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Innovative Medicines & Omics Rocuronium versus succinylcholine in general anesthesia

individuals. By inserting the tube into the trachea, it Due to its depolarizing mechanism of action, it is not the best
facilitates the administration of breathing agents, the muscle relaxant and can have dangerous side effects such as
removal of carbon dioxide, and the delivery of oxygen. masseter spasm, increased intragastric pressure, increased
This procedure ensures adequate ventilation, secures the intraocular pressure, muscle fasciculation, myalgia, and
patient’s airway, and minimizes the risk of aspiration of hyperkalemia. 14,15 Consequently, the administration of
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stomach contents swiftly and effectively. During this succinylcholine is not advised in a number of circumstances,
operation, weight-based induction drugs are administered such as burns, some neurological illnesses, and patients with
intravenously, followed by a muscle relaxant to achieve a deficiency of cholinesterase. 16
unconsciousness and muscle paralysis in less than 60 s. 3 The search for a substitute for succinylcholine, offering
Muscle relaxants are essential for achieving the jaw superior intubating conditions with a similar onset as
relaxation necessary for successful tracheal intubation. The depolarizing muscle relaxants but without its adverse
development and understanding of muscle relaxants have effects, led to the introduction of several medications
evolved significantly over the centuries, beginning with such as atracurium, mivacurium, vecuronium, and
ancient observations and leading to modern pharmaceutical pancuronium. While these medications did not provide
advancements. An ancient scientist, Homer, mentioned an immediate onset of action, they lacked the drawbacks
the “arrow poison,” which was also called “curare,” in his associated with succinylcholine. In 1994, rocuronium
writings. Another scientist, Bernard (1813 – 1878), later bromide, a nondepolarizing amino-steroidal muscle
4
performed experiments demonstrating curare’s action at relaxant, was introduced clinically. Unlike succinylcholine,
the neuromuscular junction. In 1814, Boride and Waterton rocuronium had no adverse effects. The neuromuscular
5
demonstrated that animals could survive curare injection inhibiting activity of rocuronium bromide acts quickly
with continued ventilation. In 1954, Griffith introduced and lasts for an intermediate amount of time. 17,18 Due to
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the first muscle relaxant, d-tubocurarine, describing it as a its quick onset and intermediate duration, rocuronium has
reliable medication for skeletal muscle relaxation. However, been shown to be a safe substitute for succinylcholine in
d-tubocurarine had drawbacks, including delayed onset of endotracheal intubation. It is supposed to induce excellent
action, ganglion block, muscarinic block, and side effects intubating circumstances in 60 s when administered at
such as tachycardia and hypotension, despite producing ED95 dosage but with a prolonged duration of action. At a
jaw relaxation. dose of 1.2 mg/kg, rocuronium had an onset period similar
to that of succinylcholine. 19,20
In 1954, Beecher and Todd found that patients who
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received d-tubocurarine had a higher death rate than those Rocuronium acts by binding to nicotinic acetylcholine
who did not. Gallamine tri-ethiodide, another muscle receptors without activating these ion receptor channels.
relaxant, was then introduced in 1947, but it also had This action prevents acetylcholine from binding to its
undesirable effects like d-tubocurarine. 9-11 In a recent article, receptors, thereby preventing end plate potential and
Elisha et al. discussed the case study of Bovet, who, in 1952, muscle contraction. Mivacurium non-depolarizing
finally introduced a synthetic depolarizing muscle relaxant, agents are not significantly metabolized, either by
succinylcholine chloride, with quick onset and an ultra-short acetylcholinesterase or pseudocholinesterase. However,
half-life. It brought about a revolution in anesthesia, and it reversal of their blockade depends on metabolism,
12
remains the preferred substance to aid tracheal intubation redistribution, and excretion of the relaxants by the body
to date. Its fast action and quick recovery make it a favored or by administration of the reversal agents (cholinesterase
drug for planned as well as emergency surgeries. 13 inhibitors). Rocuronium has no contraindications, like a
depolarizing muscle relaxant; however, hypersensitivity to
Succinylcholine, which resembles acetylcholine, is the agent has been reported. In addition, rocuronium has
hence considered an agonist. Due to its close resemblance, been suggested as a substitute for succinylcholine because
depolarizing muscle relaxants (DMR) bind with the of its pharmacokinetic properties. 21,22 This study compares
acetylcholine receptors, generating the muscle action the effectiveness of rocuronium with succinylcholine in
potential. The depolarizing relaxants have biphasic action, terms of hemodynamic parameters, ease of intubation, and
with an initial contraction accompanied by a period of time to action during general anesthesia.
relaxation lasting from minutes to hours. Their action lasts
until the depolarizing agents are cleared by plasma since 2. Methods
they are not subject to hydrolysis by acetylcholinesterase.
The action of DMR is terminated when it diffuses away 2.1. Study design
from the neuromuscular (NM) junction and is metabolized The study was conducted at Maharishi Markandeshwar
by the pseudocholinesterase enzyme synthesized by the liver. Multispecialty Hospital in Mullana, Ambala, India. This

Volume 1 Issue 1 (2024) 108 doi: 10.36922/imo.3196