A clinical comparative study of two intubating doses of cis-atracurium during general anaesthesia for gynaecological surgery

Abstract

INTRODUCTIONCisatracurium besilate is a cis-cis isomer (51W89:1R-cis 1'R-cis atracurium), one of the 10 stereoisomers of atracurium that constitutes 15% of the atracurium mixture, an intermediate duration non-depolarising neuromuscular blocking drug. It is about three to four times more potent than atracurium and devoid of cardiovascular side effects in doses of upto 8 times of ED95. The ED95 of cisatracurium is 0.05mg/kg. 1-5The rate limiting step in the degradation of cisatracurium is Hoffmann degradation.(organ independent elimination) to form laudanosine and monoquaternary alcohol. 77% of drug is cleared via Hoffmann degradation which is a ph and temperature dependent process, rest 23% of drug get cleared through organ dependent means, and renal elimination accounts for 16% of this. Hydrolysis by non-specific esterases is not an important pathway for cisatracurium degradation. It is not associated with histamine release in humans. Although the liver and kidneys play only a small role in the excretion of cisatracurium besilate, urinary and hepatic elimination pathways are important for the metabolites of laudanosine. 5-8The total body clearance (CL), steady-state Vd and elimination half-life of cisatracurium besilate in patients with normal organ function are approximately 0.27 to 0.34 L/h/kg (4.7 ml/min/kg), 0.11 to 0.16 L/kg and 22 to 35 minutes, respectively. The volume of distribution (Vd) ABSTRACT Background: Cisatracurium is one of the cis-cis isomer of atracurium (51W89:1R-cis 1'R-cis atracurium) an intermediate duration non-depolarising neuromuscular blocking drug and is devoid of histamine release. However, 2× ED95 dose of cisatracurium does not provide satisfactory intubating condition. The recommended intubating dose of cisatracurium is 3 ×ED95. The objective of this study was to evaluate and compare duration of action, hemodynamic effects and any adverse effects for different doses of cisatracurium. Methods: After Institutional Ethical Committee approval and informed patient consent, 80 patients of ASA I and II in the age group of 20-60 years were selected and included in the study. Patients were divided in two groups of 40 each, group A received intravenously 3×ED95 (0.15 mg/kg) loading dose of cisatracurium and group B received intravenously 4×ED95 (0.2 mg/kg) loading dose of cisatracurium. Results: After induction, MAP and HR shows decrease in both groups but neither statistically nor clinically significant. Better hemodynamic stability and longer duration of action was found in group B compared to group A. No adverse effects noted in both groups. Conclusions: 4×ED95 dose of cisatracurium provides longer duration of action and more stable hemodynamic status than 3×ED95. No associated signs of histamine release were detected clinically.

Prospective Clinical Comparative Assessment of Intubating Conditions and Neuromuscular Blocking Effects of Two Different Doses of Cisatracurium.

“…It correlates with our study. [7] Amini Shahram et al (2011) studied effects of different doses of cisatracurium on appropriate time for endotracheal intubation and hemodynamic changes during anaesthesia and found that the mean clinical duration of action with 0.15 mg/kg was 44.93±5.40 minutes while with 0.2 mg/kg was 57.03±4.21 minutes, which correlates with our study. [8] Bluestein LS, Stinson LW, et al (1996) reported that increasing the initial dose of cisatracurium (from 0.1 to 0.15 and 0.2mg/kg) increased the mean time of clinically effective duration (45 to 55 and 61 min) respectively, which correlates with our study results.…”

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

“…who did not perceive any noteworthy changes in HR too and inferred that the maximum HR changes were small and non-significant. [ 13 14 ] The overall change in HR and MAP in the study was minimal, perhaps attributable to the use of N 2 O, barbiturate, and fentanyl that masked the hemodynamic changes associated with histamine release, making it more difficult to recognize the clinical signs of this phenomenon. El Kasaby et al .…”

A clinical comparative study to evaluate the efficacy of intubating doses of atracurium and cisatracurium in patients undergoing general anesthesia

“…El-kasaby et al, 16 in their study observed that hemodynamic stability for both mean arterial pressure and heart rate was more evident when cisatracurium with higher dosage (4ED 95 and 6ED95) as compared to (2ED 95 dose of atracurium and 2ED95 dose of cisatracurium which was statistically significant (P<0.05) which can be attributed to absence of dose-dependent histamine release in cisatracurium group. Jammar et al, 24 also concluded better hemodynamics with higher dose of (4ED95) cisatracurium compared to the lower dose (3ED95).…”