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PubMed1997

Monitoring orbicularis oculi predicts good intubating conditions after vecuronium in children.

PURPOSE: The aim of the study was to compare visual estimation of onset of neuromuscular blockade at both the adductor pollicis (AP) and the orbicularis oculi (OO) in children and to determine if monitoring the OO could predict good intubating conditions during vecuronium-induced neuromuscular blockade. METHODS: Thirty ASAI--II children (1.5-9 yr) were studied. Anaesthesia was induced with 6-8 mg.kg-1 thiopentone. The ulnar nerve at the wrist and the temporal branch of the facial nerve were stimulated every 10 sec using train-of-four (TOF) stimuli. Vecuronium, 0.15 mg.kg-1, was administered as a bolus. The responses at both the OO and the AP were evaluated visually. Patients were randomly divided into two groups. In the AP group (n = 15), the trachea was intubated when the AP was completely blocked. In the OO group (n = 15), intubation was performed when the OO was completely blocked. Intubating conditions were scored on a scale of 1 to 4. RESULTS: All the patients had complete blockade at both the orbicularis oculi and the adductor pollicis. In the two group, time from injection of vecuronium to complete neuromuscular blockade was shorter at the orbicularis oculi than at the adductor pollicis, 1.5 +/- 0.5 min vs 2.3 +/- 0.7 min, respectively, (P < 0.05; mean +/- SD) in the AP group, 1.7 +/- 0.3 min vs 2.3 +/- 0.8 min, respectively in the OO group (P < 0.05). Intubating conditions were excellent in all patient except one, where it was rated as good. They did not differ between groups. CONCLUSION: Following administration of 0.15 mg.kg-1 vecuronium in children, monitoring of the OO can detect good intubating conditions 0.7 min earlier than with monitoring of the AP.

Child↗
PubMed1986

Contribution of muscle relaxant to the haemodynamic course of high-dose fentanyl anaesthesia: a comparison of pancuronium, vecuronium and atracurium.

To define the role of muscle relaxants in haemodynamic responses to high-dose (75 micrograms X kg-1) fentanyl anaesthesia and to noxius stimuli associated with intubation and sternal spread during coronary artery bypass surgery, we compared haemodynamics between three groups of patients given either pancuronium (0.1 mg X kg-1, n = 11), vecuronium (0.086 mg X kg-1, n = 11) or atracurium (0.43 mg X kg-1, n = 12). Additional doses of the relaxants were given to maintain a 90 per cent neuromuscular block. Patients given pancuronium showed no increases in mean values of heart rate, arterial pressure or cardiac output during the induction of anaesthesia or after intubation, whereas a decrease in these variables was observed in the vecuronium group. The haemodynamics in the atracurium group were intermediate compared with the other two study groups. In spite of a decrease in coronary perfusion pressure, no patient given vecuronium developed myocardial ischaemia. An advantage of vecuronium over pancuronium and atracurium was an attenuation of the blood pressure response to sternotomy. Patients given atracurium had a small increase in pulmonary vascular resistance during sternotomy. Our patients continued their beta-adrenergic antagonist medication until the morning of the day of operation and they were pretreated with a small intravenous dose of diazepam (0.1 mg X kg-1) before induction of anaesthesia. These drugs may have prevented the deleterious haemodynamic effects observed by some investigators after the administration of pancuronium during high-dose fentanyl anaesthesia.

Adult↗
PubMed1997

Dose-response to anaesthetic induction with sufentanil: haemodynamic and electroencephalographic effects.

PURPOSE: To determine the effect of a five-fold variation in sufentanil dose on the haemodynamic and electroencephalo graphic (EEG) response to anaesthetic induction and tracheal intubation. METHODS: Thirty-four patients undergoing elective coronary artery bypass grafting (CABG) participated in this randomized double-blind study. Patients in Group L (n = 17) received 3 micrograms.kg-1 sufentanil and those in Group H (n = 17) 15 micrograms.kg-1. Premedication was 60 micrograms.kg-1 lorazepam po. Anaesthesia and neuromuscular blockade were induced by infusing sufentanil and 0.15 mg.kg-1 vecuronium i.v. over five minutes. Haemodynamic data and the electroencephalographic (EEG) spectral edge were acquired by computer and compared at Control, Induction and Intubation. RESULTS: Sufentanil dose did not affect the haemodynamic or EEG response at end-induction. No bradyarrhythmias occurred, and the incidence of hypotension was 12% in both groups. However, during induction apparent electromyographic artifacts and a transiently greater increase in heart rate were observed in Group H. The serum sufentanil concentration at Induction was 6.1 +/- 1.8 ng.ml-1 in Group L and 25.4 +/- 8.8 ng.ml-1 in Group H, and did not correlate with haemodynamic changes. No patient recalled any intraoperative event. CONCLUSION: Increasing sufentanil dose from 3 to 15 micrograms-1 does not influence the ultimate haemodynamic response to induction. Combined with lorazepam premedication, 3 micrograms-1 sufentanil produces near-maximal haemodynamic and EEG effects and is adequate for induction and tracheal intubation of patients undergoing CABG. Sufentanil 15 micrograms.kg-1 is no more efficacious, and causes transient cardiovascular stimulation.

Aged↗
PubMed1997

Train-of-four and double burst stimulation fade at the great toe and thumb.

PURPOSE: We compared probabilities of tactile detection of fade in response to train-of-four (TOF), double burst stimulation3.3 (DBS3.3), and DBS3.2 at the great toe with those at the thumb. METHODS: One hundred and thirty adult patients anaesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl were studied. At varying degrees of neuromuscular block caused by vecuronium, an observer determined the presence or absence of fade in response to TOF DBS3.3, or DBS3.2 at the great toe and that at the thumb. The relationship between T1/T0 or TOF ratio (T4/T1) measured at the great toe and that at the thumb was also examined. RESULTS: When TOF ratios were 0-0.10, 0.11-0.20, 0.21-0.30, 0.31-0.40, 0.41-0.50, 0.51-0.60, 0.61-0.70, and 0.71-1.00, the probabilities of detection of fade in response to TOF at the great toe (thumb) were 77 (100), 66 (100), 58 (96), 52 (77), 39 (38), 26 (23), 2(4), and 0(0)%, respectively (P < 0.05 at TOF ratio 0-0.40). Similarly, the probabilities of detection of fade in response to DBS3.3 at the great toe were lower than at the thumb when TOF ratios were 0.21-0.80, and those in response to DBS3.2 at the great toe were lower than at the thumb when TOF ratios were 0.61-0.80. A dose relationship was observed between T1/T0 or TOF ratio at the great toe and that at the thumb. CONCLUSION: This study suggests that the probability of tactile detection of fade in response to TOF, DBS3.3, or DBS3.2 at the great toe is less than that at the thumb. The present results may be because the flexor hallucis brevis muscle is more resistant to non-depolarizing neuromuscular relaxant than the adductor pollicis muscle and that the ratio of fade in response to neurostimulation at the great toe is higher than at the thumb.

Adult↗
PubMed1995

Post-tetanic burst count: a stimulating pattern for profound neuromuscular blockade.

The purpose of this study was to compare the pattern of recovery from vecuronium 0.07 mg.kg-1 induced neuromuscular blockade using post-tetanic burst count (PTBC)-(three short tetanic bursts of 0.2 msec duration every 20 msec given every second following a tetanus), and post-tetanic count (PTC)-(0.2 msec single twitch stimuli given every second following a tetanus) using an accelerometer in 60 adult patients during nitrous oxide-oxygen-isoflurane anaesthesia. In addition, the relationship among PTBC, PTC, and T1 (the 1st response in the train-of-four (TOF) stimulation) was examined to investigate whether the PTBC had an advantage over the PTC or TOF for evaluating intense neuromuscular blockade. The PTBC was greater than PTC during the 15-35 min after the administration of vecuronium (unpaired t test with Bonferroni's correction, P < 0.05). Time to the return of PTB response was shorter than that of PTT (17.7 +/- 3.2 vs 22.7 +/- 3.7 min, unpaired t test, P = 0.0005). Time from the return of PTB to that of T1 was longer than the time from the return of PTC to that of T1 (13.3 +/- 2.6 vs 9.2 +/- 2.8 min, unpaired t test, P = 0.0003). At the return of T1, PTBC was greater than PTC (14.3 +/- 6.9 vs 9.4 +/- 2.3, unpaired t test, P = 0.0153). These results suggest that, using PTBC, a more profound level of neuromuscular blockade can be evaluated than that using PTC.

Adult↗
PubMed1995

Secondary hyperparathyroidism shortens the action of vecuronium in patients with chronic renal failure.

The authors studied the duration of action of vecuronium in 15 patients with normal renal function and 40 patients with chronic renal failure to evaluate the effect of secondary hyperparathyroidism on the action of vecuronium. The patients were divided into four groups: 15 patients with normal renal function (Group A); nine patients with chronic renal failure who did not need haemodialysis (Group B); 15 anephric patients who did not require parathyroidectomy (Group C); and 16 anephric patients who underwent parathyroidectomy because of severe secondary hyperparathyroidism (Group D). The ratio of the height of the first twitch (T1) to the baseline value before vecuronium administration was measured by an electromyogram. Baseline T1 was obtained after anaesthesia induction with thiamylal iv. The time to 10% recovery of the first twitch (REC 10) after administration of vecuronium 0.12 mg.kg-1 iv was measured in each group. Anaesthesia was maintained with isoflurane and nitrous oxide in oxygen, and supplemented with fentanyl iv. Patients in Group D showed shorter REC 10 (51 +/- 4 min) than those in Groups B (71 +/- 6 min) and C (80 +/- 10 min) (P < 0.05), but similar REC 10 to patients in Group A (37 +/- 4 min). These results suggest that the duration of action of vecuronium in anephric patients with secondary hyperparathyroidism is shorter than in those without secondary hyperparathyroidism.

Anesthesia, Inhalation↗
PubMed1995

Anaesthetic induction in a child with end-stage cardiomyopathy.

The purpose of this clinical report is to discuss the anaesthetic management of a patient with end-stage cardiomyopathy. An eight-year-old boy sustained electro-mechanical dissociation following a "standard anaesthetic induction" but was subsequently successfully anaesthetized using a combination of etomidate, midazolam, lidocaine, vecuronium and glycopyrrolate. Anaesthetic techniques and their relationship to the specific category of cardiomyopathy (dilated, hypertrophic or restrictive) are discussed. The potential detrimental effects of anaesthetic sympatholysis, myocardial depression and negative chronotropy on cardiac output are explained.

Anesthesia, Intravenous↗
PubMed1994

Pharmacodynamic behaviour of vecuronium in primary hyperparathyroidism.

This study evaluated the potency and time course of action of vecuronium in patients with primary hyperparathyroidism (HPT) and marked hypercalcaemia during nitrous oxide-opioid anaesthesia. Twenty ASA physical status I and II patients were studied by measuring the force of contraction of the adductor pollicis in response to stimulation of the ulnar nerve: ten control patients and ten patients with HPT and ionized calcium concentration over 2.80 mEq.L-1. After induction of anaesthesia with thiopentone and maintenance with N2O/O2 and fentanyl, vecuronium was administered to determine cumulative dose-response curves. When maximum block had been obtained, twitch height was maintained at 10% of baseline value over 20 min by adjusting the infusion rate of a syringe-pump containing vecuronium and vecuronium plasma concentration (EC90ss) was determined. During spontaneous recovery, after termination of infusion, the recovery index, the time from 25 to 75% recovery, was measured. The dose to produce 90% block was greater in the HPT than in control group: 69 (24) vs 54 (18) micrograms.kg-1 (P < 0.02). The calculated ED50 was also greater in HPT: 42 (4) vs 31 (5) micrograms.kg-1 in controls (P < 0.001). (Values are given as mean and coefficient of variation). The slope of the dose-response curve, the dose necessary to maintain 90% block, and the EC90ss did not differ. The RI25-75 was slower in the HPT group although the difference did not reach statistical significance. It is concluded that hyperparathyroidism with hypercalcaemia increases vecuronium requirement; only during the onset of neuromuscular blockade.

Adolescent↗
PubMed2005

Delayed recovery of vecuronium neuromuscular block in diabetic patients during sevoflurane anesthesia.

PURPOSE: To study recovery from vecuronium-induced neuromuscular block in diabetic patients during total iv or sevoflurane anesthesia. METHODS: 30 diabetic patients were assigned to diabetes mellitus (DM)-total iv anesthesia (TIVA); (n = 15) or DM-sevoflurane (S) groups (n = 15). Thirty healthy patients were divided into control-TIVA (n = 15) or control-S groups (n = 15). In the DM-TIVA or control-TIVA groups and DM-S or control-S groups, anesthesia was maintained with propofol and fentanyl, and nitrous oxide-oxygen-sevoflurane 1.7%, respectively. After receiving vecuronium 0.1 mg.kg(-1)iv, recovery of the train-of-four (TOF) was compared among the four groups. RESULTS: Times to the return of T2, T3, or T4 in the DM-TIVA and DM-S groups were longer than in the control-TIVA and control-S groups (46.9 +/- 13.8 vs 32.2 +/- 10.7 and 32.6 +/- 8.7 min for T2, P < 0.05). T1/control in the DM-S group was less than in the control-TIVA and DM-TIVA groups 50 to 120 and 70 to 120 min after receiving vecuronium, respectively (P < 0.05). T1/control in the control-S group was less than in the control-TIVA group 80 to 120 min after receiving vecuronium (P < 0.05). TOF ratio in the DM-S group was less than in the control-TIVA, DM-TIVA, and control-S groups, 60 to 120, 80 to 120, and 80 to 120 min after receiving vecuronium, respectively (P < 0.05). CONCLUSION: In diabetic patients receiving vecuronium, recovery of T1/control and TOF ratio are delayed during sevoflurane anesthesia, but not in association with total iv anesthesia.

Adult↗
PubMed2002

Systolic blood pressure, not BIS, is associated with movement during laryngoscopy and intubation.

OBJECTIVE: To compare bispectral index (BIS) values to hemodynamic variations, in order to evaluate adequacy of anesthesia during orotracheal intubation with muscle relaxants. METHODS: Forty-one patients ASA I-II, scheduled for elective peripheral surgery under general anesthesia with tracheal intubation were enrolled in the study. Fentanyl/thiopental followed by vecuronium were used for induction. Onset of relaxation was monitored at the orbicularis occuli (OO) muscle using train-of-four stimulation. Intubation was performed when no response at the OO was detected visually. Intubating conditions were noted. The "isolated forearm" technique was used to detect movement during laryngoscopy/intubation. BIS values, pulse rate (PR), and systolic pressure were recorded before induction, during laryngoscopy/intubation and 60 sec after intubation. RESULTS: Although intubating conditions were clinically adequate for all patients, ten out of 41 had movement of the isolated arm during laryngoscopy/intubation. BIS values were not significantly different for these patients: 67 (55-83) compared to those who had no movement: 60 (35-80), P = 0.6. During laryngoscopy, PR increased for all patients while systolic pressure increased significantly only in patients who moved: 125 (100-136) mmHg vs those who did not: 108 (67-140), P < 0.05. CONCLUSION: Systolic pressure elevations were associated with inadequate anesthesia as evaluated by the "isolated forearm" technique, during laryngoscopy/intubation. BIS values were not different between groups, suggesting that systolic blood pressure may be a better predictor of inadequate anesthesia under the circumstances described.

Adjuvants, Anesthesia↗
PubMed2003

The ED(95) of end-tidal sevoflurane concentration for the smooth exchange of the tracheal tube for a laryngeal mask airway is 2.97%.

PURPOSE: Exchanging the tracheal tube for the laryngeal mask airway (the TT/LMA exchange) while the patient is still anesthetized avoids coughing associated with tracheal extubation. This study was conducted to determine the end-tidal concentration of sevoflurane that prevented response to this exchange in 50% patients (MAC(TT/LMA)). METHODS: We studied 21 adult male patients, ASA I, aged 21-54 yr. Anesthesia was induced with thiamylal and sevoflurane, and the trachea was intubated following vecuronium neuromuscular blockade. Anesthesia was maintained with sevoflurane and nitrous oxide in oxygen. After surgery, a predetermined end-tidal sevoflurane concentration was achieved and a steady state was maintained for at least 20 min. The concentration at which the TT/LMA exchange was attempted was determined by a modification of Dixon's up-and-down method with 0.25% as the step size. At the time of the TT/LMA exchange, no residual nitrous oxide > 3% was detected, and the return to normal neuromuscular function was confirmed. When the TT/LMA exchange was accomplished without coughing, movement, or airway obstruction, it was considered a smooth exchange. RESULTS: Sevoflurane MAC(TT/LMA) determined using the up-and-down method was 2.63% +/- 0.14%. The 50% effective dose obtained using a probit analysis was similar [2.53% (95% confidence limits, 2.13-2.82%)]. CONCLUSION: Sevoflurane MAC(TT/LMA) in adult male patients was 2.63% (1.54 MAC) and may be useful for the smooth exchange of the tracheal tube for the LMA in a clinical setting.

Adult↗
PubMed1996

Duration of succinylcholine and vecuronium blockade but not potency correlates with the ratio of endplate size to fibre size in seven muscles in the goat.

PURPOSE: Muscles differ in their response to neuromuscular relaxants. This study investigated whether (1) the relative responses of muscles is inverted between succinylcholine (SUX) and vecuronium (VEC), and (2) differences in dose-response or duration of action are related to the morphology of fibres, endplates and acetylcholine receptors (AChR) in muscles. METHODS: In goats during thiopentone anaesthesia, the evoked EMG response to indirect train-of-four stimulation was monitored and the cumulative dose-response curves and duration of action of SUX and VEC in the diaphragm, cricoary-tenoideus dorsalis, thyroarytenoideus, transversus abdominis, rectus abdominis, soleus and gastrocnemius muscles were determined and related to their fibre composition, fibre size, endplate size, endplate to fibre size ratio, AChR number or AChR density by regression analysis. RESULTS: There were no differences in the ED50S of SUX [range, 119 +/- 11 (SE) to 159 +/- 20 micrograms.kg-1] or VEC [range, 2.8 +/- 0.2 to 3.7 +/- 0.8 microgram.kg-1] among muscles. With either drug, duration to 25% or 50% T1 recovery was shortest at the laryngedl muscles and longest at abdominal muscles (P = 0.0001), and correlated directly with fibre size (r > or = 0.40; P < 0.004) and inversely with the endplate to fibre size ratio (r > or = 0.40; P < 0.008). CONCLUSION: The results show that (1) the relative responses of muscles do not differ between depolarizing and non-depolarizing relaxants; (2) the duration of blockade is shorter in muscles composed of small fibres with large endplates relative to fibre size; and (3) there is no relation between fibre type composition and sensitivity to muscle relaxants.

Animals↗
PubMed1996

The precipitate formed by thiopentone and vecuronium.

PURPOSE: To determine the composition and solubility of the precipitate formed by thiopentone and vecuronium in vitro. METHODS: The precipitate formed by mixing thiopentone 2.5% and vecuronium 0.1% at room temperature was analyzed by ultraviolet spectrophotometry and high performance liquid chromatography (HPLC). The solubility of the precipitate in human plasma was measured by HPLC. RESULTS: The UV absorption spectrum of the precipitate resembled that of thiopentone. HPLC analysis produced a single peak with the same retention time as thiopentone (4.6 min). In human plasma the solubility of the precipitate was not different from that of thiopentone acid. The solubility of thiopentone was greater than that of the precipitate. CONCLUSION: The precipitate formed by thiopentone and vecuronium in vitro consisted of thiopentone acid, which was insoluble in human plasma.

Chemical Precipitation↗
PubMed2003

Neuromuscular block with vecuronium reduces the rapidly extracted auditory evoked potentials index during steady state anesthesia.

PURPOSE: During clinical monitoring, vecuronium appeared to reduce the rapidly extracted auditory evoked potentials index (A-line ARX index or AAI) to some extent. A prospective and randomized study was designed to analyze this phenomenon. METHODS: Forty adult patients undergoing elective surgery were studied. After tracheal intubation, anesthesia was maintained with an end-tidal isoflurane concentration (F(ET)ISO) of 1.0% for 20 min, then a 10-mL dose of either vecuronium 0.05 mg*kg(-1), 0.1 mg*kg(-1), 0.2 mg*kg(-1) or saline was administered in a randomized, double-blind design. The AAI and bispectral index (BI(hx)) were monitored throughout the study and analyzed off-line. RESULTS: BI(hx) was unaltered after the administration of saline or vecuronium. The mean of the averaged (per patient) AAI values recorded from two minutes to ten minutes after the administration of saline or vecuronium 0.05 mg*kg(-1) did not differ significantly from the corresponding mean recorded from 15 min to 20 min after F(ET)ISO maintained 1.0% (P = 0.678, 0.169), however after the administration of vecuronium 0.1 mg*kg(-1) or 0.2 mg*kg(-1), AAI was reduced from 18.3, 18.0 to 14.8, 13.4 (P = 0.016, 0.017). CONCLUSIONS: Neuromuscular block with vecuronium reduces AAI in patients during steady state anesthesia without surgical stimuli, while BI(hx) is unaltered. The cut-off values of AAI for events should be determined according to the level of neuromuscular blockade when monitoring the depth of anesthesia/sedation.

Adult↗
PubMedDate not supplied

Airway management of a patient with tracheal stenosis for surgery in the prone position.

PURPOSE: When tracheal intubation is required in a patient with an uncollapsible tracheal stenosis, the tip of the tube is usually positioned proximal to the stenosis. Only the tip of the tube may be in the trachea and the tube can be dislodged. We report the successful airway management of a patient with an uncollapsible tracheal stenosis who underwent cranial surgery in the prone position. CLINICAL FEATURES: A 49-yr-old man with the saber-sheath trachea (stenosis of the entire intrathoracic trachea) was scheduled for a posterior fossa surgery for resection of a cerebellar tumour. Anesthesia was induced by allowing the patient to inhale spontaneously oxygen and increasing concentrations of sevoflurane up to 5%, without airway obstruction. After injection of vecuronium, an airway exchange catheter was inserted orally into the trachea. A laryngeal mask airway was then inserted with the exchange catheter in place and, with the aid of a fibrescope, a 6.0-mm reinforced tracheal tube was passed through the laryngeal mask into the trachea so that the tip of the tube was about 1 cm proximal to the stenosis. The patient was turned to the prone position and the operation proceeded uneventfully. CONCLUSIONS: The laryngeal mask and an airway exchange catheter were used as backups to tracheal intubation in this patient with tracheal stenosis in the prone position. Should the trachea be extubated accidentally, it may be re-intubated through the laryngeal mask and ventilation may be possible through the laryngeal mask or the exchange catheter.

Anesthetics, Inhalation↗
PubMed2003

Edrophonium effectively antagonizes neuromuscular block at the laryngeal adductors induced by rapacuronium, rocuronium and cisatracurium, but not mivacurium.

PURPOSE: To examine the efficacy of antagonism of rapacuronium-, mivacurium-, rocuronium- and cisatracurium-induced neuromuscular block at the laryngeal adductors (LA). METHODS: One hundred four patients were randomly assigned to one of eight study groups. They either received rapacuronium 1.5 mg x kg(-1), mivacurium 0.25 mg x kg(-1), rocuronium 0.9 mg x kg(-1) or cisatracurium 0.15 mg x kg(-1). Patients in each treatment group either received edrophonium (0.5 mg x kg(-1)) at 10% recovery of the first twitch (T1) of train-of-four (TOF) at the LA or were allowed to recover spontaneously from neuromuscular block. The effect of antagonism on speed of recovery of neuromuscular function at the LA was evaluated. RESULTS: The time to recovery to a TOF ratio of 0.9 at the LA, when compared to the spontaneous recovery group, was significantly shortened by the administration of edrophonium in patients receiving rapacuronium [19.2 +/- 7.8 vs 26.2 +/- 4.9 (mean +/- SD) min], rocuronium (24.7 +/- 14.3 vs 44.4 +/- 13.0 min) and cisatracurium (24.2 +/- 5.7 vs 35.1 +/- 7.6 min). Edrophonium administration did not shorten complete recovery from mivacurium-induced block (15.7 +/- 8.0 vs 17.6 +/- 6.1 min). CONCLUSION: Recovery from rapacuronium-, rocuronium- or cisatracurium- induced neuromuscular block to a TOF ratio of 0.9 as measured at the LA was shortened by the administration of edrophonium, when compared to spontaneous recovery.

Adolescent↗