EFFECT OF NITROUS OXIDE

AND LIGNOCAINE IN
REDUCING PAIN OF
ROCURONIUM INJECTION IN
ADULT PATIENTS
PRESENTER:
Dr. NIRMEEN FATIMA
PGY2, RIMS, IMPHAL

INTRODUCTION
Rocuronium provides intubating conditions almost similar to those seen
with succinylcholine within 4590 seconds with dose 0.6- 1.2mg/kg.
But it causes pain on iv injection with an incidence of 50-80%.
Various methods were used to alleviate the pain caused by rocuronium.
These include administration of :Lidocaine a local anaesthetic of the amide type
Nitrous oxide a centrally acting sedative and analgesic agent

MATERIALS AND METHODS

80 patients of ASA grade I & II, aged 18-65 years undergoing
elective surgery under general anaesthesia were randomly allotted into two
groups (n=40).
Group O : received 100% oxygen and 2ml of 2% lidocaine
Group N : received 50% nitrous oxide oxygen mixture and 2ml of 2%
lidocaine.

MATERIALS AND METHODS

Patients in Group O (n=40) were preoxygenated with 100% oxygen.
Patients in Group N (n=40) were preoxygenated with 50% nitrous oxide mixture in
oxygen.
Once the patient has inhaled 50% nitrous oxide oxygen mixture (Group N) or
pure oxygen (Group O) for two minutes,
the forearm was occluded with a tourniquet upto 70 mm Hg to occlude the vein
After 1 min, the occlusion was released and a subparalysing dose of rocuronium
0.06mg/kg(1mg/ml) diluted with 0.9% normal saline was administered.
The patients were observed and asked immediately if they had pain in the arm,
and the response were assessed according to the Mc Crirrick and Hunter scale.

MATERIALS AND METHODS

Assessment of pain during injection of rocuronium
according to Mc Crirrick and Hunter scale.

Degree of pain
None ( 0 )
Mild ( 1 )

Moderate ( 2 )

Response
No response to questioning
Pain in response to questioning only, without any behavioral signs.
Pain reported in response to questioning and accompanied by behavioral
signs , or pain reported without any questioning.
Strong vocal response or response accompanied by facial

Severe ( 3)

withdrawal or tears.

grimacing, arm

MATERIALS AND METHODS

Anaesthesia was then induced with 2.5% thiopentone 5mg/kg

i.v. When the eyelash reflex was abolished, an intubating dose
of rocuronium 0.6 mg/kg was injected over 10 seconds and
withdrawal movements, if any, was recorded.
The results were tabulated and statistically analysed.

RESULTS AND OBSERVATIONS

Table 1. Demographic profile among two groups.
Patient
Parameter

Group O (n=40)

Group N (n=40)

Statistical test

Age (meanSD)
in yrs.

36.78 12.972

35.12 11.371

Student T test t = 78
0.605

Weight
(meanSD) in kg

54.70 9.196

Sex

Male =
15(37.5%)

Male = 10(25%)

Female=
25(62.5%)

Female =
30(75%)

51.72 7.432

Degree of
Freedom

Student T test t = 78
1.591
Chi square test
(X2)=1.455

P value and
inference
0.547
(NS)
0.116
(NS)
0.228
(NS)

RESULTS AND OBSERVATIONS

Fig.1.Graphical representation of distribution of pain among two groups

RESULTS AND OBSERVATIONS

Table 3. Statistical test for pain among two groups
Pain

Group

Total

Chi square (x2)

P value

6.275

0.012(S)

Group O

Group N

No pain

30 (75%)

38 (95%)

68

Mild pain

10 (25%)

2 (5%)

12

Total

40

40

80

RESULTS AND OBSERVATIONS

Table 4. Distribution of withdrawal movements and statistical test among two group S.
Group

Withdrawal
No
Withdrawal

Total
Wrist
Withdrawal

Arm Withdrawal Generalized

movement

Group O

31(77.5%)

5(12.5%)

4(10%)

40

Group N

38(95%)

2(5%)

40

RESULTS AND OBSERVATIONS

Fig.2. Graphical representation of distribution of withdrawal movements among two groups

RESULTS AND OBSERVATIONS

Fig.3a.Graphical representation of
distribution of pain among both sexes in
group O

Fig. 3b. Graphical representation of

distribution of pain among both sexes in
group N.

DISCUSSION
o In this study, incidence of mild pain in group O is 25% and 5% in group N
which is similar to the study conducted by Sharma et al where they
reported 22.5% in group O and 2.5% in group N which might be because of
nitrous oxide and lignocaine which has additive and different analgesic
modalities.
o The exact mechanism of pain has not been ascertained.
o Various theories proposed :o Peripheral veins are innervated with polymodal C- nociceptors which
mediate pain response and are activated by the osmolality or pH of the
rocuronium solution.
o Release of endogenous mediators such as histamine, kinin cascade and
other substances.

DISCUSSION
In this study 22.5% patients in group O and 5% of patients in group N had
withdrawal movements to the intubating dose of rocuronium. Sharma et al
also demonstrated withdrawal movements in 15% of patients in group O2
and 45% of patients in group N2O which is higher than our incidence. This is
because we used two drugs with different analgesic modalities whereas
Sharma et a used only nitrous oxide.
Kwak HJ et al demonstrated that combination of nitrous oxide and
lignocaine pretreatment significantly reduced withdrawal movements
(3.1%) in paediatric patients compared to lignocaine alone (25.8%) which is
comparable to our study where 5% had withdrawal movements in group N
and 22.5% in group O.

DISCUSSION

The central antinociceptive effects of N2O may prevent the pain from the
local irritant effect of rocuronium.
N2O has been reported to affect a variety of different receptors including
opioid, noradrenergic, acetylcholine, GABA and NMDA receptors.
The effect of lignocaine was more likely the result of local anaesthetic
effect at the site of injection.
Mencke T et al demonstrated that women experienced more pain on
injection of rocuronium compared to males (45% Vs 20%) and concluded
that some pretreatment is necessary especially in women which was
similar tour findings in our study.

CONCLUSION
From this study, the following conclusions can be
made :
Nitrous oxide and Lignocaine can be used for pretreatment
to prevent rocuronium injection pain.
Pretreatment of two different analgesic modalities, nitrous
oxide and lignocaine better prevents pain and withdrawal
movements associated with rocuronium injection than when
used alone.

REFERANCES
1. Naguib M, Lien CA. Pharmacology of muscle relaxants and their antagonists. In:Miller RD editor. Millers anesthesia 7th ed. Vol-1 Philadephia,USA:
Churchill livingstone elsevier;2010.p.859-67.
2.Huizinga AC, Vandenbrom RH, Wierda JM, Hommes FD, Hennis PJ. Intubating conditions and onset of neuromuscular block of rocuronium
9426); a comparison with suxamethonium. Acta Anaesthesiol Scand. 1992 Jul;36(5):463-8.

(Org

3. Puhringer FK, Khuenl-Brady KS, Koller J, Mitterschiffthaler G. Evaluation of the Endotracheal Intubating conditions of rocuronium (org 9426) and
succinylcholine in outpatient surgery. Anesth Analg 1992;75:37-40.
4. Moorthy SS, Dierdorf SF. Pain on injection of Rocuronium bromide. Anesth Analg 1995;80:1067.
5.Steegers MAH, Robertson EN. Pain on injection of Rocuronium bromide. Anesth Analg 1996;83:203.
6.Borgeat A, Kwiatkowski D. Spontaneous movements associated with rocuronium : is pain on injection the cause?. Br J Anaesth 1997;79:382-3.
7. Blunk JA, Seifert F, Schmelz M, Reeh PW, Koppert W.Injection pain of rocuronium and vecuronium is evoked by direct activation of nociceptive nerve
endings. Eur J Anaesth 2003 Mar;20(3):245-3.
8. Klement W, Arndt JO. Pain on i.v. injection of some anesthetic agents is evoked by the unphysiological osmolality or pH of their formulations. Br J
Anaesth 1991;66:1895.
9. Mencke T, Schreiber JU, Knoll H, Stracke C, Kleinschmidt S,
Rensing H et al. Women report more pain on injection of a recurarization dose of
rocuronium: A randomized, prospective, placebo-controlled trial. Acta Anaesthesiol Scand. 2004;8(10):1245-8.
10. Cheong KF, Wong WH. Pain on injection of Rocuronium : Influence of two doses of lidocaine pretreatment. Br J Anaesth 2000;84(1):106-7.