Cylcosporinepancuronium interaction in a patient with a renal allograft

Crosby, Edward T.; Robblee, James A.

doi:10.1007/bf03010635

Cited by 36 publications

(9 citation statements)

References 7 publications

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“…These authors also proposed that cremophor increases the effective concentration of pancuronium at the neuromuscular junction. 13 This may have been a factor in the prolonged muscle paralysis demonstrated in our patient.…”

Section: Commentmentioning

confidence: 72%

Prolonged Paralysis Associated with Long‐Term Pancuronium Use

Haas

Shaefer²,

Miwa³

et al. 1989

Pharmacotherapy

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We cared for a 4-year-old patient who had undergone orthotopic liver transplantation and was placed on a ventilator for respiratory distress associated with Pneumocystis carinii pneumonia. The neuromuscular blocking agent pancuronium bromide 1 .O-1.2 mg every hour as needed was used to facilitate artificial ventilation for 40 days. On discontinuation of pancuronium, the patient experienced severe, generalized neuromuscular dysfunction. Because no improvement was seen for 2 weeks, the acetylcholinesterase inhibitors edrophonium and pyridostigmine were instituted. Shortly thereafter the patient's condition began to improve. Gradual improvement occurred over 3-4 months and the patient has since returned to baseline neurologic function. We suggest that long-term pancuronium use was the cause of the patient's prolonged paralysis. The improvement experienced after the initiation of antidotal therapy strongly supports our proposal. (Pharmacotherapy 1989;9(3):154-157)Pancuronium, a nondepolarizing, neuromuscular blocking agent, was introduced in the United States in 1972.' It is 5 times more potent than D-tubOcUrarine, and has few cardiovascular, histamine-releasing, and hormonal actions.2 It combines with cholinergic receptors at the postsynaptic membrane of the neuromuscular iunction and prevents transmission ranges from 0.06-0.10 mg/kg.3 Paralysis is maintained by administering an additional 2-4 mg every 1-2 hours as needed.3 We cared for a child who experienced prolonged muscle paralysis after longterm pancuronium therapy. Case Reportof neuroelectrical impulses by acetylcholine.' It also acts to a lesser extent by presynaptic inhibition of the release of acetylcholine molecules from the nerve terminal into the synaptic cleft.' Pancuronium acts only on striated muscle; it causes no change in smooth muscle f~n c t i o n .~ Neuromuscular blockade produced by the drug may be reversed by acetylcholinesterase inhibitors such as edrophonium, pyridostigmine, and neostigmine.4Pancuronium is used to eliminate the spontaneous resistance efforts of patients during surgery or mechanical ventilation by providing skeletal muscle relaxati~n.~ The intravenous single initial dose From the DeDartments of Pharmacv Practice (Drs. Shaefer and A 4-year-old, 12.4-kg girl underwent orthotopic liver transplantation in October 1986 for biliary atresia. In March 1988 she was admitted for treatment of Pneumocystis carinii pneumonia. Four days after admission she required intubation. Pancuronium, initially 1.0 mg every hour as needed and later increased to 1.2 mg every hour as needed, was given to facilitate ventilation therapy. The frequency of dosing was determined by the nurse caring for the patient based on pulse oximetry and arterial blood gas values. The patient was 100% paralyzed the majority of the time because when her level of paralysis was allowed to decrease, her oxygen saturations dropped below acceptable levels. Pancuro-Miwa) and Surbery (Drs. Wood and Shaw). Universitv of Nebras-nium was administered dailv for 40 davs (total 438 _ _

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Section: Commentmentioning

confidence: 72%

Prolonged Paralysis Associated with Long‐Term Pancuronium Use

Haas

Shaefer²,

Miwa³

et al. 1989

Pharmacotherapy

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“…Sidi et al, who performed a prospective study, showed that cyclosporine was related to prolonged neuromuscular blockade and respiratory failure after renal transplantation [3]. There are case reports indicating that the duration of action of vecuronium was prolonged in patients receiving cyclosporine [4,5]. Cyclosporine is usually administered to patients undergoing organ transplantation or who already have transplanted organs.…”

Section: Discussionmentioning

confidence: 99%

Does cyclosporine affect the duration of action of vecuronium in renal transplant recipients?

et al. 1995

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The duration of action of vecuronium was tested in 41 surgical patients to evaluate whether cyclosporine modulates the action of vecuronium. The patients were divided into three groups: 12 patients with normal renal function (group A); 14 renal transplant recipients who had received cyclosporine before surgery (group B); and 15 patients with chronic renal failure undergoing surgery other than renal transplantation and who did not receive cyclosporine (group C). The times to 10% and 20% recovery of the first twitch (REC 10 and REC 20) after intravenous administration of vecuronium 0.12 mg·kg were measured using an electromyogram in each group. REC 10 and REC 20 were significantly prolonged in the patients of group B (REC 10: 93±18 min, REC 20: 110±14 min) and group C (REC 10: 80±10 min, REC 20: 89±12 min) than in the patients of group A (REC 10: 39±5 min, REC 20: 45±5 min) (P<0.01). There was no significant difference in the duration of action of vecuronium between the patients of groups B and C. In summary, cyclosporine did not prolong the duration of action of vecuronium in the renal transplant recipients when the same dose was administered compared with the patients with chronic renal failure who did not receive cyclosporine.

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“…Cyclosporine and a component of its vehicle, cremophor, both potentiate neuromuscular blockade. The effects are most marked with pancuromium and vecuronium and less so with atracurium ( 42,67).…”

Section: General Anesthesia In Patients With Esrdmentioning

confidence: 95%

Anesthetic Considerations for the Dialysis Patient

Graybar

Work

Barber

1989

Seminars in Dialysis

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1960 72. Bnscia MJ. Cimino JE. Appel K, H u k c h BJ: Chronic hemodialysis using venipuncture and a surgically created artenovenous fistula. N 73. Vinik HR. Reves JG. Greenblatt DJ. Abernethy DR. Smith LR: The pharmacokinetia of midazolam in chronic renal failure patients. Anes-74. Hinsdale JG. Lipkouitz GS. Hoover E L Vascular access for hemodialysis in the elderly: Rewlts and perspectives in a geriatric population. Did Trunsplrmr 14:560-565. 1985 75. McGregor AD. Jones WK. Perlman D Blood flow in the arm under brachial plexus anaesthesia. J Hand Srrrg 10:21-24. 1985 76. Bromage PR. Genel M: Brachial plexus anesthesia in chronic renal failure. Anesihesiulog~~ 36488-493, 1972 77. Bromage PR: Penetration of local anesthetics. in Epidural ,4nu/gesia, edited by Bromage PR.

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Cylcosporinepancuronium interaction in a patient with a renal allograft

Cited by 36 publications

References 7 publications

Prolonged Paralysis Associated with Long‐Term Pancuronium Use

Prolonged Paralysis Associated with Long‐Term Pancuronium Use

Does cyclosporine affect the duration of action of vecuronium in renal transplant recipients?

Anesthetic Considerations for the Dialysis Patient

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