The Effect of Rocuronium on the Response of Composite Variability Index (CVI) to Laryngoscopy

The Composite Variability Index (CVI, Aspect Medical System, Norwood MA) is a new parameter
(measurement) that provides information about the amount of painful stimulation during
surgery. It is part of the Bispectral Index (BIS, Aspect Medical Systems, Norwood MA), a
well-established and widely used parameter that shows how awake/asleep patients are during
general anesthesia and may indicate a need for more medication. The CVI component provides
specific information about whether the patient needs pain medication (called opioids) and
not just medication that makes you sleep (called hypnotics). The CVI is made of the BIS
number and a measure of facial muscle movement (EMG). Both these components increase with
painful stimulation, and decrease when pain medication is given.

Neuromuscular blocking drugs (NMD) are paralyzing medications that are often used during
surgery to relax the body and make it easier for the surgeon to perform the surgery and the
anesthesiologist to insert the breathing tube (called intubation). Facial muscles are
resistant to NMD effects, but they might affect the EMG reading, making the CVI less useful
when a patient needs NMD. The M-entropy monitor (GE Healthcare, Helsinki, Finland) is
similar to the BIS monitor with CVI and is affected by large NMD doses. The purpose of this
study is to examine the effect of rocuronium, a NMD, on the response of CVI and M-entropy to
laryngoscopy under anesthesia. A laryngoscopy is the standard way of examining and opening
the patient's airway before inserting the breathing tube. It is fairly stimulating so
anesthesiologists sometimes, but not always, administer a NMD (in varying doses) before
performing the laryngoscopy in standard care.

Eighty subjects will be recruited from those scheduled for surgery requiring general
anesthesia at St Vincent's Hospital. Subjects must have ASA status of 1 or 2 (be fairly
healthy), a BMI between 18-35 (reasonably healthy weight), and be between the ages of 18 and
75. They will not be eligible if they take certain medications or are expected to have a
difficult intubation.

Subjects will be randomized (assigned by chance) to one of four rocuronium doses of 0, 0.2,
0.4, or 0.6 mg kg-1. All are acceptable clinical doses for performing a laryngoscopy. In the
operating room, routine monitors will be applied, including a BIS sensor and an M-Entropy
sensor. Subjects will receive 0.025 mg kg-1 midazolam (a standard pre-op dose) and will be
put to sleep. Once asleep, the subject will receive a rocuronium dose, followed by
laryngoscopy three minutes later. The anesthesiologist performing the laryngoscopy will not
know what dose of rocuronium the subject received. CVI, entropy, amount of muscle
relaxation, and vital signs will be monitored and recorded throughout the procedure.

Subjects will receive propofol and remifentanil infusions during the case. These are
commonly used medications for anesthesia. The subjects will also be randomized (assigned by
chance) to two additional groups. One group will receive a remifentanil infusion of 2ng ml-1
and the other group will receive a 8ng ml-1 remifentanil infusion. Both doses are acceptable
and often used during standard clinical care. The propofol infusion will be adjusted to keep
the BIS number between 45-60. The anesthesiologist will not be able to see the CVI value.
The times of certain intraoperative events, such as intubation and incision, will be
recorded. All subjects will receive a morphine bolus (0.10-0.15 mg/kg) towards the end to
reduce post-operative pain, as per standard clinical care. As the subject wakes up, time to
eye opening and orientation will be recorded. The subject will rate their pain on a
numerical pain scale and the quality of emergence will be assessed.

Upon arrival in the PACU, subjects will be asked to rate their pain again using the same
pain scale. The pain score will be evaluated every 10 minutes for half an hour, then every
hour until they are discharged from PACU. The total dose of pain medications administered in
PACU will be recorded. Upon PACU discharge, subjects will be asked to rate their overall
experience with anesthesia. Demographic data will also be collected. All data will be kept
in locked file cabinets and study results will be shared with research personnel at Aspect
Medical Systems.

Inclusion Criteria:

- Presence of ASA physical status class I or II. (This will exclude subjects with
significant medical problems).

- Body mass index between 18 and 35 kg m-2.

- No use of psychotropic or neuropsychiatric medications.

- A airway assessment with no indication of a difficult intubation including a class I
or II Malampatti airway and a mandible-to-hyoid distance of greater than three
fingerbreadths.

- Age between 18-75 years.

Exclusion Criteria:

- Does not meet inclusion criteria.