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Fu L, Gan Y, Liu X, Chen C, Zhao Y, Qin Y, Chen G, Song H, Ke B. Design, synthesis, and biological evaluation of new bis-benzylisoquinoline-based analogues as potential neuromuscular blocking agents. Bioorg Med Chem Lett 2024; 108:129793. [PMID: 38735343 DOI: 10.1016/j.bmcl.2024.129793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
Neuromuscular blocking agents (NMBAs) are widely used in anesthesia for intubation and surgical muscle relaxation. Novel atracurium and mivacurium derivatives were developed, with compounds 18c, 18d, and 29a showing mivacurium-like relaxation at 27.27 nmol/kg, and 15b, 15c, 15e, and 15h having a shorter duration at 272.7 nmol/kg. The structure-activity and configuration-activity relationships of these derivatives and 29a's binding to nicotinic acetylcholine receptors were analyzed through molecular docking. Rabbit trials showed 29a has a shorter duration compared to mivacurium. This suggests that linker properties, ammonium group substituents, and configuration are crucial for NMBA activity and duration, with compound 29a emerging as a potential ultra-short-acting NMBA.
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Affiliation(s)
- Lin Fu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu Gan
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041 Sichuan, China
| | - Xiaofeng Liu
- Central Nervous System Drug Key Laboratory of Sichuan Province, Sichuan Credit Pharmaceutical CO., Ltd., Luzhou, China
| | - Chen Chen
- Central Nervous System Drug Key Laboratory of Sichuan Province, Sichuan Credit Pharmaceutical CO., Ltd., Luzhou, China
| | - Yi Zhao
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041 Sichuan, China
| | - Yong Qin
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Gang Chen
- Central Nervous System Drug Key Laboratory of Sichuan Province, Sichuan Credit Pharmaceutical CO., Ltd., Luzhou, China
| | - Hao Song
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, Sichuan Province, China.
| | - Bowen Ke
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041 Sichuan, China.
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Daga RG, Bali IK, Patil PN, Daga RG, Daga R, Devika GS. Comparison of Intubating Conditions at 60 Seconds with Cisatracurium 4*ED95 Dose and Cisatracurium 2*ED95 Dose Plus Priming Dose and Low Dose Ketamine. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2023; 15:S960-S963. [PMID: 37694022 PMCID: PMC10485433 DOI: 10.4103/jpbs.jpbs_265_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction To compare the intubating conditions at 60 seconds between 4*ED95 dose of cisatracurium and 2*ED95 dose of cisatracurium in combination with priming and low dose ketamine. Primary Objective jaw relaxation for laryngoscopy, vocal cord position on laryngoscopy, and coughing or bucking response to intubation. Secondary Objective To compare the hemodynamic changes up 10 minutes after intubation in the two groups. In this prospective study, a total of 68 patients were undergoing general anesthesia for surgery with placement of endotracheal tube placement. Patients will be divided into two groups comprising 34 patients each. The patients were allocated one of the two groups by computerized randomization. *Group A received bolus dose of cisatracurium which is 0.2 mg/kg (4*ED95). **Group B received cisatracurium in dose of 0.1 mg/kg (2*ED95) with priming (which is 10% of the bolus dose) and low dose ketamine of about 0.5 mg/kg. It was possible to achieve acceptable laryngoscopy and intubating condition in both the groups within 90 seconds. When grades of laryngoscopy and ease of intubation were compared, 2*ED95 dose along with priming plus low dose ketamine produced superior results than 4*ED95 group. When the mean arterial pressure and pulse rate were compared between the two groups, it was observed that mean arterial pressure and pulse rate were only slightly higher in the 2*ED95 along with priming and ketamine.
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Affiliation(s)
- Rahul G. Daga
- Department of Anesthesia and Critical Care, Suretech Hospital, Dhantoli, Nagpur, Maharashtra, India
| | | | - Pushparaj Nilkanth Patil
- Department of Pediatrics, NAMO Meri Silvassa, DNH&DD(UT), Union Teritory of Dadra and Nagar Haveli and Daman and Diu, India
| | | | - Rashmi Daga
- Dr RR Kambe Dental College and Hospital, Akola, Maharashtra, India
| | - G. S. Devika
- Department of Pharmaceutical Analysis, Cherraan’s College of Pharmacy, Coimbatore, Tamil Nadu, India
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Greco M, Caruso PF, Angelotti G, Aceto R, Coppalini G, Martinetti N, Albini M, Bash LD, Carvello M, Piccioni F, Monzani R, Montorsi M, Cecconi M. REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study). J Clin Med 2023; 12:jcm12020563. [PMID: 36675492 PMCID: PMC9866312 DOI: 10.3390/jcm12020563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Background: Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. Methods: We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. Results: From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value < 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Conclusions: Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.
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Affiliation(s)
- Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Correspondence:
| | - Pier Francesco Caruso
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | | | - Romina Aceto
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Coppalini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Albini
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Roberta Monzani
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
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Interlandi C, Di Pietro S, Costa GL, Spadola F, Iannelli NM, Macrì D, Ferrantelli V, Macrì F. Effects of Cisatracurium in Sevoflurane and Propofol Requirements in Dog-Undergoing-Mastectomy Surgery. Animals (Basel) 2022; 12:ani12223134. [PMID: 36428361 PMCID: PMC9686472 DOI: 10.3390/ani12223134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/27/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
The purpose of the present study was to test whether the addition of cisatracurium in combination with propofol and sevoflurane would result in a change in doses of used anesthetic drugs. Ten dogs (Group A) undergoing elective unilateral mastectomy surgery were included in the study. To induce and maintain anesthesia, subjects received propofol and sevoflurane at varying doses; analgesia was performed with remifentanil. After three months, the same subjects (Group B) underwent contralateral mastectomy and received the same anesthetic protocol with the addition of cisatracurium at a dosage of 0.2 mg/kg−1. The following parameters were monitored during anesthesia: heart rate, systolic blood pressure, end-tidal CO2, oxygen saturation, halogenate requirement, and rectal temperature at baseline (T0), induction (T1), 5 (T5), 10 (T10), 15 (T15), 20 (T20), 25 (T25), 30 (T30), and 35 (T35) time points. In Group A, halogenate requirement was reduced at all the time points other than T1 (p < 0.001); in Group B, the percentage of halogenate requirement was already reduced at T1 and remained constant during the experimental period, showing no significant intragroup differences. The dose requirements of sevoflurane and propofol varied significantly between the two groups, with significantly lower dosages in the Group B (the cisatracurium-treated group). Moreover, patients treated with cisatracurium showed a stable anesthetic plan. The nondepolarizing-muscle-relaxant cisatracurium besylate could be considered a useful adjunct to anesthetic protocols.
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Affiliation(s)
- Claudia Interlandi
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
| | - Simona Di Pietro
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
| | - Giovanna L. Costa
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
- Correspondence: ; Tel.: +39-090-6766709; Fax: +39-090-6766758
| | - Filippo Spadola
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
| | - Nicola M. Iannelli
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
| | - Daniele Macrì
- Zooprophylactic Institute, Via Gino Marinuzzi 3, 90100 Palermo, Italy
| | | | - Francesco Macrì
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Via Palatucci Annunziata, 98168 Messina, Italy
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Peng P, Zheng Z, Yu J, Gao X, Yang J, Zhao C, Zhang F. Practical Process for synthesizing R-Tetrahydropapaverine─A Key Intermediate of Cisatracurium Besylate (Nimbex). Org Process Res Dev 2022. [DOI: 10.1021/acs.oprd.2c00243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peng Peng
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou 310014, China
| | - Zhibo Zheng
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou 310014, China
| | - Jun Yu
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong District, Shanghai 201203, China
| | - Xuezhi Gao
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong District, Shanghai 201203, China
| | - Jiangtao Yang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong District, Shanghai 201203, China
| | - Chuanmeng Zhao
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong District, Shanghai 201203, China
| | - Fuli Zhang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong District, Shanghai 201203, China
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Van Wijnsberghe AS, Ida KK, Dmitrovic P, Tutunaru A, Sandersen C. Neuromuscular blockade effects of cisatracurium in 11 cats undergoing ophthalmological surgery anaesthetised with isoflurane. J Feline Med Surg 2022; 24:402-406. [PMID: 34152242 PMCID: PMC10812242 DOI: 10.1177/1098612x211021829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CASE SERIES SUMMARY This case series describes the neuromuscular blockade (NMB) following 0.15 mg/kg intravenous (IV) cisatracurium administration in 11 cats undergoing ophthalmological surgery and anaesthetised with isoflurane. Anaesthetic records were analysed retrospectively. Neuromuscular function was assessed by a calibrated train-of-four (TOF) monitor. Cats were 73 ± 53 months old, weighed 4 ± 1 kg and were of American Society of Anesthesiologists' physical classification 2. Duration of anaesthesia and surgery were 144 ± 27 and 94 ± 24 mins, respectively. The lowest TOF count was zero in four cats, four in six cats and for one cat the TOF ratio never decreased below 31%. The time of onset was between 1 and 6 mins after the administration of cisatracurium and the mean duration of action was 20.4 ± 10.1 mins. RELEVANCE AND NOVEL INFORMATION Cisatracurium at a dose of 0.15 mg/kg IV did not consistently induce a TOF count of zero in all cats. The dose used in these cats did not produce any remarkable cardiovascular side effects. Although the NMB was not complete, the dose given was sufficient to produce central eyeball position, which was the goal of the ophthalmic surgeries.
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Affiliation(s)
- Anne-Sophie Van Wijnsberghe
- Department of Anaesthesia and Resuscitation, Faculty of Veterinary Medicine, University Veterinary Clinic (CVU), Uliège, Belgium
| | - Keila K Ida
- A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, TX, USA
| | - Petra Dmitrovic
- Department of Anaesthesia and Resuscitation, Faculty of Veterinary Medicine, University Veterinary Clinic (CVU), Uliège, Belgium
| | - Alexandru Tutunaru
- Department of Anaesthesia and Resuscitation, Faculty of Veterinary Medicine, University Veterinary Clinic (CVU), Uliège, Belgium
| | - Charlotte Sandersen
- Department of Anaesthesia and Resuscitation, Faculty of Veterinary Medicine, University Veterinary Clinic (CVU), Uliège, Belgium
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Complete biosynthesis of the bisbenzylisoquinoline alkaloids guattegaumerine and berbamunine in yeast. Proc Natl Acad Sci U S A 2021; 118:2112520118. [PMID: 34903659 PMCID: PMC8713753 DOI: 10.1073/pnas.2112520118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 12/28/2022] Open
Abstract
This work demonstrates microbial biosynthesis of bisbenzylisoquinoline (bisBIA) alkaloids. We show that several didomain epimerases can function in yeast to epimerize the nonnative substrate N-methylcoclaurine, an essential step in bisBIA biosynthesis. The N-methylcoclaurine epimerase activity was increased 10-fold by combining individual reductase and oxidase domains from different plant species. Strain engineering and optimization of media and growth conditions increased the bisBIA titer over 10,000-fold. We show that strains can be engineered to primarily produce one bisBIA product by selection of the cytochrome P450 variant that couples the monomer BIA subunits. We then leverage our bisBIA biosynthetic strain as a platform for the screening of other plant enzymes to produce two additional plant natural products de novo in a heterologous host. Benzylisoquinoline alkaloids (BIAs) are a diverse class of medicinal plant natural products. Nearly 500 dimeric bisbenzylisoquinoline alkaloids (bisBIAs), produced by the coupling of two BIA monomers, have been characterized and display a range of pharmacological properties, including anti-inflammatory, antitumor, and antiarrhythmic activities. In recent years, microbial platforms have been engineered to produce several classes of BIAs, which are rare or difficult to obtain from natural plant hosts, including protoberberines, morphinans, and phthalideisoquinolines. However, the heterologous biosyntheses of bisBIAs have thus far been largely unexplored. Here, we describe the engineering of yeast strains that produce the Type I bisBIAs guattegaumerine and berbamunine de novo. Through strain engineering, protein engineering, and optimization of growth conditions, a 10,000-fold improvement in the production of guattegaumerine, the major bisBIA pathway product, was observed. By replacing the cytochrome P450 used in the final coupling reaction with a chimeric variant, the product profile was inverted to instead produce solely berbamunine. Our highest titer engineered yeast strains produced 108 and 25 mg/L of guattegaumerine and berbamunine, respectively. Finally, the inclusion of two additional putative BIA biosynthesis enzymes, SiCNMT2 and NnOMT5, into our bisBIA biosynthetic strains enabled the production of two derivatives of bisBIA pathway intermediates de novo: magnocurarine and armepavine. The de novo heterologous biosyntheses of bisBIAs presented here provide the foundation for the production of additional medicinal bisBIAs in yeast.
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Ali H. Revisiting the role of MRGPRX2 on hypersensitivity reactions to neuromuscular blocking drugs. Curr Opin Immunol 2021; 72:65-71. [PMID: 33857758 DOI: 10.1016/j.coi.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 01/23/2023]
Abstract
Anaphylaxis is caused by a variety of triggers including Food and Drug Administration (FDA)-approved antibiotics, contrast media and neuromuscular blocking drugs (NMBDs). Traditionally, drug-induced anaphylaxis was thought to result mainly from IgE-mediated histamine release from mast cells. Recently, a G protein-coupled receptor known as MRGPRX2 has been identified and shown to be highly expressed on human skin but not lung mast cells. The demonstration that many NMBDs induce degranulation in human mast cells via MRGPRX2 led to the idea that this receptor contributes to NMBD-induced hypersensitivity reactions. However, other studies have raised doubts regarding its role in drug-induced hypersensitivity. This review discusses the current status and controversy on MRGPRX2's role on NMBD-induced hypersensitivity.
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Affiliation(s)
- Hydar Ali
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, 240 South 40th Street, Philadelphia, PA 19104, USA.
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Alam M, Ranjan R, Avinash R. Cisatracurium versus atracurium for abdominal surgeries regarding condition of intubation and hemodynamic effect: A randomized double-blind study. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_246_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ni C, Li Y, Li Z, Tian L, Fu J, Wu K, Wang Y, Yao M, Ge RS. Cisatracurium stimulates testosterone synthesis in rat and mouse Leydig cells via nicotinic acetylcholine receptor. J Cell Mol Med 2020; 24:14184-14194. [PMID: 33111502 PMCID: PMC7754058 DOI: 10.1111/jcmm.16029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 12/17/2022] Open
Abstract
As a cis-acting non-depolarizing neuromuscular blocker through a nicotinic acetylcholine receptor (nAChR), cisatracurium (CAC) is widely used in anaesthesia and intensive care units. nAChR may be present on Leydig cells to mediate the action of CAC. Here, by Western blotting, immunohistochemistry and immunofluorescence, we identified that CHRNA4 (a subunit of nAChR) exists only on rat adult Leydig cells. We studied the effect of CAC on the synthesis of testosterone in rat adult Leydig cells and mouse MLTC-1 tumour cells. Rat Leydig cells and MLTC-1 cells were treated with CAC (5, 10 and 50 μmol/L) or nAChR agonists (50 μmol/L nicotine or 50 μmol/L lobeline) for 12 hours, respectively. We found that CAC significantly increased testosterone output in rat Leydig cells and mouse MLTC-1 cells at 5 μmol/L and higher concentrations. However, nicotine and lobeline inhibited testosterone synthesis. CAC increased intracellular cAMP levels, and nicotine and lobeline reversed this change in rat Leydig cells. CAC may increase testosterone synthesis in rat Leydig cells and mouse MLTC-1 cells by up-regulating the expression of Lhcgr and Star. Up-regulation of Scarb1 and Hsd3b1 expression by CAC was also observed in rat Leydig cells. In addition to cAMP signal transduction, CAC can induce ERK1/2 phosphorylation in rat Leydig cells. In conclusion, CAC binds to nAChR on Leydig cells, and activates cAMP and ERK1/2 phosphorylation, thereby up-regulating the expression of key genes and proteins in the steroidogenic cascade, resulting in increased testosterone synthesis in Leydig cells.
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Affiliation(s)
- Chaobo Ni
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Anesthesiology and Pain Research Center, Jiaxing University Affiliated Hospital, The First Hospital of Jiaxing, Jiaxing, China
| | - Yang Li
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zengqiang Li
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lili Tian
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jie Fu
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Keyang Wu
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiyan Wang
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming Yao
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Anesthesiology and Pain Research Center, Jiaxing University Affiliated Hospital, The First Hospital of Jiaxing, Jiaxing, China
| | - Ren-Shan Ge
- Department of Anesthesiology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Severe Intraoperative Bradycardia during Laparoscopic Cholecystectomy due to Rapid Peritoneal Insufflation. Case Rep Anesthesiol 2020; 2020:8828914. [PMID: 32566315 PMCID: PMC7294365 DOI: 10.1155/2020/8828914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/12/2020] [Accepted: 05/19/2020] [Indexed: 12/01/2022] Open
Abstract
Laparoscopy is becoming increasingly popular in gynecological and general surgical operations. There are complications that are inherent to the laparoscopy techniques; amongst them is intraoperative vagal-mediated bradycardia that results from peritoneal stretching. This can occur due to high flow rate of gas during peritoneal insufflation, a practice still happening nowadays. We report a case of a middle-aged hypertensive patient who was undergoing elective laparoscopic cholecystectomy. The patient was assessed more than once preoperatively by the anesthesia team for blood pressure optimization. The patient underwent general anesthesia and developed severe bradycardia immediately after peritoneal insufflation. The management started immediately by stopping the insufflation and deflating the abdomen. Afterwards, atropine was administered intravenously, and CPR was started preemptively according to the ACLS protocol to prevent the patient from progressing into cardiac arrest. She responded to the management and became vitally stable within one minute. After confirming that there was no cardiac or metabolic insult through rapid blood investigations and agreeing that the cause of bradycardia was the rapid insufflation, the surgical team proceeded with the surgery in the same setting using low flow rate of CO2 to achieve pneumoperitoneum. There were no complications in the second time and the operation was completed smoothly. The patient was extubated and shifted to the postanesthesia care unit to monitor her condition. The patient was stable and conscious and later shifted to the wards and discharged on routine follow-up after confirming that there were no complications in the postoperative follow-up. Therefore, it is important to monitor the flow rate of CO2 during peritoneal insufflation in laparoscopic surgery as rapid peritoneal stretch can cause severe bradycardia that might progress into cardiac arrest, especially in hypertensive patients. It is also important for the anesthetist to be vigilant and ready to manage such cases.
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12
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Chen IY, Liang YY, Chen KS, Lee WM, Wang HC. Comparison of the neuromuscular blocking effects of cisatracurium during isoflurane or propofol anesthesia in dogs. Vet Anaesth Analg 2020; 47:454-462. [PMID: 32409258 DOI: 10.1016/j.vaa.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare the neuromuscular blocking effects of cisatracurium during isoflurane versus propofol anesthesia in dogs. STUDY DESIGN Prospective, randomized study. ANIMALS A total of 20 healthy, client-owned dogs (16 females, four males) weighing 12.5-22 kg and aged 1-8 years. METHODS Dogs undergoing elective surgery were randomized in equal numbers to an isoflurane (ISO) or propofol (PPF) group. Other drugs used during anesthesia were equal between groups. Single-twitch (ST) stimulation was used to monitor neuromuscular response. After recording the baseline ST (T0), cumulative doses of cisatracurium (0.05 mg kg-1) were administered intravenously until ST/T0 ≤5%. Effective doses 50 (ED50) and 95 (ED95) of cisatracurium in each group were calculated from group dose-response curves. Recovery of ST (TR) was defined as spontaneous recovery of ST to 80-120% of T0 remaining stable for 2 minutes. The ST after each dose of cisatracurium, duration 25% (time after the last dose until 25% recovery of TR), recovery index (time to recovery from 25% to 75% of TR) and duration to TR (time after the last dose until recovery of TR) were recorded. RESULTS Incremental doses of cisatracurium, median (range), were 2 (1-3) in ISO and 4 (2-5) in PPF to achieve ≥95% depression of ST/T0 (p < 0.01). ED50 and ED95 were 20 μg kg-1 and 117 μg kg-1 in ISO and 128 μg kg-1 and 167 μg kg-1 in PPF, respectively. The duration 25%, recovery index and duration to TR, median (range), were longer in ISO [22.6 (10.3-24.3), 5.3 (3.0-7.8) and 36.1 (20.1-49.7) minutes, respectively] than in PPF [10.2 (6.8-16.5), 3.0 (2.0-3.8) and 17.7 (14.2-28.7) minutes, respectively] (p < 0.01). CONCLUSIONS AND CLINICAL RELEVANCE Cisatracurium-induced neuromuscular blockade was significantly enhanced and prolonged by isoflurane compared with propofol.
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Affiliation(s)
- I-Ying Chen
- Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yun-Yu Liang
- Veterinary Medicine Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Kuan-Sheng Chen
- Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan; Veterinary Medicine Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Wei-Ming Lee
- Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan; Veterinary Medicine Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Hsien-Chi Wang
- Department of Veterinary Medicine, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan; Veterinary Medicine Teaching Hospital, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan.
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Lorenzutti AM, Zarazaga MP, Sakai DM, Nejamkin P, Rosetti V, Duran V, Martin-Flores M. Context-sensitive recovery of neuromuscular function from vecuronium in dogs: Effects of dose and dosing protocol. Vet J 2019; 248:14-17. [PMID: 31113556 DOI: 10.1016/j.tvjl.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 11/25/2022]
Abstract
Recovery of neuromuscular function is a gradual phenomenon whereby function progresses from absent to normal. The speed of spontaneous recovery can be used to predict the time when neuromuscular function is expected to be restored. However, the speed of recovery might be affected by the dose of the neuromuscular blocker administered, and by the dosing regimen of that dose. The effects of both factors on the speed of spontaneous recovery from vecuronium were evaluated. Seven dogs were anesthetized three times and the train-of-four (TOF) ratio was measured with acceleromyography. Vecuronium was administered at 0.1 mg/kg, 0.2 mg/kg, or 0.1 mg/kg followed by two doses of 0.05 mg/kg was administered each time. In the divided-dose treatment group, aliquots were administered on return of the first twitch (T1) of the TOF from the previous dose. The duration of surgical block, from injection to return of T1, was longest for the divided-dose protocol, intermediate for 0.2 mg/kg single bolus, and shortest for 0.1 mg/kg (P < 0.0001). The recovery period, from return of T1 to a TOF ratio ≥0.9, was longer for 0.2 mg/kg administered as a single bolus than for the other two groups (P = 0.007). Doubling the dose of a single bolus of vecuronium extended the time of surgical block and prolonged the duration of the recovery period. However, dividing that dose into smaller aliquots extended the period of surgical block while shortening the recovery period. Hence, the spontaneous reappearance of T1 should not be used in isolation to predict the time to complete recovery of neuromuscular function.
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Affiliation(s)
- A M Lorenzutti
- Institute of Basic and Applied Science, Veterinary Medicine, National University of Villa María, Córdoba, Argentina
| | - M P Zarazaga
- Institute of Basic and Applied Science, Veterinary Medicine, National University of Villa María, Córdoba, Argentina
| | - D M Sakai
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - P Nejamkin
- Teaching Hospital, Faculty of Veterinary Science, National University of the Center of Buenos Aires Province, University Campus, Tandil, Argentina
| | - V Rosetti
- Institute of Basic and Applied Science, Veterinary Medicine, National University of Villa María, Córdoba, Argentina
| | - V Duran
- Institute of Basic and Applied Science, Veterinary Medicine, National University of Villa María, Córdoba, Argentina
| | - M Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
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Abstract
General anaesthesia for the patient with a history of anaesthesia-related anaphylaxis is challenging. Precautions against anaphylaxis and the use of skin test negative drugs can reduce but not eliminate the risk. In the majority of such cases, subsequent anaesthesia is uneventful. However, the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist. We present a case of anaphylaxis to cisatracurium following a negative skin test.
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Affiliation(s)
- B A Fraser
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria
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Preclinical Pharmacology in the Rhesus Monkey of CW 1759-50, a New Ultra-short Acting Nondepolarizing Neuromuscular Blocking Agent, Degraded and Antagonized by L-Cysteine. Anesthesiology 2018; 129:970-988. [PMID: 30212413 DOI: 10.1097/aln.0000000000002408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Structure-activity studies were performed to identify a new neuromuscular blocking agent retaining the ultra-short acting characteristics of gantacurium, including degradation and reversal by L-cysteine, but lacking its histaminoid properties in man. CW 1759-50 has emerged from this program. METHODS Adduction of CW 1759-50 with L-cysteine was studied by high-performance liquid chromatography and mass spectrometry. Institutional Animal Care and Use Committee-approved comparisons of CW 1759-50 to gantacurium were performed in rhesus monkeys. ED95 for neuromuscular blockade was established. Spontaneous recovery was compared to reversal by L-cysteine in paired studies of boluses or infusions. In addition, changes in mean arterial pressure and heart rate after very large doses of 15 to 60 × ED95 were compared. RESULTS The half-time of adduction of L-cysteine to CW 1759-50 in vitro was 2.3 min. The ED95 of CW 1759-50 was 0.069 ± 0.02 mg/kg; ED95 of gantacurium was 0.081 ± 0.05 mg/kg (P = 0.006). Duration of action (recovery to 95% twitch height after 98 to 99% blockade) was as follows: CW 1759-50, 8.2 ± 1.5 min; and gantacurium, 7.4 ± 1.9 min; (n = 8 and 9, P = 0.355). Administration of L-cysteine (30 mg/kg) shortened recovery (i.e., induced reversal) from CW 1759-50 after boluses or infusions (P always less than 0.0001). Recovery intervals (5 to 95% twitch) ranged from 6.1 to 6.7 min (and did not differ significantly) after boluses of 0.10 to 0.50 mg/kg, as well as control infusions (P = 0.426 by analysis of variance). Dose ratios comparing changes of 30% in mean arterial pressure or heart rate to ED95 for neuromuscular blockade (ED 30% Δ [mean arterial pressure or heart rate]/ED95) were higher for CW 1759-50 than for gantacurium. CONCLUSIONS CW 1759-50, similar to gantacurium, is an ultra-short acting neuromuscular blocking agent, antagonized by L-cysteine, in the monkey. The circulatory effects, however, are much reduced in comparison with gantacurium, suggesting a trial in humans.
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Aguilar A, Moll X, García F, Andaluz A. Neuromuscular block monitoring after the administration of 1 mg/kg intravenous cis-atracurium in the anaesthetized pig. J Vet Pharmacol Ther 2018; 42:67-73. [DOI: 10.1111/jvp.12707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/22/2018] [Accepted: 07/23/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Adrià Aguilar
- Animal Medicine and Surgery Department; College of Veterinary Medicine; Universitat Autònoma de Barcelona; Bellaterra, Barcelona Spain
| | - Xavier Moll
- Animal Medicine and Surgery Department; College of Veterinary Medicine; Universitat Autònoma de Barcelona; Bellaterra, Barcelona Spain
| | - Félix García
- Animal Medicine and Surgery Department; College of Veterinary Medicine; Universitat Autònoma de Barcelona; Bellaterra, Barcelona Spain
| | - Anna Andaluz
- Animal Medicine and Surgery Department; College of Veterinary Medicine; Universitat Autònoma de Barcelona; Bellaterra, Barcelona Spain
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Cisatracurium induces mast cell activation and pseudo-allergic reactions via MRGPRX2. Int Immunopharmacol 2018; 62:244-250. [PMID: 30032049 DOI: 10.1016/j.intimp.2018.07.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/09/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pseudo-allergic reactions occur when patients receive muscle relaxants during perioperative anesthesia. These reactions may result in a serious threat to the patient's life, particularly to a child's life. Cisatracurium, a relatively new NMBA, has resulted in bronchospasms and cardiovascular collapse. However, the mechanisms underlying the anaphylactoid reactions caused by cisatracurium have not been fully elucidated. METHODS In the present study, the MRGPRX2-related pseudo-allergic reactions induced by cisatracurium were investigated using hindpaw swelling and extravasation assays in vivo and mast cell degranulation assays. RESULTS Cisatracurium caused anaphylactoid reactions in wild-type mice. However, cisatracurium did not induce a similar phenomenon in KitW-sh/W-sh mice. Furthermore, mast cell-related G protein-coupled receptor B2-knockout mice did not display an inflammatory response upon treatment with cisatracurium. Cisatracurium induced LAD2 cell degranulation, leading to the dose-dependent release of β-hexosaminidase, histamine and TNF-α. However, cisatracurium only induced the release of low levels of these mediator LAD2 cells transfected with MRGPRX2 siRNA. Cisatracurium also stimulated intracellular Ca2+ influx in MRGPRX2-HEK293 cells compared with that in NC-HKE293 cells. Interestingly, cytokine release was not observed in LAD2 cells even with high dose of cisatracurium. CONCLUSIONS Cisatracurium activated MRGPRX2 and triggered mast cell degranulation, leading to anaphylactoid reactions. Therefore, strategies targeting MRGPRX2 might potentially block cisatracurium-induced pseudo-allergic reactions.
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Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg 2017; 106:509-528. [PMID: 28712906 DOI: 10.1016/j.wneu.2017.07.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In neurotrauma care, a better understanding of treatments after traumatic brain injury (TBI) has led to a significant decrease in morbidity and mortality in this population. TBI represents a significant medical problem, and complications after TBI are associated with the initial injury and postevent intracranial processes such as increased intracranial pressure and brain edema. Consequently, appropriate therapeutic interventions are required to reduce brain tissue damage and improve cerebral perfusion. We present a contemporary review of literature on the use of pharmacologic therapies to reduce intracranial pressure after TBI and a comparison of their efficacy. METHODS This review was conducted by PubMed query. Only studies discussing pharmacologic management of patients after TBI were included. This review includes prospective and retrospective studies and includes randomized controlled trials as well as cohort, case-control, observational, and database studies. Systematic literature reviews, meta-analyses, and studies that considered conditions other than TBI or pediatric populations were not included. RESULTS Review of the literature describing the current pharmacologic treatment for intracranial hypertension after TBI most often discussed the use of hyperosmolar agents such as hypertonic saline and mannitol, sedatives such as fentanyl and propofol, benzodiazepines, and barbiturates. Hypertonic saline is associated with faster resolution of intracranial hypertension and restoration of optimal cerebral hemodynamics, although these advantages did not translate into long-term benefits in morbidity or mortality. In patients refractory to treatment with hyperosmolar therapy, induction of a barbiturate coma can reduce intracranial pressure, although requires close monitoring to prevent adverse events. CONCLUSIONS Current research suggests that the use of hypertonic saline after TBI is the best option for immediate decrease in intracranial pressure. A better understanding of the efficacy of each treatment option can help to direct treatment algorithms during the critical early hours of trauma care and continue to improve morbidity and mortality after TBI.
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Affiliation(s)
- Ahmed M Alnemari
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brianna M Krafcik
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Daniel Gaudin
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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Abstract
Abstract
Background
CW002, a novel nondepolarizing neuromuscular blocking agent of intermediate duration, is degraded in vitro by l-cysteine; CW002-induced neuromuscular blockade (NMB) is antagonized in vivo by exogenous l-cysteine.1 Further, Institutional Animal Care and Use Committee–approved studies of safety and efficacy in eight anesthetized monkeys and six cats are described.
Methods
Mean arterial pressure, heart rate, twitch, and train-of-four were recorded; estimated dose producing 95% twitch inhibition (ED95) for NMB and twitch recovery intervals from 5 to 95% of baseline were derived. Antagonism of 99 to 100% block in monkeys by l-cysteine (50 mg/kg) was tested after bolus doses of approximately 3.75 to 20 × ED95 and after infusions. Vagal and sympathetic autonomic responses were recorded in cats. Dose ratios for [circulatory (ED20) or autonomic (ED50) changes/ED95 (NMB)] were calculated.
Results
ED95s of CW002 in monkeys and cats were 0.040 and 0.035 mg/kg; l-cysteine readily antagonized block in monkeys: 5 to 95% twitch recovery intervals were shortened to 1.8 to 3.6 min after 3.75 to 10 × ED95 or infusions versus 11.5 to 13.5 min during spontaneous recovery. ED for 20% decrease of mean arterial pressure (n = 27) was 1.06 mg/kg in monkeys; ED for 20% increase of HR (n = 27) was 2.16 mg/kg. ED50s for vagal and sympathetic inhibition in cats were 0.59 and >>0.80 mg/kg (n = 14 and 15). Dose ratios for [circulatory or autonomic changes/ED95 (NMB)] were all more than 15 × ED95.
Conclusions
The data further verify the neuromuscular blocking properties of CW002, including rapid reversal by l-cysteine of 100% NMB under several circumstances. A notable lack of autonomic or circulatory effects provided added proof of safety and efficacy.
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Gao J, Yang T, Ye M, Zhang X, Tian G, Zhen Q, Ding M. High-performance liquid chromatography assay with programmed flow elution for cisatracurium in human plasma: Application to pharmacokinetics in infants and children. J Chromatogr B Analyt Technol Biomed Life Sci 2014; 955-956:58-63. [DOI: 10.1016/j.jchromb.2014.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 01/19/2014] [Accepted: 02/16/2014] [Indexed: 11/30/2022]
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Xiang Z, Yan-Liang Q, Xiao-Yang S, Yan-Hui Z, Min C, Guo-Shen G, Ming-Chun W, Zhong-Bing L, Qing-Li W, Guang-Jun H, Ming-Zhe Q, Jun T. Effects of promethazine or dexamethasone pretreatment on mivacurium-induced histamine release in children. Paediatr Anaesth 2014; 24:322-6. [PMID: 24238032 DOI: 10.1111/pan.12305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effects of pretreatment with either promethazine or dexamethasone on mivacurium-induced histamine release in children. METHODS Eighty ASA I-II children (4-10 years of age) scheduled for tonsillectomy and/or adenoidectomy were randomly divided into 4 groups (n = 20 per group) designated as either the rocuronium, mivacurium, dexamethasone (DXM), or promethazine group. Children in the DXM and promethazine groups were treated separately with intramuscular DXM 0.2 mg·kg(-1) or promethazine 0.5 mg·kg(-1) injections 60 min before operation. Radial artery blood samples were collected to quantify plasma histamine concentrations 1 min before and 1, 3, and 5 min after administration of the relaxant. Mean arterial pressure (MAP), heart rate (HR), and skin flushing were recorded at the same time. RESULTS No significant decreases in plasma histamine concentrations were observed between groups; however, more stable MAP and HR and less skin flushing were observed in DXM group participants compared with individuals in the mivacurium group (P < 0.05). By contrast, children in the promethazine group had significantly decreased plasma histamine concentrations and stable MAP and HR (without a significant increase in HR) compared with patients in mivacurium group. In addition, skin flushing was significantly decreased compared with that observed in the rocuronium group (P < 0.05). CONCLUSIONS Pretreatment with promethazine significantly decreased mivacurium-induced histamine release in children and provided stable hemodynamics during administration of anesthesia.
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Affiliation(s)
- Zhou Xiang
- Department of Anesthesiology, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei, China
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Yang CI, Fine GF, Jooste EH, Mutich R, Walczak SA, Motoyama EK. The Effect of Cisatracurium and Rocuronium on Lung Function in Anesthetized Children. Anesth Analg 2013; 117:1393-400. [PMID: 24257390 DOI: 10.1213/ane.0b013e3182a6d191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yoon Y, Lee B, Seo HS, Bang J, Ha SI, Song JG. Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-. Korean J Anesthesiol 2013; 65:147-50. [PMID: 24023998 PMCID: PMC3766781 DOI: 10.4097/kjae.2013.65.2.147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/14/2012] [Accepted: 09/20/2012] [Indexed: 12/04/2022] Open
Abstract
Cisatracurium was initially characterized to have no evident histamine-releasing potential with excellent cardiovascular stability. However, severe anaphylactic reactions to cisatracurium that resulted in bronchospasms and cardiovascular collapse have been reported worldwide. Two cases of severe anaphylactic reactions after the administration of cisatracurium are presented. The anesthetics used in both cases were lidocaine, midazolam, propofol (microemulsion propofol in the second case), remifentanil and cisatracurium. After the administration of these drugs, bronchospasm and hypotension manifested, leading to the diagnosis of anaphylaxis and appropriate treatment. Skin intradermal testing confirmed that both cases were due to immune-mediated anaphylaxis to cisatracurium, despite the fact that neither of the patients had been exposed to the allergen previously. The anaphylaxis may be due to cross-reactivity between neuromuscular blocking agents and substances with quaternary ammonium ions. Anesthesiologists should be aware that cisatracurium has the potential to trigger severe anaphylactic reactions via an immune-mediated mechanism.
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Affiliation(s)
- Yangin Yoon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Development of New Neuromuscular Blocking Agents. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Many molecules can exist as right-handed and left-handed forms that are non-superimposable mirror images of each other. They are known as enantiomers or substances of opposite shape. Such compounds are also said to be chiral (Greek chiros meaning ‘hand’). Such chiral molecules are of great relevance to anaesthetic theory and practice. This review summarizes the basic concepts, pharmacokinetic and pharmacodynamic aspects of chirality, and some specific examples of their application in anaesthesia, along with recent advances to elucidate the anaesthetic mechanisms. Chirality is relevant to anaesthesia, simply because more than half of the synthetic agents used in anaesthesia practice are chiral drugs. Almost all these synthetic chiral drugs are administered as racemic mixture, rather than as single pure enantiomers. These mixtures are not drug formulations containing two or more therapeutic substances, but combination of isomeric substances, with the therapeutic activity residing mainly in one of the enantiomer. The other enantiomer can have undesirable properties, have different therapeutic activities or be pharmacologically inert. Specific examples of application of chirality in anaesthetic drugs include inhalational general anaesthetics (e.g. isoflurane), intravenous anaesthetics (e.g. etomidate, thiopentone), neuromuscular blocking agents (e.g. cisatracurium), local anaesthetics (e.g. ropivacaine and levobupivacaine) and other agents (e.g. levosimendan, dexmedetomidine, L-cysteine). In the recent advances, chirality study has not only helped new drug development as mentioned above, but has also contributed in a more profound way to the understanding of the mechanism of anaesthesia and anaesthetic drugs.
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Affiliation(s)
- Sukanya Mitra
- Departments of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
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Lee H, Jeong S, Choi C, Jeong H, Lee S, Jeong S. Anesthesiologist's satisfaction using between cisatracurium and rocuronium for the intubation in the anesthesia induced by remifentanil and propofol. Korean J Anesthesiol 2013; 64:34-9. [PMID: 23372884 PMCID: PMC3558647 DOI: 10.4097/kjae.2013.64.1.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/11/2012] [Accepted: 07/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although cisatracurium has many advantages in anesthetic practices, the best choice of a nondepolarizing neuromuscular blocking agent that can replace succinylcholine is rocuronium. However, it is reported that remifentanil with propofol might provide reliable intubating condition, even without a neuromuscular blocking agent; therefore, it might improve the intubating condition with cisatracurium. This study examined intubating conditions after administering rocuronium or cisatracurium in a rapid sequence induction with remifentanil-propofol. METHODS Fifty two ASA physical status 1 or 2 adult patients scheduled for an elective surgery were enrolled in a randomized double-blinded trial. Anesthesia was induced in all patients with propofol 2.0 mg/kg and remifentanil 0.5 µg/kg, administered over 60 seconds. Rocuronium 0.9 mg/kg (3 × ED(95), R group, n = 23) or cisatracurium 0.15 mg/kg (3 × ED(95), C group, n = 29) was administered after the induction sequence. Laryngoscopy was attempted when the anesthesiologist thought it was 90 seconds after drug administration and appropriate time for intubation. The examiner, another anesthesiologist, recorded the exact time to intubation and suppression of maximal T1 on TOF. The intubating condition was assessed by the first anesthesiologist, as excellent, good, poor or not possible. RESULTS The best time to laryngoscopy was predicted by measuring TOF and was found to be significantly longer in the C group (197 ± 53 s) than in the R group (102 ± 49 s) (P value < 0.05). However, time to larygoscopy, intubating condition during the laryngoscopy, and hemodynamic changes after intubation was similar in both groups. CONCLUSIONS Despite fundamentally slower onset time, cisatracurium can provide quite good intubating conditions, which were comparable to those achieved with equipotent doses of rocuronium, which is more expensive in anesthesia inducted with remifentanil and propofol.
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Affiliation(s)
- Hyunjung Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Hwasun, Korea
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Jeong HJ, Lee SH, Kim HJ, Kwak SH. Effects on Intubating Conditions of Pretreatment with Remifentanil before Administration of Cisatracurium. Chonnam Med J 2012; 48:96-102. [PMID: 22977750 PMCID: PMC3434798 DOI: 10.4068/cmj.2012.48.2.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 08/09/2012] [Accepted: 08/13/2012] [Indexed: 11/16/2022] Open
Abstract
Cisatracurium provides superior hemodynamic stability with only minor release of histamine, and its metabolism via Hoffman elimination is independent of organ function. However, use of cisatracurium is limited because of reportedly slower onset and unsatisfactory intubating conditions. Many studies have shown that remifentanil might provide reliable intubating conditions; thus, we hypothesized that pretreatment with remifentanil before administration of cisatracurium might result in acceptable intubating conditions. Sixty healthy patients scheduled for elective surgery were enrolled and randomly divided into three groups: saline (Group I, n=20), remifentanil 0.5 µg/kg (Group II, n=20), and remifentanil 1.0 µg/kg (Group III, n=20). The anesthesia was induced with propofol 2.0 µg/kg given intravenously over 30 s followed by injection over 30 s of a different dose of remifentanil according to the study protocol. We examined the intubating condition by jaw relaxation, vocal cord state, and diaphragmatic response 90 s after administering cisatracurium. We also measured mean blood pressure, heart rate, and the onset time, which is the interval from the end of neuromuscular blocking agent administration until suppression of maximal T1 on a train-of four sequence. The mean values of the intubating condition after endotracheal intubation in Groups II and III were significantly lower than that in Group I (p<0.005), although the overall onset time of cisatracurium did not differ significantly between the three groups. Our results suggest that supplementation with remifentanil in an induction regimen with cisatracurium improves the quality of the intubating condition even though the onset time of cisatracurium is not shortened.
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Affiliation(s)
- Hye Jin Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
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Withington D, Ménard G, Varin F. Cisatracurium pharmacokinetics and pharmacodynamics during hypothermic cardiopulmonary bypass in infants and children. Paediatr Anaesth 2011; 21:341-6. [PMID: 21223452 DOI: 10.1111/j.1460-9592.2010.03514.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypothermia potentiates neuromuscular blockade in adults during cardiopulmonary bypass (CPB) but the pediatric literature is sparse. Temperature-dependent Hoffman degradation of cisatracurium may allow reduction in infusion rate (IR) during hypothermia. The effect of hypothermic CPB on the pharmacokinetics (PK) and pharmacodynamics (PD) of cisatracurium has not been described in children. METHODS AND MATERIALS Using neuromuscular monitoring with a Datex Relaxograph, cisatracurium IR was adjusted to obtain a pseudo-steady state during each phase of surgery (pre-CPB, CPB, post-CPB). Paired samples were taken at each phase. Cisatracurium plasma concentrations (Cpss) were determined by HPLC. Core and skin temperatures were recorded. RESULTS Data from ten infants were analyzed: Group 1: mean 33.6°C; Group 2: mean 21.9°C. To maintain T1% between 5% and 10% in Group 2, the IR was decreased by a mean of 89% (P < 0.001). IR was not significantly different in Group 1. Post-CPB IR approximated pre-CPB rates in both groups. During CPB, Cpss fell by 27% in Group 1 and by 50% in Group 2 (P = 0.039). Post-CPB Cpss was not significantly different to pre-CPB in either group. Clearance did not change significantly in Group 1 but fell significantly in Group 2 during CPB (P = 0.002). Clearance post-CPB was unchanged from pre-CPB. CONCLUSIONS Cisatracurium IR may be decreased by around 60% during CPB with moderate hypothermia but can be maintained at baseline during mild hypothermia.
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Affiliation(s)
- Davinia Withington
- Department of Anesthesia, McGill University, Montreal Children's Hospital, Montreal, QC, Canada.
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Correa CMN, Sudo GZ, Sudo RT. Hemodynamic effects of atracurium and cisatracurium and the use of diphenhydramine and cimetidine. Rev Bras Anestesiol 2010; 60:52-63. [PMID: 20169263 DOI: 10.1016/s0034-7094(10)70006-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 10/06/2009] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Since atracurium can cause hypotension in humans, the hemodynamic effects of atracurium and cisatracurium as well as the hemodynamic protection of diphenhydramine and cimetidine were investigated in rats. METHODS 1) Wistar rats were anesthetized with sodium pentobarbital and prepared according to Brown et al. to evaluate different doses of atracurium and cisatracurium in the reduction of T4/T1 equal or greater than 95%. 2) Assessment of the hemodynamic changes caused by the intravenous administration of atracurium and cisatracurium by monitoring the blood pressure in the carotid artery and the electrocardiogram of rats. 3) Observation of the hemodynamic protection of prior treatment with the intravenous administration of diphenhydramine (2 mg.kg(-1)) and/or cimetidine (4 mg.kg(-1)). STATISTICAL ANALYSIS Student t test and ANOVA. RESULTS Doses of 1 mg.kg(-1) and 0.25 mg.kg(-1) of atracurium and cisatracurium respectively did not change the mean arterial pressure (MAP). Doses of 4 mg.kg(-1) of atracurium and cisatracurium decreased MAP to 62.8 +/- 4.5% and 82.5 +/- 2.3% respectively when compared to control levels. When the rats were pre-treated with diphenhydramine and cimetidine, diastolic pressure was reduced to 95.4% +/- 2.5%. With cimetidine, diastolic pressure was reduced to 82.7 +/- 8.4% when compared to the control group. The effects on systolic and diastolic blood pressure were reflected in the levels of MAP. CONCLUSIONS The isolated administration of diphenhydramine and cimetidine did not prevent the reduction in mean arterial pressure induced by atracurium. However, the association of both drugs was able to prevent the hemodynamic effects of atracurium. The doses of cisatracurium used in this study did not cause a reduction in blood pressure significant enough to justify the use of the preventive measures used in the atracurium groups.
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Lin SP, Chang KY, Chen YJ, Lin SM, Chang WK, Chan KH, Ting CK. Priming with rocuronium to accelerate the onset time of cisatracurium during intubation. J Chin Med Assoc 2009; 72:15-9. [PMID: 19181592 DOI: 10.1016/s1726-4901(09)70014-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The priming technique, in which a small dose of nondepolarizing muscle relaxant is administered 3-6 minutes before giving the intubation dose, can speed up the onset of muscle relaxation in patients with paralysis during intubation. We investigated the priming technique and compared 2 different priming agents (rocuronium and cisatracurium) at a priming time of 3 minutes and its effect on decreasing the onset time of cisatracurium. METHODS A total of 60 patients with ASA physical status I-II scheduled for elective surgery were enrolled. After induction with propofol and fentanyl, the patients were randomized into 1 of 3 groups. Group 1 received rocuronium 0.06 mg/kg as a priming dose. Group 2 received cisatracurium 0.01 mg/kg as a priming dose. Group 3 received normal saline and constituted the control group. After a 3-minute priming time, intubation doses of cisatracurium were given (Groups 1 and 2, 0.14 mg/kg; Group 3, 0.15 mg/kg). First twitch height percentage (T1/T0%; % of control) and train-of-four percentage (T4/T1%) were recorded every 10 seconds from baseline until T1/T0% reached 0. RESULTS Rocuronium (Group 1) and cisatracurium (Group 2) significantly accelerated the onset of cisatracurium (Group 1, 117.0 +/- 29.0 seconds; Group 2, 151.0 +/- 37.5 seconds; Group 3, 221.5 +/- 36.6 seconds; all p < 0.001). CONCLUSION Priming with rocuronium or cisatracurium for 3 minutes significantly accelerated the onset of cisatracurium. Priming with rocuronium for 3 minutes improved the onset time of cisatracurium even more than priming with cisatracurium itself.
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Affiliation(s)
- Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C
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Benítez Morillo M, Casares Vivas M, Tejada Ruiz F, Narváez Bermejo J. Reacción anafiláctica tipo IV y SCACEST por vasoespasmo coronario secundarios a administración de cisatracurio. Med Intensiva 2008; 32:260-1. [DOI: 10.1016/s0210-5691(08)70951-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kariman A, Shahabeddin M. Xylazine Premedication does not Modify the Onset and Duration of Cisatracurium Blockade in Anaesthetized Dogs. ACTA ACUST UNITED AC 2007; 54:254-6. [PMID: 17523959 DOI: 10.1111/j.1439-0442.2007.00888.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to evaluate the effect of xylazine as premedication on the onset time and duration of cisatracurium neuromuscular blockade in anaesthetized dogs. This study was carried out on 12 healthy dogs aged 0.5-6 years and weighing 9-26 kg undergoing various elective surgical procedures. The dogs were randomly divided into two groups of t (test) and c (control), with six dogs each. In group t, premedication was conducted using acepromazine maleate 0.3 mg kg(-1) and xylazine 0.3 mg kg(-1) and in group c only acepromazine (same dose) was injected intramuscularly 20 min before general anaesthesia. After induction with thiopental, anaesthesia was maintained with halothane in oxygen to deliver an end-tidal halothane concentration of 1.1%. Neuromuscular blockade was induced with cisatracurium 0.2 mg kg(-1) and monitored using the train-of-four (TOF) stimulation pattern applied at the ulnar nerve. The onset time of cisatracurium blockade was 195 +/- 85.44 s in test and 153.3 +/- 38.16 s in control group. The duration of neuromuscular blockade was 24.8 +/- 4.79 min in t and 28.3 +/- 5.46 min in the c group. Statistical analysis of the data showed no significant difference between groups in terms of onset and duration of neuromuscular blockade.
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Affiliation(s)
- A Kariman
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran.
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Serra CSM, Oliveira AC. Cisatracurium: myographical and electrophysiological studies in the isolated rat muscle. Fundam Clin Pharmacol 2006; 20:291-8. [PMID: 16671964 DOI: 10.1111/j.1472-8206.2006.00395.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Myographical and electrophysiological studies of cisatracurium were performed, in vitro, in the isolated sciatic nerve-extensor digitorum longus muscle preparation of the rat. Indirect twitches were generated at 0.1 Hz and tetanic contractions at 50 Hz. endplate potentials (epps) were generated in trains of 50 Hz. The electrophysiological variables used in the analysis of the epps were: amplitude of the first epp in the train, average amplitude of the 30 degrees to the 59 degrees epp in the train (epps-plateau), tetanic rundown (percent loss in amplitude of epps-plateau relative to the first epp in the train), quantal size and quantal content. The myographical results showed that the inhibitory concentration 50% (IC(50)) of cisatracurium for the blockade of twitches (0.48 microm) is 12 times its IC(50) for the induction of tetanic fade (0.04 microm). The electrophysiological results showed a concentration dependent decrease in the amplitudes of first epps in the trains and of epps-plateau in the two used concentrations (0.13 microm and 0.38 microm). The tetanic rundown was intensified only in the presence of the higher (0.38 microm) concentration of cisatracurium. In cisatracurium 0.13 microm (a concentration which affects only tetanic contractions, inducing their fade, while leaving the twitch unaffected) there was a decrease in the quantal content of the first epp and of epps-plateau in the train. In cisatracurium (0.38 microm), a concentration, which affects the twitch, there was a decrease of the quantal size and of quantal content of epps-plateau, but not of the quantal content of the first epp in the train. The results indicate that the fade of the tetanic contraction induced by cisatracurium at the concentration of 0.13 microm is entirely because of a pre-synaptic blocking effect while the decrease in the twitch induced by cisatracurium at the concentration of 0.38 microm is due to a post-synaptic blocking effect.
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Affiliation(s)
- C S M Serra
- Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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Adams WA, Mark Senior J, Jones RS, Williams JM, Gleed RD. cis-Atracurium in dogs with and without porto-systemic shunts. Vet Anaesth Analg 2006; 33:17-23. [PMID: 16412128 DOI: 10.1111/j.1467-2995.2005.00231.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the non-depolarizing neuromuscular blocking drug cis-atracurium in dogs with porto-systemic shunts, and to compare it in clinically normal animals. ANIMALS Thirteen dogs of mixed breed and sex, aged between 3 and 31 months old, weighing 2.2-25.5 kg, with ASA physical status II-IV, and undergoing surgical attenuation of porto-systemic shunt. A control group of 11 bitches of mixed breed, between 8 and 60 months old, and weighing 4.5-41.0 kg, all ASA physical status I, undergoing routine ovarohysterectomy were also studied. MATERIALS AND METHODS Pre-anaesthetic medication was an opioid analgesic, given either alone or in combination with acepromazine. Following induction of general anaesthesia with intravenous (IV) propofol and oro-tracheal intubation, anaesthesia was maintained using isoflurane in either oxygen or oxygen and nitrous oxide. Ventilation was controlled. The train of four (TOF) technique was used to monitor neuromuscular blockade. An initial dose of 0.1 mg kg(-1)cis-atracurium was given IV and additional doses of 0.03 mg kg(-1)cis-atracurium were administered when at least one twitch of the TOF was present. RESULTS Except for one dog that was killed during surgery because its anomaly was inoperable, all animals recovered satisfactorily from anaesthesia and surgery. In dogs with porto-systemic shunt, onset of neuromuscular blockade was 3.1 +/- 1.1 minutes (mean +/- SD) and in control dogs was 3.4 +/- 0.7 minutes (not significantly different). Neuromuscular blockade lasted 34 +/- 13 minutes in dogs with porto-systemic shunt and 29 +/- 17 minutes in control dogs (not significantly different). CONCLUSIONS The presence of porto-systemic shunt did not affect the rate of onset or duration of action of cis-atracurium. CLINICAL RELEVANCE cis-Atracurium may have a use in veterinary anaesthesia for producing neuromuscular blockade in dogs with hepatic insufficiency, including those with porto-systemic shunt.
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Affiliation(s)
- Wendy A Adams
- University Department of Anaesthesia, University Clinical Departments, Liverpool, UK.
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Mertes PM, Dewachter P, Laxenaire MC. Complications anaphylactiques et anaphylactoïdes de l'anesthésie générale. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s0246-0289(03)00098-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Karila C, Brunet-Langlot D, Labbez F, Paupe J, de Blic J, Scheinmann P. Allergie aux curares chez l’enfant. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s0335-7457(03)00237-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Moneret-Vautrin DA. [Skin tests for diagnosis of curare allergy]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21 Suppl 1:97s-107s. [PMID: 12091991 DOI: 10.1016/s0750-7658(02)00618-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D A Moneret-Vautrin
- Service de médecine interne, immunologie clinique et allergologie, hôpital central, avenue du Maréchal de Lattre-de-Tassigny, 54035 Nancy, France.
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Krombach J, Hunzelmann N, Köster F, Bischoff A, Hoffmann-Menzel H, Buzello W. Anaphylactoid reactions after cisatracurium administration in six patients. Anesth Analg 2001; 93:1257-9, table of contents. [PMID: 11682408 DOI: 10.1097/00000539-200111000-00043] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPLICATIONS We report six cases of anaphylactoid reaction after the administration of the muscle relaxant cisatracurium. They include two first-time documented anaphylactoid reactions after a precurarising dose. These incidents challenge existing views of a substantially reduced anaphylactoid potential of cisatracurium relative to other muscle relaxants.
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Affiliation(s)
- J Krombach
- Department of Anesthesiology, University of Köln, Köln, Germany
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Adams WA, Robinson KJ, Mark Senior J, Jones RS. The use of the nondepolarizing neuromuscular blocking drug cis-atracurium in dogs. Vet Anaesth Analg 2001; 28:156-160. [DOI: 10.1046/j.1467-2987.2001.00045.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/1999] [Accepted: 07/21/2000] [Indexed: 11/20/2022]
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Legros CB, Orliaguet GA, Mayer MN, Labbez F, Carli PA. Severe Anaphylactic Reaction to Cisatracurium in a Child. Anesth Analg 2001. [DOI: 10.1213/00000539-200103000-00018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Legros CB, Orliaguet GA, Mayer MN, Labbez F, Carli PA. Severe anaphylactic reaction to cisatracurium in a child. Anesth Analg 2001; 92:648-9. [PMID: 11226094 DOI: 10.1097/00000539-200103000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- C B Legros
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Necker-Enfants Malades, Paris, France
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Naguib M, Riad W. Dose-response relationships for edrophonium and neostigmine antagonism of atracurium and cisatracurium-induced neuromuscular block. Can J Anaesth 2000; 47:1074-81. [PMID: 11097536 DOI: 10.1007/bf03027958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To study the dose-response relationships for neostigmine and edrophonium during antagonism of neuromuscular block induced by atracurium and cisatracurium. METHODS One hundred and twenty eight, ASA group 1 or 2 adults were given either 0.5 mg x kg(-1) atracurium or 0.1 mg x kg(-1) cisatracurium during fentanyl-thiopental-nitrous oxide-isoflurane anesthesia. The neuromuscular block was measured by an acceleration-responsive transducer. Responses were defined in terms of percent depression in the first twitch (T1) and train-of-four (TOF) response. When spontaneous recovery of first twitch height reached 10% of its initial control value, edrophonium (0.1, 0.2, 0.4, or 1 mg x kg(-1)) or neostigmine (0.005, 0.01, 0.02, or 0.05 mg x kg(-1)) was administered by random allocation. Neuromuscular function in another sixteen subjects was allowed to recover spontaneously. RESULTS At five minutes, unlike edrophonium, neostigmine was equally effective against atracurium and cisatracurium with respect to T1 recovery. The neostigmine T1-ED50 was 10.3 +/- 1.06 (SEM) microg x kg(-1) after atracurium and 11.2 +/- 1.06) microg x kg(-1) after cisatracurium. The edrophonium ED50 was 157 +/- 1.07 microg x kg(-1) with atracurium and 47.4 +/- 1.07 microg x kg(-1) with cisatracurium, giving a neostigmine:edrophonium potency ratios of 15.2 +/- 1.7 and 4.2 +/- 0.41 (P < 0.001) for atracurium and cisatracurium, respectively. At 10 min neostigmine was 13 +/- 1.4 times as potent as edrophonium for achieving 50% TOF recovery after atracurium paralysis. After cisatracurium the potency ratio was 11.8 +/- 1.3 (NS). CONCLUSIONS Although there were differences at five minutes, neostigmine:edrophonium potency ratios at 10 min, were similar in both relaxants studied.
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Affiliation(s)
- M Naguib
- Department of Anesthesia at the University of Iowa College of Medicine, Iowa City 52242-1009, USA
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Affiliation(s)
- N Hunzelmann
- Department of Dermatology, University of Cologne, Germany
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Abstract
UNLABELLED In an effort to determine the extent to which atracurium may represent an exception to the rule that molar potency predicts onset time, we studied the onset profile of atracurium after a dose selected to produce approximately 95% twitch depression. We compared these results with data obtained in a previous study after the administration of vecuronium, rocuronium, and cisatracurium. Eighteen ASA physical status I and II patients were studied. After the induction of anesthesia, tracheal intubation was accomplished without relaxants. The evoked electromyographic response to 0.10-Hz single stimuli was continuously recorded. After baseline stabilization, a single bolus of atracurium, averaging 0.21 mg/kg, was administered. If peak twitch depression did not fall within the range of 90%-98%, the patient was excluded. The time to 50% and 90% of peak effect was recorded. The time to 90% of maximal effect (192 +/- 23 s) was not different from that previously observed for vecuronium (201 +/- 20 s). The time to 50% of peak effect (110 +/- 15 s) was shorter (P < 0.05) after atracurium administration than after vecuronium (125 +/- 9 s). The onset times recorded for atracurium were slower than previously observed after rocuronium and more rapid than that which was seen after cisatracurium (P < 0.001). The observed onset profile of atracurium was considerably slower than anticipated, based on the drug's molar potency. The 95% effective dose (microM/kg) may not be a reliable predictor of a muscle relaxant's onset time, when the drug administered is a mixture isomers of varying potency. IMPLICATIONS The speed of onset of atracurium is slower than predicted, based on its molar potency. Potency of a relaxant may not be a reliable predictor of its time to peak effect, when the drug administered is a mixture of isomers with widely different neuromuscular activities.
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Affiliation(s)
- A F Kopman
- Department of Anesthesiology, New York Medical College, Valhalla, USA.
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Kopman AF, Klewicka MM, Neuman GG. Molar Potency is Not Predictive of the Speed of Onset of Atracurium. Anesth Analg 1999. [DOI: 10.1213/00000539-199910000-00042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Carroll MT, Mirakhur RK, Lowry DW, McCourt KC, Kerr C. Neuromuscular blocking effects and train-of-four fade with cisatracurium: comparison with other nondepolarising relaxants. Anaesthesia 1998; 53:1169-73. [PMID: 10193219 DOI: 10.1046/j.1365-2044.1998.00616.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neuromuscular blocking drugs exhibit different degrees of fade in response to train-of-four stimulation believed to represent their relative prejunctional effects. The present study was designed to compare the train-of-four fade after cisatracurium and compare this with other commonly used muscle relaxants. Train-of-four fade during onset and recovery of block were recorded after administration of cisatracurium 0.05 or 0.1 mg.kg-1, atracurium 0.5 mg.kg-1, vecuronium 0.08 mg.kg-1, mivacurium 0.15 mg.kg-1 or rocuronium 0.6 mg.kg-1 to patients anaesthetised with fentanyl, nitrous oxide and a propofol infusion. Neuromuscular monitoring was by stimulation of the ulnar nerve and recording the force of contraction of the adductor pollicis muscle. The onset and recovery of block were also measured. Train-of-four fade during onset of block was greater with the lower dose of cisatracurium compared with the higher dose of cisatracurium and all other relaxants. Train-of-four fade during recovery was similar. The median times (and ranges) for the onset of maximum block were 3.4 (2.1-5.6), 1.5 (1.2-2.3), 2.1 (1.2-2.6), 2.0 (1.5-2.7) and 1.0 (0.7-1.3) min for cisatracurium 0.1 mg.kg-1 and atracurium, mivacurium, vecuronium and rocuronium, respectively. The median times (and ranges) for the recovery of T1 to 25% of control and to a train-of-four ratio of 0.8 were 41 (21-50) and 65 (40-78); 43 (37-54) and 69 (58-79); 15 (11-20) and 25 (19-30); 31 (23-46) and 60 (45-117); and 33 (18-57) and 50 (28-76) min following cisatracurium, 0.1 mg.kg-1, atracurium, mivacurium, vecuronium and recuronium, respectively.
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Affiliation(s)
- M T Carroll
- Department of Anaesthetics, Queen's University of Belfast, UK
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Reich DL, Mulier J, Viby-Mogensen J, Konstadt SN, van Aken HK, Jensen FS, DePerio M, Buckley SG. Comparison of the cardiovascular effects of cisatracurium and vecuronium in patients with coronary artery disease. Can J Anaesth 1998; 45:794-7. [PMID: 9793671 DOI: 10.1007/bf03012152] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Cisatracurium besylate (Nimbex Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) is an intermediate-acting bis-benzylisoquinolinium neuromuscular blocking drug that is one of the stereoisomers of atracurium. At doses < or = 8 x ED95, it caused no clinically important cardiovascular side effects or histamine release in healthy patients. The purpose of the present study was to investigate the haemodynamic effects of high doses of cisatracurium in patients with coronary artery disease. METHODS One hundred patients undergoing myocardial revascularization participated in a pilot study (seven patients) and a double-blinded, randomized, controlled trial comparing the haemodynamic effects of cisatracurium with vecuronium at three centres. The patients were anaesthetized using oxygen 100%, with etomidate, fentanyl and a benzodiazepine, and tracheal intubation was facilitated using succinylcholine. After baseline haemodynamic measurements, the study drug was administered over 5-10 sec according to group assignment: Group A (pilot) cisatracurium, 0.20 mg.kg-1 (4 x ED95), (n = 7); Group B-cisatracurium, 0.30 mg.kg-1 (6 x ED95), (n x ED95), (n = 31); Group C-vecuronium, 0.30 mg.kg-1 (6 x ED95), (n = 31); Group D cisatracurium, 0.40 mg.kg-1 (8 x ED95), (n = 21); Group E-vecuronium, 0.30 mg.kg-1 (6 x ED95), (n = 10). The haemodynamic measurements were repeated at 2, 5, and 10 min after cisatracurium or vecuronium. RESULTS Two patients in Group D had > 20% decreases in MAP, but only one required therapy for hypotension. The haemodynamic changes from pre- to post-injection in the cisatracurium patients were minimal and similar to patients receiving vecuronium. CONCLUSIONS In patients with coronary artery disease, rapid cisatracurium (4-8 x ED95) boluses and vecuronium (6 x ED95) result in minor, clinically insignificant haemodynamic side effects.
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Affiliation(s)
- D L Reich
- Department of Anesthesiology, Mount Sinai Medical Center, New York, NY, USA.
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Brandom BW, Woelfel SK, Ference A, Dayal B, Cook DR, Kerls S. Effects of cisatracurium in children during halothane-nitrous oxide anesthesia. J Clin Anesth 1998; 10:195-9. [PMID: 9603588 DOI: 10.1016/s0952-8180(98)00007-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To determine the neuromuscular blocking effect and recovery profile of cisatracurium besylate in children after administration of a bolus dose that was twice the estimated dose required to produce 95% of the maximum effect (2 x ED95; 0.08 mg/kg) followed by an infusion during halothane-nitrous oxide anesthesia. STUDY DESIGN Open-label study. SETTING Teaching hospital. PATIENTS 30 male and female (ASA physical status I and II) patients, 2 to 10 years of age, scheduled for elective surgery of low to moderate risk. INTERVENTIONS After induction of general anesthesia, patients received cisatracurium 0.08 mg/kg administered over 5 to 10 seconds. For surgical procedures requiring neuromuscular block for at least 60 minutes, a second bolus dose of cisatracurium 0.02 mg/kg was administered after the first response to a train-of-four stimuli (T1) recovered to 25% of baseline. When T1 was 5% of baseline after the second dose, a 3 microg/kg/min infusion of cisatracurium was initiated and titrated to maintain 89% to 99% block for the duration of the surgery. For procedures requiring neuromuscular block of less than 60 minutes, one or more maintenance doses of 0.02 mg/kg cisatracurium were administered when T1 was 25% of baseline after the preceding dose. In 10 patients, recovery was facilitated with edrophonium 1.0 mg/kg administered when T1 was 26% to 48% of the final baseline. MEASUREMENTS AND MAIN RESULTS Evoked muscular response at the adductor pollicis was measured by electromyography. With 0.08 mg/kg, onset time (mean +/- SEM) was 4.1 +/- 0.4 minutes, and clinically effective duration was 27.3 +/- 0.9 minutes. Mean 5% to 95% and 25% to 75% recovery indices were 28.4 +/- 2. 7 minutes and 11.2 +/- 0.8 minutes, respectively. The mean infusion rate necessary to maintain 89% to 99% T1 suppression for 17 to 145 minutes was 1.7 microg/kg/min. After termination of infusion, the mean 5% to 95% and 25% to 75% recovery indices were similar to those after a single bolus dose, and time to 95% recovery was 30.4 +/- 3.0 minutes. After administration of edrophonium, full recovery (T4:T1 > or = 70%) occurred in 1.5 +/- 0.4 minutes. No clinically significant changes in heart rate or blood pressure were noted during the first 5 minutes after administration of cisatracurium 0.08 mg/kg. CONCLUSIONS Cisatracurium provided maximal neuromuscular block, cardiovascular stability, and predictable recovery at the doses tested. In view of this finding, cisatracurium should be a useful intermediate-duration neuromuscular blocking drug for children during general anesthesia.
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Affiliation(s)
- B W Brandom
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Pittsburgh, PA 15213, USA
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