Evaluation of the three different doses of cisatracurium during general anaesthesia: A prospective randomized study

Background and Aims

The present study was conducted to determine the optimal dose of cisatracurium for intubating conditions and onset and offset of neuromuscular blockade. Data in Indian population are scarce, and hence, the present study was planned to evaluate different doses of cisatracurium.

Material and Methods

The prospective randomized double-blind study was conducted on 180 patients of either sex in the age group of 20-60 yrs., having physical status class I to III, scheduled for surgery under general anesthesia. After exclusion 154 patients were randomly divided into three groups comprising 52, 51, and 51, respectively, in Group A, Group B, and group C. They received 0.1 mgkg-1, 0.2 mgkg-1, and 0.3 mgkg-1 of cisatracurium, respectively, to facilitate endotracheal intubation. Time of onset, intubating conditions, hemodynamic parameters, signs of histamine release, and recovery time were noted.

Results

Mean time to onset was maximum in group A (4.37 ± 0.48 minutes) and minimum in group C (2.33 ± 0.43 minutes). Intubating conditions were found excellent in 88% patients in group. Change in HR was found to be non-significant at all time periods, but decrease in MAP was found between 2 and 10 minutes in group C. Duration of action was longest in group C.

Conclusion

We conclude that cisatracurium in dose of 0.2 mgkg-1 and 0.3 mgkg-1 provides good-to-excellent intubating conditions within less than 3 minutes.

Neuromuscular blockade characteristics of cisatracurium in patients receiving chemotherapy: A preliminary study in breast cancer patients

Background and Aims

Cancer chemotherapeutic agents cause alteration in the response to neuromuscular blocking drugs, which can have serious perioperative implications. Magnesium, commonly found to be deficient in these patients, plays an indispensable role in neuromuscular transmission. This study aimed to understand the effect of neoadjuvant chemotherapy on the neuromuscular blocking properties of cisatracurium.

Material and Methods

One hundred female patients scheduled for breast cancer surgery were divided into two groups (n = 50 each). Group B received neoadjuvant chemotherapy with taxane, adriamycin, and cyclophosphamide, and Group A did not receive neoadjuvant chemotherapy. Neuromuscular block following cisatracurium 0.15 mg/kg was measured using peripheral nerve stimulator at the ulnar nerve. Onset time, duration of intense block, clinical duration of action, time to TOF4 after the last dose of cisatracurium, along with preoperative serum magnesium concentration were measured. Correlation and multiple regression were run to analyze the relationship between history of neoadjuvant chemotherapy, preoperative magnesium, and the abovementioned time points. Mediation analysis was done to ascertain if magnesium was mediating the observed effects.

Results

Onset time was prolonged by nearly 18% in Group B compared to Group A (P = 0.001). The duration of intense block was 35.27 ± 8.9 min in Group B and 42.07 ± 10.99 min in Group A (P < 0.001). The clinical duration of action of cisatracurium was significantly shorter in Group B (46.06 ± 8.68 min) compared to Group A (55.87 ± 11.04 min, P < 0.001). The time to TOF4 was 32.86 ± 5.66 min in Group B and 36.57 ± 8.49 min in Group A (P < 0.05). Preoperative serum magnesium levels were significantly lower in Group B (P < 0.001).

Conclusion

Patients who had received neoadjuvant chemotherapy had a delayed onset, shorter duration of action, and faster recovery for cisatracurium. Although preoperative magnesium levels were lower in Group B, it was found to be an independent predictor rather than a mediator of these effects.

Comparison of Intubating Conditions at 60 Seconds with Cisatracurium 4*ED95 Dose and Cisatracurium 2*ED95 Dose Plus Priming Dose and Low Dose Ketamine

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.

Comparison of Relaxometry Between Ulnar Nerve and Posterior Tibial Nerve After Cisatracurium Administration Using Electromyography

BACKGROUND

Electromyography can be used for quantitative neuromuscular monitoring during general anesthesia, mostly using the stimulation train-of-four (TOF) pattern. Relaxometry measures the muscular response of the adductor pollicis muscle to electrical stimulation of the ulnar nerve, which is routinely used in clinical practices for monitoring the neuromuscular block. However, when it is not always possible to be used for all patients, the posterior tibial nerve is a suitable alternative.

OBJECTIVES

Using electromyography, we compared the neuromuscular block between the ulnar and the posterior tibial nerves.

METHODS

In this study, the participants were 110 patients who met inclusion criteria and submitted their written consent. Following the administration of cisatracurium intravenously, the patients had relaxometry performed simultaneously on the ulnar and the posterior tibial nerves using electromyography.

RESULTS

Eighty-seven patients were included in the final analysis. The onset time was 296 ± 99 s at the ulnar nerve and 346 ± 146 s at the tibial nerve, with a mean difference of -50 s and a standard deviation of 164 s. The 95% limits of agreement ranged from -372 s to 272 s. The relaxation time was 105 ± 26 min at the ulnar nerve and 87 ± 25 min at the tibial nerve, with a mean difference of 18 min and a standard deviation of 20 min.

CONCLUSIONS

Using electromyography, no statistically significant difference was noticed between the ulnar and the posterior tibial nerve during the neuromuscular block. The onset time and the relaxation time assessed with an electromyogram to compare the stimulation of the ulnar and posterior tibial nerves showed large limits of agreement.

A Comparative Study of the Effect of Low-Dose Epinephrine and Ketamine on Rapid-Sequence Endotracheal Intubation by the Priming Dose Method of Cisatracurium in Patients under General Anesthesia

Background

Low-dose ephedrine and ketamine may accelerate the onset time of action of neuromuscular blocking agents. We studied the effect of ephedrine and ketamine and cisatracurium priming on endotracheal intubation conditions and the onset time of action of cisatracurium.

Materials and Methods

The study was a double-blind clinical trial performed on American Society of Anesthesiologists (ASA) class 1 and 2 patients, who were candidates for general anesthesia. In total, 120 patients were entered into the study and were divided into 4 groups, E, K, E + K, and N. The first group was given 70 mcg/kg ephedrine (E group), the second group was given 0.5 ml/kg ketamine (K group), the third group was given the same amount of ketamine plus ephedrine (E + K group), and the fourth group was given the same volume of normal saline (control group); a single dose of 0.1 mg/kg cisatracurium was given, and intubating conditions were evaluated at 60 seconds after cisatracurium administration.

Results

The mean Cooper score based on the response to laryngoscopy, the position of the vocal cords, and the movement of the diaphragm of patients in the control group with a mean of 2.53 ± 1.07 was significantly lower than in the three groups of E, K, and E + K with the means of 4.47. 1.17, 4.53 ± 1.14, and 7.63 ± 1.42, respectively (P value < 0.001). In the (E + K) group, it was significantly higher than in the two other drugs alone (P value < 0.001). The two groups of E and K alone were not significantly different from each other (P value = 0.997). The means of hemodynamic parameters were not significantly different in any of the groups (P value > 0.05).

Conclusion

According to the results of the present study, the use of low-dose ephedrine and ketamine alone can improve intubation conditions. In addition, the combined use of these drugs not only had any Positive effect on patients' hemodynamic parameters but also greatly improved intubation conditions.

A comparison of neuromuscular blockade and reversal using cisatricurium and neostigmine with rocuronium and sugamadex on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage

Background

There is a growing interest in minimally invasive left atrial appendage closure therapies. However, for successful catheter surgery, it is necessary to achieve high-quality postoperative recovery. The aim of the study is to comparison of neuromuscular blockade and reversal using cisatricurium and neostigmine with rocuronium and sugamadex on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage.

Methods

Eighty-four patients who received percutaneous LAAC were randomly placed into two groups, general anesthesia and endotracheal intubation with either propofol-remifentanil-cisatracurium-neostigmine (group C) or propofol-remifentanil-rocuronium-sugammadex (group S). The QoR-40 questionnaire was used to assess recovery quality 6 h after surgery, and the time of spontaneous respiration, the time of consciousness recovery, the time of extubation, the duration in the postanaesthesia care unit (PACU), and the adverse events after awakening were collected.

Results

Compared with the group C, the group S demonstrated significantly higher individual QoR-40 dimension scores, a significantly shorter recovery time for spontaneous respiration and consciousness, time of extubation, and duration in the PACU, and a lower incidence of transient hypoxemia, agitation, nausea and vomiting and urinary retention. There was a non-significant trend for the length of stay in the hospital in both groups.

Conclusions

General anesthesia and endotracheal intubation with propofol-remifentanil-rocuronium-sugammadex provided better quality of recovery, shorter anaesthesia duration, and lower incidence of hypoxemia and agitation. Neuromuscular blockade and reversal using rocuronium and sugamadex is better than with cisatricurium and neostigmine on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage.

Trial registration: chictr.org, ChiCTR2000031857. Registered on April 12, 2020.

An Italian single-center, 2014-2017 retrospective cohort case-control study

Background

The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation.

Methods

A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications.

Results

No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001).

Conclusions

Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.

Comparison of hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is nowadays used commonly as one the most effective treatment methods in psychiatric disorders. In patients undergoing ECT, succinylcholine is usually used. In addition, cisatracurium is occasionally used on a case report basis globally. In this study, we compared the hemodynamic changes and serum potassium levels in the use of succinylcholine and cisatracurium in ECT.

MATERIALS AND METHODS

The current crossover clinical trial was performed on 45 patients who were candidates for ECT between 2017 and 2018. The patients were given succinylcholine or cisatracurium randomly on two separate occasions of ECT. The independent t-test and Chi square Test were used to compare the data.

RESULTS

Comparison of mean systolic blood pressure (P = 0.14), diastolic blood pressure (P = 0.33), and mean arterial pressure (P = 0.23) did not show any significant difference between the two groups. The induced seizure duration (P = 0.002), return of spontaneous respiratory from seizure ending (P = 0.001), and apnea duration (P = 0.01) were significantly higher in the cisatracurium group compared to the succinylcholine group. However, the frequency of tachycardia in cisatracurium group was lower than the succinylcholine group (P < 0.001). In addition, the serum potassium level had a significant difference (P < 0.001) between the two groups.

CONCLUSION

Using cisatracurium can be an alternative to succinylcholine during ECT since it causes less elevation in serum potassium and creates a longer duration of induced seizure, more rapid re emergence of spontaneous breathing at the end of seizure (P = 0.001), and a lower prevalence of tachycardia compared to succinylcholine (P < 0.001).

[Effect of Cisatracurium to Intensify Diaphragmatic Atrophy in Mechanically Ventilated Rats]

OBJECTIVE

To investigate the role of cisatracurium in diaphragm atrophy in mechanically ventilated (MV) rats and its possible mechanism.

METHODS

30 adult male Sprague-Dawley (SD) rats were randomly assigned to 5 groups: Rats in the control (CON) group ( n=6) were fasted for 30 h without any other intervention; rats in the MV group ( n=6) were fasted for 6 h, and then mechanically ventilated for 24 h while receiving continuous infusion of sodium pentobarbital and 0.9% NaCl; rats in the MV+cisatracurium (MVC) group ( n=6) were fasted for 6 h, and then mechanically ventilated for 24 h while receiving continuous infusion of sodium pentobarbital and cisatracurium; rats in the MV+chloroquine (QMV) group ( n=6) and rats in the MV+cisatracurium+chloroquine (QMVC) group ( n=6) received intraperitoneal injection of chloroquine (30 mg/kg), an autophagy inhibitor, at 24 h and 30 min prior to MV in addition to the treatments given to the MV group and the MVC group, respectively. The rats in each group were sacrificed 30 hours later, and costal diaphragm muscle specimens were collected. The cross-sectional area (CSA) of the diaphragm fibers was observed through HE staining, and the colocalizations of TOM20 and LC3 were assessed by immunofluorescence staining. The expression levels of PINK1, Parkin, P62 and LC3, the mitophagy-related proteins, and the expression levels of MAFbx and MURF-1, muscular-atrophy-related proteins, were evaluated by Western blot.

RESULTS

Respective comparisons of the MV group with the CON group and the MVC group with the MV group showed that the CSA decreased ( P<0.05), the expression of MURF-1, MAFbx, PINK1, Parkin and LC3Ⅱ/Ⅰproteins increased ( P<0.05), the number of co-expressed mitochondria of TOM20 and LC3 and the expression of LC3 increased and the expression of P62 protein decreased ( P<0.05) in the MV and MVC groups. Respective comparisons of the QMV group with the MV group and the QMVC group with the MVC group showed that the CSA increased ( P<0.05), the expression of MURF-1, MAFbx, PINK1, Parkin and LC3Ⅱ/Ⅰ proteins increased ( P<0.05), the number of co-expressed mitochondria of TOM20 and LC3 and the expression of LC3 decreased and the expression of P62 protein decreased ( P<0.05) in the QMV and QMVC group.

CONCLUSION

Mechanical ventilation for 24 h caused diaphragm atrophy in SD rats. Cisatracurium may aggravate diaphragm atrophy in mechanically ventilated rats through the autophagy-lysosome (AL) pathway, a process that may be related to the PINK1/Parkin-mediated mitophagy, and chloroquine may reduce diaphragmatic atrophy induced by cisatracurium by blocking the AL pathway.

Targeting miRNAs with anesthetics in cancer: Current understanding and future perspectives

Anesthetics are extensively used during cancer surgeries. The progression of cancer can be influenced by perioperative events such as exposure to general or local anesthesia. However, whether they inhibit cancer or act as a causative factor for metastasis and exert deleterious effects on cancer growth differs based on the type of cancer and the therapy administration. Recent experimental data suggested that many of the most commonly used anesthetics in surgical oncology, whether general or local agents, can alter gene expression and cause epigenetic changes via modulating miRNAs. miRNAs are single-stranded non-coding RNAs that regulate gene expression at various levels, and their dysregulation contributes to the pathogenesis of cancers. However, anesthetics via regulating miRNAs can concurrently target several effectors of cellular signaling pathways involved in cell differentiation, proliferation, and viability. This review summarized the current research about the effects of different anesthetics in regulating cancer, with a particular emphasis on the role of miRNAs. A significant number of studies conducted in this area of research illuminate the effects of anesthetics on the regulation of miRNA expression; therefore, we hope that a thorough understanding of the underlying mechanisms involved in the regulation of miRNA in the context of anesthesia-induced cancer regulation could help to define optimal anesthetic regimens and provide better perspectives for further studies.

Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation

Purpose

Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy.

Methods

We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018. We categorized patients into one of three dosing strategies: fixed dose (FD), titration based solely on train-of-four (TOF), or the VSP. We documented drug consumption and determined efficacy by comparing the change in PaO₂/FiO₂ ratio (P/F) and oxygenation index (OI) from baseline up to 48 h.

Results

A total of 1047 patients were screened, and 189 met inclusion criteria (VSP = 69, TOF = 99, FD = 21). Drug consumption (mg) was significantly lower in the VSP arm: 415 [IQR 318–528] compared to both the TOF: 665 [IQR 472–927] and the FD arms: 1730 [IQR 1695–1800], p < 0.001 for each. The change in P/F and OI from baseline were statistically equivalent at all time points.

Conclusion

Without impacting efficacy of gas exchange, a protocol using ventilator synchrony for CIS titration required significantly less drug compared to TOF-based titration and a fixed dosing regimen.

Neuromuscular blockade effects of cisatracurium in 11 cats undergoing ophthalmological surgery anaesthetised with isoflurane

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.

Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome

PURPOSE

To compare the ventilatory and clinical outcomes associated with a fixed-dose cisatracurium infusion versus a titrated infusion strategy in patients with Acute Respiratory Distress Syndrome (ARDS).

MATERIALS AND METHODS

Single-center, retrospective, cohort study in a medical ICU of a tertiary care academic medical center. Adult patients ≥18 years old with a continuous infusion of cisatracurium for ≥12 h for treatment of ARDS were included. The primary outcome was the PaO2 /FiO2 ratio assessed at 24 and 48 h following cisatracurium initiation. Secondary outcomes included amount of average dose of drug administered, 28-day ventilator-free days, LOS, and hospital mortality.

RESULTS

167 patients were included; median baseline PaO2/FiO2 was 97 (76-146), median SOFA score of 9 (7-11), and ICU mortality was 71/167 (43%). In a mixed-effects model, fixed dose and titrated cisatracurium associated with similar changes in PaO2/FiO2 assessed at 24 and 48 h (p = 0.316). Fixed-dose was associated with a >3-fold increase in drug exposure (average dose 6.4 (5.4-8.0) vs. 2.0 (1.5-2.8) mcg/kg/min; p < 0.001, respectively). No differences were observed in secondary clinical endpoints.

CONCLUSION

Fixed-dose cisatracurium was associated with similar ventilatory and clinical outcomes compared to titrated strategy, yet it was associated with a 3-fold increase in dose administered.

Cisatracurium inhibits the growth and induces apoptosis of ovarian cancer cells by promoting lincRNA-p21

As a common muscle relaxant, cisatracurium has shown good antitumor effect on some tumors. Recent studies reported that cisatracurium could inhibit the progression of colon cancer by upregulating tumor suppressor gene p53. However, its role in ovarian cancer and its regulatory effect on p53 and p53 downstream targeting gene long intergenic noncoding RNA p21 (lincRNA-p21) is still unknown. Quantitative Real-time Polymerase Chain Reaction (qRT-PCR) was used to assess the expression of p53, lincRNA-p21 and miR-181b. Cell viability and proliferation were detected by CCK-8 assay and Edu staining, respectively. Wound-healing and Transwell assays were performed to determine the abilities of cell migration and invasion. Apoptosis was evaluated by TUNEL staining. Luciferase reporter assay was conducted to detect the relationship between lincRNA-p21 and miR-181b. As a result, cisatracurium could increase the expressions of p53 and lincRNA-p21 of ovarian cancer cell line (OVCAR-3) in a dose-dependent manner. In addition, cisatracurium significantly inhibited the proliferation, migration and invasion of OVACR-3 cells, and induced apoptosis. However, these above changes in biological function can be attenuated by lincRNA-p21 knockdown. Next, lincRNA-p21 could directly target miR-181b and negatively regulate its expression by luciferase reporter assay. In conclusion, cisatracurium inhibited the progression of OVCAR-3 cells through upregulation of lincRNA-p21 expression activated by p53 inhibiting miR-181b expression. The experimental results provide a new research idea for the application of cisatracurium in ovarian cancer.

Cisatracurium attenuates LPS-induced modulation of MMP3 and junctional protein expression in human microvascular endothelial cells

Acute respiratory distress syndrome (ARDS) is a life-threatening form of acute lung injury (ALI) associated with hypoxemic lung damage and inflammation. Matrix metalloproteinase protein-3 (MMP3 or Stromelysin-1) is known to promote vascular injury in ALI/ARDS. Cisatracurium, a nicotinic neuromuscular blocker, is used in ARDS patients to decrease mechanical ventilator dyssynchrony, increase oxygenation, and improve mortality. However, the magnitude and the underlying mechanisms of these potential benefits of cisatracurium remains unclear. We investigated the effect of cisatracurium on lipopolysaccharide-induced MMP3 expression in human microvascular endothelial cells. In our results, cisatracurium treatment significantly decreased LPS-induced MMP3 expression and increased expression of cell junction proteins such as vascular endothelial cadherin (VE-cadherin) and claudin-5.

Cisatracurium regulates the CXCR4/let-7a-5p axis to inhibit colorectal cancer progression by suppressing TGF-β/SMAD2/3 signalling

OBJECTIVE

To reveal the effects and related mechanism of cisatracurium on colorectal cancer (CRC) development.

METHODS

HCT116 and SW480 cells were treated with various concentrations of cisatracurium or transforming growth factor-β (TGF-β). Chemokine C-X-C-Motif Receptor 4 (CXCR4) was overexpressed and let-7a-5p was silenced in cells by transfection with pcDNA3.1-CXCR4 or let-7a-5p inhibitor. Cell Counting Kit-8 (CCK-8) assay measured cell viability, and transwell and wound healing assays evaluated cell invasion and migration, respectively. The expression levels of let-7a-5p and CXCR4 were measured using quantitative reverse transcription polymerase chain reaction (qRT-PCR). Western blotting was conducted to test the levels of CXCR4, TGF-β/SMAD2/3 signalling and metastasis-related proteins. A tumour xenograft assay was performed to assess tumour growth.

RESULTS

Cisatracurium treatment suppressed the viability and metastasis of HCT116 and SW480 cells in a concentration-dependent manner, whereas activating TGF-β/SMAD2/3 signalling significantly reversed these effects. Cisatracurium treatment markedly reduced CXCR4 expression by inhibiting TGF-β/SMAD2/3 signalling. Besides, let-7a-5p was identified as a target of CXCR4 and could be upregulated by cisatracurium. Both CXCR4 overexpression and let-7a-5p knockdown alleviated the biological roles of cisatracurium in CRC cells. Moreover, a tumour xenograft assay further confirmed that cisatracurium inhibited tumour growth and metastasis by increasing let-7a-5p expression.

CONCLUSION

Cisatracurium suppressed the viability, metastasis and tumour growth of CRC by regulating the CXCR4/let-7a-5p axis via inhibiting TGF-β/SMAD2/3 signalling. These findings provide a theoretical basis for the role of cisatracurium in the prognosis of CRC patients.

Cisatracurium inhibits the proliferation, migration and invasion of breast cancer cells by regulating the expression of miR-3174

Breast cancer is a type of cancer that begins in the breast tissue. Being a woman is the most important factor in the risk of breast cancer. Although men also get the cancer, women are much more likely to get it. This experiment was founded to investigate the effect and mechanism of Cisatracurium on breast cancer cell proliferation, migration and invasion. Breast cancer cells MDA-MB-231 were cultured in vitro. MDA-MB-231 cells were treated with cisatracurium of different concentrations for 48 h. CCK-8method detected cell proliferation, Transwell detected cell migration and invasion, Western Blot method detected the expression levels of CyclinD1, p21, MMP-2andMMP-9protein in cells, RT-qPCR) detected the expression level of miR-3174in cells. After miR-3174 inhibitor was transfected into MDA-MB-231 in order to down-regulate the expression of miR-3174, the same methods as above were used to observe the effect of the down-regulating miR-3174 expression on MDA-MB-231 cell proliferation, migration and invasion as well as the expression levels of CyclinD1, p21, MMP -2 andMMP-9 protein. After different concentrations of Cisatracurium acted on MDA-MB-231 cells, the cell inhibition rate and p21 protein expression were significantly increased (p&lt;0.05), the number of cell migration and invasion and the expression levels of CyclinD1, MMP-2 and MMP-9 were significantly reduced (p&lt;0.05), and the expression of miR-3174 in cells was significantly reduced (p&lt;0.05). After down-regulating the expression of miR-3174, the cell inhibition rate and p21 protein expression were significantly increased (p&lt;0.05), the number of cell migration and invasion and the expression levels of CyclinD1, MMP-2 and MMP-9 were significantly reduced (p&lt;0.05). Up-regulating miR-3174 expression could reverse the effect of Cisatracurium on the proliferation, migration and invasion of MDA-MB-231 cells. Cisatracurium can inhibit the proliferation, migration and invasion of breast cancer MDA-MB-231 cells, and its mechanism is related to the down-regulation of miR-3174 expression in cells.

Conventional and first derivative synchronous spectrofluorimetric methods for the simultaneous determination of cisatracurium and nalbuphine in biological fluids

Cisatracurium besylate has been determined by fast and highly sensitive spectrofluorimetric method based on measuring the fluorescence intensity of its methanolic solution at 312 nm after excitation at 230 nm (Method I). The linearity occurred over the concentration range of 10.0-130.0 ng/mL with detection limit of 1.07 ng/mL. The method was further extended for the determination of the studied drug in spiked human plasma with good percentage recoveries (97.43-103.50%). Cisatracurium is co-administered with nalbuphine during surgery. The simultaneous determination of both drugs was based on synchronous spectrofluorimetric technique. First derivative synchronous spectrofluorimetric amplitude was measured in methanol at Δ λ = 60 nm and each drug could be estimated at the zero crossing point of the other. Hence, cisatracurium could be measured at 284.6 nm while nalbuphine at 276.3 nm (Method II). The method was linear over the ranges of 50.0-750.0 ng/mL and 0.5-7.0 μg/mL with the detection limits of 2.16 ng/mL and 0.04 μg/mL for cisatracurium and nalbuphine, respectively. The method was further extended for the simultaneous determination of both drugs in spiked human urine with mean percentage recoveries of 99.99 ± 2.06 and 99.53 ± 6.17 for cisatracurium and nalbuphine, respectively. Both methods were validated in agreement with Guidelines adopted by International Council of Harmonization (ICH).

Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials

Background

Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results.

Method

A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and meta-regression analysis were performed.

Results

From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO₂/FIO₂ of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78–1.03; I² = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62–1.06; I² = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)–induced weakness. The PaO₂/FIO₂ ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO₂/FIO₂ ratio, positive end-expiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes.

Conclusion

NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.

Abnormal cisatracurium pharmacodynamics and pharmacokinetics among patients with severe aortic regurgitation during anesthetic induction

Background

This study was designed to examine whether severe aortic regurgitation will affect the pharmacodynamics (PD) and pharmacokinetics (PK) of cisatracurium during anesthetic induction.

Methods

A total of 32 patients were divided into two groups: the AR group (n = 16) and the control group (n = 16). Arterial blood samples were drawn before and at 1, 2, 4, 6, 8, 10, 16 and 20 min after intravenous injection of 0.15 mg/kg cisatracurium. TOF tests were applied to determine the onset time of maximal muscle relaxation. The concentration of cisatracurium in plasma was determined by high-performance liquid chromatography.

Results

The onset time to maximal neuromuscular block was prolonged from 2.07 ± 0.08 min to 4.03 ± 0.14 min, which indicated that the PD responses to cisatracurium were significantly delayed in the AR group (P < 0.05) compared to the control group.

A conventional two-compartment PK model showed a higher plasma concentration of cisatracurium among the AR group with markedly reduced intercompartment transfer rate (K₁₂ = 0.19 ± 0.02 and K₂₁ = 0.11 ± 0.01 in the AR group vs. K₁₂₌0.26 ± 0.01 and K₂₁ = 0.19 ± 0.01 in the control group, P < 0.01) compared to the control group.

Conclusion

Backward blood flow during diastole in severe AR impaired distribution of cisatracurium from the central compartment to the peripheral compartment, which accounted for the lagged PD responses.

Findings in this study underlie the importance of muscular blockade monitoring among patients with severe aortic regurgitation during anesthetic induction.

Registration

Name of the registry: Abnormal Cisatracurium Pharmacodynamics and Pharmacokinetics among Patients with Severe Aortic Regurgitation during Anesthetic Induction. Trial registration number: ChiCTR1800019654. Date of registration: November 20th 2018.

Cisatracurium induces mast cell activation and pseudo-allergic reactions via MRGPRX2

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.

A Comparison Between the Hemodynamic Effects of Cisatracurium and Atracurium in Patient with Low Function of Left Ventricle who are Candidate for Open Heart Surgery

Background:

The need for muscle relaxants in general anesthesia in different surgeries including cardiac surgeries, and the type of relaxant to be used considering its different hemodynamic effects on patients with heart disease can be of considerable importance. In this study, the hemodynamic effects of two muscle relaxants, Cisatracurium and Atracurium in patients whit low function of left ventricle who are candidate for open heart surgery have been considered.

Method:

This study has been designed as a randomized prospective double-blind clinical trial. The target population included all adult patients with heart disease whose ejection fraction reported by echocardiography or cardiac catheterization was 35% or less before the surgery, and were candidate for open heart surgery in Shahid Rajaei Heart Center. Taking into account the inclusion and exclusion criteria, the patients were randomly placed in two groups of 30 people each. In the induction stage, all the patients received midazolam, etomidate, and one of the considered muscle relaxant, either 0.2 mg/kg of cisatracurium or 0.5mg/kg of Atracurium within one minute. In the maintenance stage of anesthesia, the patients were administered by infusion of midazolam, sufentanil and the same muscle relaxant used in the induction stage. The hemodynamic indexes were recorded and evaluated in different stages of anesthesia and surgery as well as prior to transfer to ICU.

Results:

In regard with descriptive indexes (age and sex distributions, premedication with cardiac drugs, ejection fraction before surgery, basic disease) there was no statistically significant difference between the groups.

Conclusions:

The significant difference of hemodynamic indexes between the two groups of this study, and the need for hemodynamic stability in all stages of surgery for patients with low function of left ventricle who are candidate for open heart surgery, proves that administering Cisatracurium as the muscle relaxant is advantageous and better.

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Background

Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO₂/FiO₂ ratio less than 120 with a PEEP ≥5 cm H₂O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters.

Results

Thirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient–ventilator asynchronies occurred in 4 patients.

Conclusion

A nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block.

Effect of dexamethasone on the onset time and recovery profiles of cisatracurium

BACKGROUND

The effect of dexamethasone injection on cisatracurium-induced neuromuscular block was compared according to different injection time points.

METHODS

One hundred seventeen patients were randomly assigned to three groups: 8 mg of dexamethasone injected intravenously 2-3 h before anesthesia (group A), just before anesthesia induction (group B), and at the end of surgery (control group). Three minutes after anesthesia induction, intubation was performed without neuromuscular blockers, and acceleromyography was initiated. All patients received 0.05 mg/kg cisatracurium; the onset time and recovery profiles were recorded.

RESULTS

Eighty patients were finally enrolled. The onset time (median [interquartile range], seconds) was significantly hastened in group A (520.0 [500.0-560.0], n = 30) compared to that in group B (562.5 [514.0-589.0], n = 22) (P = 0.008) and control group (586.5 [575.0-642.5], n = 28) (P < 0.001). The onset time in group B was faster than the control group (P = 0.015). The recovery time [mean (95% CI) minutes] was significantly hastened in group A [28.5 (27.3-29.6)] compared to that in group B [32.3 (31.0-33.6)] (P < 0.001) and control group [30.9 (29.9-31.8)] (P = 0.015). The total recovery time was significantly hastened more in group A [47.1 (45.5-48.6)] than group B [52.8 (51.6-54.0) minutes] (P < 0.001) and control group [50.5 (48.7-52.3) minutes] (P = 0.008).

CONCLUSIONS

A single dose of 8 mg of dexamethasone hastened the onset and total recovery times of cisatracurium-induced block by approximately 15 and 9%, respectively if administered 2-3 h prior to surgery.

Effects of Combined Rocuronium and Cisatracurium in Laparoscopic Cholecystectomy

Background

Laparoscopic upper abdominal surgery can cause spontaneous respiration due to diaphragmatic stimulation and intra-abdominal CO₂ inflation. Therefore, sufficient muscle relaxation is necessary for a safe surgical environment.

Methods

We investigated if the combination of rocuronium and cisatracurium can counteract the delayed onset of cisatracurium’s action and delayed recovery of muscle relaxation and whether the dosage of rocuronium, which is metabolized hepatically, can be reduced. A total of 75 patients scheduled for laparoscopic cholecystectomy with an American Society of Anesthesiology physical status I-II, in the age range of 20–60 years, and with a 20–30 kg/m² body mass index were included in the study.

Results

The patients were divided into the following groups: combination group (Group RC, rocuronium 0.3 mg/kg and cisatracurium 0.05 mg/kg), rocuronium group (Group R, rocuronium 0.6 mg/kg), and cisatracurium group (Group C, cisatracurium 0.1 mg/kg), and the onset, 25% duration, recovery index, and addition/time ratio were measured. Patients in Group RC exhibited a significantly different addition/time ratio compared with patients in the other two groups (p = 0.003).

Conclusion

During laparoscopic cholecystectomy, the 95% effective dose of rocuronium in combination with cisatracurium is expected to provide a sufficient muscle relaxant effect.

Chemotherapy alters cisatracurium induced neuromuscular blockade characteristics: A prospective cohort study

STUDY OBJECTIVE

To compare the characteristics of NMDR induced muscle paralysis in breast cancer patients with and without a history of recent chemotherapy with cyclophosphamide, doxorubicin and 5-fluorouracil (CAF) regimen.

DESIGN

This is a non-randomized prospective cohort study.

SETTING

Operating room of a university-affiliated teaching hospital.

PATIENTS

Out of a total of 50 patients who had undergone mastectomy, 22 patients were allocated to the "Chemo group" and 28 patients to the "Non-Chemo group", based on a valid history of recent chemotherapy.

INTERVENTION

After induction of anesthesia with thiopental and cisatracurium, neuromuscular monitoring was started for all patients.

MEASUREMENTS

Initially the time to 100% single-twitch (ST) suppression was measured. Then, the time for the appearance of the first response to post-tetanic count (PTC) stimulation, Train-of-Four (TOF) stimulation, and TOF_50% were measured consequently.

MAIN RESULTS

Time to get ST_zero was significantly longer in the Chemo group than in the Non-chemo group. Time for the appearance of the first response of PTC and TOF and TOF_50% was significantly shorter in the Chemo group than the other group. The mean duration of intense block was 27.66 minutes in the Chemo group versus 42.47 minutes in the Non-chemo group.

CONCLUSION

This research demonstrated that in patients having undergone chemotherapy, the effect of NDMRs starts with a longer lag time and finishes earlier too. Thus, these patients are ready for intubation after a longer time. Moreover, we have to repeat cisatracurium injections after shorter intervals to maintain the desired level of blockade.

Effective doses of cisatracurium in the adult and the elderly

Background

There are few information about the differences of the effective dose (ED) of cisatracurium between the adult and the elderly. We investigated the ED and the onset time of cisatracurium in the adults and the elderly.

Methods

We studied two hundred patients of the adults aged 20 through 64 years and the elderly aged ≥ 65 years, with American Society of Anesthesiologists physical status I or II. Each 100 patients with 20 patients of each dose group, randomly selected from 30, 40, 50, 60 or 70 µg/kg of cisatracurium, were randomly allocated to the adults and the elderly groups. We recorded the 0.1 Hz single twitch responses of the adductor pollicis and the onset times to maximal blockade. The magnitude of muscle relaxation was recorded by using an acceleromyography. The effect of cisatracurium on single twitch was calculated as percent reduction. After converting each drug dose into logarithm and percent reduction of the muscle reduction into probit, the EDs representing the muscle relaxation effects of 5%, 25%, 50%, 75% and 95% were estimated using the linear regression analysis.

Results

No significant differences were found in age, weight, height, or body mass index within or between the groups. The ED₅₀ and ED₉₅ of the adult group were 35.39 and 59.58 µg/kg. The ED₅₀ and ED₉₅ of the elderly group were 34.89 and 55.50 µg/kg, respectively. The onset times were 375.4 ± 76.9 seconds in the adult group and 369.1 ± 70.0 seconds in the elderly group.

Conclusions

The ED and the onset time were not significantly different between the adult and the elderly.

Synergism between rocuronium and cisatracurium: comparison of the Minto and Greco interaction models

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.

Age and the neuromuscular blockading effects of cisatracurium

PURPOSE

To investigate the influence of age on the neuromuscular blocking effect of cisatracurium.

METHODS

90 patients with ASA I and II were assigned to the following groups according to their age: adults, children, and infants. Each group was subdivided into three subgroups according to the first dose of cisatracurium. Patients were administrated at a first dose of cisatracurium randomly, and their responses to train-of-four (TOF) stimulation were observed. When the same degree of the first response (T1) continuously repeats three times, the percentage of T1 inhibition was recorded, and the curve of dose-effect relationship and ED95 were calculated. A second dose of cisatracurium was then administrated (total volume 100 μg/kg). The recovery phase in each patient was observed upon T1 reaching the maximum blocking effect (100%).

RESULTS

Once the maximum blocking effect was reached, patients were intubated. There were 83 cases (92.2%) of patients with grade 1 and 7 (7.8%) patients with grade 2 intubating conditions. ED95 was 59.29, 55.88 and 45.39 μg/kg in adults, children, and infants, respectively. ED95 positively correlated with age. The clinical duration of neuromuscular blockade, effective action duration of neuromuscular blockade, and in vivo action duration of neuromuscular blockade in adults was longer than that in children (P<0.05), but shorter than in infants (P<0.05). However, there were no significant differences in the recovery index among groups (P>0.05).

CONCLUSION

Age influences the neuromuscular blocking effects of cisatracurium to a certain extent.

Comparison of etomidate and propofol on intubating conditions and the onset time associated with cisatracurium administration

Background

This study compared intubating conditions and the onset time associated with administration of cisatracurium, a nondepolarizing neuromuscular blocker with a relatively slow onset, according to prior injection of one of two intravenous anesthetic agents: propofol or etomidate.

Methods

Forty-six female patients, undergoing general anesthesia and endotracheal intubation for elective surgery, were randomized to two groups; group P were administered propofol (2 mg/kg) prior to cisatracurium (0.2 mg/kg); group E were administered etomidate (0.3 mg/kg) prior to cisatracurium (0.2 mg/kg). We measured intubating conditions and the onset time according to the types of intravenous anesthetic administered. Measurements of heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken immediately prior to induction; immediately and 1 min after IV anesthetic administration; and immediately and 1, 2, 3, 4, 5, 7, and 15 min after endotracheal intubation.

Results

Intubating conditions were superior in group E compared with group P (P = 0.009). The average onset time of cisatracurium was more rapid in group E (155.74 ± 32.92 s vs. 185.26 ± 38.57 s in group P; P = 0.008). There were no group differences in SBP, DBP, and HR following intravenous anesthetic drug injection and endotracheal intubation. However, SBP and DBP were substantially higher in group E after endotracheal intubation.

Conclusions

Etomidate improves intubating conditions and provide a more rapid onset time of cisatracurium during anesthetic induction compared to propofol.

Sudden cardiovascular collapse caused by severe anaphylaxis after cisatracurium use: a case report

Kounis syndrome is an acute coronary syndrome concurrently occurs with allergic or hypersensitivity reactions. In patient with this syndrome, inflammatory mediators released due to an allergic reaction implicate to induce coronary artery spasm and atheromatous plaque rupture. We describe a patient with coronary artery disease who developed acute perioperative myocardial infarction leading to cardiac arrest after the anaphylactic reaction to cisatracurium, which led to a suspicion of Kounis syndrome. Anesthesiologists should be aware that anaphylaxis or allergic reactions can progress to acute coronary syndrome, thereby significantly change the course of the disease.

Comparison of the incidence of sore throat after rapid sequence intubation with succinylcholine and cisatracurium

BACKGROUND

Postoperative sore throat is a common complication of endotracheal intubation and can lead to dissatisfaction after surgery. Airway management has the strongest influence on the incidence of sore throat and improving endotracheal intubating conditions can reduce this complaint. Type of induction agent used during anesthesia can contribute to variances in the degree of post-operative sore throat.

OBJECTIVES

We aimed to compare the incidence of postoperative sore throat after rapid sequence induction with Succinylcholine and high dose Cisatracurium.

PATIENTS AND METHODS

The study was carried out on patients admitted to Shohada-e-Tajrish hospital for emergent abdominal surgery. Of the 80 patients who were enrolled in the study, 40 were randomly assigned to receive Succinylcholine while the remaining patients received Cistracurium during induction. Sore throat, muscle ache, hoarseness, dry throat and pain were assessed in each patient at baseline in recovery and at 2, 4, 12 and 24 hours post-operation.

RESULTS

Number of patients who developed sore throat was significantly higher in the Succinylcholine group (75%) compared to Cisatracurium group (27.5%) at the time of entrance to the recovery room (P = 0.001). These numbers decreased at 2 hours post-operation (42% versus 17.5%) but the difference was still statistically significant (P < 0.05). At 12 (P = 0.062) and 24 (P = 0.14) hours post operation, the difference was no longer significant.

CONCLUSIONS

Use of high dose Cisatracurium for induction during rapid sequence intubation carries a lower chance of developing sore throat compared to Succinylcholine. Studies comparing other adverse effects of these two agents are required to guide physician's choice of induction agent.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration

Background

The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration.

Methods

A total of 140 adult patients were randomized into 4 groups to receive either 30 µg/kg ephedrine (Group 30, n = 35), 70 µg/kg ephedrine (Group 70, n = 35), 110 µg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration.

Results

An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 ± 44.7 s, Group 70: 152.6 ± 40.3 s, Group 110: 151.2 ± 51.6 s) compared to Group C (224.6 ± 56.9 s) after 0.15 mg/kg of cisatracurium (P < 0.001). Ephedrine doses of either 70 or 110 µg/kg for pretreatment significantly improved intubating conditions (P < 0.05). Systolic and diastolic blood pressure and heart rate at 1 min after tracheal intubation were significantly increased than other times in all groups (P < 0.001), with no differences among the groups. However, 5 patients in Group 110 experienced marked hypertension (systolic/diastolic blood pressure: > 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups.

Conclusions

We conclude that pre-treatment with ephedrine 70 µg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects.

[Physicochemical stability study of injectable solutions of cisatracurium besilate in clinical conditions]

OBJECTIVES

To assess the stability of cisatracurium besilate solution stored at 5°C and 25°C.

MATERIALS AND METHODS

Cisatracurium solutions at 2, 5 and 0.1mg/mL in 0.9 % sodium chloride or 5 % glucose were exposed to 5°C and 25°C under 60 % relative humidity for seven days. The physicochemical stability was assessed at 24, 48hours and seven days with dosage of the active substance, detection of degradation products and a possible racemization, measuring pH, osmolality and turbidity, assessment of coloration, visible particles and invisible particles count.

RESULTS

Cisatracurium besilate present good stability for 24hours at 5°C and 25°C for concentrations between 0.1 and 5mg/mL. Beyond 24hours, the solutions at 2 and 5mg/mL remained stable for seven days at 5°C. At 25°C, potentially toxic degradation products appear in solutions of 0.1mg/mL between 24 and 48hours. No racemization was detected, the drug remains in its active form cis.

CONCLUSION

Cisatracurium solutions at 2 and 5mg/mL may be stored at 5°C or 25°C for seven days. It's advisable to keep the solutions in a dilution of 0.1mg/mL in 0.9 % sodium chloride or 5 % glucose in the refrigerator. No diluted solution should be stored at room temperature beyond 24hours.

Consumption of Cisatracurium in different age groups, using a closed loop computer controlled system

Background

We devised this study to quantify the effect of age on the consumption of cisatracurium under general anaesthesia, using a computer controlled closed loop infusion system. We further investigated this effect on, sufentanil and propofol consumption.

Methods

74 patients of physical status I and II, requiring general anaesthesia for elective abdominal surgery, were assigned to three groups. Patients in group 1 were aged from 20 to 45, group 2 were from 46 to 64, and group 3 above 65 years old. General Anesthesia was maintained with propofol and muscle paralysis was maintained using a closed-loop computer controlled infusion of cisatracurium. For analgesia, intermittent bolus of sufentanil 10 μg was given.

Results

Cisatracurium consumption in group 1, 2 and 3 were 1.8 ± 0.3, 1.6 ± 0.4 and 1.3 ± 0.4 μg/kg/min respectively. There was significant difference of cisatracurium consumption between group 1 and 3 (P = 0.002), and the consumption of cisatracurium in group 3 was less as compared with group 2 (P = 0.04). The average recovery index of patients in group 1, 2 and 3 were 8.8 ± 2.6, 11.5 ± 2.9 and 12.7 ± 2.5 minutes respectively. There were difference between group 1 and 2 (P = 0.02). As compared with group 1, the recovery index was still longer in group 3 (P = 0.001). Patients in group 1, 2 and 3 consumed an average sufentanil 0.4 ± 0.1, 0.4 ± 0.1 and 0.3 ± 0.1 μg/kg/hr, respectively. There were statistical significant between group 1 and 3 (P < 0.0001), and the same trend was found between group 2 and 3 (P = 0.03). The Consumption of propofol in group 1, 2 and 3 were 5.1 ± 0.4, 4.3 ± 0.6 and 3.1 ± 0.5 mg/kg/hr. The difference in the propofol consumption was found statistically significant when comparing between any two groups.

Conclusion

We concluded that the sensitivity of anesthetic agents increased with age. Less medication was required to achieve a desirable effect in older patients specially those above 65 years of age, and the drug effect was prolonged.

Trial registration

ClinicalTrials.gov Identifier: NCT01785446.

A comparison of the clinical duration and recovery characteristics of cisatracurium after priming using rocuronium or cisatracurium: preliminary study

Background

The priming technique can speed up the onset of cisatracurium during intubation. However, there have been no reports on the effect of the priming technique on duration or recovery profile of cisatracurium. Therefore, we attempted to determine whether or not a priming technique with rocuronium or cisatracurium can affect clinical duration or recovery profiles of cisatracurium.

Methods

A total of 36 patients, ASA I and II, who were scheduled to undergo elective surgery, were enrolled. The patients were randomized into three groups and administered different drugs for the priming technique. Patients in group 1 received normal saline (control group). Patients in group 2 received rocuronium (0.06 mg/kg), and those in group 3 received cisatracurium (0.01 mg/kg) as a priming agent. Three minutes after injection of drugs, intubation doses of cisatracurium were administered (Group 1, 0.15 mg/kg; Groups 2 and 3, 0.14 mg/kg). Anesthesia was induced and maintained with propofol and remifentanil. Onset time, clinical duration, recovery index, recovery time, and total recovery time were measured by train of four monitoring.

Results

Onset time in the group 2 was significantly shorter than that of group 1 or 3 (P < 0.05). However, no significant differences in clinical duration, recovery index, recovery time, and total recovery time were observed among the three groups.

Conclusions

Priming with rocuronium for 3 minutes resulted in significantly accelerated onset of cisatracurium. However, it did not affect the clinical duration and recovery profiles of cisatracurium.

Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-

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.

Comparison between the Effects of Rocuronium, Vecuronium, and Cisatracurium Using Train-of-Four and Clinical Tests in Elderly Patients

Background

Postoperative residual blockade, longer duration of action for neuromuscular blockade, and slower recovery were relatively common in elderly patients.

Objectives

We aimed to investigate the safety of train-of-four ratio and clinical tests in the assessment of patient recovery, and to determine the effects of the rocuronium, vecuronium, and cisatracurium on intubation, extubation and recovery times in elderly patients undergoing abdominal surgery.

Patients and Methods

After obtaining institutional approval and informed consent, 60 patients over 60 years old and undergoing elective abdominal operations were included in this double-blind, randomized clinical trial. Following a standard anesthesia induction, 0.6mg kg-1 rocuronium, 0.1mg kg-1 vecuronium, and 0.1mg kg-1 cisatracurium were administered to the patients in Group R, Group V, and Group C, respectively. Train-of-four (TOF) ratios were recorded at 10-minute intervals during and after the operation. Modified Aldrete Score (MAS) and clinical tests were recorded in the recovery room at 10-minute intervals. In addition, intubation and extubation times, duration of recovery room stay, and any complications were recorded.

Results

Intubation time was found to be shorter in Group R than that in Groups V and C (P ˂ 0.001). Times to positive visual disturbances and grip strength tests were shorter in Group C than that in Group V (P = 0.016 and P = 0.011, respectively). In Group R and group C, time to TOF ≥ 0.9 was significantly longer than all positive clinical test times except grip strength (P < 0.05).

Conclusions

We hold the opinion that cisatracurium is safer in elderly patients compared to other drugs. We also concluded that the usage of TOF ratio together with clinical tests is suitable for assessment of neuromuscular recovery in these patients.

Anesthesiologist's satisfaction using between cisatracurium and rocuronium for the intubation in the anesthesia induced by remifentanil and propofol

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.

The effect of low dose ketamine and priming of cisatracurium on the intubating condition and onset time of cisatracurium

Background

Both ketamine and priming may accelerate the onset time of neuromuscular blocking agents. We investigate the effect of low dose ketamine and cisatracurium priming on the intubating condition and onset time of cisatracurium.

Methods

After Institutional Review Board approval, 120 consecutive patients undergoing general anesthesia were randomly assigned to one of 4 groups. All patients were injected one of normal saline (group C), cisatracurium 0.01 mg/kg (group P), ketamine 0.5 mg/kg (group K) and combination of cisatracurium 0.01 mg/kg, and ketamine 0.5 mg/kg (group PK) diluted into a 5 ml solution, followed 3 minutes later by cisatracurium 0.15 mg/kg in group C and K, and 0.14 mg/kg cisatracurium in priming group. Onset time was recorded the electromyographical responses using single twitch and intubating conditions were evaluated at 60 seconds after cisatracurium administration.

Results

The mean onset time was most significantly accelerated in Group PK and was also significantly more accelerated in Group P and K compared with Group C (P < 0.008). It was 112.7 ± 13.2, 91.4 ± 17.9, 84.9 ± 12.7 and 76.4 ± 8.3 seconds in Group C, P, K, and PK, respectively. Intubating conditions were significantly improved in Group P, K and PK than Group C (P < 0.008). Especially, Group PK showed most significant improvement of intubating conditions.

Conclusions

The combination of the low dose ketamine and cisatracurium priming accelerated the onset time and was improved the intubating conditions.

Effects on Intubating Conditions of Pretreatment with Remifentanil before Administration of Cisatracurium

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.

Effect of magnesium sulfate pretreatment on onset and recovery characteristics of cisatracurium

BACKGROUND

To determine how pretreatment with magnesium sulfate (MgSO(4)) potentiates neuromuscular blocking agents. We investigated how the onset and recovery characteristics of cisatracurium are changed by pretreatment with MgSO(4).

METHODS

After Institutional Review Board approval, a total of 48 ASA I and II patients were devided into 2 groups. Patients in each group received either the MgSO(4) 30 mg/kg (group M) in 0.9% normal saline (total volume 100 ml) or 0.9% normal saline (control group C) alone intravenously for 15 min before induction of anesthesia with propofol, remifentanil and cisatracurium 0.15 mg/kg. Anesthesia was maintained with propofol and remifentanil. Electromyographical responses were measured by train-of-four. Lag time, onset time, total recovery time, clinical duration, recovery index, and recovery time were measured. The mean arterial blood pressure, heart rate, and ionized magnesium were also measured.

RESULTS

The lag time and onset time were significantly shorter in the MgSO(4) group than the control group (P < 0.05). Recovery index, recovery time, clinical duration, and total recovery time showed no significant differences in the MgSO(4) group compared to the control group (P > 0.05). Mean arterial pressure was more significantly increased in the MgSO(4) group than in the control group at the time point immediately after the administration of MgSO(4). Heart rate showed no significant changes in both groups. The concentrations of ionized magnesium were significantly more increased at the all time point (P < 0.05).

CONCLUSIONS

MgSO(4) results in about 29% shortening of onset time of cisatracurium (0.15 mg/kg) without prolongation on the recovery of neuromuscular block.

Effect of isoflurane versus propofol-remifentanil anesthesia on neuromuscular blockade and hemodynamic responses by cisatracurium bolus injection

BACKGROUND

Inhalational anesthetics potentiate nondepolarizing muscle relaxants. Cisatracurium is a recently introduced neuromuscular blocker in Korea. We studied the effect of inhalational anesthesia and total intravenous anesthesia (TIVA) on neuromuscular blockades and hemodynamic responses by cisatracurium bolus injection.

METHODS

Forty patients undergoing elective surgery were randomly divided into isoflurane and propofol-remifentanil groups. A bolus dose of cisatracurium of 0.15 mg/kg (3 × ED(95)) was administered after induction and the onset time and clinical duration of action were recorded. The nueromuscular blockade was monitored using train-of-four (TOF) stimulation. Hemodynamic parameters were also recorded.

RESULTS

Onset time was 194.0 ± 39.1 sec in the isoflurane group and 226.5 ± 62.2 sec in the propofol-remifentanil group. Clinical duration of action was 49.2 ± 9.0 min in the isoflurane group and 43.0 ± 9.2 min in the propofol-remifentanil group. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) immediately before intubation decreased in the propofol-remifentanil group. Heart rate (HR), SBP and DBP 1 and 3 min after tracheal intubation increased in the isoflurane group.

CONCLUSIONS

Onset time was similar between isoflurane and propofol-remifentanil anesthesia. Clinical duration of action was significantly longer in isoflurane anesthesia. SBP and DBP immediately before intubation and HR, SBP and DBP 1 and 3 min after tracheal intubation were significantly different between the two groups.

Cisatracurium in different doses versus atracurium during general anesthesia for abdominal surgery

Background:

Cisatracurium in clinical practice is devoid of histamine-induced cardiovascular effects. On the other hand, 2 ED₉₅ doses of cisatracurium (100 µ g/kg) do not create satisfactory intubating conditions such as those seen with equipotent doses of atracurium. The recommended intubating dose of cisatracurium is 3 ED₉₅. To understand this discrepancy better, we evaluated the potency and onset of atracurium and cisatracurium.

Materials and Methods:

The study designed as randomized controlled clinical trial to compare between atracurium (2×ED₉₅) and different doses of cisatracurium (2×ED₉₅, 4×ED₉₅, 6×ED₉₅) regarding onset time, duration of action, condition of intubation, hemodynamic effects, and sings of histamine release clinically. Sixty four patients were randomly assigned to one of four groups, the first group (group 1) received 2×ED₉₅ dose of atracurium, group 2 received 2×ED₉₅ dose of cisatracurium, group 3 received 4×ED₉₅ dose of cisatracurium, while group 4 received 6×ED₉₅ dose of cisatracurium. The Datex relaxograph (Type NMT-100-23-01, S/N: 37541) for neuromuscular monitoring was used.

Results:

HR, MABP was statistically significant increased post-intubation with administration of 2×ED₉₅ dose of atracurium in group 1 and the same dose of cisatracurium in group 2 but 5-20 min later was not statistically significant with administration of 4×ED₉₅ and 6×ED₉₅ doses of cisatracurium in groups 3 and 4, respectively. Onset time was found to be significantly lower with 2×ED₉₅ dose of atracurium than with the same dose of cisatracurium. At the same time, higher doses of cisatracurium (4×ED₉₅ and 6×ED₉₅) showed onset time and longer duration of action that was significantly lower than with atracurium and with lower dose of cisatracurium (2×ED₉₅). Only 6×ED₉₅ dose of cisatracurium showed statistically significant difference versus the atracurium dose with higher percentages of patients with excellent condition of intubation. 4×ED₉₅ and 6×ED₉₅ doses of cisatracurium were significantly better than 2×ED₉₅ dose of cisatracurium. 2×ED₉₅ dose of atracurium and 2×ED₉₅ dose of cisatracurium were similar, while 4×ED₉₅ and 6×ED₉₅ doses of cisatracurium were significantly better than atracurium and 2×ED₉₅ dose of cisatracurium.

Conclusion:

The same dose (2×ED₉₅ dose) atracurium is more effective neuromuscular blocking agent than cisatracurium, while higher doses of cisatracurium 4×ED₉₅ and 6×ED₉₅ provide more effective, more rapid neuromuscular blocking with longer duration of action, stable hemodynamic status, and no associated signs of histamine release clinically.

Effect of cisatracurium versus atracurium on intraocular pressure in patients undergoing tracheal intubation for general anesthesia

BACKGROUND

Increase in intraocular pressure (IOP) following tracheal intubation during general anesthesia can be troublesome. We compared the influence of two muscle relaxants, cisatracurium and atracurium, on IOP in patients undergoing general anesthesia.

METHODS

This randomized, double-blind, comparative trial was conducted on 90 candidates for elective non-ophthalmic surgery under general anesthesia. Patients were 18 to 60 years old with the American Society of Anesthesiologists (ASA) class of I or II. Anesthesia was induced with fentanyl (1.5 mg/kg) and sodium thiopental (5 mg/kg). Patients received atracurium (0.5 mg/kg) or cisatracurium (0.15 mg/kg) two minutes prior to tracheal intubation. IOP, systolic (SBP) and diastolic blood pressure (DBP), and heart rate (HR) were measured at baseline (before medication), after medication (before intubation), and 2, 5, and 10 minutes after intubation.

RESULTS

In both groups IOP decreased after administration of muscle relaxants (-3.3 ± 3.6 mmHg), then increased 2 minutes after intubation (5.5 ± 4.4 mmHg), but decreased 5 (-3.3 ± 3.3 mmHg) and 10 (-0.5 ± 2.6 mmHg) minutes after intubation. IOP and SBP were significantly higher in the atracurium compared with the cisatracurium group after 2 (p < 0.001 and 0.002, respectively), 5 (p < 0.001 and 0.012, respectively), and 10 (p = 0.02 and 0.048, respectively) minutes after intubation.

CONCLUSIONS

Compared with atracurium, administration of cisatracurium can better prevent the increase of IOP following tracheal intubation in general anesthesia. The observed difference might be related to different effects on hemodynamic variables. Application of these results in patients under ophthalmic surgery is warranted.