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Saudi Journal of Anaesthesia Jul 2012Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO(2)...
BACKGROUND
Effect on hemodynamic changes and experience of robot-assisted laparoscopic radical prostatectomy (RALRP) in steep Trendelenburg position (45°) with high-pressure CO(2) pneumoperitoneum is very limited. Therefore, we planned this prospective clinical trial to study the effect of steep Tredelenburg position with high-pressure CO(2) pneumoperitoneum on hemodynamic parameters in a patient undergoing RALRP using FloTrac/Vigileo™1.10.
METHODS
After ethical approval and informed consent, 15 patients scheduled for RALRP were included in the study. In the operation room, after attaching standard monitors, the radial artery was cannulated. Anesthesia was induced with fentanyl (2 μg/kg) and thiopentone (4-7 mg/kg), and tracheal intubation was facilitated by vecuronium bromide (0.1 mg/kg). The patient's right internal jugular vein was cannulated and the Pre Sep™ central venous oximetry catheter was connected to it. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide and intermittent boluses of vecuronium. Intermittent positive-pressure ventilation was provided to maintain normocapnea. After CO(2) pneumoperitoneum, position of the patient was gradually changed to 45° Trendelenburg over 5 min. The robot was then docked and the robot-assisted surgery started. Intraoperative monitoring included central venous pressure (CVP), stroke volume (SV), stroke volume variation (SVV), cardiac output (CO), cardiac index (CI) and central venous oxygen saturation (ScvO(2)).
RESULTS
After induction of anesthesia, heart rate (HR), SV, CO and CI were decreased significantly from the baseline value (P>0.05). SV, CO and CI further decreased significantly after creating pneumoperitoneum (P>0.05). At the 45° Trendelenburg position, HR, SV, CO and CI were significantly decreased compared with baseline. Thereafter, CO and CI were persistently low throughout the 45° Trendelenburg position (P=0.001). HR at 20 min and 1 h, SV and mean arterial blood pressure after 2 h decreased significantly from the baseline value (P>0.05) during the 45° Trendelenburg position. CVP increased significantly after creating pneumoperitoneum and at the 45° Trendelenburg position (after 5 and 20 min) compared with the baseline postinduction value (P>0.05). All these parameters returned to baseline after deflation of CO(2) pneumoperitoneum in the supine position. There were no significant changes in SVV and ScvO(2) throughout the study period.
CONCLUSIONS
The steep Trendelenburg position and CO(2) pneumoperitoneum, during RALRP, leads to significant decrease in stroke volume and cardiac output.
PubMed: 23162392
DOI: 10.4103/1658-354X.101210 -
Trials Sep 2012Surgical microvascular decompression (MVD) is the curative treatment for hemifacial spasm (HFS). Monitoring MVD by recording the lateral spread response (LSR)... (Comparative Study)
Comparative Study Randomized Controlled Trial
A comparison of three induction regimens using succinylcholine, vecuronium, or no muscle relaxant: impact on the intraoperative monitoring of the lateral spread response in hemifacial spasm surgery: study protocol for a randomised controlled trial.
BACKGROUND
Surgical microvascular decompression (MVD) is the curative treatment for hemifacial spasm (HFS). Monitoring MVD by recording the lateral spread response (LSR) intraoperatively can predict a successful clinical outcome. However, the rate of the LSR varies between trials, and the reason for this variation is unclear. The aim of our trial is to evaluate the rate of the LSR after intubation following treatment with succinylcholine, vecuronium, or no muscle relaxant.
METHODS AND DESIGN
This trial is a prospective randomised controlled trial of 96 patients with HFS (ASA status I or II) undergoing MVD under general anaesthesia. Patients are randomised to receive succinylcholine, vecuronium, or no muscle relaxant before intubation. Intraoperative LSR will be recorded until dural opening. The primary outcome of this study is the rate of the LSR, and the secondary outcomes are post-intubation pharyngolaryngeal symptoms, the rate of difficult intubations, the rate of adverse haemodynamic events and the relationship between the measurement of LSR or not, and clinical success rates at 30 days after surgery.
DISCUSSION
This study aims to evaluate the impact of muscle relaxants on the rate of the LSR, and the study may provide evidence supporting the use of muscle relaxants before intubation in patients with HFS undergoing MVD surgery.
TRIALS REGISTRATION
http://www.chictr.org/ ChiCTR-TRC-11001504 Date of registration: 24 June, 2011. The date the first patient was randomised: 30 September, 2011.
Topics: Anesthesia, General; China; Electric Stimulation; Electromyography; Facial Muscles; Facial Nerve; Female; Hemifacial Spasm; Humans; Intubation, Intratracheal; Male; Microvascular Decompression Surgery; Monitoring, Intraoperative; Neuromuscular Depolarizing Agents; Prospective Studies; Research Design; Succinylcholine; Time Factors; Treatment Outcome; Vecuronium Bromide
PubMed: 22958580
DOI: 10.1186/1745-6215-13-160 -
Anaesthesia Sep 2012Deep neuromuscular blockade during certain surgical procedures may improve operating conditions. Sugammadex can be used to reverse deep neuromuscular blockade without... (Comparative Study)
Comparative Study Randomized Controlled Trial
Deep neuromuscular blockade during certain surgical procedures may improve operating conditions. Sugammadex can be used to reverse deep neuromuscular blockade without waiting for spontaneous recovery. This randomised study compared recovery times from neuromuscular blockade induced by rocuronium 0.6 mg.kg(-1), using sugammadex 4 mg.kg(-1) administered at 1-2 post-tetanic count (deep blockade) or neostigmine 50 μg.kg(-1) (plus atropine 10 μg.kg(-1)) administered at the re-appearance of the second twitch of a train-of-four stimulation (moderate blockade), in patients undergoing laparoscopic surgery. The primary efficacy variable was the time from the start of sugammadex/neostigmine administration to recovery of the train-of-four ratio to 0.9. Patients receiving sugammadex recovered 3.4 times faster than patients receiving neostigmine (geometric mean (95% CI) recovery times of 2.4 (2.1-2.7) and 8.4 (7.2-9.8) min, respectively, p<0.0001). Moreover, 94% (62/66) of sugammadex-treated patients recovered within 5 min, vs 20% (13/65) of neostigmine-treated patients, despite the difference in the depth of neuromuscular blockade at the time of administration of both drugs. The ability to provide deep neuromuscular blockade throughout the procedure but still permit reversal at the end of surgery may enable improved surgical access and an enhanced visual field.
Topics: Adult; Aged; Androstanols; Anesthesia; Anesthesia Recovery Period; Anesthetics, Intravenous; Cholinesterase Inhibitors; Electric Stimulation; Female; Heart Rate; Humans; Laparoscopy; Male; Middle Aged; Neostigmine; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Patient Safety; Propofol; Rocuronium; Sample Size; Sugammadex; Vecuronium Bromide; Young Adult; gamma-Cyclodextrins
PubMed: 22698066
DOI: 10.1111/j.1365-2044.2012.07197.x -
British Journal of Anaesthesia Dec 2011Developing a non-depolarizing neuromuscular blocking agent that, like succinylcholine, has a rapid onset and a short duration of effect remains a goal of ongoing... (Review)
Review
Developing a non-depolarizing neuromuscular blocking agent that, like succinylcholine, has a rapid onset and a short duration of effect remains a goal of ongoing research. While rocuronium fills a portion of this need, the large doses required for rapid intubation render it a much longer-acting neuromuscular blocking agent. Postoperative residual neuromuscular block (NMB) is an increasingly recognized complication of non-depolarizing neuromuscular blocking agents. This occurs because of dosing choices for neuromuscular blocking agents and anticholinesterases as well as insensitivity of typically used monitors of depth of NMB. While antagonism of NMB is necessary with partial recovery, it is unnecessary with more complete recovery. Even when monitoring with an accelerograph, reversal of NMB is complicated. In addition to the pharmacodynamics of the individual neuromuscular blocking agents, factors such as timing of anticholinesterase administration, dose of anticholinesterase, concomitant medications, electrolyte abnormalities, and hepatic or renal disease can influence the degree of reversal. Sugammadex works differently than anticholinesterases and, when administered in appropriate doses, can reverse even profound block induced with vecuronium or rocuronium. Two new fumarate neuromuscular blocking agents have a rapid onset of effect and can be reversed at any time by administration of cysteine, which could significantly reduce the risk of postoperative residual NMB.
Topics: Androstanols; Anesthesia Recovery Period; Cholinesterase Inhibitors; Cysteine; Dose-Response Relationship, Drug; Humans; Isoquinolines; Neuromuscular Blocking Agents; Postoperative Complications; Rocuronium; Sugammadex; Time Factors; Vecuronium Bromide; gamma-Cyclodextrins
PubMed: 22156271
DOI: 10.1093/bja/aer341 -
Acta Pharmacologica Sinica Dec 2011To investigate the effect of magnesium sulfate and its interaction with the non-depolarizing muscle relaxant vecuronium at adult muscle-type acetylcholine receptors in...
AIM
To investigate the effect of magnesium sulfate and its interaction with the non-depolarizing muscle relaxant vecuronium at adult muscle-type acetylcholine receptors in vitro.
METHODS
Adult muscle-type acetylcholine receptors were expressed in HEK293 cells. Drug-containing solution was applied via a gravity-driven perfusion system. The inward currents were activated by brief application of acetylcholine (ACh), and recorded using whole-cell voltage-clamp technique.
RESULTS
Magnesium sulfate (1-100 mmol/L) inhibited the inward currents induced ACh (10 μmol/L) in a concentration-dependent manner (IC(50)=29.2 mmol/L). The inhibition of magnesium sulfate was non-competitive. In contrast, vecuronium produced a potent inhibition on the adult muscle-type acetylcholine receptor (IC(50)=8.7 nmol/L) by competitive antagonism. Magnesium sulfate at the concentrations of 1, 3, and 6 mmol/L markedly enhanced the inhibition of vecuronium (10 nmol/L) on adult muscle-type acetylcholine receptors.
CONCLUSION
Clinical enhancement of vecuronium-induced muscle relaxation by magnesium sulfate can be attributed partly to synergism between magnesium sulfate and non-depolarizing muscle relaxants at adult muscle-type acetylcholine receptors.
Topics: Cell Line; Drug Synergism; Humans; In Vitro Techniques; Magnesium Sulfate; Neuromuscular Nondepolarizing Agents; Nicotinic Antagonists; Vecuronium Bromide
PubMed: 21986576
DOI: 10.1038/aps.2011.117 -
Anaesthesia Oct 2011
Topics: Aged; Anesthesia, Intravenous; Female; Humans; Medical Errors; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Vecuronium Bromide
PubMed: 21916878
DOI: 10.1111/j.1365-2044.2011.06870.x -
Journal of Anaesthesiology, Clinical... Oct 2010Rapid and safe endotracheal intubation is of paramount importance in general anaesthesia. The aim of this study was to compare the intubating conditions of...
BACKGROUND
Rapid and safe endotracheal intubation is of paramount importance in general anaesthesia. The aim of this study was to compare the intubating conditions of succinylcholine with rocuronium bromide and vecuronium bromide using "Timing principle". The timing principle entails administration of a single bolus dose of nondepolarizing muscle relaxant, followed by an induction drug at the onset of clinical weakness. PATIENTS #ENTITYSTARTX00026;
METHODS
75 patients were divided into three groups of 25 each. Patients allocated to Groups A and B received rocuronium 0.6 mg kg(-1) and vecuronium 0.12 mg kg(-1) respectively. At the onset of clinical weakness (ptosis), anesthesia was induced with propofol 2.5 mg kg(-1); intubation was accomplished after 60 seconds of induction agent in both groups. Patients in Group C received propofol 2.5mg kg(-1) followed by succinylcholine 2mg kg(-1) and their tracheas were intubated at 60s.Train of four count was assessed at adductor pollicis muscle using nerve stimulator at intubation and time to loss of TOF was observed. in group A and B. Intubating conditions were assessed according to a grading scale and haemodynamic variables were compared at 1,3 and 5 minutes after intubation.
RESULTS
Intubating conditions were either excellent(84% in group A,48% in group B and 88% in group C) or good (16% in group A, 48% in group B and 12 %in group C)and only 4% pt had poor intubating conditions in group B. Patients were interviewed postoperatively, and all were satisfied with the technique of induction of anesthesia.Rocuronium and Vecuronium are haemodynamically stable drugs as compared to Succinylcholine.
CONCLUSION
Rocuronium 0.6 mg kg(-1) provides good to excellent intubating conditions at 60 s comparable to succinylcholine after the induction of anesthesia using the timing principle.
PubMed: 21547177
DOI: No ID Found -
The Journal of International Medical... 2010This randomized trial investigated whether 5% sevoflurane potentiated neuromuscular blockade by vecuronium. General anaesthesia was induced with 5% sevoflurane in oxygen... (Randomized Controlled Trial)
Randomized Controlled Trial
This randomized trial investigated whether 5% sevoflurane potentiated neuromuscular blockade by vecuronium. General anaesthesia was induced with 5% sevoflurane in oxygen in 16 patients or with propofol in 16 patients. After loss of consciousness, vecuronium was administered to all participants at randomly assigned doses of 25, 30, 35 or 40 μg/kg. Neuromuscular blockade was assessed by use of acceleromyography to measure responses to train-of-four stimuli in the adductor pollicis and corrugator supercilii muscles. Maximum blockade was significantly more intense in the adductor pollicis among patients in the sevoflurane group than in the propofol group, whereas there was no significant between-group difference at the corrugator supercilii muscles. In both groups, maximum blockade at the corrugator supercilii was significantly less intense than that achieved at the adductor pollicis. In the dose-response analysis, the 50% and 95% effective doses were lower for sevoflurane than for propofol in both muscles, although this did not reach statistical significance. It is concluded that induction of general anaesthesia with sevoflurane might provide improved conditions for intubation and reduce airway problems.
Topics: Adult; Anesthesia; Anesthetics, Inhalation; Anesthetics, Intravenous; Demography; Dose-Response Relationship, Drug; Female; Humans; Male; Methyl Ethers; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Propofol; Sevoflurane; Vecuronium Bromide
PubMed: 21227003
DOI: 10.1177/147323001003800613 -
Acta Pharmacologica Sinica Dec 2010to investigate the changing resistance to nondepolarizing muscle relaxants (NDMRs) during the first month after denervation.
AIM
to investigate the changing resistance to nondepolarizing muscle relaxants (NDMRs) during the first month after denervation.
METHODS
the denervated and innervated skeletal muscle cells were examined on days 1, 4, 7, 14, 21, and 28 after denervation. Individual denervated and innervated cells were prepared from the flexor digitorum brevis of the surgically denervated and contralateral hind feet, respectively. Nicotinic acetylcholine receptors (nAChRs) in the cells were activated with 30 micromol/L acetylcholine, either alone or in combination with various concentrations of vecuronium. Currents were recorded using a whole-cell patch-clamp technique.
RESULTS
the concentrations of vecuronium resulting in half-maximal inhibitory responses (IC(50)) increased 1.2- (P>0.05), 1.7-, 3.7-, 2.5-, 1.9-, and 1.8-fold (P<0.05) at Days 1, 4, 7, 14, 21, and 28 after denervation, respectively, compared to the innervated control. Resistance to vecuronium appeared at Day 4, peaked at Day 7, and declined at Day 14 after denervation. Nevertheless, IC(50) values at Day 28 remained significantly higher than those for the innervated control, suggesting that the resistance to vecuronium had not disappeared at Day 28.
CONCLUSION
The NDMR doses required to achieve satisfactory clinical effects differ at different times after muscle denervation.
Topics: Acetylcholine; Animals; Cells, Cultured; Mice; Mice, Inbred BALB C; Muscle Denervation; Muscle Fibers, Skeletal; Muscle, Skeletal; Neuromuscular Nondepolarizing Agents; Patch-Clamp Techniques; Receptors, Cholinergic; Vecuronium Bromide
PubMed: 21102480
DOI: 10.1038/aps.2010.163 -
British Journal of Anaesthesia Nov 2010Sugammadex shows a dose-response relationship for reversal of neuromuscular block (NMB) during propofol anaesthesia. Sevoflurane, unlike propofol, can prolong the effect... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Sugammadex shows a dose-response relationship for reversal of neuromuscular block (NMB) during propofol anaesthesia. Sevoflurane, unlike propofol, can prolong the effect of neuromuscular blocking agents (NMBAs), increasing recovery time. This open-label, randomized, dose-finding trial explored sugammadex dose-response relationships, safety, and pharmacokinetics when administered for reversal of moderate rocuronium- or vecuronium-induced NMB during sevoflurane maintenance anaesthesia.
METHODS
After anaesthesia induction with propofol, adult patients were randomized to receive single-dose rocuronium 0.9 mg kg⁻¹ or vecuronium 0.1 mg kg⁻¹, with maintenance doses as needed. Anaesthesia was maintained with sevoflurane. NMB was monitored using acceleromyography. After the last dose of NMBA, at reappearance of T(2), single-dose sugammadex 0.5, 1.0, 2.0, or 4.0 mg kg⁻¹ or placebo was administered. The primary efficacy variable was time from the start of sugammadex administration to recovery of T₄/T₁ ratio to 0.9. Safety assessments were performed throughout.
RESULTS
The per-protocol population comprised 93 patients (rocuronium, n=46; vecuronium, n=47). A statistically significant dose-response relationship was demonstrated for mean recovery times of T₄/T₁ ratio to 0.9 with increasing sugammadex dose with both NMBAs: rocuronium, 96.3 min (placebo) to 1.5 min (sugammadex 4.0 mg kg⁻¹); vecuronium, 79.0 min (placebo) to 3.0 min (sugammadex 4.0 mg kg⁻¹). Plasma sugammadex concentrations indicated linear pharmacokinetics, independent of NMBA administered. No study drug-related serious adverse events occurred. Evidence of reoccurrence of block was reported in seven patients [sugammadex 0.5 mg kg⁻¹ (suboptimal dose), n=6; 2.0 mg kg⁻¹, n=1].
CONCLUSIONS
During sevoflurane maintenance anaesthesia, sugammadex provides well-tolerated, effective, dose-dependent reversal of moderate rocuronium- and vecuronium-induced NMB.
Topics: Adult; Androstanols; Dose-Response Relationship, Drug; Female; Humans; Male; Middle Aged; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium; Single-Blind Method; Sugammadex; Vecuronium Bromide; gamma-Cyclodextrins
PubMed: 20876699
DOI: 10.1093/bja/aeq226