# Abstract

 

## Background Rocuronium has been well known to produce withdrawal response in 50-80% patients when administered intravenously. Several drugs are administered prior injection of rocuronium to prevent the withdrawal response. We compared the preventive effect of lidocaine, ketamine, and remifentanil on the withdrawal response of rocuronium. 

## Methods A total of 120 patients undergoing various elective surgeries were enrolled. Patients were allocated into 4 groups according to the pretreatment drugs (Group N, normal saline; Groups L, lidocaine 40 mg; Group K, ketamine 0.5 mg/kg; Group R, remifentanil 1 µg/kg). Patients received drugs prepared by dilution to 3 ml volume before injection of rocuronium. Withdrawal responses after injection of rocuronium were graded on a 4-point scale. Hemodynamic changes were observed before and after administration of pretreatment drugs and after endotracheal intubation. 

## Results Incidence of withdrawal response was significantly lower in group L (20%), group K (30%), and group R (0%), than group N (87%). Severe withdrawal response was observed in 5 of the 30 patients (17%) in group L, and in 9 of the 30 patients (30%) in group K. There was no severe withdrawal response in group R. Mean blood pressure and heart rate were significantly decreased in group R compared to other groups. 

## Conclusions It seems that remifentanil (1 µg/kg intravenously) was the strongest and most effective in prevention of withdrawal response after rocuronium injection among the 3 drugs. # Results There were no dropouts and the data from all 120 patients could be analyzed. There were no significant differences among the groups in demographic data ([Table 1](#)). The incidence of withdrawal response was 87% (26/30), 20% (6/30), 30% (9/30), and 0% in group N, group L, group K, and group R, respectively ([Table 2](#)). Severe withdrawal response which is >2 on the 4-point scale occurred in 25 patients (84%) in group N (P < 0.00833). However, it was observed in 5 patients (17%) in group L, in 9 patients (30%) in group K, and in no patient in group R, respectively. The number of patients needed to be treated (NNT) to prevent pain in one who would have had pain was 1.49, 1.75, and 1.15 in group L, group K, and group R, respectively. Lidocaine (40 mg), ketamine (0.5 mg/kg), or remifentanil (1 µg/kg) decreased the withdrawal response significantly and remifentanil (1 µg/kg) was the most effective in the prevention of withdrawal response among the drugs (P < 0.00833) ([Table 2](#)). There were no significant differences in mean blood pressure and heart rate before injection of pretreatment drugs among the groups ([Figs. 1](#) and [2](#)). However, there were significant decreases in group R compared to control and other groups after injection of pretreatment drugs ([Figs. 1](#) and [2](#)). After intubation, mean blood pressure was increased in group N, group L, and group K compared to control ([Fig. 1](#)). However, in group R, mean blood pressure was significantly lower compared to other groups (P < 0.05) ([Fig. 1](#)). Heart rate increased significantly compared to control in all groups but, it was significantly lower in group R compared to other groups (P < 0.05) ([Fig. 2](#)). No erythema, venous sequels, or adverse event were observed in any patient. <figure> <p><img src="" /></p> <figcaption>Sequential changes of mean blood pressure before and after intravenous injection of normal saline, lidocaine, ketamine, and remifentanil and after endotracheal intubation. There was no significant difference in mean blood pressure before injection of pretreatment drugs (control) among the groups. After injection of pretreatment drugs, mean blood pressure was significantly decreased in group R compared to control and other groups. After intubation, it increased in group N, group L, and group K compared to control. Mean blood pressure of group R after endotracheal intubation was significantly lower than other groups (P < 0.05). Group N: normal saline, Groups L: lidocaine 40 mg, Group K: ketamine 0.5 mg/kg, Group R: remifentanil 1 µg/kg. <sup>*</sup>P < 0.05 compared with control. <sup>†</sup>P < 0.05 compared with group N. <sup>‡</sup>P < 0.05 compared with group L. <sup>§</sup>P < 0.05 compared with group K.</figcaption> </figure> <figure> <p><img src="" /></p> <figcaption>Sequential changes of heart rate before and after intravenous injection of normal saline, lidocaine, ketamine, and remifentanil and after endotracheal intubation. There was no significant difference in heart rate before injection of pretreatment drugs (control) among the groups. After injection of pretreatment drugs, heart rate was significantly decreased in group R compared to control and other groups. After intubation, heart rate was increased compared to control in all groups, but it was significantly lower in group R than other groups (P < 0.05). Group N: normal saline, Groups L: lidocaine 40 mg, Group K: ketamine 0.5 mg/kg, Group R: remifentanil 1 µg/kg. <sup>*</sup>P < 0.05 compared with control. <sup>†</sup>P < 0.05 compared with group N. <sup>‡</sup>P < 0.05 compared with group L. <sup>§</sup>P < 0.05 compared with group K.</figcaption> </figure> ::::table-wrap

::: caption
Demographic Data
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Values are mean ± SD. No significant difference among the groups. Group
N: normal saline, Groups L: lidocaine 40 mg, Group K: ketamine 0.5
mg/kg, Group R: remifentanil 1 µg/kg.:::: ::::table-wrap
::: caption
Incidence and Grade of Withdrawal Movements Associated with Rocuronium
Injection
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Values are number of patients (percentage). Group N: normal saline,
Groups L: lidocaine 40 mg, Group K: ketamine 0.5 mg/kg, Group R:
remifentanil 1 µg/kg. NNT: number needed to treat. ^\*^P < 0.00833
compared with group N. ^†^P < 0.00833 compared with group L. ^‡^P \<
0.00833 compared with group K.::::


Extracted trial result:
Outcome: withdrawal response of rocuronium (binary)
Intervention: ketamine
Comparator: normal saline
Intervention events: 9
Intervention group size: 30
Comparator events: 26
Comparator group size: 30
Notes: Used percentage to calculate events as binary outcome.