2. Rocuronium for rapid sequence induction Presenters: Dr. Said Nawaz. Dr.Reem Al-safar. Dr.Ahmed Al-sharif. Dr.Abdulla Al-harbi.

3. Rocuronium Bromide pharmacology Chemistry: Chemistry:  Monoquaternary Amino-steroid compound of Non-depolarizing neuromuscular blocking agents.  It was introduced 1995 CH 53 BrN 2 O 4 CH 53 BrN 2 O 4

4.  Presentation - Rocuronium is supplied as a sterile, isotonic solution that is clear. - Rocuronium is supplied as a sterile, isotonic solution that is clear. - pH of 4. - pH of 4.  Indications and usage - used to facilitate both rapid sequence and routine tracheal intubation. - used to facilitate both rapid sequence and routine tracheal intubation. - to provide skeletal muscle relaxation during surgery or mechanical ventilation. - to provide skeletal muscle relaxation during surgery or mechanical ventilation. - is also indicated as an adjunct in the intensive care unit (ICU) to facilitate intubation and mechanical ventilation - is also indicated as an adjunct in the intensive care unit (ICU) to facilitate intubation and mechanical ventilation

5.  Mechanism of action: It acts by competitve inhibition of α-subunit of nicotinic receptors at the motor end-plate. It acts by competitve inhibition of α-subunit of nicotinic receptors at the motor end-plate.  Onset of action: (Dose dependant) -ED95 0.3mg/kg -ED95 0.3mg/kg - Intubating dose 0.6mg/kg,maximal block 1.5min - Intubating dose 0.6mg/kg,maximal block 1.5min -Dose of 0.9-1.2mg/kg, maximal block 60-90 sec. -Dose of 0.9-1.2mg/kg, maximal block 60-90 sec. -In children : dose of 0.6mg/kg,maximal block 1min -In children : dose of 0.6mg/kg,maximal block 1min dose of 1.2mg/kg,maximal block 40 sec dose of 1.2mg/kg,maximal block 40 sec -Intrmuscular injection 1mg/kg for infants and 2mg/kg for children,maximal block 3-6 min. -Intrmuscular injection 1mg/kg for infants and 2mg/kg for children,maximal block 3-6 min.

6.  Duration of action: - Duration of action is determined by redistribution. - Duration of action is determined by redistribution. after 0.6mg/kg is 31 min after 0.6mg/kg is 31 min after 0.9-1.2mg/kg 58-67min after 0.9-1.2mg/kg 58-67min  Like other Non-DNMBA :it is highly ionized in water compound at physiological PH, VD is limited and can not cross lipid membrane barrier.  Metabolism and execration: -No metabolism. -No metabolism. -Eliminated primarily by liver and slightly by kidneys -Eliminated primarily by liver and slightly by kidneys - Elimination half life is 1-2h. - Elimination half life is 1-2h. -No active metabolites. -No active metabolites.

7.  Rocuronium in special situations

8.  Hepatic impairment  Onset time is unchanged  Duration of action is increased. (1.5 times longer)  Larger or repeat doses may have prolonged effect  Renal failure  Onset time is unchanged  Also, Duration of action is unchanged at the dose of 0.6mg/kg.

9.  Rocuronium and obesity  Same onset time compared to Non obese  Same Duration  Dose should be given according to Actual Body Weight.

10.  Rocuronium in Obstetric anesthesia  The umbilical venous plasma concentrations were 18% of maternal concentrations at delivery. Apgar score>7 in 5m.  Rocuronium can be used for rapid intubation during cesarian section if succinylcholine is contraindicated.(Koroglu et al.)

11.  Age and Rocuronium ( 0.6mg/kg )  Pediatrics (3 mos. - 1 yr):  excellent to good intubating conditions within 1 minute, with 41 minutes of clinical relaxation (median)  Pediatrics (1 yr - 12 yrs):  excellent to good intubating conditions within 1 minute, with 27 minutes of clinical relaxation (median)  Geriatric (  65 yrs):  excellent to good intubating conditions within 2.3 minutes, with 46 minutes of clinical relaxation (median)

12. The case of Rocuronium versus Succinylcholine for RSI

13. A comparison of Succinylcholine and Rocuronium for rapid sequence intubation of ED patients. Erik Laurin et al, california, AEMJ 2003  360 patients Sch  1.5 mg/kg  Relaxation 39±13 sec  Body movements 9.2±1.2  Vocal cords movements 9.0±1.5  Physician satisfaction +++  6 patients bradycardia with wide QRS  182 patients RCR  0.9 mg/kg  Relaxation 44±2.0 sec  Body movements 9.5±1.1  Vocal cords movements 9.2±1.2  Physician satisfaction  ++  None

14. Rocronium versus Succinylcholine: are they equally effective during RSI of aneasthesia Mazeruka A J., Chicago Anaesthesia and Analgesia 1998  30 children  Thiopentone 5mg/kg  SUX 1.5 mg/kg  30 children  Thiopentone 5mg/kg  RCR 1.2 mg/kg

15. What is the message?  Rocuronium can do every thing, what Succinylcholine does, with the equal efficiency, but more safely.

16. Limitations Not suitable for difficult intubation situation Not suitable for difficult intubation situation

17. Thank you