Resistance to Nondepolarizing Muscle Relaxants in Paretic Upper Extremities of Patients with Residual Hemiplegia

Moorthy, S. S.; Hilgenberg, John C.

doi:10.1213/00000539-198008000-00011

Cited by 38 publications

(14 citation statements)

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“…Therefore, we do not believe that pancuronium failed to produce muscle relaxation because of the presence of myotonic contracture. Specific pathologic states cause increased resistance to nondepolarizing muscle relaxants, e.g., upper motor neuron lesion [10], disuse atrophy [11], severe thermal injuries [12], and liver cirrhosis [13]. However, our patient was not in any of these pathologic states.…”

Section: Discussionmentioning

confidence: 85%

Unexpected resistance to pancuronium in a patient with myotonic dystrophy (myotonia dystrophica)

Akata

Sasaki

Saito

et al. 2000

Journal of Anesthesia

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baldness, and cataract formation. In addition, he appeared to have cardiac dysrhythmias associated with myotonia dystrophica, and he was diagnosed 7 years previously with Adam-Stokes' syndrome. However, without any cardiac medication, first-degree atrioventricular block (PQ interval, 0.28 s) was the only abnormality found in the resting electrocardiogram, and the echocardiogram was normal. Pulmonary function tests, chest X-rays, and arterial blood gas analysis were all within normal limits (NL). The patient's serum concentrations of electrolytes were all normal. However, the preoperative screening tests on the endocrine system revealed the presence of mild adrenocortical insufficiency due to pituitary dysfunction: urine 17-hydroxycorticosteroids, 0.85 to 2.465 (NL ϭ 3.6-9.0) mg·day Ϫ1 ; 17-ketosteroids, 1.68 to 4.35 (NL ϭ 3.0-13.0) mg·day Ϫ1 ; serum cortisol 6.2 (NL ϭ 5.5-17.0) µg·dl Ϫ1 ; serum ACTH 13 (NL ϭ 30-60) pg·ml Ϫ1 ; ACTH test, within NL. Thyroid function was, however, normal. The preoperative laboratory tests also indicated the presence of hyperlipidemia (triglycerides, 241-384 mg·dl Ϫ1 ; cholesterol, 255-286 mg·dl Ϫ1 ). Other laboratory data, including those on both hepatic and renal function, were normal. The patient had not previously undergone surgery with general anesthesia.The patient was premedicated with intramuscular hydroxyzine hydrochloride (50 mg) and atropine sulfate (0.5 mg) 45 min prior to the induction of anesthesia. Because of the adrenocortical insufficiency, 100 mg of hydrocortisone was intravenously administered immediately before induction of anesthesia. The patient was then mildly sedated with intravenous diazepam (5 mg) and fentanyl (150 µg), and the trachea was successfully intubated without using a neuromuscular blocking agent while the patient was sedated and awake. After endotracheal intubation, the lungs were easily ventilated, and anesthesia was subsequently maintained with 67% N 2 O/1-3% enflurane in oxygen and supplemented by further intravenous administration of fentanyl (total

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Section: Discussionmentioning

confidence: 85%

Unexpected resistance to pancuronium in a patient with myotonic dystrophy (myotonia dystrophica)

Akata

Sasaki

Saito

et al. 2000

Journal of Anesthesia

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“…From earlier reports it can be expected that a paretic limb will be more resistant to the effects of neuromuscular blocking agents [12,13]. During recovery, the paretic limbs show adequate recovery of TOF whereas the patient may still have TOF fade on the nonparetic limbs and may well be susceptible to respiratory depression.…”

Section: Discussionmentioning

confidence: 99%

“…After denervation, there may be an increase of cholinergic receptors. These extrajunctional areas may be more chemosensitive, resulting in a decreased threshold to acetylcholineinduced muscular response [12,13]. In the presence of neomycin, the characteristic TOF suppression may be present after administration of a neuromuscular blocking agent, but a tetanic stimulus does not result in fade.…”

Section: Discussionmentioning

confidence: 99%

Anesthesia for craniotomy in a patient with previous paralytic polio

Suneel

Sinha

Unnikrishnan

et al. 2008

Journal of Clinical Anesthesia

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“…Noch gravierender ist der trügerische Eindruck einer neuromuskulären Erholung am Ende der OP, die zu einer Extubation des noch relaxierten Patienten führen kann. Bereits 1980 beschrieben Moorthy u. Hilgenberg diese Komplikation in einem Fallbericht bei einem Patienten mit einer Hemiparese [18]. Um solche gefährlichen Fehlinterpretationen zu vermeiden, sollte in der Praxis das neuromuskuläre Monitoring bei hemiparetischen Patienten immer auf der gesunden Seite installiert werden.…”

Section: Fazit Für Die Praxisunclassified

Neuromuskuläres Monitoring bei Patienten mit Hemiparese

Muller¹,

Knüttgen²,

Vorweg³

et al. 2002

Der Anaesthesist

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The control of the neuromuscular blockade is part of the standard monitoring in general anaesthesia. However, the degree of blocking is affected by different disorders. We describe the neuromuscular monitoring in four patients suffering from central hemiplegia by stimulation of the ulnar nerve simultaneously on the paretic and the normal side. After application of non-depolarising muscle relaxants (Atracurium, Mivacurium, Rocuronium, Vecuronium) a resistance of the paretic extremity against the relaxant used was shown in all cases. A possible explanation for this observation is the spreading out of abnormal acetylcholine receptors over the surface of denervated muscle cells which could lead to a false estimation of the depth of the neuromuscular blockade. Therefore, in the clinical practice, neuromuscular monitoring must always be carried out on the normal extremity of the patient.

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Resistance to Nondepolarizing Muscle Relaxants in Paretic Upper Extremities of Patients with Residual Hemiplegia

Cited by 38 publications

References 0 publications

Unexpected resistance to pancuronium in a patient with myotonic dystrophy (myotonia dystrophica)

Unexpected resistance to pancuronium in a patient with myotonic dystrophy (myotonia dystrophica)

Anesthesia for craniotomy in a patient with previous paralytic polio

Neuromuskuläres Monitoring bei Patienten mit Hemiparese

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