EFFECT OF NITROUS OXIDE AND LIGNOCAINE IN REDUCING PAIN OF

ROCURONIUM INJECTION IN ADULT PATIENTS

EFFECT OF NITROUS OXIDE AND LIGNOCAINE IN REDUCING PAIN OF

ROCURONIUM INJECTION IN ADULT PATIENTS

PRESENTER: Dr. NIRMEEN FATIMA

PGY2, RIMS, IMPHAL

PRESENTER: Dr. NIRMEEN FATIMA

PGY2, RIMS, IMPHAL

INTRODUCTIONINTRODUCTION

Rocuronium provides intubating conditions almost similar to those seen with succinylcholine within 45–90 seconds with dose 0.6- 1.2mg/kg. But it causes pain on iv injection with an incidence of 50-80%.

Various methods were used to alleviate the pain caused by rocuronium.

These include administration of :-

Lidocaine a local anaesthetic of the amide type

Nitrous oxide a centrally acting sedative and analgesic agent

Rocuronium provides intubating conditions almost similar to those seen with succinylcholine within 45–90 seconds with dose 0.6- 1.2mg/kg. But it causes pain on iv injection with an incidence of 50-80%.

Various methods were used to alleviate the pain caused by rocuronium.

These include administration of :-

Lidocaine a local anaesthetic of the amide type

Nitrous oxide a centrally acting sedative and analgesic agent

MATERIALS AND METHODSMATERIALS AND METHODS

80 patients of ASA grade I & II, aged 18-65 years undergoing elective surgery under general anaesthesia were randomly allotted into two groups (n=40).

Group O : received 100% oxygen and 2ml of 2% lidocaine

Group N : received 50% nitrous oxide – oxygen mixture and 2ml of 2% lidocaine.

80 patients of ASA grade I & II, aged 18-65 years undergoing elective surgery under general anaesthesia were randomly allotted into two groups (n=40).

Group O : received 100% oxygen and 2ml of 2% lidocaine

Group N : received 50% nitrous oxide – oxygen mixture and 2ml of 2% lidocaine.

MATERIALS AND METHODSMATERIALS AND METHODS

Patients in Group O (n=40) were preoxygenated with 100% oxygen.

Patients in Group N (n=40) were preoxygenated with 50% nitrous oxide mixture in oxygen.

Once the patient has inhaled 50% nitrous oxide – oxygen mixture (Group N) or pure oxygen (Group O) for two minutes,

the forearm was occluded with a tourniquet upto 70 mm Hg to occlude the vein

After 1 min, the occlusion was released and a subparalysing dose of rocuronium 0.06mg/kg(1mg/ml) diluted with 0.9% normal saline was administered.

The patients were observed and asked immediately if they had pain in the arm, and the response were assessed according to the Mc Crirrick and Hunter scale.

Patients in Group O (n=40) were preoxygenated with 100% oxygen.

Patients in Group N (n=40) were preoxygenated with 50% nitrous oxide mixture in oxygen.

Once the patient has inhaled 50% nitrous oxide – oxygen mixture (Group N) or pure oxygen (Group O) for two minutes,

the forearm was occluded with a tourniquet upto 70 mm Hg to occlude the vein

After 1 min, the occlusion was released and a subparalysing dose of rocuronium 0.06mg/kg(1mg/ml) diluted with 0.9% normal saline was administered.

The patients were observed and asked immediately if they had pain in the arm, and the response were assessed according to the Mc Crirrick and Hunter scale.

MATERIALS AND METHODSMATERIALS AND METHODS

Assessment of pain during injection of rocuronium according to Mc Crirrick and Hunter scale.

Assessment of pain during injection of rocuronium according to Mc Crirrick and Hunter scale.

None ( 0 ) No response to questioning

Mild ( 1 )

 Pain in response to questioning only, without any behavioral signs.

Moderate ( 2 )

 

Pain reported in response to questioning and accompanied by behavioral

signs , or pain reported without any questioning.

Severe ( 3)Strong vocal response or response accompanied by facial grimacing, arm

withdrawal or tears.

Degree of pain Response

MATERIALS AND METHODSMATERIALS AND METHODS

Anaesthesia was then induced with 2.5% thiopentone 5mg/kg i.v. When the eyelash reflex was abolished, an intubating dose of rocuronium 0.6 mg/kg was injected over 10 seconds and withdrawal movements, if any, was recorded.

The results were tabulated and statistically analysed.

Anaesthesia was then induced with 2.5% thiopentone 5mg/kg i.v. When the eyelash reflex was abolished, an intubating dose of rocuronium 0.6 mg/kg was injected over 10 seconds and withdrawal movements, if any, was recorded.

The results were tabulated and statistically analysed.

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Table 1. Demographic profile among two groups. Table 1. Demographic profile among two groups.

Patient Parameter

Group O (n=40) Group N (n=40) Statistical test Degree of Freedom

P value and inference

Age (mean±SD) in yrs.

36.78 ± 12.972 35.12 ± 11.371 Student T test t = 0.605

78 0.547

(NS)

Weight (mean±SD) in kg

54.70 ± 9.196 51.72 ± 7.432 Student T test t = 1.591

78 0.116

(NS)

Sex Male = 15(37.5%)

Male = 10(25%) Chi square test (X2)=1.455

1 0.228

(NS)Female= 25(62.5%)

Female = 30(75%)

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Fig.1.Graphical representation of distribution of pain among two groups Fig.1.Graphical representation of distribution of pain among two groups

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Table 3. Statistical test for pain among two groups Table 3. Statistical test for pain among two groups

Pain Group Total Chi square (x2) P value

Group O Group N

No pain 30 (75%) 38 (95%) 68 6.275 0.012(S)

Mild pain 10 (25%) 2 (5%) 12

Total 40 40 80

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Table 4. Distribution of withdrawal movements and statistical test among two groupS. Table 4. Distribution of withdrawal movements and statistical test among two groupS.

Group Withdrawal Total

No Withdrawal

Wrist Withdrawal

Arm Withdrawal Generalized movement

Group O 31(77.5%) 5(12.5%) 4(10%) 0 40

Group N 38(95%) 0 2(5%) 0 40

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Fig.2. Graphical representation of distribution of withdrawal movements among two groups Fig.2. Graphical representation of distribution of withdrawal movements among two groups

RESULTS AND OBSERVATIONSRESULTS AND OBSERVATIONS

Fig.3a.Graphical representation of distribution of pain among both sexes in group O

Fig.3a.Graphical representation of distribution of pain among both sexes in group O

Fig. 3b. Graphical representation of distribution of pain among both sexes in group N.

Fig. 3b. Graphical representation of distribution of pain among both sexes in group N.

DISCUSSIONDISCUSSION

o In this study, incidence of mild pain in group O is 25% and 5% in group N which is similar to the study conducted by Sharma et al where they reported 22.5% in group O and 2.5% in group N which might be because of nitrous oxide and lignocaine which has additive and different analgesic modalities.

o The exact mechanism of pain has not been ascertained. o Various theories proposed :-

o Peripheral veins are innervated with polymodal C- nociceptors which mediate pain response and are activated by the osmolality or pH of the rocuronium solution.

o Release of endogenous mediators such as histamine, kinin cascade and other substances.

o In this study, incidence of mild pain in group O is 25% and 5% in group N which is similar to the study conducted by Sharma et al where they reported 22.5% in group O and 2.5% in group N which might be because of nitrous oxide and lignocaine which has additive and different analgesic modalities.

o The exact mechanism of pain has not been ascertained. o Various theories proposed :-

o Peripheral veins are innervated with polymodal C- nociceptors which mediate pain response and are activated by the osmolality or pH of the rocuronium solution.

o Release of endogenous mediators such as histamine, kinin cascade and other substances.

DISCUSSIONDISCUSSION

In this study 22.5% patients in group O and 5% of patients in group N had withdrawal movements to the intubating dose of rocuronium. Sharma et al also demonstrated withdrawal movements in 15% of patients in group O2

and 45% of patients in group N2O which is higher than our incidence. This is because we used two drugs with different analgesic modalities whereas Sharma et a used only nitrous oxide.

Kwak HJ et al demonstrated that combination of nitrous oxide and lignocaine pretreatment significantly reduced withdrawal movements (3.1%) in paediatric patients compared to lignocaine alone (25.8%) which is comparable to our study where 5% had withdrawal movements in group N and 22.5% in group O.

In this study 22.5% patients in group O and 5% of patients in group N had withdrawal movements to the intubating dose of rocuronium. Sharma et al also demonstrated withdrawal movements in 15% of patients in group O2

and 45% of patients in group N2O which is higher than our incidence. This is because we used two drugs with different analgesic modalities whereas Sharma et a used only nitrous oxide.

Kwak HJ et al demonstrated that combination of nitrous oxide and lignocaine pretreatment significantly reduced withdrawal movements (3.1%) in paediatric patients compared to lignocaine alone (25.8%) which is comparable to our study where 5% had withdrawal movements in group N and 22.5% in group O.

DISCUSSIONDISCUSSION

The central antinociceptive effects of N2O may prevent the pain from the local irritant effect of rocuronium.

N2O has been reported to affect a variety of different receptors including opioid, noradrenergic, acetylcholine, GABA and NMDA receptors.

The effect of lignocaine was more likely the result of local anaesthetic effect at the site of injection.

Mencke T et al demonstrated that women experienced more pain on injection of rocuronium compared to males (45% Vs 20%) and concluded that some pretreatment is necessary especially in women which was similar tour findings in our study.

The central antinociceptive effects of N2O may prevent the pain from the local irritant effect of rocuronium.

N2O has been reported to affect a variety of different receptors including opioid, noradrenergic, acetylcholine, GABA and NMDA receptors.

The effect of lignocaine was more likely the result of local anaesthetic effect at the site of injection.

Mencke T et al demonstrated that women experienced more pain on injection of rocuronium compared to males (45% Vs 20%) and concluded that some pretreatment is necessary especially in women which was similar tour findings in our study.

CONCLUSIONCONCLUSION

From this study, the following conclusions can be made :

Nitrous oxide and Lignocaine can be used for pretreatment to prevent rocuronium injection pain.

Pretreatment of two different analgesic modalities, nitrous oxide and lignocaine better prevents pain and withdrawal movements associated with rocuronium injection than when used alone.

From this study, the following conclusions can be made :

Nitrous oxide and Lignocaine can be used for pretreatment to prevent rocuronium injection pain.

Pretreatment of two different analgesic modalities, nitrous oxide and lignocaine better prevents pain and withdrawal movements associated with rocuronium injection than when used alone.

REFERANCESREFERANCES

1. Naguib M, Lien CA. Pharmacology of muscle relaxants and their antagonists. In:Miller RD editor. Miller’s anesthesia 7th ed. Vol-1 Philadephia,USA: Churchill livingstone elsevier;2010.p.859-67.

2.Huizinga AC, Vandenbrom RH, Wierda JM, Hommes FD, Hennis PJ. Intubating conditions and onset of neuromuscular block of rocuronium (Org 9426); a comparison with suxamethonium. Acta Anaesthesiol Scand. 1992 Jul;36(5):463-8.

3. Puhringer FK, Khuenl-Brady KS, Koller J, Mitterschiffthaler G. Evaluation of the Endotracheal Intubating conditions of rocuronium (org 9426) and succinylcholine in outpatient surgery. Anesth Analg 1992;75:37-40.

4. Moorthy SS, Dierdorf SF. Pain on injection of Rocuronium bromide. Anesth Analg 1995;80:1067.

5.Steegers MAH, Robertson EN. Pain on injection of Rocuronium bromide. Anesth Analg 1996;83:203.

6.Borgeat A, Kwiatkowski D. Spontaneous movements associated with rocuronium : is pain on injection the cause?. Br J Anaesth 1997;79:382-3.

7. Blunk JA, Seifert F, Schmelz M, Reeh PW, Koppert W.Injection pain of rocuronium and vecuronium is evoked by direct activation of nociceptive nerve endings. Eur J Anaesth 2003 Mar;20(3):245-3.

8. Klement W, Arndt JO. Pain on i.v. injection of some anesthetic agents is evoked by the unphysiological osmolality or pH of their formulations. Br J Anaesth 1991;66:189–5.

9. Mencke T, Schreiber JU, Knoll H, Stracke C, Kleinschmidt S, Rensing H et al. Women report more pain on injection of a recurarization dose of rocuronium: A randomized, prospective, placebo-controlled trial. Acta Anaesthesiol Scand. 2004;8(10):1245-8.

10. Cheong KF, Wong WH. Pain on injection of Rocuronium : Influence of two doses of lidocaine pretreatment. Br J Anaesth 2000;84(1):106-7.

1. Naguib M, Lien CA. Pharmacology of muscle relaxants and their antagonists. In:Miller RD editor. Miller’s anesthesia 7th ed. Vol-1 Philadephia,USA: Churchill livingstone elsevier;2010.p.859-67.

2.Huizinga AC, Vandenbrom RH, Wierda JM, Hommes FD, Hennis PJ. Intubating conditions and onset of neuromuscular block of rocuronium (Org 9426); a comparison with suxamethonium. Acta Anaesthesiol Scand. 1992 Jul;36(5):463-8.

3. Puhringer FK, Khuenl-Brady KS, Koller J, Mitterschiffthaler G. Evaluation of the Endotracheal Intubating conditions of rocuronium (org 9426) and succinylcholine in outpatient surgery. Anesth Analg 1992;75:37-40.

4. Moorthy SS, Dierdorf SF. Pain on injection of Rocuronium bromide. Anesth Analg 1995;80:1067.

5.Steegers MAH, Robertson EN. Pain on injection of Rocuronium bromide. Anesth Analg 1996;83:203.

6.Borgeat A, Kwiatkowski D. Spontaneous movements associated with rocuronium : is pain on injection the cause?. Br J Anaesth 1997;79:382-3.

7. Blunk JA, Seifert F, Schmelz M, Reeh PW, Koppert W.Injection pain of rocuronium and vecuronium is evoked by direct activation of nociceptive nerve endings. Eur J Anaesth 2003 Mar;20(3):245-3.

8. Klement W, Arndt JO. Pain on i.v. injection of some anesthetic agents is evoked by the unphysiological osmolality or pH of their formulations. Br J Anaesth 1991;66:189–5.

9. Mencke T, Schreiber JU, Knoll H, Stracke C, Kleinschmidt S, Rensing H et al. Women report more pain on injection of a recurarization dose of rocuronium: A randomized, prospective, placebo-controlled trial. Acta Anaesthesiol Scand. 2004;8(10):1245-8.

10. Cheong KF, Wong WH. Pain on injection of Rocuronium : Influence of two doses of lidocaine pretreatment. Br J Anaesth 2000;84(1):106-7.