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Intramuscular rocuronium in infants and children. Dose-ranging and tracheal intubating conditions
1Department of Anesthesia, University of California, San Francisco 94143-0648, USA.
Insights
Intramuscular rocuronium via deltoid injection allows rapid tracheal intubation in infants and children. Doses of 1,000 mcg/kg for infants and 1,800 mcg/kg for children are effective, though duration may be limiting.
Area of Science:
- Anesthesiology
- Pediatric Critical Care
- Pharmacology
Background:
- Intravenous rocuronium offers rapid onset and intermediate duration.
- Intramuscular administration may enable tracheal intubation without prolonged paralysis in pediatric patients.
Purpose of the Study:
- Determine optimal intramuscular rocuronium dose for tracheal intubation in infants and children.
- Establish optimal timing for tracheal intubation following intramuscular rocuronium administration.
Main Methods:
- Two-phase study involving 45 pediatric patients (3 months-5 years).
- Phase I: Dose-finding (800-2,400 mcg/kg) via quadriceps or deltoid injection to assess twitch depression.
- Phase II: Optimal deltoid dose (1,000 mcg/kg infants, 1,800 mcg/kg children) evaluated for intubation timing.
Main Results:
- Deltoid injections achieved complete twitch depression; median time to 50% ventilation depression was 3.2 min (infants) and 2.8 min (children).
- Adequate to excellent intubating conditions were achieved at 2.5 min in infants and 3.0 min in children.
- Twitch recovery occurred at approximately 57 min (infants) and 70 min (children).
Conclusions:
- Deltoid intramuscular rocuronium (1,000 mcg/kg infants, 1,800 mcg/kg children) facilitates rapid tracheal intubation in pediatric patients.
- Effective intubation is possible even under light anesthesia.
- The duration of action of these higher doses may impact clinical usefulness.
Background:
Rocuronium's rapid onset and intermediate duration of action with intravenous administration suggests that intramuscular administration might facilitate tracheal intubation without producing prolonged paralysis. Accordingly, in infants and children, the authors measured onset at the adductor pollicis and respiratory muscles to determine the optimal dose (phase I), then gave this optimal dose to determine the optimal time for tracheal intubation (phase II).
Methods:
The authors studied 45 unpremedicated patients aged 3 months to 5 yr. In phase I, 25 patients were anesthetized with nitrous oxide and halothane and breathed spontaneously; twitch tension and minute ventilation were measured. Rocuronium (800-2,400 micrograms/kg) was injected into the quadriceps or deltoid muscle; doses varied, using an "up-down" technique, the goal being to bracket the dose depressing twitch 75-90% within 5 min. In phase II, deltoid injections of the optimal dose from phase I (infants: 1,000 micrograms/kg; children: 1,800 micrograms/kg) were given to 20 patients anesthetized with 0.82-1.0% halothane. Tracheal intubation was attempted 1.5-3.0 min later; time to tracheal intubation was varied, using an "up-down" technique.
Results:
In phase I, 5 of 7 patients given quadriceps injections (1,200-2,200 micrograms/kg) had slow onset of twitch and ventilatory depression. With deltoid injections (800-2,400 micrograms/kg), all patients developed complete twitch depression; median time to 50% depression of minute ventilation was 3.2 min in infants and 2.8 min in children. In phase II, intubating conditions were consistently adequate or good-excellent at 2.5 min in infants and 3.0 min in children. Initial twitch recovery was at 57 +/- 13 min (mean +/- SD) in infants and 70 +/- 23 min in children.
Conclusions:
Deltoid injections of rocuronium, 1,000 micrograms/kg in infants and 1,800 micrograms/kg in children, rapidly permit tracheal intubation in infants and children, despite a light plane of anesthesia. Duration of action of these large doses might limit clinical utility.