Superficial venous thrombophlebitis caused by rocuronium

Abstract

Pain is one of the major disadvantages of rocuronium, which is used during induction of anesthesia. Even at subparalyzing doses, 50-100% of patients complain of intense pain. Sudden flexion and withdrawal movement in the wrist or arm have been reported following rocuronium use in many papers. No information about risk factors leading to this withdrawal movement or pain on injection is available and whether this reaction leads to erythema or to venous sequelae (i.e. thrombosis and thrombophlebitis) has not been systematically investigated. However, in both of our cases, visible reactions occurred and both patients were diagnosed with venous superficial thrombophlebitis. Therefore, we believe that rocuronium-related pain may, in part, be because of direct venous injury.

"Getting Under Your Skin”: First Reported Case of Transient Reactive Phlebitis Involving Vancomycin Infusion Therapy

“…There have been several other reports of a TRP occurring after initiation of a medication drip, though none have reported vancomycin as a causative agent. Previously reported medications include morphine, pethidine, rocuronium, propofol, ciprofloxacin, diphenhydramine, and eptifibatide [5][6][7][8][9][10][11][12][13]. TRP is isolated to the recipient extremity and occurs downstream to the infusing intravenous cannula [5,[10][11][12][13].…”

“…TRP is isolated to the recipient extremity and occurs downstream to the infusing intravenous cannula [5,[10][11][12][13]. Symptoms include a vermiform rash comprising the region of phlebitis and may be associated with mild pain [5][6][7][8]10,13]. Pruritis, urticaria, and febrile episodes have not been reported.…”

“…These include directly mediated histamine release, activation of the kallikrein-kinin system with bradykinin generation, direct activation of c-nociceptors, and the release of local mediators. [8,[10][11][12][13]. A histamine-mediation reaction appears less likely to be the cause of TRP due to the absence of typical histamine-associated symptoms such as pruritis or urticaria, as well as the commonly utilized anti-histamine medication diphenhydramine having been reported in TRP [13].…”

“…Pruritis, urticaria, and febrile episodes have not been reported. As the namesake may suggest, symptoms are transient and completely resolve with cessation of the causative medication [ 8 , 10 , 13 ]. Symptoms resolve within minutes to hours of cessation.…”

Transient phlebitis: an unusual effect of intravenous diphenhydramine

“…5 Transient phlebitis has been described after intravenous administration of several drugs (meperidine, morphine, rocuronium, propofol, eptifibatide and ciprofloxacin). [5][6][7][8][9][10] Hypothesised mechanisms associated with this phenomenon include tissue damage, local mediator release, histamine release, direct activation of C-nociceptors and activation of kallikrein-kinin system with bradykinin generation. 5 6 Diphenhydramine is an antihistamine (H-1 receptor antagonist) with anticholinergic and sedative effects.…”