Cumulation and reversal with prolonged infusions of atracurium and vecuronium

Martineau, Raymond; St-Jean, B.; Kitts, John B.; Curran, Michael; Lindsay, Patrice; Hull, Kathryn A.; Miller, Donald R.

doi:10.1007/bf03008228

Cited by 23 publications

(16 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…10 In that trial, maintenance requirements of atracurium were unaltered during a similar period of infusion. On the other hand, infusions of vecuronium had to be decreased by more than 50% over two hours to prevent progressive deepening of the level of neuromuscular block.…”

Section: Discussionmentioning

confidence: 92%

See 1 more Smart Citation

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion

Miller

Wherrett

Hull

et al. 2000

Can J Anesth/J Can Anesth

Self Cite

View full text Add to dashboard Cite

Purpose: The dissimilar pharmacokinetic properties of cisatracurium (CIS) and rocuronium (ROC) predict different potential for drug cumulation when these drugs are administered by continuous infusion. A study was therefore undertaken to compare cumulation potential of CIS and ROC during surgical procedures of relatively long duration (2-4 hr). Methods: Sufentanil/propofol-N 2 O anesthesia was administered to 40 ASA I and II adults. In a double-blind protocol, patients were randomly allocated to receive a continuous iv infusion of either CIS or ROC, titrated in progressive increments or decrements as required to achieve and maintain 95 ± 5% depression of the T1 response of the adductor pollicis muscle, using a Datex NMT-100 Relaxograph EMG monitor applied at the wrist. At the end of surgery, 60 µg·kg -1 neostigmine plus 15 µg·kg -1 atropine were administered for reversal. Results: The duration of infusion was 104 ± 33 min in group CIS and 110 ± 23 min in group ROC (P=NS). In both groups, a progressive decrease in potency-adjusted infusion rates was observed after 30 min, then stabilized beyond 60 min. When allowing for an initial period of stabilization, mean potency-adjusted infusion requirements were: CIS 0.81 ± 0.02 µg·kg -1 ·min -1 and ROC 5.58 ± 1.94 µg·kg -1 ·min -1 . There were no differences between groups at any time with regard to potency-adjusted infusion requirements necessary to maintain 90-99% block (P=NS). However, drug costs/hr for maintenance of neuromuscular block were less with CIS ($3.57 ± 0.09) than with ROC ($6.03 ± 0.27), P < 0.001. Conclusion: When adjusted to equipotency, infusion requirements of CIS and ROC vary at similar rates during general anesthesia. Despite pharmacokinetic differences, neither drug demonstrates cumulation for infusion lasting up to 3.5 hr.Objectif : Les propriétés pharmacocinétiques différentes du cisatracurium (CIS) et du rocuronium (ROC) laissent présager un potentiel différent d'accumulation lorsqu'on les administre en perfusion continue. Une étude a donc été menée pour comparer le potentiel d'accumulation de CIS et de ROC pendant des interventions chirurgicales de durée relativement longue (2-4 h). Méthode : Une anesthésie à base de sufentanil/propofol-N 2 O a été administrée à 40 adultes d'état physique ASA I et II. Selon un protocole à double insu, les patients ont été répartis de façon aléatoire et ont reçu une perfusion iv continue de CIS ou de ROC en doses progressives ou dégressives comme l'exigent la réalisation et le maintien d'une dépression de 95 ± 5 % de la réponse à T1 du muscle adducteur du pouce, en utilisant un moniteur Datex NMT-100 Relaxograph EMG appliqué au poignet. À la fin de l'opération, 60 µg·kg -1 de néostigmine et 15 µg·kg -1 d'atropine ont été administrés pour renverser le bloc. Résultats : La perfusion a duré 104 ± 33 min dans le groupe CIS et 110 ± 23 min dans le groupe ROC (P=NS). Dans les deux groupes, une baisse progressive des vitesses de perfusion ajustée en fonction de la puissance a été observée après 30 min, puis stabilisée a...

show abstract

Section: Discussionmentioning

confidence: 92%

“…10 In contrast, infusion requirements of atracurium (when potency-adjusted), remain constant for the same level of block. This observation implies absence of cumulation with atracurium, due to the much shorter elimination half-life of this drug (t 1/2 ß=20-25 min vs 60-70 min for vecuronium).…”

Section: Reports Of Investigationmentioning

confidence: 99%

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion

Miller

Wherrett

Hull

et al. 2000

Can J Anesth/J Can Anesth

Self Cite

View full text Add to dashboard Cite

show abstract

“…As a result, the infusion rate required for constant effect is expected to decrease with time, as was found in several studies. [2][3] For example, in Martineau et al . 2 the infusion requirements of vecuronium decreased by almost half over a two-hour period, from 1 to 0.5 µg·kg…”

mentioning

confidence: 99%

“…[2][3] For example, in Martineau et al . 2 the infusion requirements of vecuronium decreased by almost half over a two-hour period, from 1 to 0.5 µg·kg…”

mentioning

confidence: 99%

See 1 more Smart Citation

Cumulation and flexibility with infusions of neuromuscular blocking drugs

Donati

2000

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

HE major problem addressed in neuromuscular research over the past 60 yr has been to provide a fast onset/rapid recovery nondepolarizing agent without side effects. The driving force behind this agenda is a patient safety problem, that is the possibility to secure the airway within 1-1.5 min and a rapid (5-10 min) recovery should intubation fail. This quest for new agents has not produced the perfect drug, but over the past decades, a trend towards faster onset, shorter duration compounds can be observed.The availability of short acting neuromuscular blockers has another benefit quite separate from the rapid on/off property. It allows the clinician to increase or decrease rapidly the intensity of surgical relaxation, depending on actual need, and this is best accomplished when neuromuscular blocking drugs are given as infusions. The depth of anesthesia required for a given surgical procedure is not constant. The need for muscle relaxation also varies throughout surgery. It is probably highest at the time of tracheal intubation, is moderate at peritoneal incision and closure, and lowest at skin closure. These rough guidelines depend on the patient and the procedure. Infusions aside, anesthesiologists commonly inject neuromuscular relaxants according to need. A relatively large dose is given at the beginning for tracheal intubation, with no response seen at the adductor pollicis with indirect nerve stimulation. A somewhat more modest level of relaxation is needed for the start of the surgery, less relaxation is usually present for most of the procedure, and top-up doses are often needed for closure. Full recovery is a must at the end of the case.Provided that recovery is rapid, there is, however, very little disadvantage in keeping relaxation relatively constant at a deep level throughout surgery. Most modern neuromuscular relaxants have virtually no cardiovascular effects, so an overdose has few, if any, immediate consequences. This is not the case for narcotics, inhalational agents and intravenous anesthetics, all of which produce hypotension if a large dose is administered. Moreover, the dose of muscle relaxant can be adjusted by using a nerve stimulator. Thus, an attractive solution for the administration of muscle relaxants is by infusion, adjusted to fit most requirements during the case (usually one twitch in the train-of-four). The basic properties of the perfect neuromuscular blocking drug for administration by infusion can be imagined easily:(1) fast onset to have the option to increase relaxation quickly if required; (2) rapid recovery because neuromuscular function must return to normal after anesthesia; and (3) constant infusion rate to keep the effect constant with time. The first two of these properties are part of what is considered essential for an ideal neuromuscular blocking drug. In addition, a constant infusion rate allows profound relaxation without concern for recovery, with the anesthesiologist's attention devoted to other tasks. To accomplish this, a drug must be non-cumulative, which intu...

show abstract

Prolonged Neuromuscular Blockade in Two Critically Ill Patients Treated With Atracurium

Hoey,

Joslin,

Nahum

et al. 1995

Pharmacotherapy

View full text Add to dashboard Cite

Recent literature suggests that the risk of prolonged neuromuscular blockade associated with atracurium compared with other nondepolarizing neuromuscular blocking agents may be minimal. Two patients experienced prolonged weakness associated with the administration of atracurium. Both received atracurium 0.5–0.7 mg/kg/hour in combination with methylprednisolone 500–600 mg/day. Electromyographic results and creatine kinase levels were suggestive of muscular weakness in both patients. Despite high‐dose corticosteroid therapy, the electromyographic evidence supporting prolonged weakness did not suggest typical corticosteroid myopathy. Although some clinicians advocate routine administration of atracurium in critically ill patients due to the relative lack of reports of prolonged weakness, this may be premature. Although there are fewer reports of atracurium‐associated prolonged weakness compared with pancuronium and vecuronium, the patients we describe suggest that it may occur.

show abstract

Cumulation and reversal with prolonged infusions of atracurium and vecuronium

Abstract: A randomized, double-blind study was undertaken to compare the tendencies for cumulation, and reversal characteristics of atracurium (A TR ) and vecuronium (VEC ) when administered by continuous in fusion for

Cited by 23 publications

References 21 publications

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion

Cumulation and flexibility with infusions of neuromuscular blocking drugs

Prolonged Neuromuscular Blockade in Two Critically Ill Patients Treated With Atracurium

Contact Info

Product

Resources

About