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Lee K, Jenkins KD, Sparkle T. A Narrative Overview of Current Anesthetic Drugs in Electroconvulsive Therapy. Life (Basel) 2021; 11:life11090981. [PMID: 34575130 PMCID: PMC8466199 DOI: 10.3390/life11090981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/30/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022] Open
Abstract
Electroconvulsive therapy (ECT) is a definitive treatment for patients with psychiatric disorders that are severe, acute, or refractory to pharmacologic therapy. Providing anesthesia for ECT is challenging, as the effect of drugs on hemodynamics, seizure duration, comfort, and recovery must be considered. We highlight and aim to review the common anesthetics used in ECT and related evidence. While drugs such as methohexital, succinylcholine, and etomidate have been used in the past, other drugs such as dexmedetomidine, ketamine, and remifentanil may provide a more balanced anesthetic with a greater safety profile in select populations. Overall, it is essential to consider the patient’s co-morbidities and associated risks when deciding on an anesthetic drug.
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Jang EA, Kim TY, Jung EG, Jeong S, Bae HB, Lee S. Donepezil-related inadequate neuromuscular blockade during laparoscopic surgery: A case report. World J Clin Cases 2020; 8:5341-5346. [PMID: 33269268 PMCID: PMC7674726 DOI: 10.12998/wjcc.v8.i21.5341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels. This drug may potentially interact with neuromuscular blocking agents (NMBAs) that act on muscular acetylcholine receptors during general anesthesia. Herein, we present a case of inadequate neuromuscular blockade with rocuronium, a nondepolarizing NMBA, in a dementia patient who had taken donepezil.
CASE SUMMARY A 71-year-old man was scheduled for laparoscopic gastrectomy. He had been taking donepezil 5 mg for dementia. General anesthesia was induced with propofol and remifentanil. The depth of neuromuscular blockade was monitored by train-of-four (TOF) stimulation. After the administration of rocuronium, the TOF ratio decreased at an unusually slow rate, and a TOF count of 0 was detected 7 min later. After intubation, a TOF count of 1 was detected within 1 min, and a TOF ratio of 12% was detected within 2 min. The TOF count remained at 4 even with an additional bolus and continuous infusion of rocuronium, suggesting resistance to this NMBA. Instead of propofol, an inhalation anesthetic was administered alongside another NMBA (cisatracurium). Then, the quality of neuromuscular blockade improved, and the TOF count remained at 0-1 for the next 70 min. No further problems were encountered with respect to surgery or anesthesia.
CONCLUSION Donepezil may be responsible for inadequate neuromuscular blockade during anesthesia, especially when total intravenous anesthesia is used.
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Affiliation(s)
- Eun-A Jang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Tae-Young Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Eu-Gene Jung
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Seongtae Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Seongheon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
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Wang X, Huang K, Yan H, Lan F, Yao D, Li Y, Xue J, Wang T. The median effective dose (ED50) of cis-Atracurium for laryngeal mask airway insertion during general Anaesthesia for patients undergoing urinary surgery. BMC Anesthesiol 2020; 20:68. [PMID: 32192431 PMCID: PMC7081559 DOI: 10.1186/s12871-020-00982-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 03/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background In clinical practice, the laryngeal mask airway is an easy-to-use supraglottic airway device. However, the cis-atracurium dosage for laryngeal mask insertion has not been standardised. We aimed to determine the optimal dose of cis-atracurium using a sequential method for successful laryngeal mask insertion. Methods The cohort study protocol is registered at clinicaltrial.gov (NCT-03668262). Twenty-three patients undergoing elective urinary surgery were sequentially administered cis-atracurium doses as follows: 150, 100, 70, 50, 30, and 20 μg·kg− 1. The main outcome involved the determination of the response to laryngeal mask airway insertion: ≥16 points and < 16 points indicated “satisfactory” and “unsatisfactory” responses, respectively. The median effective dose was estimated using the mean of the seven crossovers from “satisfactory” and “unsatisfactory” responses. The primary outcome involved the determination of the median effective dose (ED50) of cis-atracurium for laryngeal mask airway insertion. Results The median effective dose of cis-atracurium was 26.5 μg·kg− 1 (95% CI 23.6–29.8) using the sequential method. Heart rate was decreased in the 50 μg·kg− 1 group compared to that in the 30 μg·kg− 1 group at timepoints T7, T8, and T10 (P = 0.0482, P = 0.0460, and P = 0.0236, respectively), but no difference was observed in the 20 μg·kg− 1 group. Systolic blood pressure was decreased in the 50 μg·kg− 1 group compared to that in the 20 μg·kg− 1 group at timepoints T2, T3, and T4 (P = 0.0159, P = 0.0233, and P = 0.0428, respectively). The train-of-four value was significantly lower in the 50 μg·kg− 1 group than in the 30 μg·kg− 1 group at timepoint T3 (P = 0.0326). Conclusions The ED50 of cis-atracurium was 26.5 μg·kg− 1 for laryngeal mask airway insertion. Trial registration Clinicaltrial.gov Registry, NCT03668262, Registered on 11 September 2018.
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Affiliation(s)
- Xiaohua Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, 100053, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China.
| | - Ke Huang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Hao Yan
- Department of Urinary surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Fei Lan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Dongxu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Yanhong Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Jixiu Xue
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, 100053, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China.
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Gaffar EA, Fattah SA, Atef HM, Omera MA, Abdel-Aziz MA. Kinemyography (KMG) versus Electromyography (EMG) neuromuscular monitoring in pediatric patients receiving cisatracurium during general anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Emad A. Gaffar
- Department of Anesthesiology, Faculty of Medicine , Suez Canal University Hospitals , Ismailia, Egypt
| | - Salah A. Fattah
- Department of Anesthesiology, Faculty of Medicine , Suez Canal University Hospitals , Ismailia, Egypt
| | - Hossam M. Atef
- Department of Anesthesiology, Faculty of Medicine , Suez Canal University Hospitals , Ismailia, Egypt
| | - Magdy A. Omera
- Department of Anesthesiology, Faculty of Medicine , Suez Canal University Hospitals , Ismailia, Egypt
| | - Mohammed A. Abdel-Aziz
- Department of Anesthesiology, Faculty of Medicine , Suez Canal University Hospitals , Ismailia, Egypt
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Abdulatif M, Lotfy M, Mousa M, Afifi MH, Yassen K. Sugammadex antagonism of rocuronium-induced neuromuscular blockade in patients with liver cirrhosis undergoing liver resection: a randomized controlled study. Minerva Anestesiol 2018; 84:929-937. [DOI: 10.23736/s0375-9393.18.12217-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Park WY, Choi JC, Yun HJ, Jeon YG, Park G, Choi JB. Optimal dose of combined rocuronium and cisatracurium during minor surgery: A randomized trial. Medicine (Baltimore) 2018; 97:e9779. [PMID: 29517695 PMCID: PMC5882426 DOI: 10.1097/md.0000000000009779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/14/2017] [Accepted: 01/11/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Combined rocuronium and cisatracurium have synergistic effects. We investigated whether reduced doses are effective during coadministration, by monitoring neuromuscular relaxation during surgery. METHODS This randomized, controlled clinical trial was registered at http://clinicaltrials.gov (registration number NCT02495038). The participants were 81 patients scheduled for elective mastoidectomy and tympanoplasty. Participants were assigned to groups, including the intubating dose group (Group I, n = 27; combined ED95 rocuronium and ED95 cisatracurium), the small reduction group (Group S, n = 27; dose reduced by 10% of each ED95), or the large reduction group (Group L, n = 27; dose reduced by 20% of each ED95). Drugs were administered to patients and a timer was started using TOF-Watch monitoring. TOF (train-of-four) was monitored at the ulnar nerve, at a setting of 2 Hz/12 s. We recorded the time to TOF ratio = 0 (onset), time to first TOF ratio > 25% (duration 25%), and TOF 25-75% (recovery index) under total intravenous anesthesia. One-way analysis of variance was used for statistical analyses (α = 0.05, β = 0.2). RESULTS There were no significant demographic differences between groups. Group L had a longer duration to onset (mean ± standard deviation, 399.3 ± 147.8 seconds) and shorter duration 25% (39.4 ± 6.8 minutes) compared to Group I (212.8 ± 56.0 s and 51.3 ± 8.47 minutes, respectively) and Group S (230.7 ± 60.6 s and 47.9 ± 10.7 minutes, respectively). There were no other significant differences between groups. CONCLUSION Our findings contribute to determining clinically effective combinations of rocuronium and cisatracurium, as well as to predicting the pharmacokinetic characteristics of the synergistic effects. We suggest that reducing doses of both drugs by approximately 10% of their respective ED95 values is sufficient to maintain neuromuscular relaxation during minor surgery.
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Affiliation(s)
- Woo Young Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Anesthesia, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | - Jae Chan Choi
- Department of Anesthesiology and Pain Medicine, Intensive Care Medicine, Brain Research Group, Yonsei University Wonju College of Medicine, Wonju
| | - Hey Jeong Yun
- Department of Anesthesia, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
| | | | - Gisoon Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Ajou University, College of Medicine, Suwon, Republic of Korea
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Liu Y, Cao W, Liu Y, Wang Y, Lang R, Yue Y, Wu AS. Changes in duration of action of rocuronium following decrease in hepatic blood flow during pneumoperitoneum for laparoscopic gynaecological surgery. BMC Anesthesiol 2017; 17:45. [PMID: 28320323 PMCID: PMC5359965 DOI: 10.1186/s12871-017-0335-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 03/01/2017] [Indexed: 11/10/2022] Open
Abstract
Background A moderate insufflation pressure and deep neuromuscular blockade (NMB) have been recommended in laparoscopic surgery in consideration of the possible reduction in splanchnic perfusion due to the CO2-pneumoperitoneum. Since the liver is the major organ for rocuronium metabolism, the question of whether NMB of rocuronium would change with the variation of liver perfusion during pneumoperitoneum during laparoscopic surgery merits investigation. Methods In this prospective study, a total of sixty female patients scheduled for either selective laparoscopic gynaecological surgery (group laparoscopy) or laparotomy for gynaecological surgery (group control) were analyzed. Rocuronium was administered with closed-loop feedback infusion system, which was also applied to monitor NMB complied with good clinical research practice (GCRP). The onset time, clinical duration, and recovery index were measured. Hepatic blood flow was assessed by laparoscopic intraoperative ultrasonography before insufflation/after entering the abdominal cavity (T1), 5 min after insufflation in the Trendelenburg position/5 min after skin incision (T2), 15 min after insufflation in the Trendelenburg position/15 min after skin incision (T3), 30 min after insufflation in the Trendelenburg position/30 min after skin incision (T4), and 5 min after deflation/before closing the abdomen (T5) in group laparoscopy/group control respectively. The relationship between the clinical duration of rocuronium and portal venous blood flow was analyzed using linear or quadratic regression. Result The clinical duration and RI of rocuronium were both prolonged significantly in group laparoscopy (36.8 ± 8.3 min; 12.8 ± 5.5 min) compared to group control (29.0 ± 5.8 min; 9.8 ± 4.0 min) (P < 0.0001; P = 0.018). A significant decrease was found in portal venous blood flow during the entire pneumoperitoneum period in group laparoscopy compared with group control (P < 0.0001). There was a significant correlation between the clinical duration of rocuronium and portal venous blood flow (Y = 51.800-0.043X + (1.86E-005) X2; r2 = 0.491; P < 0.0001). Conclusion Rocuronium-induced NMB during laparoscopic gynaecological surgery might be prolonged due to the decrease in portal venous blood flow induced by CO2-pneumoperitoneum. Less rocuronium could be required to achieve a desirable NMB in laparoscopic gynaecological surgery. Trial registration ChiCTR. Registry number: ChiCTR-OPN-15007524. Date of registration: December 4, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0335-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - Wen Cao
- Department of Ultrasonography, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - Yu Liu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - Ren Lang
- Department of Liver and Gallbladder, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - Yun Yue
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China.
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Jeon S, Kwon JY, Kim HK, Kim TK. Synergism between rocuronium and cisatracurium: comparison of the Minto and Greco interaction models. Korean J Anesthesiol 2016; 69:341-9. [PMID: 27482310 PMCID: PMC4967628 DOI: 10.4097/kjae.2016.69.4.341] [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: 02/15/2016] [Revised: 03/30/2016] [Accepted: 04/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background This study was conducted to investigate the pharmacodynamic interaction between rocuronium and cisatracurium using the response surface model, which is not subject to the limitations of traditional isobolographic analysis. Methods One hundred and twenty patients were randomly allocated to receive one of the fifteen predefined combinations of rocuronium and cisatracurium. To study single drugs, cisatracurium 0.2, 0.15, or 0.1 mg/kg or rocuronium 0.8, 0.6 or 0.4 mg/kg doses were administered alone. To study the pharmacodynamic interaction, drugs were applied in three types of combination ratio, i.e., half dose of each drug alone, 75% of each single dose of rocuronium and 25% of each single dose of cisatracurium, and vice versa. Train-of-four (TOF) ratio and T1% (first twitch of the TOF presented as percentage compared to the initial T1) were used as pharmacodynamic endpoints, and the Greco and Minto models were used as surface interaction models. Results The interaction term α of the Greco model for TOF ratio and T1% measurements showed synergism with values of 0.977 and 1.12, respectively. Application of the Minto model resulted in U50 (θ) values (normalized unit of concentration that produces 50% of the maximal effect in the 0 < θ < 1 region) less than 1 for both TOF ratio and T1% measurements, indicating that rocuronium and cisatracurium exhibit synergism. Conclusions Response surface modeling of the interaction between rocuronium and cisatracurium, based on considerations of their effects on muscle relaxation as measured by TOF ratio and T1%, indicated that the two drugs show considerable
synergism.
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Affiliation(s)
- Soeun Jeon
- Department of Anesthesia and Pain Medicine, Pusan National University Hospital, Busan, Korea
| | - Jae Young Kwon
- Department of Anesthesia and Pain Medicine, Pusan National University Hospital, Busan, Korea.; Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Hae-Kyu Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Hospital, Busan, Korea.; Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Tae Kyun Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.; Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
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Yu B, Ouyang B, Ge S, Luo Y, Li J, Ni D, Hu S, Xu H, Liu J, Min S, Li L, Ma Z, Xie K, Miao C, Wu X. Incidence of postoperative residual neuromuscular blockade after general anesthesia: a prospective, multicenter, anesthetist-blind, observational study. Curr Med Res Opin 2016; 32:1-9. [PMID: 26452561 DOI: 10.1185/03007995.2015.1103213] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Evidences demonstrate that postoperative residual neuromuscular blockade (rNMB) is a primary and frequent anesthetic risk factor for postoperative complications. This study was designed to mitigate the paucity of data regarding the occurrence and degree of rNMB in a real-life setting. METHODS This prospective, multicenter, anesthetist-blind, observational study enrolled 1571 Chinese adults undergoing elective open or laparoscopic abdominal surgery lasting ≤4 hours from 32 hospitals across China. The patients received anesthesia in accordance with routine practice at the study site. Neuromuscular blockade (NMB) was monitored using acceleromyography, with rNMB defined as a train-of-four (TOF) ratio <0.9. RESULTS The patients' mean age was 46 years and 71% were female. The procedures included laparoscopic (67%), open abdominal (31%), and laparoscopic to open abdominal (2%). NMB was reversed with neostigmine in 78% of patients. The overall incidence of rNMB at extubation was 57.8%, and the proportions of participant with TOF ratios <0.6, 0.6-0.7, 0.7-0.8, 0.8-0.9 were 22.9%, 6.9%, 11.1% and 16.9%, respectively, immediately prior to endotracheal extubation. Age <45 years (OR = 0.630, 95% CI = 0.496-0.801, p = 0.002), use of one neuromuscular blocking agent (NMBA) (OR = 0.387, 95% CI = 0.243-0.618, p < 0.0001), time from neostigmine administration to endotracheal extubation ≥10 min (OR = 0.513, 95% CI = 0.400-0.658, p < 0.0001) and time from last NMBA administration to endotracheal extubation ≥60 min (OR = 0.902, 95% CI = 0.801-0.989, p = 0411) were correlated with non-rNMB at the time of extubation. CONCLUSIONS This observational study demonstrated that the overall incidence of rNMB at the time of endotracheal extubation was high in Chinese patients undergoing abdominal procedures, which necessitates appropriate management in current real-life practice. CLINICAL TRIAL REGISTRY NUMBER NCT01871064.
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Affiliation(s)
- Buwei Yu
- a a Department of Anesthesiology , Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Baoyi Ouyang
- b b The First Affiliated hospital of Guangzhou Medical University , Guangzhou , China
| | - Shengjin Ge
- c c Zhongshan Hospital of Fudan University , Shanghai , China
| | - Yan Luo
- a a Department of Anesthesiology , Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Jun Li
- d d The Second Affiliated Hospital of Wenzhou Medical College , Wenzhou , China
| | - Dongmei Ni
- e e Peking University First Hospital , Beijing , China
| | - Shuangfei Hu
- f f Zhejiang Provincial People's Hospital , Hangzhou , China
| | - Hui Xu
- g g Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology , Wuhan , China
| | - Jin Liu
- h h West China Hospital, West China School of Medicine, Sichuan University , Chengdu , China
| | - Su Min
- i i The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Longyun Li
- j j China-Japan Union Hospital, Jilin University , Changchun , China
| | - Zhengliang Ma
- k k Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School , Nanjing , China
| | - Kangjie Xie
- l l Zhejiang Cancer Hospital , Hangzhou , China
| | - Changhong Miao
- m m Fudan University Shanghai Cancer Center , Shanghai , China
| | - Xinmin Wu
- e e Peking University First Hospital , Beijing , China
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Dahaba A, Suljevic I, Bornemann H, Wu XM, Metzler H. No regional difference in cisatracurium dose–response and time-course-of-action between patients in China and Bosnia. Br J Anaesth 2011; 106:331-335. [DOI: 10.1093/bja/aeq369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Kopman A, Lien C, Naguib M. Neuromuscular dose–response studies: determining sample size. Br J Anaesth 2011; 106:194-8. [DOI: 10.1093/bja/aeq310] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kopman A, Lien C, Naguib M. Determining the potency of neuromuscular blockers: are traditional methods flawed? Br J Anaesth 2010; 104:705-10. [DOI: 10.1093/bja/aeq094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Claudius C, Skovgaard LT, Viby-Mogensen J. Acceleromyography and mechanomyography for establishing potency of neuromuscular blocking agents: a randomized-controlled trial. Acta Anaesthesiol Scand 2009; 53:449-54. [PMID: 19317862 DOI: 10.1111/j.1399-6576.2008.01866.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acceleromyography (AMG) is increasingly being used in neuromuscular research, including in studies establishing the potency of neuromuscular blocking and reversal agents. However, AMG is insufficiently validated for use interchangeably with the gold standard, mechanomyography (MMG) for this purpose. The aim of this study was to compare AMG and MMG for establishing dose-response relationship and potency, using rocuronium as an example. METHODS We included 40 adult patients in this randomized-controlled single-dose response study. Anaesthesia was induced and maintained with propofol and opioid. Neuromuscular blockade was induced with rocuronium 100, 150, 200 or 250 microg/kg. Neuromuscular monitoring was performed with AMG (TOF-Watch SX) with pre-load (Hand Adapter) at one arm and MMG (modified TOF-Watch SX) on the other, using 0.1 Hz single twitch stimulation. Dose-response relationships were determined for both recording methods using log (dose) against probit (maximum block). The obtained slopes of the regression lines, ED(50), ED(95) and the maximum block were compared. RESULTS The ED(50) and ED(95) [95% confidence interval (CI)] for AMG were 185 microg/kg(167-205 microg/kg) and 368 microg/kg(288-470 microg/kg), compared with 174 microg/kg(159-191 microg/kg) and 338 microg/kg(273-418 microg/kg) for MMG. There were no statistically significant biases in maximum block, ED(50), ED(95) or slopes obtained with the two methods. CONCLUSION Our results indicate that any possible difference between AMG and MMG is so small that it justifies AMG to be used for establishing the potency of neuromuscular blocking agents. However, the wide CIs show that we cannot rule out a 13% higher ED(50) and a 26% higher ED(95) for AMG.
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Affiliation(s)
- C Claudius
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, DK - Denmark.
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Liu M, Dilger JP. Synergy between pairs of competitive antagonists at adult human muscle acetylcholine receptors. Anesth Analg 2008; 107:525-33. [PMID: 18633030 DOI: 10.1213/ane.0b013e31817b4469] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Synergistic neuromuscular blocking effects have been observed clinically with certain pairs of nicotinic acetylcholine receptor (nAChR) competitive antagonists. The mechanism for synergy has not been elucidated. We tested the hypothesis that synergy arises from a differential selectivity of antagonists for the two ligand binding sites on adult human nAChR. METHODS We expressed nAChR in BOSC23 cells. We applied ACh with or without antagonists to outside-out patches and measured macroscopic currents at room temperature. We determined the IC(90) for (+)-tubocurarine, metocurine, pancuronium, vecuronium, cisatracurium, rocuronium, and atracurium. For 15 combinations of two antagonists, we determined the IC(90) for one antagonist in the presence of the IC(70) of a second antagonist. We constructed isobolograms for 90% inhibition. For single antagonists, we measured inhibition of receptors containing mutations in the epsilon- and delta-subunits to determine site selectivity. RESULTS Two pairs of antagonists, metocurine+cisatracurium and cisatracurium+ atracurium exhibited additive inhibition. Ten combinations, including (+)-tubocurarine+ pancuronium and pancuronium+vecuronium, were highly synergistic such that the combination was two to three times more effective than expected for additivity. Three combinations were 1.5-1.6 times more effective than expected for additivity. Inhibition by (+)-tubocurarine and metocurine was sensitive to mutations in the epsilon-subunit only. Vecuronium was affected by the delta-subunit mutation only. Inhibition by other antagonists was decreased by mutations in either subunit. CONCLUSIONS Many combinations of antagonists exhibited synergistic effects on adult human nAChR. Synergy was observed with structurally similar and dissimilar antagonists. The degree of synergy did not always correlate well with site specificity assayed with mutants. In some, but not all cases, the synergy at the receptor level correlated with clinical determinations of synergy. We conclude that the synergistic actions of muscle relaxants can be partially explained by direct interactions with adult human nAChR.
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Affiliation(s)
- Man Liu
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11790, USA
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15
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Maybauer DM, Geldner G, Blobner M, Pühringer F, Hofmockel R, Rex C, Wulf HF, Eberhart L, Arndt C, Eikermann M. Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium. Anaesthesia 2007; 62:12-7. [PMID: 17156221 DOI: 10.1111/j.1365-2044.2006.04862.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In a randomised, controlled, double-blind, multicentre trial in 338 patients, we assessed the incidence of residual paralysis following administration of cisatracurium or rocuronium. The incidence at the end of surgery was significantly lower in patients treated with rocuronium (62 of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28) min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top-up dose to recovery of the train-of-four ratio to 0.9) was significantly longer and more variable for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and variability of duration of action are greater with rocuronium compared with cisatracurium. These pharmacodynamic differences do not necessarily translate into a higher incidence of residual paralysis, because clinicians compensate for the longer duration of action and variability of rocuronium by terminating administration of the neuromuscular blocking earlier.
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Affiliation(s)
- D M Maybauer
- Klinik für Anästhesiologie und Intensivmedizin, Philipps-Universität Marburg, Germany
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Mak PHK, Irwin MG. The effect of cisatracurium and rocuronium on cisatracurium precurarization and the priming principle. J Clin Anesth 2004; 16:83-7. [PMID: 15110367 DOI: 10.1016/j.jclinane.2003.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2002] [Revised: 04/28/2003] [Accepted: 04/28/2003] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE To demonstrate the effect of administering a precurarizing dose of cisatracurium or rocuronium on the speed of onset of cisatracurium, and to review the possible mechanisms and value of the priming principle. DESIGN Double-blind, randomized, controlled trial. SETTING Inpatient anesthesia in a university teaching hospital. PATIENTS 90 ASA physical status I and II patients undergoing elective surgery requiring endotracheal intubation. INTERVENTIONS Three groups of 30 patients each were investigated. Following induction of anesthesia with fentanyl and propofol, Group 1 received cisatracurium 0.015 mg.k(-1), Group 2 received rocuronium 0.09 mg. kg(-1), and Group 3 (control) received normal saline. Six minutes after priming, Groups 1 and 2 received cisatracurium 0.135 mg. kg(-1) whereas Group 3 received cisatracurium 0.15 mg. kg(-1). MEASUREMENTS AND MAIN RESULTS In each group, first twitch height and the train-of-four ratios were recorded every 10 seconds after the initial priming dose. Intubation was attempted after the first twitch height became less than 15% of baseline. The decrease in the train-of-four ratios at 6 minutes was 0.97 for cisatracurium and 0.85 for rocuronium. The onset of muscle relaxation was significantly faster after priming with cisatracurium and rocuronium (71.7 +/- 21.3 and 65 +/- 19.8 sec, respectively) compared with control (148.7 +/- 43.1 sec). Females receiving both muscle relaxants had a faster onset of paralysis than did males (65.9 +/- 20.6 vs. 79.2 +/- 20.6 and 55 +/- 14.5 vs. 71.7 +/- 20.4 sec). Intubation conditions were either excellent or satisfactory in all patients. CONCLUSIONS Six minutes after precurarization, there is no significant difference between rocuronium and cisatracurium when used as priming drugs. An even faster onset time with both drugs was demonstrated in females. The use of priming doses of 25% to 30% of ED(95) may cause symptomatic muscle weakness. The mechanisms of the priming principle are discussed.
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Affiliation(s)
- Peter H K Mak
- Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, Taiwan ROC.
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Dugdale AHA, Adams WA, Jones RS. The clinical use of the neuromuscular blocking agent rocuronium in dogs. Vet Anaesth Analg 2002; 29:49-53. [DOI: 10.1046/j.1467-2987.2001.00057.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2000] [Accepted: 01/15/2001] [Indexed: 11/20/2022]
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Jellish WS, Brody M, Sawicki K, Slogoff S. Recovery from neuromuscular blockade after either bolus and prolonged infusions of cisatracurium or rocuronium using either isoflurane or propofol-based anesthetics. Anesth Analg 2000. [PMID: 11049917 DOI: 10.1213/00000539-200011000-00037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We examined the recovery characteristics of cisatracurium or rocuronium after bolus or prolonged infusion under either isoflurane or propofol anesthesia. Sixty patients undergoing neurosurgical procedures of at least 5 h were randomized to receive either isoflurane with fentanyl (Groups 1 and 2) or propofol and fentanyl (Groups 3 and 4) as their anesthetic. Groups 1 and 3 received cisatracurium 0.2 mg/kg IV bolus, spontaneously recovered, after which time an infusion was begun. Groups 2 and 4 received rocuronium 0.6 mg/kg IV, spontaneously recovered, and an infusion was begun. Before the end of surgery, the infusion was stopped and recovery of first twitch (T(1)), recovery index, clinical duration, and train-of-four (TOF) recovery was recorded and compared among groups by using appropriate statistical methods. Clinical duration was shorter for rocuronium compared with cisatracurium using either anesthetic. Cisatracurium T(1) 75% recovery after the infusion was shorter with propofol compared with isoflurane. Cisatracurium TOF 75% recovery was similar after either bolus or infusion, but rocuronium TOF 75% recovery after the infusion was delayed. Infusion rates decreased for cisatracurium but remained relatively constant for rocuronium regardless of the anesthetic used. Isoflurane enhances the effect of both muscle relaxants but prolonged cisatracurium recovery more than rocuronium. Of the two muscle relaxants studied, rocuronium's recovery was most affected by length of the infusion. Cisatracurium may be a more desired muscle relaxant for prolonged procedures because recovery was least affected by prolonged infusion. IMPLICATIONS This study describes the effect of different anesthetic techniques on the recovery of two different muscle relaxants, cisatracurium and rocuronium, when administered as either a single bolus or prolonged infusion during neurosurgery. This study demonstrates the feasibility of using these relaxants for these prolonged procedures.
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Affiliation(s)
- W S Jellish
- Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois 60153, USA.
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Jellish WS, Brody M, Sawicki K, Slogoff S. Recovery from neuromuscular blockade after either bolus and prolonged infusions of cisatracurium or rocuronium using either isoflurane or propofol-based anesthetics. Anesth Analg 2000; 91:1250-5. [PMID: 11049917 DOI: 10.1097/00000539-200011000-00037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED We examined the recovery characteristics of cisatracurium or rocuronium after bolus or prolonged infusion under either isoflurane or propofol anesthesia. Sixty patients undergoing neurosurgical procedures of at least 5 h were randomized to receive either isoflurane with fentanyl (Groups 1 and 2) or propofol and fentanyl (Groups 3 and 4) as their anesthetic. Groups 1 and 3 received cisatracurium 0.2 mg/kg IV bolus, spontaneously recovered, after which time an infusion was begun. Groups 2 and 4 received rocuronium 0.6 mg/kg IV, spontaneously recovered, and an infusion was begun. Before the end of surgery, the infusion was stopped and recovery of first twitch (T(1)), recovery index, clinical duration, and train-of-four (TOF) recovery was recorded and compared among groups by using appropriate statistical methods. Clinical duration was shorter for rocuronium compared with cisatracurium using either anesthetic. Cisatracurium T(1) 75% recovery after the infusion was shorter with propofol compared with isoflurane. Cisatracurium TOF 75% recovery was similar after either bolus or infusion, but rocuronium TOF 75% recovery after the infusion was delayed. Infusion rates decreased for cisatracurium but remained relatively constant for rocuronium regardless of the anesthetic used. Isoflurane enhances the effect of both muscle relaxants but prolonged cisatracurium recovery more than rocuronium. Of the two muscle relaxants studied, rocuronium's recovery was most affected by length of the infusion. Cisatracurium may be a more desired muscle relaxant for prolonged procedures because recovery was least affected by prolonged infusion. IMPLICATIONS This study describes the effect of different anesthetic techniques on the recovery of two different muscle relaxants, cisatracurium and rocuronium, when administered as either a single bolus or prolonged infusion during neurosurgery. This study demonstrates the feasibility of using these relaxants for these prolonged procedures.
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Affiliation(s)
- W S Jellish
- Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois 60153, USA.
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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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Donati F. Neuromuscular blocking drugs for the new millennium: current practice, future trends--comparative pharmacology of neuromuscular blocking drugs. Anesth Analg 2000; 90:S2-S6. [PMID: 10809511 DOI: 10.1097/00000539-200005001-00002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- François Donati
- Department of Anesthesia, University of Montréal, Montréal, Québec, Canada
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22
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Motamed C, Donati F. Intubating conditions and blockade after mivacurium, rocuronium and their combination in young and elderly adults. Can J Anaesth 2000; 47:225-31. [PMID: 10730732 DOI: 10.1007/bf03018917] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Mivacurium-rocuronium combinations have been demonstrated to be more potent than either drug given alone. Combinations were compared with mivacurium and rocuronium, with respect to onset, intubating conditions, and duration of action in young and elderly adults. METHODS Fentanyl-propofol-N2O-isoflurane anesthesia was given to ASA I and II adults aged 18-65 yr (45 patients) and over 66 yr (45 patients). In this blinded randomized study, we compared accelerographic adductor pollicis response and visual assessment of response to facial nerve stimulation after 0.25 mg x kg(-1) mivacurium, 0.6 mg x kg(-1) rocuronium, and a combination of 0.08 mg kg(-1) mivacurium plus 0.2 mg x kg(-1) rocuronium. Intubating conditions at 2.5 min were rated as excellent, good, fair or poor. RESULTS Onset times were similar for all drugs regimens and for both age groups (204-276 sec at the thumb; 142-196 sec at the eye) (P<0.05 between muscles). Intubating conditions were similar in all groups, and rated good or excellent, except in two subjects. In young patients duration to 25% recovery was longer (P<0.05) for rocuronium (mean +/- SD) (39+/-11 min) than for either mivacurium (23+/-6 min), or the combination (27+/-7 min). Duration was prolonged in the elderly for rocuronium (54+/-17 min), and the combination (35+/-11 min), but not for mivacurium (24+/-6 min). CONCLUSIONS Mivacurium-rocuronium combinations yield onset times and intubating conditions similar to either parent agent with only two thirds as much total drug. Duration for such a mixture is similar to that of mivacurium in young adults and slightly prolonged in the elderly.
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Affiliation(s)
- C Motamed
- Department of Anaesthesia, Hôtel-Dieu, Centre Hospitalier de l'Université de Montréal, Québec, Canada
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Lien CA. Combining non-depolarizing neuromuscular blocking agents: synergism, addition or antagonism? Curr Opin Anaesthesiol 1999; 12:467-71. [PMID: 17013353 DOI: 10.1097/00001503-199908000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the quality of currently available relaxants has improved, the need to combine relaxants to minimize the incidence and severity of their side-effects has decreased. Little work has been done in the past year characterizing the effects of combining different non-depolarizing neuromuscular blocking agents. That which has been done sheds some light on the nature of their interactions.
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Affiliation(s)
- C A Lien
- Department of Anesthesiology, New York Presbyterian Hosiptal, New York, NY, USA
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Affiliation(s)
- D R Bevan
- Department of Anesthesia, Vancouver Hospital & Health Sciences Centre, B.C., Canada
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