title: Pretreatment with remifentanil, fentanyl, or lidocaine to prevent withdrawal after rocuronium using venous occlusion technique in children and adolescents: a prospective randomized placebo-controlled double-blind study.
abstract: BACKGROUND
  Pain caused by intravenous injection of the muscle relaxant rocuronium bromide is common in children and adolescents. The cause of this unwanted effect is still unclear, and different pretreatment drugs have been administered in attempts to alleviate this side effect, with varying degrees of success.
  
  
  OBJECTIVE
  This study used a 60-s venous occlusion technique to evaluate the effectiveness of pretreatment with lidocaine, fentanyl, or remifentanil in preventing pain-induced withdrawal caused by intravenous injection of rocuronium bromide during the induction of general anesthesia.
  
  
  METHODS
  One hundred and one child and adolescent patients, ASA Ι-II, requiring various surgical procedures under general anesthesia with muscle relaxation and mechanical ventilation, were enrolled. Patients were allocated randomly using computer-generated randomization into one of four pretreatment groups: a remifentanil group (1 µg/kg, n = 25), fentanyl group (1 µg/kg, n = 26), lidocaine 1% group (0.5 mg/kg, n = 25), and normal saline group (n = 25). Drug doses were prepared in normal saline to a total volume of 5 ml. Venous occlusion was applied 10 cm above the venous access site. Pretreatment drugs were injected and retained for 60 s at the site of injection by an anesthetist blinded to group allocation. After release of the tourniquet, rocuronium (0.5 mg/kg) was then injected over 5 s, and withdrawal was recorded by another anesthetist blinded to group allocation. Descriptive statistics, analysis of variance, and a chi-squared test were used to statistically analyze the results as appropriate.
  
  
  RESULTS
  Compared to normal saline, all other pretreatment groups scored a significantly lower mean of withdrawal response (P < 0.001). Lidocaine was superior to both remifentanil (P < 0.05) and fentanyl (P < 0.05) in suppressing the withdrawal response to rocuronium injection. Remifentanil was superior to fentanyl in suppressing the withdrawal response caused by rocuronium injection (P < 0.001).
  
  
  CONCLUSIONS
  Using a venous occlusion technique for 60 s, lidocaine was found to be most effective in preventing the withdrawal effect caused by rocuronium injection in children and adolescents. Lidocaine was superior to remifentanil which, in turn, was more effective than fentanyl.
authors.affiliation: Department of Anesthesia and ICU, Faculty of Medicine, University of Jordan and Jordan University Hospital, Queen Rania Street, Amman, 11942, Jordan, s.halaweh@ju.edu.jo.
authors.forename: S A
authors.initials: SA
authors.lastname: Abu-Halaweh
authors.forename: A K
authors.initials: AK
authors.lastname: Aloweidi
authors.forename: I Y
authors.initials: IY
authors.lastname: Qudaisat
authors.forename: M O
authors.initials: MO
authors.lastname: Al-Hussami
authors.forename: K R
authors.initials: KR
authors.lastname: Al Zaben
authors.forename: A S
authors.initials: AS
authors.lastname: Abu-Halaweh
mesh_terms: D000293:Adolescent; D000732:Androstanols / Q000008:administration & dosage*; D000768:Anesthesia, General / Q000379:methods; D002648:Child; D002675:Child, Preschool; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use*; D006801:Humans; D007275:Injections, Intravenous; D008012:Lidocaine / Q000627:therapeutic use*; D008297:Male; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage; D010146:Pain / Q000517:prevention & control; D010880:Piperidines / Q000627:therapeutic use*; D011446:Prospective Studies; D000077208:Remifentanil; D000077123:Rocuronium
chemical_list: D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D010880:Piperidines; D008012:Lidocaine; D000077208:Remifentanil; D005283:Fentanyl; D000077123:Rocuronium