, regional anesthesia with the help of retrobulbar or peribulbar blocks or topical anesthesia is being used in cataract surgeries. (2) The main role of anesthesia is akinesia-establishment that helps the surgeon during the operations; the retrobulbar technique is more effective and rapid than the peribulbar methods in achieving the akinesia. However it may carry dangerous side effects such as brainstem affection, posterior ocular bleeding, and optic nerve injury (3, 4). Moreover, Hyaluronidase has useful effects in establishing akinesia (2). Peribulbar anesthesia is applied widely in cataract surgeries; however, the onset of akinesia is way behind and slower in comparison to that for the retrobulbar technique (5). Although the fact that the technique of peribulbar block brings less severe toxicities comparing to the retrobulbar method (3)(4), nonetheless, surgeons may still use it less frequently due to the slower onset of the effect and it’s inadequate movement block (5). According to some studies, the effect of using cisatracurium and rocuronium as adjuvant to the peribulbar block in developing ameliorated conditions in absence of any adverse effects, and in hastening the onset of akinesia have been implicated (5)(6). Moreover; since an inadequate motor block interferes negatively while the surgeon is operating, and undesired eye movements under microscope may cause complications that in certain occasions prove irremediable, and considering the possibility of widely using of peribulbar blockages in cataract surgeries through establishing akinesia, a low dose of cisatracurium, rocuronium, and hyaluronidase in combination with a local anesthetic solution was used in this study for the purpose of accelerating total akinesia of the eyes, ocular muscle paresis, and for a more satisfaction of the surgeon during his surgery. The above-mentioned plan has been used for the purpose of comparing the effect of using cisatracurium, rocuronium, and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar-induced akinesia in cataract surgeries.
The aim of this study is to compare the effect of using cisatracourium, rocuronium and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar induced akinesia regarding the degree of akinesia.
Patients and methods After approval from The Ethics and Research Committee of Anesthesia Department, Faculty of Medicine, Ain Shams University and obtaining written informed consents, 135 adult patients, of both sexes, with ASA grade I and II, in the age group 30-70 years, scheduled for elective cataract surgery under local anesthesia, were admitted to the ophthalmology operating theatre and enrolled in a prospective randomized controlled trial. The patients were randomly allocated in three study groups (45 patients in each group) according to the medications they received.
Exclusion Criteria:
1- Patients with history of abnormal bleeding.
2- Patients with history of allergy to local anesthetics.
3- Neuromuscular diseases.
4- Communicating problems.
An ampoule of hyaluronidase 1500 IU was dissolved by 1ml of Lidocaine 2% and added to a vial of 50 ml of lidocaine 2% (hyaluronidase concentration is 30 IU/ml).
5 ml of this vial was taken and added to another 5 ml of lidocaine 2% (without hyaluronidase).
Thus, the local anesthetic mixture contains 10 ml of lidocaine 2% supplemented with hyaluronidase 15 IU/ml.
Patients were randomly allocated into three groups:
Group C: Control group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% containing hyaluronidase 15 IU/ml plus 0.5 ml saline 0.9%.
Group A: Cisatracurium group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml cisatracurium 1 mg.
Group R: Rocuronium group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml rocuronium 5mg.
Patient Care, monitoring and measurements:
A peripheral IV cannula was inserted and standard monitoring including: pulse oximetry, electrocardiogram and automated noninvasive blood pressure.
Before performing the block, baseline globe movements in the major directions of gaze (superior, inferior, medial and lateral) were assessed. LA solution was injected using a 25 mm 25 G needle.
The needle was introduced along the inferior wall of the orbit to a depth of 20 mm with the sharp bevel facing to the globe. The direction of injection was almost perpendicular to the frontal plane and parallel to the sagittal plane; the eye was in the neutral position. Injection was performed after negative aspiration. A gentle digital massage of the eyeball, between scoring the akinesia to facilitate diffusion of local anesthesia mixture was done.
All blocks were performed by the same investigator and the surgeries were done by the same surgeon.
Evaluation of the block:
Immediately motor block assessment included lid akinesia (lid closure by orbicularis oculi muscle and lid opening by the levator palpebrae superioris muscle) and globe akinesia (globe movement in all directions by the 4 recti muscles) according to the scoring system that is shown in table (1).
Table (1): Scoring system (7)
Akinesia of the extra-ocular muscles including the levator muscle:
0= 0-1mm movement in 1 or 2 main directions OR 0-4 mm movement in levator muscle.
1= 1mm movement in more than 2 main directions
OR 2mm movement in any main direction
OR more than 4mm movement in levator muscle.
2= more than 2mm movement in any main direction
OR 2mm movement in 2 or more main directions.
Akinesia of the orbicularis muscle:
0= Complete akinesia.
1= Partial movement in either or both eyelid margins.
2= Normal movement in either or both eyelid margins. For assessment of lid akinesia, the patients were asked to open their eyelids (levator muscle) and then squeeze them together maximally (orbicularis muscle).Orbicularis oculi muscle was examined separately by using the score in table (1).
Globe akinesia was assessed by examination of the movements of the extra-ocular muscles in all of the 4 main directions on a scale from 0 to 2 as shown in table (1). The block was considered to be satisfactory when loss of at least two movements of the 4 cardinal directions occurred. Failure of the block excluded the patient from the study and received general anesthesia.
Lid opening, lid closure and extra-ocular muscles movements in the 4 cardinal directions were assessed before the block then after the block at 1 minute, 3 minutes, 5 minutes and 10 minutes. Both sides are compared for more accurate assessment of motor block.
Arterial blood pressure, heart rate and arterial oxygen saturation (SpO2) were assessed before the block, then after 15, 30 and 60 minutes after performing the block.
Hypotension and bradycardia were defined as: 20% or more decrease in the mean arterial blood pressure and heart rate, respectively, in relation to the preblock value.
Monitoring for the development of bradycardia or ventricular ectopies (oculocardiac reflex) were done and facilities were available for rapid management by immediate notification of the surgeon for temporary cessation of surgical stimulation until the heart rate increases and administration of IV atropine (10 µg/kg) if the condition persists.
Sample size estimation: To show a difference of eye and lid movement with p-value < 0.05 and power 81%, we needed at least 45 patients per group to compare the rocuronium, cisatracurium and control groups.
Background and Objectives: Peribulbar anesthesia is widely used in cataract surgeries; but, the onset of akinesia is way behind and slower in comparison to that for the retrobulbar technique. The effect of using adjuvant to the peribulbar block in developing ameliorated conditions in absence of any adverse effects, and in accelerating the onset of akinesia have been implicated. We investigate the effect of using rocuronium, cisatracourium and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar induced akinesia as regards the degree of akinesia. …show more content…
Methods: 135 women scheduled for cataract surgery were divided into three groups of patients (45 patients in each group) who received peribulbar local eye anesthesia of a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% containing hyaluronidase 15 IU/ml plus 0.5 ml saline 0.9% (group C), a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml cisatracurium 1 mg.
(group A) and a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml rocuronium 5 mg (group R). Lid akinesia, globe akinesia, hemodynamics and side effects were evaluated between
groups.
Results: One minute after the injection, the number of individuals reaching to the total akinesia was 15 (33%) with rocuronium, 9 (20%) with cisatracurium, and 0 (0%) in control group. Three minutes after the injection, the number of subjects reaching to total akinesia was 21 (46%) with rocuronium, 15 (33%) with cisatracurium and 6 (13%) in control group. Five minutes after injection, the number of subjects reaching to total akinesia was 33 (73%) with rocuronium, 27 (60%) with cisatracurium, and 21 (46%) with control group. Also; in the 10th minute after the injection, the number of subjects reaching to total akinesia was 39 (86%) with rocuronium, 33(73%) with cisatracurium, and 30 (66%) with control. Total akinesia is comparatively more frequent in group of rocuronium and cisatracurium than in the control group. Number of individuals with complete lid akinesia was higher in rocuronium group after 10 minutes is more than cisatracurium and control groups but there was no statistically significant difference among the three groups regarding lid akinesia. We did not observe any side effects during the study related to the peribulbar block or the used drugs.
Conclusions: this study demonstrated that addition of low-dose cisatracourium and rocuronium to the anesthetic drug is recommended in order to enhance the quality of akinesia especially when hyaluronidase is not added.
INTRODUCTION: Local anesthesia has been developed greatly in recent years. Surgeons have been using the local anesthesia for ophthalmological procedures since 1884. (1) Nowadays, regional anesthesia with the help of retrobulbar or peribulbar blocks or topical anesthesia is being used in cataract surgeries. (2) The main role of anesthesia is akinesia-establishment that helps the surgeon during the operations; the retrobulbar technique is more effective and rapid than the peribulbar methods in achieving the akinesia. However it may carry dangerous side effects such as brainstem affection, posterior ocular bleeding, and optic nerve injury (3, 4). Moreover, Hyaluronidase has useful effects in establishing akinesia (2). Peribulbar anesthesia is applied widely in cataract surgeries; however, the onset of akinesia is way behind and slower in comparison to that for the retrobulbar technique (5). Although the fact that the technique of peribulbar block brings less severe toxicities comparing to the retrobulbar method (3)(4), nonetheless, surgeons may still use it less frequently due to the slower onset of the effect and it’s inadequate movement block (5). According to some studies, the effect of using cisatracurium and rocuronium as adjuvant to the peribulbar block in developing ameliorated conditions in absence of any adverse effects, and in hastening the onset of akinesia have been implicated (5)(6). Moreover; since an inadequate motor block interferes negatively while the surgeon is operating, and undesired eye movements under microscope may cause complications that in certain occasions prove irremediable, and considering the possibility of widely using of peribulbar blockages in cataract surgeries through establishing akinesia, a low dose of cisatracurium, rocuronium, and hyaluronidase in combination with a local anesthetic solution was used in this study for the purpose of accelerating total akinesia of the eyes, ocular muscle paresis, and for a more satisfaction of the surgeon during his surgery. The above-mentioned plan has been used for the purpose of comparing the effect of using cisatracurium, rocuronium, and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar-induced akinesia in cataract surgeries.
The aim of this study is to compare the effect of using cisatracourium, rocuronium and hyaluronidase as adjuvant agents to the local anesthetic substance on peribulbar induced akinesia regarding the degree of akinesia.
Patients and methods After approval from The Ethics and Research Committee of Anesthesia Department, Faculty of Medicine, Ain Shams University and obtaining written informed consents, 135 adult patients, of both sexes, with ASA grade I and II, in the age group 30-70 years, scheduled for elective cataract surgery under local anesthesia, were admitted to the ophthalmology operating theatre and enrolled in a prospective randomized controlled trial. The patients were randomly allocated in three study groups (45 patients in each group) according to the medications they received.
Exclusion Criteria:
1- Patients with history of abnormal bleeding.
2- Patients with history of allergy to local anesthetics.
3- Neuromuscular diseases.
4- Communicating problems.
An ampoule of hyaluronidase 1500 IU was dissolved by 1ml of Lidocaine 2% and added to a vial of 50 ml of lidocaine 2% (hyaluronidase concentration is 30 IU/ml).
5 ml of this vial was taken and added to another 5 ml of lidocaine 2% (without hyaluronidase).
Thus, the local anesthetic mixture contains 10 ml of lidocaine 2% supplemented with hyaluronidase 15 IU/ml.
Patients were randomly allocated into three groups:
Group C: Control group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% containing hyaluronidase 15 IU/ml plus 0.5 ml saline 0.9%.
Group A: Cisatracurium group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml cisatracurium 1 mg.
Group R: Rocuronium group received a mixture (8 ml) containing equal parts of Marcaine 0.5%, lidocaine 2% plus 0.5 ml rocuronium 5mg.
Patient Care, monitoring and measurements:
A peripheral IV cannula was inserted and standard monitoring including: pulse oximetry, electrocardiogram and automated noninvasive blood pressure.
Before performing the block, baseline globe movements in the major directions of gaze (superior, inferior, medial and lateral) were assessed. LA solution was injected using a 25 mm 25 G needle.
The needle was introduced along the inferior wall of the orbit to a depth of 20 mm with the sharp bevel facing to the globe. The direction of injection was almost perpendicular to the frontal plane and parallel to the sagittal plane; the eye was in the neutral position. Injection was performed after negative aspiration. A gentle digital massage of the eyeball, between scoring the akinesia to facilitate diffusion of local anesthesia mixture was done.
All blocks were performed by the same investigator and the surgeries were done by the same surgeon.
Evaluation of the block:
Immediately motor block assessment included lid akinesia (lid closure by orbicularis oculi muscle and lid opening by the levator palpebrae superioris muscle) and globe akinesia (globe movement in all directions by the 4 recti muscles) according to the scoring system that is shown in table (1).
Table (1): Scoring system (7)
Akinesia of the extra-ocular muscles including the levator muscle:
0= 0-1mm movement in 1 or 2 main directions OR 0-4 mm movement in levator muscle.
1= 1mm movement in more than 2 main directions
OR 2mm movement in any main direction
OR more than 4mm movement in levator muscle.
2= more than 2mm movement in any main direction
OR 2mm movement in 2 or more main directions.
Akinesia of the orbicularis muscle:
0= Complete akinesia.
1= Partial movement in either or both eyelid margins.
2= Normal movement in either or both eyelid margins. For assessment of lid akinesia, the patients were asked to open their eyelids (levator muscle) and then squeeze them together maximally (orbicularis muscle).Orbicularis oculi muscle was examined separately by using the score in table (1).
Globe akinesia was assessed by examination of the movements of the extra-ocular muscles in all of the 4 main directions on a scale from 0 to 2 as shown in table (1). The block was considered to be satisfactory when loss of at least two movements of the 4 cardinal directions occurred. Failure of the block excluded the patient from the study and received general anesthesia.
Lid opening, lid closure and extra-ocular muscles movements in the 4 cardinal directions were assessed before the block then after the block at 1 minute, 3 minutes, 5 minutes and 10 minutes. Both sides are compared for more accurate assessment of motor block.
Arterial blood pressure, heart rate and arterial oxygen saturation (SpO2) were assessed before the block, then after 15, 30 and 60 minutes after performing the block.
Hypotension and bradycardia were defined as: 20% or more decrease in the mean arterial blood pressure and heart rate, respectively, in relation to the preblock value.
Monitoring for the development of bradycardia or ventricular ectopies (oculocardiac reflex) were done and facilities were available for rapid management by immediate notification of the surgeon for temporary cessation of surgical stimulation until the heart rate increases and administration of IV atropine (10 µg/kg) if the condition persists.
Sample size estimation: To show a difference of eye and lid movement with p-value < 0.05 and power 81%, we needed at least 45 patients per group to compare the rocuronium, cisatracurium and control groups.