Comparison of different doses of atracurium for quality of muscle relaxation during modified rapid sequence induction in emergency laparotomy: A prospective randomised double blind study

Abstract

Background and Aims: In emergency and non-fasting patients posted for laparotomy under general anaesthesia, rapid sequence induction (RSI) is preferred, and it is routinely done by using succinylcholine or rocuronium. Using higher doses of atracurium [i.e. 3-4 times the 95% effective dose (ED95)] can provide acceptable intubating conditions in a short time. The primary objective of our study was to compare two different higher doses of atracurium to achieve good intubating conditions for RSI without using a priming dose. The secondary objective was to compare the duration of muscle relaxation using neuromuscular monitoring and haemodynamic responses during and after intubation. Methods: Sixty patients were enroled and randomly assigned into two groups:-, group A1 (atracurium: 0.75 mg/kg) and group A2 (atracurium: 1 mg/kg). After premedication, anaesthesia was induced with propofol 2-2.5 mg/kg and atracurium injections, followed by intubation within a minute by trained anaesthesiologists. Meanwhile, intubating conditions, neuromuscular monitoring using train-of-four (TOF) measurements and post-tetanic-count and haemodynamics were recorded. Data were analysed statistically by using the Chi-square test and Student’s t-test. Results: Excellent intubation conditions (without coughing or bucking) were attained in 56.7% of cases in group A2 and in 13.3% in group A1 ( P < 0.001). Duration of muscle relaxation, measured by time until TOF is two, was more prolonged in group A2 (79.2 ± 9.2 min) than in group A1 (60.13 ± 8.7 min, P < 0.001). Conclusion: Acceptable intubating conditions can be achieved in a minute with the use of a high dose of atracurium (1 mg/kg) during RSI. Hence, atracurium can be used as an alternative drug for RSI.

Risk of bias in published randomised controlled trials

“…The demographic data of the 27 included articles are given in Table 1 . [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] Overall, 13 out of 27 were judged as having a low risk of bias. [ 5 6 9 10 12 15 16 20 21 22 23 24 27 ] In contrast, 6 out of 27 had a high risk of bias,[ 4 13 14 25 28 30 ] and 8 out of 27 had some concerns regarding biases.…”

“…[ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] Overall, 13 out of 27 were judged as having a low risk of bias. [ 5 6 9 10 12 15 16 20 21 22 23 24 27 ] In contrast, 6 out of 27 had a high risk of bias,[ 4 13 14 25 28 30 ] and 8 out of 27 had some concerns regarding biases. [ 7 8 11 17 18 19 26 29 ] In domain 1, that is, bias arising from the randomisation process, 3 out of 27 had some concerns regarding biases.…”

“…[ 25 28 30 ] Rest of the trials were judged as having a low risk of bias. [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 29 ] In domain 2, that is, bias due to deviations from intended interventions, 7 out of 27 had some concerns regarding biases. [ 5 8 11 13 14 18 29 ] and the remaining trials were judged as having a low risk of bias.…”

“…[ 5 8 11 13 14 18 29 ] and the remaining trials were judged as having a low risk of bias. [ 4 6 7 9 10 12 15 16 17 19 20 21 22 23 24 25 26 27 28 30 ] In domain 3, that is, bias due to missing outcome data, all the were considered as having a low risk of bias. [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] In domain 4, that is, bias in the measurement of the outcome, 2 out of 27 had a high risk of bias,[ 5 28 ] 6 out of 27 had some concerns regarding the risk of bias,[ 7 17 19 25 26 30 ] and the remaining trials were judged as having a low risk of bias.…”

“…[ 4 6 7 9 10 12 15 16 17 19 20 21 22 23 24 25 26 27 28 30 ] In domain 3, that is, bias due to missing outcome data, all the were considered as having a low risk of bias. [ 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ] In domain 4, that is, bias in the measurement of the outcome, 2 out of 27 had a high risk of bias,[ 5 28 ] 6 out of 27 had some concerns regarding the risk of bias,[ 7 17 19 25 26 30 ] and the remaining trials were judged as having a low risk of bias. [ 6 8 9 10 11 12 13 14 15 16 18 20 21 22 23 24 27 29 ] In domain 5, that is, bias in the selection of the reported result, 3 out of 27 had some concerns regarding biases, and the remaining trials were judged as having a low risk of bias [ Figure 1 ].…”