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British Journal of Anaesthesia Feb 2014Burn patients develop resistance to non-depolarizing neuromuscular blocking agents (NDNMBAs) and require a significantly large dose to produce a desired clinical...
BACKGROUND
Burn patients develop resistance to non-depolarizing neuromuscular blocking agents (NDNMBAs) and require a significantly large dose to produce a desired clinical response. Pathophysiological changes related to burn injury may alter pharmacokinetics (PK) and pharmacodynamics of NDNMBAs. The purpose of this study was to compare vecuronium PK in burns vs non-burns.
METHODS
Twenty adults, aged 23-58 yr, with 27-81% total body surface area (TBSA) burn, were studied at 4-57 post-burn days and compared with age- and sex-matched, non-burn controls. Vecuronium 0.12 mg kg(-1) was given i.v. as a single bolus within 10 s. Blood samples (n=20) were collected over 12 h at predetermined time points. NONMEM was used to describe plasma drug concentration-time profiles for burns and non-burns.
RESULTS
A three-compartment model best described vecuronium concentration-time profiles. Burn patients showed enhanced distributional clearance at the terminal phase (0.12 vs 0.095 litre min(-1), P<0.0001), which yielded shorter elimination half-life for vecuronium (5.5 vs 6.6 h, P<0.001). BURN was the single most significant covariate that explained the altered vecuronium disposition in burns.
CONCLUSIONS
The altered drug distribution between tissues may partially explain the known resistance to vecuronium in patients with major burns.
Topics: Adult; Burns; Female; Humans; Male; Middle Aged; Neuromuscular Blocking Agents; Vecuronium Bromide; Young Adult
PubMed: 24067332
DOI: 10.1093/bja/aet309 -
British Journal of Anaesthesia Jan 2014Resistance to non-depolarizing neuromuscular blocking agents induced by sepsis is associated with the qualitative change in the nicotinic acetylcholine receptor (nAChR)....
Pharmacodynamic changes with vecuronium in sepsis are associated with expression of α7- and γ-nicotinic acetylcholine receptor in an experimental rat model of neuromyopathy.
BACKGROUND
Resistance to non-depolarizing neuromuscular blocking agents induced by sepsis is associated with the qualitative change in the nicotinic acetylcholine receptor (nAChR). This study aims to investigate the effects of sepsis on the neuromuscular block properties of vecuronium in relation to the expression of fetal and neuronal α7 type nAChR.
METHODS
Male Sprague-Dawley rats were randomly divided into sham and sepsis groups. Sepsis was induced by caecal ligation and puncture (CLP). The rats were injected i.v. with ulinastatin or normal saline on Day 10. Neuromuscular block properties of vecuronium were evaluated and neuromuscular function was assessed by electromyography on Days 1, 3, 7, and 14 after CLP. Expression of fetal and neuronal type α7-nAChR on the tibialis anterior muscle was assessed using immunohistochemistry and western blot. The mRNA encoding for γ- and α7 subunits was evaluated by real-time polymerase chain reaction.
RESULTS
The half maximal inhibitory response of vecuronium in the sepsis group significantly increased, peaked on Day 7, and then declined on Day 14 (P<0.05). The neuromuscular function decreased with increasing postoperation time in the sepsis group (P<0.05). Sepsis significantly increased the expression of γ- and α7-nAchR along with expression of γ- and α7 subunits mRNA, peaked on Day 7, and declined on Day 14 (P<0.05). Ulinastatin suppressed the expression of receptor protein and mRNA encoding for γ- and α7 subunits (P<0.05).
CONCLUSIONS
Pharmacodynamic changes with vecuronium seem to be associated with the expression of γ- and α7-nAChR in the skeletal muscle. Ulinastatin can improve this effect by inhibiting the expression of these receptors.
Topics: Animals; Dose-Response Relationship, Drug; Glycoproteins; Immunohistochemistry; Male; Muscle, Skeletal; Neuromuscular Diseases; Neuromuscular Nondepolarizing Agents; Rats; Rats, Sprague-Dawley; Receptors, Nicotinic; Sepsis; Vecuronium Bromide; Weight Gain; alpha7 Nicotinic Acetylcholine Receptor
PubMed: 23903895
DOI: 10.1093/bja/aet253 -
Anaesthesia Sep 2013We investigated whether a bolus injection of 20 ml saline with arm elevation might shorten the onset time of vecuronium administered via a dorsal hand vein. Thirty... (Randomized Controlled Trial)
Randomized Controlled Trial
We investigated whether a bolus injection of 20 ml saline with arm elevation might shorten the onset time of vecuronium administered via a dorsal hand vein. Thirty patients were randomly allocated to the bolus saline group or control group. General anaesthesia was induced and maintained with remifentanil and propofol. Vecuronium 0.1 mg.kg(-1) was administered to all patients, followed in the treatment group by bolus injection of 20 ml saline and arm elevation. Response to train-of-four stimulation was measured by acceleromyography at the adductor pollicis muscle. The mean (SD) lag time was 47.2 (14.5) s in the bolus saline group and 67.9 (12.2) s in the control group (p = 0.0002). The time to 95% block of T1 was 104.6 (29.9) s in the bolus saline group and 128.3 (15.8) s in the control group (p = 0.011). Bolus saline injection results in shortened lag time and onset time of neuromuscular block with vecuronium.
Topics: Accelerometry; Adolescent; Adult; Aged; Arm; Electric Stimulation; Female; Humans; Injections, Intravenous; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Patient Positioning; Sodium Chloride; Time; Vecuronium Bromide; Young Adult
PubMed: 23789813
DOI: 10.1111/anae.12333 -
Brazilian Journal of Anesthesiology... 2013Intravenous regional anesthesia (IVRA) for upper limb surgeries with traditional high dose of lidocaine can lead to life threatening side effects. In order to avoid... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND AND OBJECTIVE
Intravenous regional anesthesia (IVRA) for upper limb surgeries with traditional high dose of lidocaine can lead to life threatening side effects. In order to avoid these potential life threatening side effects, many modified techniques of IVRA have been attempted by using a low dose of lidocaine, muscle relaxant and opioid.
METHOD
The present study is carried out in sixty unpremedicated ASA Class 1 and 2 patients to compare the sensory and motor characteristics, cardio-respiratory parameters and side-effects during intra-operative and post-tourniquet deflation period between the patients who received 40mL of 0.5% lidocaine alone (n=30) and those who received a combination of 40mL of 0.25% lidocaine with 0.05mg fentanyl and 0.5mg vecuronium (n=30) in IVRA for upper limb orthopedic surgeries. The results were analyzed for statistical significance using a paired student t test.
RESULTS
The difference between the two groups regarding the mean time of onset and complete sensory and motor block was statistically significant. But 15 minutes after the injection of anesthetic solution, there was complete sensory and motor block in both groups.
CONCLUSION
Although the short delay observed in the onset and attainment of complete sensory and motor block may theoretically delay the start of surgery for 10-15 minutes but clinically that time will be spent in the preparation of surgical field. So this combination can be used safely and effectively in intravenous regional anesthesia for upper limb orthopedic surgeries with reduced chance of local anesthetic toxicity.
Topics: Adult; Anesthesia, Conduction; Anesthetics, Combined; Anesthetics, Intravenous; Arm; Female; Fentanyl; Humans; Lidocaine; Male; Prospective Studies; Vecuronium Bromide
PubMed: 23683447
DOI: 10.1016/S0034-7094(13)70226-5 -
Neurologia Medico-chirurgica 2013The effects of intraoperative magnetic resonance (iMR) imaging on the neuromuscular blockade of vecuronium bromide were investigated in neurosurgery. Fifty patients with...
The effects of intraoperative magnetic resonance (iMR) imaging on the neuromuscular blockade of vecuronium bromide were investigated in neurosurgery. Fifty patients with American Society of Anesthesiologists grades I-II scheduled for craniotomy operation were divided into two groups (n = 25 each) with no difference in demographic data: the iMR imaging group and control group. Train-of-four (TOF) stimulation through an accelerometer was used to monitor onset, maintenance, and recovery of muscle relaxation caused by vecuronium. Vecuronium bromide was intravenously injected after anesthesia induction. The dosage of vecuronium bromide in the iMR imaging group was larger than in the control group, but not significantly. Duration of vecuronium bromide administration and operation time were significantly longer in the iMR imaging group than in the control group. Time from drug discontinuation to operation termination, and to return to neurosurgery intensive care unit were not different. Time taken by first twitch (T1) in response to TOF stimulation to recover by 25%, and muscle relaxant recovery index were significantly greater in the control group than in the iMR imaging group. The body temperature of the patients increased gradually in the iMR imaging group but decreased in the control group. iMR imaging can prolong the operation time, increase the body temperature of the patient, and remarkably shorten the clinical action time and muscle relaxation recovery index of vecuronium.
Topics: Adult; Anesthesia Recovery Period; Anesthesia, General; Body Temperature; Brain Neoplasms; Craniotomy; Female; Glioma; Humans; Injections, Intravenous; Intraoperative Complications; Magnetic Resonance Imaging; Male; Middle Aged; Muscle Relaxation; Neuromuscular Depolarizing Agents; Neuromuscular Monitoring; Reference Values; Time Factors; Vecuronium Bromide
PubMed: 23615407
DOI: 10.2176/nmc.53.201 -
Brazilian Journal of Anesthesiology... 2013We investigated the effect of Nitrous Oxide (N2O) on controlled hypotension in low-flow isoflurane-dexmedetomidine anesthesia in terms of hemodynamics, anesthetic... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND AND OBJECTIVES
We investigated the effect of Nitrous Oxide (N2O) on controlled hypotension in low-flow isoflurane-dexmedetomidine anesthesia in terms of hemodynamics, anesthetic consumption, and costs.
METHODS
We allocated forty patients randomly into two equal groups. We then maintained dexmedetomidine infusion (0.1 μg.kg(-1).min(-1)) for 10 minutes. Next, we continued it until the last 30 minutes of the operation at a dose of 0.7 μg.kg(-1).hour(-1). We administered thiopental (4-6 mg. kg(-1)) and 0.08-0.12 mg.kg(-1) vecuronium bromide at induction for both groups. We used isoflurane (2%) for anesthesia maintenance. Group N received a 50% O2-N2O mixture and Group A received 50% O2-air mixture as carrier gas. We started low-flow anesthesia (1L.min(-1)) after a 10-minute period of initial high flow (4.4L.min(-1)). We recorded values for blood pressure, heart rate, peripheral O2 saturation, inspiratory isoflurane, expiratory isoflurane, inspiratory O2, expiratory O2, inspiratory N2O, expiratory N2O, inspiratory CO2, CO2 concentration after expiration, Minimum Alveolar Concentration. In addition, we determined the total consumption rate of fentanyl, dexmedetomidine and isoflurane as well as bleeding.
RESULTS
In each group the heart rate decreased after dexmedetomidine loading. After intubation, values were higher for Group A at one, three, five, 10, and 15 minutes. After intubation, the patients reached desired hypotension values at minute five for Group N and at minute 20 for group A. MAC values were higher for Group N at minute one, three, five, 10, and 15 (p<0.05). FiO2 values were high between minute five and 60 for Group A, while at minute 90 Group N values were higher (p<0.05). FiIso (inspiratuvar isofluran) values were lower in Group N at minute 15 and 30 (p<0.05).
CONCLUSION
By using dexmedetomidine instead of nitrous oxide in low flow isoflurane anesthesia, we attained desired MAP levels, sufficient anesthesia depth, hemodynamic stability and safe inspiration parameters. Dexmedetomidine infusion with medical air-oxygen as a carrier gas represents an alternative anesthetic technique.
Topics: Adult; Anesthesia, Inhalation; Anesthetics, Inhalation; Female; Hemodynamics; Humans; Hypotension, Controlled; Male; Nitrous Oxide; Prospective Studies
PubMed: 23601256
DOI: 10.1016/S0034-7094(13)70210-1 -
American Journal of Medical Quality :... 2013Medication errors due to look-alike drugs put patients at risk and can be fatal. Neuromuscular blocking agents, such as vecuronium, can cause awake-paralysis in patients...
Medication errors due to look-alike drugs put patients at risk and can be fatal. Neuromuscular blocking agents, such as vecuronium, can cause awake-paralysis in patients if administered as a single agent. Recent literature reported six cases in which vecuronium was inadvertently administered instead of the antibiotic drug cefazolin. This article describes a standardized quality improvement process used at The Johns Hopkins Hospital that was locally implemented following an adverse drug event and culminated in a nationwide FDA-mandated drug recall of vecuronium.
Topics: Cefazolin; Drug Labeling; Drug Recalls; Female; Humans; Medication Errors; Middle Aged; Neuromuscular Blocking Agents; Quality Improvement; United States; Vecuronium Bromide
PubMed: 23508529
DOI: 10.1177/1062860613478730 -
British Journal of Anaesthesia Apr 2013There have been no evidence-based comparisons of motor-evoked potential (MEP) monitoring with no and partial neuromuscular block (NMB). We compared the effects of... (Comparative Study)
Comparative Study Randomized Controlled Trial
Comparison of motor-evoked potentials monitoring in response to transcranial electrical stimulation in subjects undergoing neurosurgery with partial vs no neuromuscular block.
BACKGROUND
There have been no evidence-based comparisons of motor-evoked potential (MEP) monitoring with no and partial neuromuscular block (NMB). We compared the effects of different levels of NMB including no NMB on MEP parameters.
METHODS
MEP-monitored 120 patients undergoing neurosurgery were enrolled. The patients were randomly allocated to four groups: Group A was to maintain two train-of-four (TOF) counts; Group B was to maintain a T(1)/Tc of 0.5; Group C was to maintain a T(2)/Tc of 0.5 (T(1,2), first or second twitch height of TOF; Tc, control twitch height); Group D did not maintain NMB. The mean MEP amplitude, coefficient of variation (CV), the incidence of spontaneous respiration or movement, the efficacy of MEP, and haemodynamic parameters were compared.
RESULTS
The median [inter-quartile range (IQR)] amplitudes of the left leg for Groups A, B, C, and D were 0.23 (0.15-0.57), 0.44 (0.19-0.79), 0.28 (0.15-0.75), and 0.75 (0.39-1.35) mV, respectively. The median (IQR) CVs of the left leg were 71.1 (56.9-88.8), 76.1 (54.2-93.1), 59.8 (48.6-95.6), and 25.2 (17.3-35.0), respectively. The differences between groups of the mean amplitudes of the left arm and both legs were statistically significant (Kruskal-Wallis test, P=0.011 for the left leg). For all limbs, the differences between groups of the CVs were significant (P<0.001, for the left leg). Other parameters were not different.
CONCLUSIONS
If NMB is used during MEP monitoring, a target T(2)/Tc of 0.5 is recommended. In terms of the MEP amplitude and variability, no NMB was more desirable than any level of partial NMB.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthesia, Intravenous; Arterial Pressure; Electric Stimulation; Evoked Potentials, Motor; Female; Functional Laterality; Heart Rate; Humans; Male; Middle Aged; Monitoring, Intraoperative; Movement; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Neurosurgical Procedures; Sample Size; Treatment Outcome; Vecuronium Bromide; Young Adult
PubMed: 23378247
DOI: 10.1093/bja/aes395 -
British Journal of Anaesthesia Jun 2013Neuromuscular blocking drugs (NMBDs) are the most common cause of intraoperative anaphylaxis in Western Australia. Differences in the rates of anaphylaxis between...
BACKGROUND
Neuromuscular blocking drugs (NMBDs) are the most common cause of intraoperative anaphylaxis in Western Australia. Differences in the rates of anaphylaxis between individual agents have been surmised in the past, but not proven, and are an important consideration if agents are otherwise equivalent.
METHODS
We estimated a rate of anaphylaxis to NMBDs by analysing cases of NMBD anaphylaxis referred to the only specialized diagnostic centre in Western Australia over a 10 yr period. Exposure was approximated by analysing a 5 yr period of NMBD ampoule sales data. Agents were also ranked according to the prevalence of cross-reactivity in patients with previous NMBD anaphylaxis.
RESULTS
Rocuronium was responsible for 56% of cases of NMBD anaphylaxis, succinylcholine 21%, and vecuronium 11%. There was no difference in the severity of reactions for different NMBDs. Rocuronium had a higher rate of IgE-mediated anaphylaxis compared with vecuronium (8.0 vs 2.8 per 100,000 exposures; P=0.0013). The prevalence of cross-reactivity after NMBD anaphylaxis suggested that succinylcholine also has a high risk of triggering anaphylaxis. Cisatracurium had the lowest prevalence of cross-reactivity in patients with known anaphylaxis to rocuronium or vecuronium.
CONCLUSIONS
Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anaphylaxis; Androstanols; Child; Child, Preschool; Cross Reactions; Female; Humans; Incidence; Male; Middle Aged; Neuromuscular Blocking Agents; Rocuronium; Time Factors; Vecuronium Bromide; Western Australia
PubMed: 23335568
DOI: 10.1093/bja/aes506 -
American Journal of Veterinary Research Jan 2013To evaluate the effectiveness of reduction of inspired oxygen fraction (Fio(2)) or application of positive end-expiratory pressure (PEEP) after an alveolar recruitment... (Randomized Controlled Trial)
Randomized Controlled Trial
Effects of reduction of inspired oxygen fraction or application of positive end-expiratory pressure after an alveolar recruitment maneuver on respiratory mechanics, gas exchange, and lung aeration in dogs during anesthesia and neuromuscular blockade.
OBJECTIVE
To evaluate the effectiveness of reduction of inspired oxygen fraction (Fio(2)) or application of positive end-expiratory pressure (PEEP) after an alveolar recruitment maneuver (ARM) in minimizing anesthesia-induced atelectasis in dogs.
ANIMALS
30 healthy female dogs.
PROCEDURES
During anesthesia and neuromuscular blockade, dogs were mechanically ventilated under baseline conditions (tidal volume, 12 mL/kg; inspiratory-to-expiratory ratio, 1:2; Fio(2), 1; and zero end-expiratory pressure [ZEEP]). After 40 minutes, lungs were inflated (airway pressure, 40 cm H(2)O) for 20 seconds. Dogs were then exposed to baseline conditions (ZEEP100 group), baseline conditions with Fio(2) reduced to 0.4 (ZEEP40 group), or baseline conditions with PEEP at 5 cm H(2)O (PEEP100 group; 10 dogs/group). For each dog, arterial blood gas variables and respiratory system mechanics were evaluated and CT scans of the thorax were obtained before and at 5 (T5) and 30 (T30) minutes after the ARM.
RESULTS
Compared with pre-ARM findings, atelectasis decreased and Pao(2):Fio(2) ratio increased at T5 in all groups. At T30, atelectasis and oxygenation returned to pre-ARM findings in the ZEEP100 group but remained similar to T5 findings in the other groups. At T5 and T30, lung static compliance in the PEEP100 group was higher than values in the other groups.
CONCLUSIONS AND CLINICAL RELEVANCE
Application of airway pressure of 40 cm H(2)O for 20 seconds followed by Fio(2) reduction to 0.4 or ventilation with PEEP (5 cm H(2)O) was effective in diminishing anesthesia-induced atelectasis and maintaining lung function in dogs, compared with the effects of mechanical ventilation providing an Fio(2) of 1.
Topics: Anesthesia; Anesthetics, Intravenous; Animals; Dog Diseases; Dogs; Female; Lung; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Oxygen Consumption; Positive-Pressure Respiration; Propofol; Pulmonary Alveoli; Pulmonary Atelectasis; Radiography, Thoracic; Respiration, Artificial; Respiratory Mechanics; Tomography, X-Ray Computed; Vecuronium Bromide
PubMed: 23270342
DOI: 10.2460/ajvr.74.1.25