Influence Of Stimulation Frequency On Rocuronium And Pancuronium-induced Neuromuscular Block Onset. Acceleromyography Evaluation [influência Da Freqüência De Estímulos Na Instalação Do Bloqueio Neuromuscular Produzido Pelo Rocurônio E Pancurônio. Avaliação Pelo Método Acelerográfico]

BACKGROUND AND OBJECTIVES: Factors associated to patients and neuromuscular blockers (NMB), as well as others inherent to neuromuscular function monitoring, may affect neuromuscular block onset. This study aimed at the influence of two different stimulation frequencies on rocuronium and pancuronium-induced neuromuscular block. METHODS: Participated in this study 120 patients, physical status ASA I and II, submitted to elective procedures under general anesthesia, who were randomly allocated in two groups, according to the stimulation frequency employed to monitor neuromuscular block: Group I - 0. 1 Hz (n = 60) and Group II - 1 Hz (n = 60). Two subgroups were formed within each group (n = 30), according to the neuromuscular blocker: Sub-group P (pancuronium) and Subgroup R (rocuronium). Patients were premedicated with muscular midazolam (0.1 mg.kg-1), 30 minutes before surgery. Anesthesia was induced with propofol (2.5 mg.kg-1) preceded by alfentanil (50 μg.kg-1) and followed by pancuronium or rocuronium. Patients were ventilated under mask with 100% oxygen until 75% or more decrease in adductor pollicis muscle response, when laryngoscopy and tracheal intubation were performed. Neuromuscular function was monitored by acceleration transducer. The following parameters were evaluated: pancuronium and rocuronium onset time; time for complete block and tracheal intubation conditions. RESULTS: Mean times (seconds) for pancuronium-induced neuromuscular block onset and for complete neuromuscular block were: Group I (159.33 ± 35,22 and 222 ± 46.56) and Group II (77.83 ± 9.52 and 105.96 ± 15.58); rocuronium-induced values were: Group I (83 ± 17.25 and 125.33 ± 20.12) and Group II (48.96 ± 10.16 and 59.83 ± 10.36) with statistical difference between groups. Tracheal intubation conditions were satisfactory in 117 patients (97.5%) and unsatisfactory in 3 (2.5%). CONCLUSIONS: Rocuronium and pancuronium-induced neuromuscular block onset and time required for complete adductor pollicis muscle neuromuscular block are shorter when higher stimulation frequencies are applied.541312McCoy, E.P., Mirakhur, R.K., Connolly, F.M., The influence of the duration of control stimulation on the onset and recovery of neuromuscular block (1995) Anesth Analg, 80, pp. 364-367Feldman, S.A., Khaw, K., The effect of dose and the rate of stimulation on the action of rocuronium (1995) Eur J Anaesth, 12, pp. 15-17Donati, F., Plaud, B., Meistelman, C., A method to measure elicited contraction of laryngeal adductor muscles during anesthesia (1991) Anesthesiology, 74, pp. 827-832Donati, F., Onset of action of relaxants (1988) Can J Anaesth, 35, pp. S52-S58Bowman, W.C., Rodger, I.W., Houston, J., Structure action relationships among some desacetoxy analogues of pancuronium and vecuronium in the anesthetized cat (1988) Anesthesiology, 69, pp. 57-62Mallampati, S.R., Gatt, S.P., Gugino, L.D., A clinical sign to predict difficult tracheal intubation: A prospective study (1985) Can J Anaesth, 32, pp. 429-434Helbo-Hansen, S., Ravlo, O., Trap-Andersen, S., The influence of alfentanil on the intubating conditions after priming with vecuronium (1988) Acta Anaesthesiol Scand, 32, pp. 41-44Curran, M.J., Donati, F., Bevan, D.R., Onset and recovery of atracurium and suxamethonium-induced neuromuscular blockade with simultaneous train-of-four and single twitch stimulation (1987) Br J Anaesth, 59, pp. 989-994Bell, P.F., Gibson, F.M., Mirakhur, R.K., Comparison of single twitch and train-of-four modes of stimulation for measurement of non-depolarizing neuromuscular block (1988) Br J Anaesth, 60, pp. 343PCooper, R.A., Mirakhur, R.K., Elliott, P., Estimation of the potency of ORG 9426 using two different modes of nerve stimulation (1992) Can J Anaesth, 39, pp. 139-142Maddineni, V.R., Mirakhur, R.K., Cooper, R., Potency estimation of mivacurium: Comparison of two different modes of nerve stimulation (1993) Br J Anaesth, 70, pp. 694-695Viby-Mogensen, J., Engbaek, J., Eriksson, L.I., Good Clinical Research Practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents (1996) Acta Anaesthesiol Scand, 40, pp. 59-74Hans, P., Dewé, W., Albert, A., Onset time on neuromuscular block and intubating conditions: Influence of different stimulation patterns (1997) Acta Anaesthesiol Belg, 48, pp. 15-21De Mey, J.C., De Laat, M., Factors influencing the profile of onset of relaxation (1997) Acta Anaesthesiol Belg, 48, pp. 7-10Goat, V.A., Yeung, M.L., Blakeney, C., The effect of blood flow upon the activity of gallamine triethiodide (1976) Br J Anaesth, 48, pp. 69-73Saxena, P.R., Dhasmana, K.M., Prakash, O., A comparison of systemic and regional haemodynamic effects of d-tubocurarine, pancuronium and vecuronium (1983) Anesthesiology, 59, pp. 102-108Chauvin, M., Lebreault, C., Duvaldestin, P., The neuromuscular blocking effect of vecuronium on the human diaphragm (1987) Anesth Analg, 66, pp. 117-122Pansard, J.L., Chauvin, M., Lebreault, C., Effect of an intubating dose of succinylcholine and atracurium on the diaphragm and adductor pollicis muscle in humans (1987) Anesthesiology, 67, pp. 326-330Girling, K.J., Mahajan, R.P., The effect of stabilization on the onset of neuromuscular block when assessed using accelerometry (1996) Anesth Analg, 82, pp. 1257-1260Galindo, A., Procaine, pentobarbital and halothane: Effects at the mammalian myoneural junction (1971) J Pharmacol Exp Ther, 177, pp. 360-368Smith, C.E., Donati, F., Bevan, D.R., Differential effects of pancuronium on masseter and adductor pollicis muscles in humans (1989) Anesthesiology, 71, pp. 57-61Carnie, J.C., Street, M.K., Kumar, B., Emergency intubation on the trachea facilitated by suxamethonium (1986) Br J Anaesth, 58, pp. 498-501Huizinga, A.C., Vandenbrom, R.H., Wierda, J.M., Intubating conditions and onset time of neuromuscular block of ORG 9426 (rocuronium), a new nondepolarizing neuromuscular blocking agent: A comparison with suxamethonium (1992) Acta Anaesthesiol Scand, 36, pp. 463-468De Mey, J.C., De Baerdemaeker, L., De Laat, M., The onset of neuromuscular block at the masseter muscle as a predictor of optimal intubating conditions with rocuronium (1999) Eur J Anaesthesiol, 16, pp. 387-389Bali, I.M., Dundeee, J.W., Effect of I.V. induction regimens on endotracheal intubation with alcuronium and atracurium (1985) Br J Anaesth, 57, pp. 830-831Fuchs-Buder, T., Sparr, H.J., Ziegenfuss, T., Thiopental or etomidate for rapid sequence induction with rocuronium (1998) Br J Anaesth, 80, pp. 504-506McCourt, K.C., Salmela, L., Mirakhur, R.K., Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia (1998) Anaesthesia, 53, pp. 867-871Skinner, H.J., Biswas, A., Mahajan, R.P., Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction (1998) Anaesthesia, 53, pp. 702-710Keaveny, J.P., Knell, P.J., Intubation under induction doses of propofol (1988) Anaesthesia, 43, pp. S80-S81McKeating, K., Bali, I.M., Dundee, J.W., The effects of thiopentone and propofol on upper airway integrity (1988) Anaesthesia, 43, pp. 638-640Braga, A.F.A., Potério, G.M.B., Braga, F.S.S., Intubação traqueal sem relaxantes musculares, utilizando propofol como agente de indução (1991) Rev Bras Anestesiol, 41 (SUPPL. 13). , CBA130Scheller, M.S., Zornow, M.H., Saidman, L.J., Tracheal intubation without the use of muscle relaxants: A technique using propofol and varying doses of alfentanil (1992) Anesth Analg, 75, pp. 788-793Braga, A.F.A., Braga, F.S.S., Potério, G.M.B., The effect of different doses of propofol on tracheal intubating conditions without muscle relaxant in children (2001) Eur J Anaesth, 18, pp. 384-388Dobson, A.P., McCluskey, A., Meakin, G., Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia (1999) Anaesthesia, 54, pp. 172-19

Neuromuscular And Cardiovascular Effects Of Pipecuronium. A Comparative Study Between Different Doses.

BACKGROUND AND OBJECTIVES: Pipecuronium is a non-depolarizing neuromuscular blocker with similar properties to pancuronium, but without cardiovascular effects. Neuromuscular effects, conditions of tracheal intubation, and hemodynamic repercussions of two different doses of pipecuronium were evaluated. METHOD: Patients were divided into two groups according to the dose of pipecuronium: Group I (0.04 mg x kg(-1)) and Group II (0.05 mg x kg(-1)). Intramuscular midazolam (0.1 mg x kg(-1)) was administered 30 minutes before the surgery. Propofol (2.5 mg x kg(-1)), preceded by fentanyl (5 microg x kg(-1)) and pipecuronium (0.04 and 0.05 mg x kg(-1) for Groups I and II, respectively), was administered for anesthetic induction. Patients were ventilated with 100% oxygen via a face mask until a 75% reduction in the amplitude of the response to an isolated stimulus (1 Hz) is achieved, at which time laryngoscopy and intubation were carried out. Anesthetic maintenance was achieved with isoflurane (0.5 to 1%) with a mixture of 50% O2 and N2O. Mechanical ventilation was used to maintain P(ET)CO2 between 32 and 36 mmHg. The pharmacodynamics of pipecuronium was evaluated by acceleromyography. RESULTS: Mean times and standard deviation for the onset of action, clinical duration (T1(25%)), and recovery index (T1(25-75%)) were: Group I (122.10 +/- 4.18 sec, 49.63 +/- 9.54 min, and 48.21 +/- 6.72 min), and Group II (95.78 +/- 8.91 sec, 64.84 +/- 13.13 min, and 48.52 +/- 4.95 min). Onset of action, clinical duration, and conditions of tracheal intubation were significantly different for both groups. CONCLUSIONS: Pipecuronium at a dose of 0.05 mg x kg(-1) can be used in prolonged procedures in which cardiovascular changes should be avoided.586587592, 582-58

The Influence Of Sevoflurane And Isoflurane On The Recovery From Cisatracurium-induced Neuromuscular Block [influência Do Sevoflurano E Do Isoflurano Na Recuperação Do Bloqueio Neuromuscular Produzido Pelo Cisatracúrio]

Background and Objectives - The effects of neuromuscular blockers on the neuromuscular junction are potentiated by volatile anesthetics. This study aimed at evaluating the influence of sevoflurane and isoflurane on the recovery of cisatracurium-induced neuromuscular block. Methods - Ninety ASA I and II patients undergoing elective surgeries under general anesthesia were included in this study. Patients were allocated in three groups: Group I (sevoflurane), Group II (isoflurane) and Group III (propofol). All patients were premedicated with intramuscular midazolam (0.1 mg.kg-1) 30 min before surgery. Anesthesia was induced with alfentanil (50 μg.kg-1), propofol (2.5 mg.kg-1) and cisatracurium (0.15 mg.kg-1). Patients were then ventilated under mask with 100% O2 until disappearance of all TOF responses when laryngoscopy and tracheal intubation were performed. Volatile agents for anesthetic maintenance were introduced immediately after tracheal intubation in 2% and 1% concentrations, respectively, for sevoflurane and isoflurane, as well as the propofol continuous infusion (7 to 10 mg.kg-1.h-1) for Group III. All patients received a 50% mixture of O2 and N2O. Neuromuscular function was monitored by adductor pollicis muscle acceleromyography with TOF stimulation at 15-second intervals. Clinical duration of neuromuscular block (T125%) and recovery index (RI=T125.75%) were evaluated. Results - Mean time and standard deviation for clinical duration (T125%) and recovery index (RI=T125.75%) were respectively: Group I (66.2 ± 13.42 min and 23.6 ± 5.02 min), Group II (54.4 ± 6.58 min and 14.9 ± 3.82 min) and Group III (47.2 ± 7.43 min and 16.2 ± 2.93 min). There were significant differences in clinical duration between Groups I and II, I and III and II and III. There was a significant difference in recovery index between Group I and the other groups. Conclusions - The recovery from cisatracurium-induced neuromuscular block was longer during anesthesia with volatile agents as compared to propofol. The most pronounced effect was observed with sevoflurane.525517524Rupp, S.M., Miller, R.D., Gencarelli, P.J., Vecuronium-induced neuromuscular blockade during enflurane, isoflurane, and halothane anesthesia in humans (1984) Anesthesiology, 60, pp. 102-105Vanlinthout, L.E.H., Booij, L.H.D.J., Van Egmond, J., Effect of isoflurane and sevoflurane on the magnitude and time course of neuromuscular block produced by vecuronium, pancuronium and atracurium (1996) Br J Anaesth, 76, pp. 389-395Suzuki, T., Iwasaki, K., Fukano, N., Duration of exposure to sevoflurane effects dose-response relationship of vecuronium (2000) Br J Anaesth, 85, pp. 732-734Xue, F.S., Liao, X., Tong, S.Y., Dose-response and time-course of the effect of rocuronium bromide during sevoflurane anaesthesia (1998) Anaesthesia, 53, pp. 25-30Wulf, H., Ledowski, T., Linstedt, U., Neuromuscular blocking effects of rocuronium during desflurane, isoflurane, and sevoflurane anaesthesia (1998) Can J Anaesth, 45, pp. 526-532Withington, D.E., Donati, F., Bevan, D.R., Potentiation of atracurium neuromuscular blockade by enflurane: Time-course of effect (1991) Anesth Analg, 72, pp. 469-473Ortiz, J.R., Percaz, J.A., Efecto de la técnica anestésica sobre la recuperación del bloqueo neuromuscular por cisatracurio (2001) Rev Esp Anestesiol Reanim, 48, pp. 117-121Braga, A.F.A., Potério, G.M.P., Braga, F.S.S., Influência do sevoflurano e do isoflurano na duração do bloqueio neuromuscular produzido pelo rocurônio (2001) Rev Bras Anestesiol, 51, pp. 2-9Miller, R.D., Way, W.L., Dolan, W.M., Comparative neuromuscular effects of pancuronium, gallamine and succinylcholine during forane and halothane anesthesia in man (1971) Anesthesiology, 35, pp. 509-514Agoston, S., Interactions of volatile anaesthetics with rocuronium bromide in perspective (1994) Eur J Anaesth, 11 (SUPPL. 9), pp. 107-111Yasuda, N., Lockhart, S.H., Eger E.I. II, Comparison of kinetics of sevoflurane and isoflurane in humans (1991) Anesth Analg, 72, pp. 316-324Yasuda, N., Lockhart, S.H., Eger E.I. II, Kinetics of desflurane, isoflurane, and halothane in humans (1991) Anesthesiology, 74, pp. 489-498Wulf, H., Kahl, M., Ledowski, T., Argumentation of the neuromuscular blocking effects of cisatracurium during desflurane, sevoflurane, isoflurane or total i.v. anaesthesia (1998) Br J Anaesth, 80, pp. 308-312Mallampati, S.R., Gatt, S.P., Gugino, L.D., A clinical sign to predict difficult tracheal intubation: A prospective study (1985) Can J Anaesth, 32, pp. 429-434Oris, B., Crul, J.F., Vandermeersch, E., Muscle paralysis by rocuronium during halothane, enflurane, isoflurane, and total intravenous anesthesia (1993) Anesth Analg, 77, pp. 570-573Shanks, C.A., Fragen, R.J., Ling, D., Continuous intravenous infusion balanced, enflurane, or isoflurane anesthesia (1993) Anesthesiology, 78, pp. 649-651Hemmerling, T.M., Shuettler, J., Schwilden, H., Desflurane reduces the effective therapeutic infusion rate (ETI) of cisatracurium more than isoflurane, sevoflurane, or propofol (2001) Can J Anaesth, 48, pp. 532-537Pollard, B.J., Interactions involving relaxants (1994) Applied Neuromuscular Pharmacology, pp. 202-228. , Pollard BJ, Oxford, Oxford University PressVitez, T.S., Miller, R.D., Eger E.I. II, Comparison in vitro of isoflurane and halothane potentiation of d-tubocurarine and succinylcholine neuromuscular blockades (1974) Anesthesiology, 41, pp. 53-56Waud, B.E., Waud, D.R., The effects of diethyl ether, enflurane and isoflurane at the neuromuscular junction (1975) Anesthesiology, 42, pp. 275-280Waud, B.E., Decrease in dose requirements of d-tubocurarine by volatile anesthetics (1979) Anesthesiology, 51, pp. 298-302Brett, R.S., Dilger, J.P., Yland, K.F., Isoflurane causes "flickering" of the acetylcholine receptor channel: Observations using the patch clamp (1988) Anesthesiology, 69, pp. 161-170Lowry, D.W., Mirakhur, R.K., Carroll, M.T., Potency and time course of mivacurium block during sevoflurane, isoflurane and intravenous anesthesia (1999) Can J Anaesth, 46, pp. 29-33Driessen, J.J., Crul, J.F., Jansen, R., Isoflurane and neuromuscular blocking drugs (1986) Anaesth Int Care, 182, pp. 76-82Cannon, J.F., Fahey, M.R., Castagnoli, K.P., Continuous infusion of vecuronium: The effect of anesthetic agents (1987) Anesthesiology, 67, pp. 503-506Shanks, C.A., Pharmacokinetics of the nondepolarizing neuromuscular relaxants applied to the calculation of bolus and infusion dosage regimens (1986) Anesthesiology, 64, pp. 72-86Hunter, J.M., New neuromuscular blocking drugs (1995) N England J Med, 332, pp. 1691-1699Fisher, D.M., Rosen, J.I., A pharmacokinetic explanation for increasing recovery time following larger or repeated doses of nondepolarizing muscle relaxants (1986) Anesthesiology, 65, pp. 286-291Ginsberg, B., Glass, P.S., Quill, T., Onset and duration of neuromuscular blockade following high-dose vecuronium administration (1989) Anesthesiology, 71, pp. 201-205Bock, M., Klippel, K., Nitsche, B., Rocuronium potency and recovery characteristics during steady-state desflurane, sevoflurane, isoflurane or propofol anaesthesia (2000) Br J Anaesth, 84, pp. 43-47Belmont, M.R., Lien, C.A., Quessy, S., The clinical neuromuscular pharmacology of 51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia (1995) Anesthesiology, 82, pp. 1139-1145Lepage, J.Y., Malinovsky, J.M., Malinge, M., Pharmacodynamic dose response and safety study of cisatracurium (51W89) in adult surgical patients during N2O-O2-opioid anesthesia (1996) Anesth Analg, 83, pp. 823-829Carpenter, R.L., Eger E.I. II, Johnson, B.H., Pharmacokinetics of inhaled anesthetics in humans: Measurements during and after the simultaneous administration of enflurane, isoflurane, methoxyflurane and nitrous oxide (1986) Anesth Analg, 65, pp. 575-582Wright, P.M.C., Hart, P., Lau, M., The magnitude and time course of vecuronium potentiation by desflurane versus isoflurane (1995) Anesthesiology, 82, pp. 404-411Gill, S.S., Bevan, D.R., Donati, F., Edrophonium antagonism of atracurium during enflurane anaesthesia (1990) Br J Anaesth, 64, pp. 300-305Baurain, M.J., D'Hollander, A.A., Melot, C., Effects of residual concentrations of isoflurane on the reversal of vecuronium-induced neuromuscular blockade (1991) Anesthesiology, 74, pp. 474-47

Priming Versus Bolus. A Comparative Study With Different Cisatracurium Doses [dose Preparatória Versus Injeção Unica. Estudo Comparativo Entre Diferentes Doses De Cisatracúrio]

Background and Objectives - The priming technique is an alternative to shorten nondepolarizing neuromuscular blockers onset time. This study aimed at evaluating maximum neuromuscular block onset, tracheal intubation conditions and cardiocirculatory changes determined by different cisatracurium single or fractional doses. Methods - Participated in this study 80 patients physical status ASA I and II, who were distributed into two groups according to cisatracurium doses: Group I (0.1 mg.kg-1) and Group II (0.2 mg.kg-1). Subgroups were constituted according to the curarization technique employed: subgroups P1 and P2 (priming-dose) - 0.02 mg.kg-1 or 0.04 mg.kg-1 cisatracurium, respectively, followed one minute later, by 0.08 mg.kg-1 or 0.16 mg.kg-1 of the same neuromuscular blocker, respectively; subgroups U1 and U2 - total bolus injection of 0.1 mg.kg-1 or 0.2 mg.kg-1 cisatracurium, respectively. Anesthesia was induced with etomidate, preceded by alfentanil. Train of Four (TOF) stimulation was applied at 12-second intervals to monitor neuromuscular function. Maximum neuromuscular blockade onset time, tracheal intubation conditions and changes in hemodynamic parameters (arterial mean blood pressure and heart rate) were evaluated. Results - Mean times for maximum neuromuscular block onset were: Group / (3.90 ± 0.60 min and 3.88 ± 0.74 min, for subgroups P1 and U1, respectively) and Group II (1.40 ± 0.40 min and 2 ± 0.30 min, for subgroups P2 and U2, respectively) with no significant differences. Comparison between subgroups P1 and P2 and between subgroups U1 and U2, has shown statistically significant differences. Tracheal intubation conditions were acceptable in all patients and there were no cardiovascular changes. Conclusions - Fractional cisatracurium doses have not shortened maximum neuromuscular block onset as compared to bolus injections. They have however produced acceptable tracheal intubation conditions without cardiovascular changes.531916Donati, F., Onset of action of relaxants (1988) Can J Anaesth, 35, pp. S52-S58Foldes, F.F., Nagashima, H., Kornak, P.H., Effect of priming (1993) Anaesth Pharmacol Rev, 1, pp. 49-56Koller, M.E., Husby, P., High-dose vecuronium may be an alternative to suxamethonium for rapid-sequence intubation (1993) Acta Anaesthesiol Scand, 37, pp. 465-468Potério, G.M.B., Braga, A.F.A., Condições de intubação traqueal com pancurônio. O princípio do priming-dose (1989) Rev Bras Anestesiol, 39 (SUPPL. 11), pp. CBA26Braga, A.F.A., Potério, G.M.B., Emprego do pancurônio e alcurônio em doses fracionadas na obtenção de relaxamento muscular para intubação traqueal (1993) Rev Bras Anestesiol, 43 (SUPPL. 17), pp. CBA76Braga, A.A., Potério, G.B., Rousselet, M.S., Atracúrio e intubação traqueal: Priming-dose X injeção única (1994) Rev Bras Anestesiol, 44 (SUPPL. 18), pp. CBA115Mellinghoff, H., Radbruch, L., Diefenbach, C., A comparison of cisatracurium and atracurium onset of neuromuscular block after bolus injection and recovery after subsequent infusion (1996) Anesth Analg, 83, pp. 1072-1075Bluestein, L.S., Stinson L.W., Jr., Lennon, R.L., Evaluation of cisatracurium, a new neuromuscular blocking agent, for tracheal intubation (1996) Can J Anaesth, 43, pp. 925-931Mallampati, S.R., Gatt, S.P., Gugino, L.D., A clinical sign to predict difficult tracheal intubation: A prospective study (1985) Can J Anaesth, 32, pp. 429-434Goldberg, M.E., Larijani, G.E., Azad, S.S., Comparison of tracheal intubating conditions and neuromuscular blocking profiles after intubating doses of mivacurium chloride or succinylcholine in surgical outpatients (1989) Anesth Analg, 69, pp. 93-99Baumgarten, R.K., Carter, C.E., Reynolds, W.J., Priming with nondepolarizing relaxants for rapid tracheal intubation: A double-blind evaluation (1988) Can J Anaesth, 35, pp. 5-11Storella, R.J., Jaffe, J., Mehr, E., In vitro investigation of the priming principle for rapid neuromuscular block (1989) Br J Anaesth, 62, pp. 478-482Foldes, F.F., Rapid tracheal intubation with non-depolarizing neuromuscular blocking drugs: The priming principle (1984) Br J Anaesth, 56, p. 663Schwarz, S., Ilias, W., Lackner, F., Rapid tracheal intubation with vecuronium: The priming principle (1985) Anesthesiology, 62, pp. 388-391Redai, I., Feldman, S.A., Priming studies with rocuronium and vecuronium (1995) Eur J Anaesth, 11, pp. 11-13Paton, W.D.M., Waud, D.R., The margin of safety of neuromuscular transmission (1967) J Physiol, 191, pp. 59-90Waud, B.E., Waud, D.R., The margin of safety of neuromuscular transmission in the muscle of the diaphragm (1972) Anesthesiology, 37, pp. 417-422Mehta, M.P., Choi, W.W., Gergis, S.D., Facilitation of rapid endotracheal intubations with divided doses of non-depolarizing neuromuscular blocking drugs (1985) Anesthesiology, 62, pp. 392-395Hofmockel, R., Bernad, G., Time-course of action and intubating conditions with rocuronium bromide under propofol-alfentanil anaesthesia (1995) Eur J Anaesth, 12, pp. 69-72Feldman, S.A., Rocuronium: Onset times and intubating conditions (1994) Eur J Anaesth, 9, pp. 49-52Musich, J., Walts, L.F., Pulmonary aspiration after a priming dose of vecuronium (1986) Anesthesiology, 64, pp. 517-519Van Aken, H., Mertes, N., Haess, G.M., Pretreatment technique for fast intubation with vecuronium: Intubation conditions and unwanted effects (1986) Acta Anaesthesiol Belg, 37, pp. 199-204Engbaek, J., Viby-Mogensen, J., Pre-curarization: A hazard to the patient? (1984) Acta Anaesthesiol Scand, 28, pp. 61-62Mahajan, R.P., Laverty, J., Lung function after vecuronium pre-treatment in young, healthy patients (1992) Br J Anaesth, 69, pp. 318-319Aziz, L., Jahangir, S.M., Choudhury, S.N.S., The effect of priming with vecuronium and rocuronium on young and elderly patients (1997) Anesth Analg, 85, pp. 663-666Mirakhur, R.K., Lavery, G.G., Gibson, F.M., Intubating conditions after vecuronium and atracurium given in divided doses (the priming technique) (1986) Acta Anaesthesiol Scand, 30, pp. 347-350Glass, P.S., Wilson, W., Mace, J.A., Is the priming principle both effective and safe? (1989) Anesth Analg, 68, pp. 127-134Miller, R.D., The priming principle (1985) Anesthesiology, 62, pp. 381-382Braga, A.F.A., Potério, G.M.B., Braga, F.S.S., Rocurônio: Dose preparatória versus injeção única (1999) Rev Bras Anestesiol, 49, pp. 379-384Harrop-Griffiths, A.W., Grounds, R.M., Moore, M., Intubating conditions following pre-induction priming with alcuronium (1986) Anaesthesia, 41, pp. 282-286Deepika, K., Kenaan, C.A., Bikhazi, G.B., Influence of the priming technique on pharmacodynamics and intubating conditions of cisatracurium (1999) J Clin Anesth, 11, pp. 572-575Stevens, J.B., Walker, S.C., Fontenot, J.P., The clinical neuromuscular pharmacology of cisatracurium versus vecuronium during outpatient anesthesia (1997) Anesth Analg, 85, pp. 1278-1283Hoffmann, W., Schwarz, U., Ruoff, M., Effects of priming technique on onset profile of cisatracurium (1999) Anaesth Reanim, 24, pp. 130-133Puhringer, F.K., Scheller, A., Kleinsasser, A., The effect of different priming doses on the pharmacodynamics of cisatracurium (2000) Anaesthesist, 49, pp. 102-105Naguib, M., Abdulatif, M., Gyasi, H.D., Priming with atracurium: Improving intubating conditions with additional doses of thiopental (1986) Anesth Analg, 65, pp. 1295-1299Muir, A.W., Anderson, K.A., Pow, E., Interaction between rocuronium bromide and some drugs used during anaesthesia (1994) Eur J Anaesth, 11, pp. 93-98Muir, A.W., Houston, J., Marshall, R.J., A comparison of the neuromuscular blocking and autonomic effects of two new short-acting muscle-relaxants with those of succinylcholine in the anesthetized cat and pig (1989) Anesthesiology, 70, pp. 533-540Cason, B., Baker, D.G., Hickey, R.F., Cardiovascular and neuromuscular effects of three steroidal neuromuscular blocking drugs in dogs (Org 9619, Org 9426, Org 9991) (1990) Anesth Analg, 70, pp. 382-388Savarese, J.J., Lien, C.A., Belmont, M.R., The clinical pharmacology of new benzylisoquinoline-diester compounds, with special consideration of cisatracurium and mivacurium (1997) Anaesthesist, 46, pp. 840-849Doenicke, A.W., Czeslick, E., Moss, J., Onset time, endotracheal intubating conditions, and plama histamina after cisatracurium and vecuronium administration (1998) Anesth Analg, 87, pp. 434-438Lepage, J.Y., Malinovsky, J.M., Malinge, M., Pharmacodynamic dose-response and safety study of cisatracurium (51W89) in adult surgical patients during N2O-O2 opioid anesthesia (1996) Anesth Analg, 83, pp. 823-829Bryson, H.M., Faulds, D., Cisatracurium besilate. A review of its pharmacology and clinical potential in anaesthetic practice (1997) Drugs, 53, pp. 848-866Reich, D.L., Mulier, J., Viby-Mogensen, J., Comparison of the cardiovascular effects of cisatracurium and vecuronium in patients with coronary artery disease (1998) Can J Anaesth, 45, pp. 794-79

Influence Of Hypnotics On Cisatracurium-induced Neuromuscular Block. Use Of Acceleromyograhpy

Background and objective: Different drugs, including hypnotics, may influence the pharmacodynamic effects of neuromuscular blockers (NMB). The aim of this study was to evaluate the influence of propofol and etomidate on cisatracurium-induced neuromuscular blockade. Method: We included 60 patients, ASA I and II, undergoing elective surgery under general anesthesia in the study and randomly allocated them into two groups, according to their hypnotic drug: GI (propofol) and GII (etomidate). Patients received intramuscular (IM) midazolam (0.1mg.kg-1) as premedication and we performed induction with propofol (2.5mg.kg-1) or etomidate (0.3mg.kg1), preceded by fentanyl (250mg) and followed by cisatracurium (0.1mg.kg-1). The patients were ventilated with 100% oxygen until obtaining a reduction of 95% or more in the adductor pollicis response amplitude, with subsequent laryngoscopy and tracheal intubation. Neuromuscular function was monitored by acceleromyograhpy. We evaluated the onset of action of cisatracurium, tracheal intubation conditions, and hemodynamic repercussions. Results: The mean time and standard deviations of cisatracurium onset were: GI (86.6. ±. 14.3. s) and GII (116.9. ±. 11.6. s), with a significant difference (p. <. 0, 0001). Intubation conditions were acceptable in 100% of GI and 53.3% of GII patients (p. <. 0.0001). Conclusion: Induction of neuromuscular blockade with cisatracurium was faster, with better intubation conditions in patients receiving propofol compared to those receiving etomidate, without hemodynamic repercussions. © 2013 Elsevier Editora Ltda.633249253Fuchs-Buder, T., Claudius, C., Skovgaard, L.T., Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision (2007) Acta Anaesthesiol Scand, 51, pp. 789-808Viby-Mogensen, J., Engbaek, J., Eriksson, L.I., Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents (1996) Acta Anaesthesiol Scand, 40, pp. 59-74Viby-Mogensen, J., Ostergaard, D., Donati, F., Pharmacokinetic studies of neuromuscular blocking agents: good clinical research practice (GCRP) (2000) Acta Anaesthesiol Scand, 44, pp. 1169-1190Muir, A.W., Anderson, K.A., POW, E., Interaction between rocuronium bromide and some drugs, used during anaesthesia (1994) Eur J Anaesthesiol, 11 (SUPPL 9), pp. 93-98Gill, R.S., Scott, R.P.F., Etomidate short the onset time of neuromuscular block (1992) Br J Anaesth, 69, pp. 444-446Dilger, J.P., Liu, Y., Vidal, A.M., Interactions of general anaesthetics with single acetylcholine receptor channels (1995) Eur J Anaesthesiol, 12, pp. 31-39Abdel-Zaher, A.O., Askar, F.G., The myoneural effects of propofol emulsion (Diprivan) on the nerve-muscle preparations of rats (1997) Pharmacol Res, 36 (4), pp. 323-332Braga, A.F.A., Braga, F.S.B., Potério, G.M.B., The effect of different doses of propofol on tracheal intubating conditions without muscle relaxant in children (2001) Eur J Anaesthesiol, 18, pp. 384-388Savarese, J.J., Lien, C.A., Belmont, M.R., The clinical pharmacology of new benzylisoquinoline-diester compounds, with special consideration of cisatracurium and mivacurium (1997) Anaesthesist, 46, pp. 840-849Munhoz, D.C., Braga, A.F.A., Potério, G.M.B., Influência do propofol e do etomidato no bloqueio neuromuscular produzido pelo rocurônio Avaliação pela aceleromiografia (2002) Rev Bras Anestesiol, 52, pp. 673-680Bluestein, L.S., Stinson, L.W., Lennon, R.L., Evaluation of cisatracurium, a new neuromuscular blocking agent, for tracheal intubation (1996) Can J Anaesth, 43, pp. 925-931Kirov, K., Motamed, C., Decailliot, F., Comparison of the neuromuscular blocking effect of cisatracurium and atracurium on the larynx and adductor pollicis (2004) Acta Anaesthesiol Scand, 48, pp. 577-581Taha, S.K., Siddik-Sayyid, S.M., Alameddine, M., Propofol is superior to thiopental for intubation without muscle relaxants (2005) Can J Anaesth, 52, pp. 249-253Erhan, E., Ugur, G., Gunusen, I., Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade (2003) Can J Anaesth, 50, pp. 108-115Barker, P., Langton, J.A., Wilson, I.G., Movements of the vocal cords on induction of anaesthesia with thiopentone or propofol (1992) Br J Anaesth, 69, pp. 23-25Brown, G.W., Patel, Ellis, F.R., Comparison of propofol and thiopentone for laryngeal mask insertion (1991) Anaesthesia, 46, pp. 771-772Kallar, M.D., Propofol allows intubation without relaxants (1990) Anesthesiology, 73, pp. A21Woods, A.W., Allam, S., Tracheal intubation without the use neuromuscular blocking agents (2005) Br J Anaesth, 94, pp. 151-158Sneyd, R., O' Sullivan, E., Tracheal intubation without neuromuscular blocking agents: is there any point? (2010) Br J Anaesth, 104, pp. 535-537Siddik-Sayyid, S.M., Taha, S.K., Aouad, M.T., Propofol 2m/kg is superior to propofol 2mg/kg for tracheal intubation in children during sevoflurane induction (2011) Acta Anaesthesiol Scand, 55, pp. 535-538De Mey, J.C., De Baerdemaeker, L., De Laat, M., The onset of neuromuscular block at the masseter muscle as a predictor of optimal intubating conditions with rocuronium (1999) Eur J Anaesthesiol, 16, pp. 387-389Braga Ade, F., Munoz, D.C., Braga, F.S., Influence of stimulus frequency on blockade induced by pancuronium and rocuronium: study on rats phrenic nerve-diaphragm preparation (2007) Acta Cir Bras, 22, pp. 446-450Curran, M.J., Donati, F., Bevan, D.R., Onset and recovery of atracurium and suxamethonium - induced neuromuscular blockade with simultaneous train-of-four and single twitch stimulation (1987) Br J Anaesth, 59, pp. 989-994Girling, K.J., Mahajan, R.P., The effect of stabilization on the onset of neuromuscular block when assessed using accelerometry (1996) Anesth Analg, 82, pp. 1257-1260McCoy, E.P., Mirakhur, R.K., Maddineni, V.R., Pharmacokinetics of rocuronium after bolus and continuous infusion during halothane anaesthesia (1995) Br J Anaesth, 76, pp. 29-33Saxena, P.R., Dhasmana, K.M., Prakash, O., A comparison of systemic and regional haemodynamic effects of d-tubocurarine, pancuronium. and vecuronium (1983) Anesthesiology, 59, pp. 102-108Scott, R.P.F., Savarese, J.J., Basta, S.J., Clinical pharmacology of atracurium given high dose (1986) Br J Anaesth, 58, pp. 834-838Tullock, W.C., Diana, P., Cook, D.R., Neuromuscular and cardiovascular effects of high-dose vecuronium (1990) Anesth Analg, 70, pp. 86-90Aun, C.S.T., Sung, R.Y.T., O'Meara, M.E., Cardiovascular effects of intravenous induction in children: comparison between propofol and thiopentone (1993) Br J Anaesth, 70, pp. 647-653Fuchs-Buder, T., Claudius, C., Skovgaard, L.T., Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision (2007) Acta Anaesthesiol Scand, 51, pp. 789-808Viby-Mogensen, J., Engbaek, J., Eriksson, L.I., Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents (1996) Acta Anaesthesiol Scand, 40, pp. 59-74Viby-Mogensen, J., Ostergaard, D., Donati, F., Pharmacokinetic studies of neuromuscular blocking agents: good clinical research practice (GCRP) (2000) Acta Anaesthesiol Scand, 44, pp. 1169-1190Muir, A.W., Anderson, K.A., POW, E., Interaction between rocuronium bromide and some drugs, used during anaesthesia (1994) Eur J Anaesthesiol, 11 (SUPPL 9), pp. 93-98Gill, R.S., Scott, R.P.F., Etomidate short the onset time of neuromuscular block (1992) Br J Anaesth, 69, pp. 444-446Dilger, J.P., Liu, Y., Vidal, A.M., Interactions of general anaesthetics with single acetylcholine receptor channels (1995) Eur J Anaesthesiol, 12, pp. 31-39Abdel-Zaher, A.O., Askar, F.G., The myoneural effects of propofol emulsion (Diprivan) on the nerve-muscle preparations of rats (1997) Pharmacol Res, 36 (4), pp. 323-332Braga, A.F.A., Braga, F.S.B., Potério, G.M.B., The effect of different doses of propofol on tracheal intubating conditions without muscle relaxant in children (2001) Eur J Anaesthesiol, 18, pp. 384-388Savarese, J.J., Lien, C.A., Belmont, M.R., The clinical pharmacology of new benzylisoquinoline-diester compounds, with special consideration of cisatracurium and mivacurium (1997) Anaesthesist, 46, pp. 840-849Munhoz, D.C., Braga, A.F.A., Potério, G.M.B., Influência do propofol e do etomidato no bloqueio neuromuscular produzido pelo rocurônio Avaliação pela aceleromiografia (2002) Rev Bras Anestesiol, 52, pp. 673-680Bluestein, L.S., Stinson, L.W., Lennon, R.L., Evaluation of cisatracurium, a new neuromuscular blocking agent, for tracheal intubation (1996) Can J Anaesth, 43, pp. 925-931Kirov, K., Motamed, C., Decailliot, F., Comparison of the neuromuscular blocking effect of cisatracurium and atracurium on the larynx and adductor pollicis (2004) Acta Anaesthesiol Scand, 48, pp. 577-581Taha, S.K., Siddik-Sayyid, S.M., Alameddine, M., Propofol is superior to thiopental for intubation without muscle relaxants (2005) Can J Anaesth, 52, pp. 249-253Erhan, E., Ugur, G., Gunusen, I., Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade (2003) Can J Anaesth, 50, pp. 108-115Barker, P., Langton, J.A., Wilson, I.G., Movements of the vocal cords on induction of anaesthesia with thiopentone or propofol (1992) Br J Anaesth, 69, pp. 23-25Brown, G.W., Patel, Ellis, F.R., Comparison of propofol and thiopentone for laryngeal mask insertion (1991) Anaesthesia, 46, pp. 771-772Kallar, M.D., Propofol allows intubation without relaxants (1990) Anesthesiology, 73, pp. A21Woods, A.W., Allam, S., Tracheal intubation without the use neuromuscular blocking agents (2005) Br J Anaesth, 94, pp. 151-158Sneyd, R., O' Sullivan, E., Tracheal intubation without neuromuscular blocking agents: is there any point? (2010) Br J Anaesth, 104, pp. 535-537Siddik-Sayyid, S.M., Taha, S.K., Aouad, M.T., Propofol 2m/kg is superior to propofol 2mg/kg for tracheal intubation in children during sevoflurane induction (2011) Acta Anaesthesiol Scand, 55, pp. 535-538De Mey, J.C., De Baerdemaeker, L., De Laat, M., The onset of neuromuscular block at the masseter muscle as a predictor of optimal intubating conditions with rocuronium (1999) Eur J Anaesthesiol, 16, pp. 387-389Braga Ade, F., Munoz, D.C., Braga, F.S., Influence of stimulus frequency on blockade induced by pancuronium and rocuronium: study on rats phrenic nerve-diaphragm preparation (2007) Acta Cir Bras, 22, pp. 446-450Curran, M.J., Donati, F., Bevan, D.R., Onset and recovery of atracurium and suxamethonium - induced neuromuscular blockade with simultaneous train-of-four and single twitch stimulation (1987) Br J Anaesth, 59, pp. 989-994Girling, K.J., Mahajan, R.P., The effect of stabilization on the onset of neuromuscular block when assessed using accelerometry (1996) Anesth Analg, 82, pp. 1257-1260McCoy, E.P., Mirakhur, R.K., Maddineni, V.R., Pharmacokinetics of rocuronium after bolus and continuous infusion during halothane anaesthesia (1995) Br J Anaesth, 76, pp. 29-33Saxena, P.R., Dhasmana, K.M., Prakash, O., A comparison of systemic and regional haemodynamic effects of d-tubocurarine, pancuronium. and vecuronium (1983) Anesthesiology, 59, pp. 102-108Scott, R.P.F., Savarese, J.J., Basta, S.J., Clinical pharmacology of atracurium given high dose (1986) Br J Anaesth, 58, pp. 834-838Tullock, W.C., Diana, P., Cook, D.R., Neuromuscular and cardiovascular effects of high-dose vecuronium (1990) Anesth Analg, 70, pp. 86-90Aun, C.S.T., Sung, R.Y.T., O'Meara, M.E., Cardiovascular effects of intravenous induction in children: comparison between propofol and thiopentone (1993) Br J Anaesth, 70, pp. 647-65