SINGH,

SUXAMETHONIUM
ROCURONIUM FOR INTUBATION
Indian J.BHATIA,
Anaesth.TULSIANI
2004; 48 :(2)
: 129-133

129

COMPARISON OF ONSET TIME, DURATION OF ACTION

AND INTUBATING CONDITIONS ACHIEVED WITH
SUXAMETHONIUM AND ROCURONIUM
Dr. Singh Ajeet1 Dr. Bhatia Pradeep Kumar2 Dr. Tulsiani Kishan Lal3
SUMMARY
In a prospective randomized double blind study, tracheal intubating conditions, using 0.6 mgkg-1 rocuronium (Group A) and
1.5 mgkg-1 suxamethonium (Group B) were compared in 40 patients. The time to achieve maximum blockade and the clinical duration
of action were also compared by twitch stimulation using biometer accelograph. All patients were premedicated with
inj. pentazocine, inj. diazepam and inj. atropine and induced with inj. thiopentone. Intubating conditions were assessed and graded
at 60 seconds after injection of relaxant. While the onset time and duration of action were found to be more with rocuronium but the
results showed no significant difference in the intubating conditions achieved in both the groups.

Keywords : Intubation, Monitoring : Neuromuscular, Relaxants: Rocuronium, Suxamethonium.

Introduction
Today, endotracheal intubation is an integral part
of administration of anaesthesia during surgical procedures.
Suxamethonium, a depolarizing muscle relaxant with its
rapid onset and short duration of action is still relaxant of
choice to facilitate tracheal intubation. In addition to
fasciculations, suxamethonium has got many side effects
such as bradycardia and other dysrhythmias, rise in serum
potassium, post operative myalgia, rise in intraocular,
intragastric and intracranial pressure, incidences of
prolonged recovery in patients with pseudo-cholinesterase
deficiency and triggering of malignant hyperthermia.

intubating conditions, onset time and duration of action of

rocuronium and suxamethonium.

Because most of the side effects of suxamethonium

reflect its depolarizing mechanism of action therefore search
for ideal neuromuscular blocking agent focused on nondepolarising type of relaxants which has rapid onset time
and offers good to excellent intubation conditions, as
rapidly as suxamethonium and which lacks the above
mentioned adverse effects. Rocuronium (org 9426), a new
nondepolarising aminosteroidal muscle relaxant
is chemically 2-morpholino, 3-desacetyl, 16-N-allyl
pyrrolidino derivative of vecuronium, differing from it at
3 positions on steroid nucleus. The present study compares

Informed consent was obtained from all the patients

and they were divided into 2 groups. Group A (n=20)
patients receiving suxamethonium, group B (n=20) patients
receiving rocuronium bromide.

1. M.D., Ex. Resident

2. M.D., Assistant Professor
3. M.D., Professor and Head
Dept. of Anaesthesiology and Critical Care
M.G. Hospital, Dr. S.N. Medical College,
Jodhpur 342 003. RAJASTHAN
Correspond to :
Dr. Pradeep Bhatia
A 54/3, Arvind Nagar, Golf Link Raod,
Jodhpur 342 011. RAJASTHAN
(Accepted for publication on 10-01-2004)

Methods
After obtaining institutional ethical committee
clearence the study was carried out on 40 patients in the
department of anaesthesiology, Dr. S.N. Medical College,
Jodhpur. The patients were randomly selected from either
sex and between 16 to 60 years. Patients, excluded from
the study were pregnant females, patients suffering from
neuromuscular disorders, obese patients and patients with
ASA grade III and IV.

To ascertain the ease of intubation, every patient

was examined for mallampati classification (Young and
Samson modification). Patients were given tab. diazepam
5 mg orally previous night and inj. diazepam 5 mg inj.
atropine 0.6 mg inj. pentazocine 30 mg, I.V. 30 min
before starting the surgery. In operation theatre the vital
parameters were recorded, a venous line was secured and
infusion of crystalloid solution was started. Chest leads for
continuous cardiac and respiratory monitoring were
attached, prior to induction and monitoring started. Oxygen
saturation was measured by pulse oximeter using a finger
probe.
Neuromuscular blockade was measured by twitch
height in response to ulnar nerve stimulation. For
monitoring of neuromuscular transmission, surface electrode
of biometer accelograph was fixed on ulnar side of volar
surface of wrist and the transducer fixed on corresponding
thumb.

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INDIAN JOURNAL OF ANAESTHESIA, APRIL 2004

The patients were preoxygenated with 100% O2 for

3 minutes and induced with inj. thiopentone sodium 2.5%
(3-4 mgkg-1) I.V. till eyelash reflex disappeared. For
seeking supramaximal stimulation, single twitch stimulation
at 1 Hz was used. Once the control response was gained,
neuromuscular blocking agent for intubation was injected.
In group A, inj. suxamethonium was given in a dose of
1.5 mgkg-1 and patients in group B received rocuronium
bromide (Esmeron Organon Teknika) 0.6 mgkg-1.
(2 X ED95).
The time duration from injection of relaxant to
maximum depression of twitch height was noted and that
represented the onset time for that relaxant. 60 seconds.
after injection of muscle relaxant, the patients were
intubated orally by a different observer and simultaneously,
intubation conditions were noted and scored according to
a modification of the method described by Krieg et al.1
Score

Jaw relaxation
(Laryngoscopy)

Vocal
cords

Response to
intubation

Poor (impossible)

Closed

Severe coughing
or bucking

Minimal (difficult)

Closed

Mild coughing

Moderate (fair)

Moving

Slight diaphragmatic
movement

Good (easy)

Open

None

Table 1 : Demographic data.

Group - A (n=20)

Group - B (n=20)

Age (yrs.)
Range

18-58

19-60

Mean

35.79

35.26

S.D.

12.81

14.84
p>0.1

Sex
M:F

11:9

11:9

Range

42-68

38-76

Mean

58.95

64.74

S.D.

8.172

12.33

Body weight (kgs)

0.05<p<0.1

As shown in table-2, the time to achive maximum

blockade was 65.89 (4.63) sec, and 87.94 (5.9) sec
respectively in suxamethonium and rocuronium group
(p<0.001). Duration of action of suxamethonium and
recuronium was 318 (60) sec and 1705.8 (132) seconds
respectively (p<0.001).
Table 2 : Onset time and duration of action of
neuromuscular blocking agents (suxamethonium and
rocuronium).
Group - A

Group - B

Onset time (sec)

Total score of intubation conditions

8-9
Excellent
8-7
Good
3-5
Fair
0-2
Poor

Range

58-68

71-90

Mean

65.89

87.94

S.D.

4.63

5.90

Range

198-474

1482-1920

After inflating the cuff of endotracheal tube, it was

connected to bains circuit and controlled ventilation was
started. Time for reappearance of twitch height upto 25%
of initial response, from the injection of relaxant was
noted and it represented the duration of action of relaxant.

Mean

318.0

1705.8

S.D.

60.0

132.0

Patients were maintained with O2 + N2O Halothane

and atracurium and at the end of surgery, muscle paralysis
was reversed with inj. neostigmine and inj. atropine. At
the end of study, data collected were statistically compared
using students t test and chi-square test.
Observation and results
Patients in both the groups had comparable age
and sex ratio statistics (table-1). Datas comparing the body
weight in the two groups have statiscally significant
p value but none of the patients had a body weight, more
than 20% above the expected weight.

P<0.001
Duration of action (sec)

P<0.001

Total intubation score achieved at 60 secs was 7.37

(2.07) and 7.79 (1.27) in suxamethonium and recuronium
groups respectively (table-3). The statistical evaluation was
insignificant (p>0.1). In either group, no significant
complications occurred at the time of intubation, relating
to drug administration (table-4).
Table 3 : Total intubating score achieved after injection
of neuromuscular blocking agent
Group - A

Group - B

Range

1-9

4-9

Mean

7.368

7.789

S.D.

2.068

1.274
p>0.1

SINGH, BHATIA, TULSIANI : SUXAMETHONIUM ROCURONIUM FOR INTUBATION

with these laryngeal movements are two drawbacks that

cannot make the low dose rocuronium as a desirable
technique for rapid sequence intubation.

Table 4 : Complications at the time of laryngoscopy.

Group - A

Complications

131

Group - B

No.

No.

Bradycardia

10

Tachycardia

10

50

12

60

Laryngospasm

V.P.B.S.

Others

Nil

30

30

Discussion
Traditionally suxamethonium has been the
neuromuscular blocking drug of choice for rapid sequence
induction and minimizing the chances of regurgitation and
aspiration. The use of suxamethonium can however be
associated with many side effects. Hence, a non depolarising
neuromuscular blocker with a rapid onset of action,
preferably of a shorter duration is desirable.
Initial studies in animals showed that rocuronium,
being a low potency compound, was associated with a
rapid onset of effect when compared with other compounds
such as pancuronium and vecuronium.2,3 This has since
been demonstrated in many clinical studies that the onset
of action of rocuronium is significantly faster when
compared to equipotent doses of atracurium and vecuronium,
although slightly slower than that of suxamethonium.4 Thats
why rocuronium was selected for the purpose of rapid
sequence induction, in the present study.
Initial studies in animals demonstrated rocuronium
to be 10-20% as potent as vecuronium and ED90 doses were
found to be from 0.26 mgkg-1 to 0.30 mgkg-1.5 Intubating
dose of rocuronium used in this study is 600 gmkg-1
(i.e. 2xED90).
Previous studies have shown that intubating
conditions at 60 secs are generally excellent or good with
a dose of 0.6 mgkg-1 and are 95% clinically acceptable at
45 seconds.6,7,8 Although Prien and Zann9 have used
rocuronium 0.3 mgkg -1 (1xED 90) under alfentanil/
propofol and fentanly/thiopentone/enflurane anaesthesia
but they required a deeper plane of anaesthesia as a
prerequisite for this low dose relaxant technique to facilitate
tracheal intubation. Onset time was found to be 657 secs
and 6912 secs in propofol/alfentanil and fentanyl/
thiopentone/enflurane groups respectively. The intubating
conditions were good or excellent in majority of cases but
slight muscular reactions to tube placement occurred
frequently. The extra anaesthetic depth needed, coupled

Use of higher dose of rocuronium to improve

intubating conditions during rapid sequence intubation
and to cut short the onset time below 60 secs has been
advocated by various workers10,11,12,13 but doses larger then
0.6 mgkg-1 would be associated with a long duration of
action which may be inappropriate in many situations.
In most studies, an appropriate timing of tracheal
intubation has been determined by 3 ways.
1.

Clinical judgement

2.

Neuromuscular monitoring either by twitch

suppression (maximum blockade) or TOF ratio

3.

Predetermined time after the administration of

neuromuscular blocking agent e.g. 60 secs, 90 secs,
120 secs etc.

The technique using judgement alone is relatively

insensitive. Onset time differs with different nerve
stimulation rates used. Cooper et al14 found onset time for
rocuronium 0.6 mgkg-1 as 90 sec by 0.1 Hz stimulation
and 58 sec using TOF stimulation. Alternatively, a
predetermined time for tracheal intubation can be used.
In a trial by Mc Court et al6, tracheal intubating
conditions during rapid induction of anaesthesia using
0.6 mgkg-1 rocuronium or 1 mgkg-1 suxamethonium, were
studied and conditions were scored at 60 secs. Intubating
conditions were found to be equally acceptable in both
groups. In study by Awarez-Gomez et al,8 intubating
conditions of standard doses of vecuronium and rocuronium
were compared at 60 secs or 90 secs. At 60 sec after
administration of rocuronium, excellent conditions were
present in all patients. In the present study, intubation was
attempted at 60 secs of the injection of muscle reaxant for
rapid sequence inductions as proposed by other workers.6,7
Land and Stovner15 were probably the first to introduce
a rating scale as a tool for the assessment of intubating
conditions in which the three main criteria: Jaw relaxation,
vocal cords (position and motility) and reaction to intubation
were rated by descriptive scores such as excellent,
satisfactory or fair but this allows a large room for
subjective interpretation of data. These three main criteria15
remained the basis of numerous subsequent modification
of their rating scale by others. One of the most frequently
used modifications, still in use today, was introduced by
Krieg et al1 in 1980 in which a numeric value is assigned
to signify quality of intubating conditions. Cooper modification
of this rating scale was used in the present study.

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INDIAN JOURNAL OF ANAESTHESIA, APRIL 2004

Results of present study, regarding intubating

conditions are summarized in table-3 showing total
intubating score achived and the frequency distribution of
excellent, good, fair and poor conditions achieved after
the administration of either rocuronium 0.6 mgkg-1 or
suxamethonium 1.5 mgkg-1 following routine induction for
elective operations. Taking together those patients with
excellent and good intubating condition, pooled data of
our study shows that there is not an appreciable difference
in the frequency distribution of clinically acceptable
intubating conditions, after the administration of
suxamethonium and rocuronium. The clinically acceptable
conditions are present in 85% and 95% in the two groups
receiving suxamethonium and rocuronium respectively.
Similar results were found in the studies carried out by
other workers and thus our results are in agreement with
the findings of other authors.
The comparative datas amongst the results obtained
by other workers and of our series are shown in the
following table.
Intubating Conditions
(In %)
Clinically acceptable

Clinically
non acceptable

Authors

Year

Puhringer et al7

1992

Roc.
Suxa

100
100

0
0

Cooper et al14

1993

Roc.
Suxa

95
100

5
0

Pollart et al16

1995

Roc.

80

20

Wierda et al17

1995

Roc.

100

Dubois et al18

1995

Roc.
Sux.

100
92.5

0
7.5

Our Series

Roc = Rocuronium

Roc.
95
(0.6 mgkg-1)
Sux.
85

5
15

Sux = Suxamethonium

To avoid further confusion and describing the

intubating conditions under 4 categories (i.e. excellent,
good, fair and poor), we have also compared the individual
parameters i.e. jaw relaxation, condition of vocal cords
and response to intubation by quantative score rated on a
0 to 3 scale but no significant difference has been observed
between the quantative value of each component of
intubating score.
The intubating conditions after 0.9 mgkg -1
rocuronium appeared to be practically identical to those
observed after 1 mgkg-1 suxamethonium i.e. 96% v/s 97%
clinically acceptable intubating conditions.6 However poor

intubating conditions also occurred in 4 % and 3% of

patients after rocuronium and suxamethonium, respectively.
Sparr19 and Crul et al,13 investigated rocuroniums
potential in emergency intubating conditions using it strictly
according to the scenario for rapid sequence induction
in unpremedicated but still elective cases. In those
studies, the frequency distribution of excellent, good
or clinically acceptable intubating conditions, 60 secs after
600 mgmkg-1 or 900 mgmkg-1 rocuronium were compared
with those observed after 1 mgkg-1 suxamethonium. The
results indicate that intubating conditions were more
favourable at 60 sec after administration of rocuronium in
the dose of 900 mgmkg-1 compared to dose of 600 mgmkg-1
in unpremedicated patients. In premedicated patients, who
received 600 mgmkg-1 rocuronium 5-10 min after induction
with I.V. anaesthetic, intubating conditions were comparable
with those obtained with a dose of 900 mgmkg-1 rocuronium.
In the present study, patients were premedicated with 30
mg pentazocine, 5 mg diazepam and 0.6 mg atropine and
rocuronium was given 5 min, after receiving the I.V.
anaesthetic, hence our results in relation to the frequency
of distribution of intubating conditions are comparable with
suxamethonium, even at 60 secs.
Similar results about onset time and intubating
conditions were found in other studies of Dubois et al,18
Huizinga et al.20 In these studies no difference was observed
in the frequency distribution of clinically acceptable
intubating conditions at 60 secs and 90 secs after the
administration of suxamethonium or rocuronium.
Wierda et al17 compared the onset time of
rocuronium 250 gkg-1 and found it to be 220 sec and 190
secs respectively. Puhringer et al7 and Dubois et al18 found
the onset times as 72 sec and 48 sec and 130 secs and
74 secs respectively for rocuronium 600 gmkg-1 and
suxamethonium 1000 gmkg-1 respectively. The time to
achieve maximum block of approximately 88 secs with
rocuronium was significantly longer than a time of about
65 secs with suxamethonium in the present study and is in
accordance with the finding of other authors.
Magorian et al21 compared the duration of action
of rocuronium in doses of 0.6 mgkg-1, 0.9 mgkg-1
and 1.2. mgkg-1 with that of suxamethonium in the dose
of 1 mgkg-1. They were found to be 2220 sec, 3180 secs,
4380 sec and 540 secs respectively. In our study duration
of action of rocuronium 0.6 mgmkg-1 and suxamethonium
1.5 mgmkg-1 are 1704 secs and 318 sec respectively and
in accordance with prior studies.21,22,23
No significant side effects were observed during
laryngoscopy and intubation in both the groups however

SINGH, BHATIA, TULSIANI : SUXAMETHONIUM ROCURONIUM FOR INTUBATION

non significant complications like arrythmias and

laryngospasm did appear in 70% patients of each group
and were likely to be due to adrenergic responses during
laryngoscopy and intubation, rather than to the effect of
drugs.
Conclusion
Rocuronium in the dose of 0.6 mgkg-1 can be used
as an alternative to suxamethonium as a part of rapid
sequence induction, provided there is no anticipated
difficulty in intubation.

133

11. De Mey J C, Van Overschelde H, De Laat M et al. The

influence of dose on the profile of onset of neuromuscular
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rocuronium, an evaluation in perspective. Eur J Anaesth 1995;
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13. Crul J F, Vanbelleghem V, Buyse L et al. Rocuronium with
alfantenil and propofol allows intubation within 45 secs. Eur
J Anaesth 1995; 12 (1): 111-12.

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