SummaryWe have assessed the effect of two induction agents on tracheal intubating conditions after rocuronium 0.6 mg.kg À1 in unpremedicated patients undergoing simulated rapid sequence induction. Following pre-oxygenation, anaesthesia was induced with propofol up to 2.5 mg.kg À1 (n 35) or etomidate 0.3 mg.kg À1 (n 36), and further increments as required. After loss of verbal contact, cricoid pressure was applied and rocuronium was injected. Laryngoscopy was performed at 45 s and intubation attempted at 60 s after rocuronium had been given. Ninety-four per cent of patients in the propofol group had clinically acceptable (good or excellent) intubating conditions compared to only 75% in the etomidate group (p 0.025). Owing to coughing, one patient in the etomidate group could not be intubated on the first attempt. A greater pressor response also followed intubation after induction with etomidate. We conclude that etomidate and rocuronium alone cannot be recommended for intubation at 60 s under rapid sequence induction conditions. After a period of oxygenation an intravenous barbiturate followed immediately by a full dose of muscle relaxant have long been used to permit rapid tracheal intubation in the patient at risk of aspiration [1, 2]. Thiopentone and suxamethonium are traditionally used for this purpose. Rocuronium has been shown to be a suitable alternative to suxamethonium for rapid tracheal intubation [3]. Pharyngeal and laryngeal reflexes are more depressed by propofol than by other intravenous induction agents [4] and may create more favourable intubating conditions. Propofol is increasingly being used as the induction agent of choice for rapid tracheal intubation in patients who are haemodynamically stable [5]. The main problem concerning induction of anaesthesia with propofol is dose-related hypotension and this may preclude its use in the elderly and hypovolaemic patients [6][7][8][9].Of the current induction agents, etomidate causes the least haemodynamic disturbance and may be more suitable when cardiac stability is desirable [6, 7, 10]. We were interested to see if intubating conditions and cardiovascular changes under rapid sequence induction conditions were acceptable if anaesthesia was induced with etomidate and rocuronium, rather than with propofol and rocuronium.
Patients and methodAfter obtaining approval from the hospital ethics committee and informed patient consent, we studied 71 adult patients aged 18-75 years, ASA grades I and II, undergoing elective surgery. Patients with potential airway problems were not studied. No patient had hepatic or renal impairment or was receiving any medication known to interact with neuromuscular blocking agents. Patients were unpremedicated and randomly allocated to receive either propofol or etomidate after a 3-min period of preoxygenation. The estimated induction dose in the propofol group was 2.5 mg.kg À1 , and 0.3 mg.kg À1 in the etomidate group. The agent was titrated over 30 s until verbal contact was lost. Further increments were given if required. H...
Atracurium kinetics and dynamics are near-normal even in patients with fulminant hepatic failure and renal failure; laudanosine accumulation will occur, but this is not associated with measurable central neurological effects. Implantation of a functioning liver graft results in clearance of laudanosine, which seems to be independent of renal function. Atracurium is an appropriate choice for producing neuromuscular blockade for periods of several days in patients with fulminant hepatic failure and renal impairment.
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