The Effect of Propofol and Remifentanil Sequence on ED50 and ED95 of Rocuronium in Rapid Sequence Induction Anesthesia
Condition: Anesthesia; Neuromuscular Blockade
Study type: Interventional
Phase: Phase 4

Summary: 
      Rapid sequence induction (RSI) is a well-known procedure to maintain a safe and rapid airway
      in patients especially at risk of aspiration. Propofol and rocuronium are generally used
      agents for RSI. However, the difficult airway scenarios are always valid for these patients,
      even without predictive signs of difficult airway. Therefore, it is important to decrease the
      rocuronium dose used in RSI to achieve a rapid recovery of a neuromuscular conduction with
      the aid of a reversal agent in case of difficult airway. The short acting opioids such as
      remifentanil may be helpful to reduce the dose of rocuronium in RSI.
    

Detailed description: 
      Rapid sequence induction is a widely used anesthesia technique to achieve a safe airway
      control. However, the difficult airway may be expected in these patients as in the others. In
      the difficult airway situation, cholinesterase inhibitors and sugammadex may be used for the
      reversal. However, sugammadex is not always available due to its cost in every hospital. In
      addition to this, it is well-known that cholinesterase inhibitors do not work well in case of
      deep neuromuscular block. In consideration of these informations, the recovery of the
      neuromuscular block gain an importance in patients undergoing RSI with difficult airway.
      Therefore, decreasing the dosage of non-depolarizing neuromuscular agent may be helpful in
      case of the difficult airway situations. With the aim of decreasing the neuromuscular blocker
      dosage, opioid analgesics especially remifentanil is preferred combined with propofol to
      decrease the hemodynamic response to laryngoscopy and intubation. A recent study demonstrated
      that after induction of anesthesia with remifentanil and propofol, ED50 of rocuronium for
      acceptable intubation conditions was 0.20 mg/kg. In another study, the authors showed that
      the administration sequence of propofol and remifentanil for target controlled anesthesia
      affect the onset time of rocuronium due to change in cardiac output. The authors concluded
      that the prior administration of remifentanil decreased the cardiac output and delayed the
      onset time of rocuronium.

      The investigators hypothesized that prior administration of remifentanil compared to propofol
      may increase the ED50 and ED95 of rocuronium for acceptable intubation conditions in RSI.
    

Intervention name(s): Propofol; Remifentanil; Rocuronium
Intervention type(s): Drug; Drug; Drug
Intervention description(s): Propofol will be used in either two arms. The injection sequence will be changed. In propofol arm of the study, general anesthesia will be started with 2 mg/kg propofol administered within 15 seconds. And, then remifentanil will be given. In remifentanil arm of the study, 2 mg/kg propofol will be applied within 15 seconds following remifentanil injection.; Remifentanil will be used in either two arms. The injection sequence will be changed. In remifentanil arm, general anesthesia will be started with 2 μg/kg remifentanil administered within 30 seconds. And then propofol will be given. In propofol arm of the study the same dose will be applied within 30 seconds following propofol administration.; Rocuronium will be used for either two study arms. Rocuronium will be given in a 0.8 mg/kg dosage in the first study subject. And then, if the intubation condition is acceptable, the dose of the rocuronium will be decreased by 0.1 mg/kg for the next patient. Otherwise, if the intubation condition is not acceptable, the rocuronium dosage will be increased by 0.1 mg/kg for the next patient. This will be continue for ten crossover points (the point that turn from unsuccessful intubation to successful intubation).
Other intervention name(s): Ultiva; Esmeron
Intervention MeSH terms: Remifentanil; Propofol; Rocuronium
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Screening
Keywords: propofol; remifentanil; rocuronium