Influences of sevoflurane and isoflurane on neuromuscular blockade by continuous infusion of cisatracurium in elderly patients
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Objective To compare the effects of sevoflurane and isoflurane on the neuromuscular blockade produced by continuous infusion of cisatracurium in elderly patients.Methods Sixty geriatric patients scheduled for ear-nose-throat surgeries or maxillofacial surgeries under general anesthesia were randomly divided into three groups. Group S and Group I were maintained with inhalation of one minimum alveolar concentration (MAC) of sevoflurane and isoflurane, respectively, while Group C was maintained with target controlled infusion of propofol (target plasma concentration 2-3 μg/ml). Neuromuscular blockade was maintained with continuous cisatracurium infusion in three groups and was monitored using train-of-four (TOF) stimulation by recording the contraction force of adductor pollicis muscle with a TOF-Watch SX monitor to maintain T1, the first twitch in the TOF, at 10% of baseline. The onset time, the infusion rate of cisatracurium, the spontaneous recovery index (T1 25% to 75%), and the time interval from T1 at 10% of baseline to recovery of TOF ratio of 0.9 were recorded.Results Thirty minutes after cisatracurium administration, the infusion rate in Group S and Group I was reduced compared with Group C (P0.05). Forty-five minutes after cisatracurium administration, the infusion rate in Group I was greater than that in Group S (P0.05).Conclusion Equivalent concentration of either sevoflurane or isoflurane can potentiate the neuromuscular blockade by continuous infusion of cisatracurium in elderly patients.Keywords:
Adductor pollicis muscle
Neuromuscular monitoring
Continuous Infusion
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OBJECTIVE: To evaluate the safety and efficacy of cisatracurium besylate, a neuromuscular blocking agent in infants zero to 2 yrs of age. DESIGN: An open-label study to evaluate efficacy and safety of cisatracurium as a continuous infusion in infants. SETTING: A tertiary pediatric intensive care unit. PATIENTS: Eleven children, 0-2 yrs of age, requiring prolonged neuromuscular blockade. INTERVENTIONS: Cisatracurium besylate, 0.1 mg/kg, was administered as an intravenous bolus dose and repeated if necessary until a >90% neuromuscular blockade, as determined by train-of-four response, was achieved. Patients were allowed to recover to 90% blockade (I/IV twitch) after the initial bolus and were administered continuous infusion at 2 &mgr;g/kg/min. The continuous infusion rate was adjusted to maintain a train-of-four response of 0-I/IV, with an increase in the rate preceded by a bolus dose of cisatracurium besylate. An electromyographic monitor was used to measure recovery at the end of infusion, when possible. Heart rate and blood pressure were recorded after the initial bolus dose and after changes in infusion rates. Blood samples were drawn at steady-state during cisatracurium infusion at several different times during the study and at the end of infusion for measurement of plasma cisatracurium and laudanosine concentrations. MEASUREMENTS AND MAIN RESULTS: The mean infusion rate of cisatracurium besylate required to maintain train-of-four response of 0-I/iv was 5.4 +/- 3.0 &mgr;g/kg/min. The mean total duration of infusion was 64.5 +/- 36 hrs. Ten percent and complete neuromuscular recovery occurred at 26.6 +/- 10.4 and 74.8 +/- 32 mins, respectively, after discontinuation of infusion. Mean cisatracurium and laudanosine concentrations were 342.5 +/- 169 and 163.3 +/- 116 ng/mL, respectively. Four (37%) patients had undetectable (<5 ng/mL) cisatracurium concentrations at the time of 100% neuromuscular recovery (train-of-four response of IV/IV or no fade at 50 mA on the electromyogram). No significant hemodynamic changes were observed during treatment with cisatracurium besylate (p <.05). CONCLUSIONS: A longer period of recovery from neuromuscular blockade was observed compared with reports of older children. Recovery from neuromuscular blockade after long-term use was not associated with any adverse events in the immediate postinfusion period. Cisatracurium besylate is a safe and effective neuromuscular blocking agent for children 0-2 yrs of age.
Bolus (digestion)
Continuous Infusion
Loading dose
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Objective To compare the effects of sevofturane on neuromuscular block induced by rocuronium in the patients with or without diabetes mellitus. Methods Thirty diabetic and 30 non-diabetic ASA Ⅱ patients aged 45-64 yr scheduled for elective middle or lower abdominal surgery were studied. Both diabetic and non-diabetic patients were randomly assigned to one of 2 groups (n = 15 each): propofol group (group P) and sevoflurane group (group S). All patients were anesthetized with midazolam, propofol and fentanyl. After loss of consciousness tracheal intubation was performed after rocuronium 0.6 mg/kg and anesthesia was maintained with iv propofol infusion in group P. In group S tracheal intubation was performed under topical anesthesia with 1% amethacaine injected through cricotbyroid membrane. Anesthesia was maintained with sevoflurane inhalation (end-tidal concentration 1.71 %). Rocuronium 0.6 mg/kg was given iv at 10 min after inhalation of sevoflurane was started. Neuromuscular function was assessed by accelerograpby (TOF-Watch SX, Orgnnon, Holland). TOF stimulation of ulnar nerve was used. The onset time, duration of action and recovery index (for T1 to return from 25% to 75% of the control twitch) were recorded. The T1/T0 and TOF (T4/T1) ratios were recorded at 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 110 and 120 min after a single bolus of rocuronium. Results There was no significant difference in onset time and duration of action between diabetic and non-diabetic patients in both propofol and sevoflurane groups. The recovery index was significantly higher in diabetic patients than in non-diabetic patients in group S. The recovery index was significantly higher in group S than in group P in diabetic patients. The ratios of T1/T0 and TOF were significantly lower in group S than in group P in diabetic patients during 60-120 min after a single bolus of rocuronium. The TOF ratio was significantly lower in diabetic patients than in non-diabetic patients in group S during 80-120 min after a single bolus of rocuronium. Conclusion The effect of sevoflurane on rocuronium-induced neuromuscular block is enhanced in diabetic patients compared with non-diabetic patients.
Key words:
Androstanols; Diabetes mellitus; Neuromuscular blockade; Sevoflurane
Midazolam
Neuromuscular monitoring
Bolus (digestion)
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To evaluate residual effects of inhalational anesthetics after reversal of neuromuscular blocking agent, neuromuscular function was monitored after halothane or sevoflurane anesthesia in thirty-seven patients (ASA physical status I or II) for elective surgery after obtaining informed consent. Electromyograph of the adductor pollicis muscle in response to train of four (TOF) stimulation was monitored throughout the study. The first twitch of TOF (T1; % of its control) and the ratio of the fourth twitch to the first twitch of TOF (T4/T1; TR) were recorded at 0, 2, 5, 10, and 15 min after reversal. The patients were divided into five groups; 1) the fentanyl group (n = 7) received fentanyl/N2O; 2) in the halothane stop group (n = 6), halothane was discontinued at least fifteen minutes before neostigmine administration; 3) in the halothane stable group (n = 7), 0.7% halothane was maintained until fifteen minutes after neostigmine; 4) in the sevoflurane stop group (n = 12), sevoflurane was discontinued fifteen minutes before the reversal; 5) in the sevoflurane stable group (n = 5), 3% sevoflurane was maintained until fifteen minutes after the reversal. Anesthesia was induced by thiopental 4 mg.kg-1 and suxamethonium 1 mg.kg-1 and the patients were intubated. After initial dose of vecuronium 0.1 mg.kg-1, the additional dose of 0.02 mg.kg-1 was administered to maintain T1 under 10% of the control value. At the end of the surgery atropine 0.015 mg.kg-1 and neostigmine 0.04 mg.kg-1 were administered to reverse vecuronium when T1 had recovered to 25% of its control. Halothane groups did not differ from fentanyl group. Recovery of T1 at 15 min was suppressed after discontinuation of sevoflurane (86.0 +/- 8.2%) in comparison with fentanyl (97.0 +/- 8.3%). Both T1 (75.4 +/- 12.2%) and TR (68.0 +/- 12.6%) at 15 min after the reversal during 3% sevoflurane inhalation were below those of the stable group. We conclude that the residual sevofulrane after discontinuation of inhalation may impair the neuromuscular transmission after the reversal of neuromuscular blockade. Neuromuscular function should be monitored after the end of anesthesia even though the patient is fully awake.
Vecuronium bromide
Neuromuscular monitoring
Adductor pollicis muscle
Neuromuscular transmission
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Objective To investigate the effect of diabetes mellitus on neuromuscular blocking effect of cisatracurium in patients. Methods Forty ASA Ⅱ patients, aged 30-64 yr, weighing 44-90 kg, scheduled for neurosurgical operation under general anesthesia, were assigned into 2 groups (n = 20 each): type 2 diabetes mellitus group (group D) and non-diabetes mellitus group (group ND). General anesthesia was induced with midazolam,fentanyl and etomidate. Neuromuscular block was assessed with Epoch XP nerve electrophysiology monitor. A train-of-four stimulation of ulnar nerve was used. Cisatracurium 0.15 mg/kg was injected intravenously over 5 s after T1 was maintained at 100%. Tracheal intubation was performed after the onset of the muscle relaxant. Anesthesia was maintained with iv infusion of propofol 4-8 mg· kg - 1 · h - 1 and remifentanil 0.1-0.3μg· kg - 1 · min - 1. The effect of inmbation was evaluated and graded. The onset time, clinical duration, recovery time and recovery index were recorded. Results The onset time was significantly longer in group D than in group ND ( P ＜ 0.05). There was no significant difference in the clinical duration, recovery time and recovery index and intubation effect grade between the two groups ( P ＞ 0.05). Conclusion Diabetes can prolong the onset time of cisatracurium, but has no effect on the clinical duration and recovery time.
Key words:
Diabetes mellitus; Atracurium; Neuromuscular blockade
Midazolam
Etomidate
Neuromuscular monitoring
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Adductor pollicis muscle
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Desflurane
Adductor pollicis muscle
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This study evaluated the effect of sevoflurane anesthesia on neuromuscular blockade with rocuronium in dogs. Six healthy beagle dogs were anesthetized four times with a minimum 14-day washout period. On each occasion, the dogs were administered 1.25-, 1.5-, 1.75-, or 2.0-fold of the individualized minimum alveolar concentration (MAC) of sevoflurane and received an infusion of rocuronium (0.5 mg/kg followed by 0.2 mg/kg/hr) for 120 min. Neuromuscular function was monitored with acceleromyography and train-of-four (TOF) stimulation of the left hind limb. Time to achieve TOF count 0 (onset time), time from the onset of neuromuscular blockade to the reappearance of TOF count 4 (blockade period), and time from the onset of rocuronium infusion to attaining a 70 or 90% TOF ratio (TOFR70 or TOFR90) were recorded. There were no significant differences in the onset time, blockade period, and plasma rocuronium concentration between the sevoflurane MAC multiples. The TOFR70 and TOFR90 were dose-dependently prolonged with the sevoflurane MAC multiples. There were significant differences in the TOFR70 and TOFR90 between the 1.25 sevoflurane MAC (median: 55 and 77.5 min, respectively) and 1.75 sevoflurane MAC (122.0 and 122.6 min; P=0.020 and P=0.020, respectively), 1.25 sevoflurane MAC and 2.0 sevoflurane MAC (126.0 and 131.4 min; P=0.020 and P=0.020), and 1.5 sevoflurane MAC (97.5 and 121.3 min) and 2.0 sevoflurane MAC (P=0.033 and P=0.032). In dogs, sevoflurane anesthesia produced dose-dependent prolongation of recovery from neuromuscular blockade produced by rocuronium.
Beagle
Minimum alveolar concentration
Neuromuscular monitoring
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Objective To investigate the influence of propofol target controlled infusion anesthesia(TIVA) and sevoflurane anesthesia on the neuromuscular block effect of cisatracurium.Methods Sixty ASA class Ⅰ or Ⅱ patients,scheduled for ENT(ears,nose,throat) surgery were randomly divided into four groups of equal number to receive either 0.1mg/kg cisatracurium under sevoflurane(SA) or propofol TIVA(PA),or 0.15mg/kg cisatracurium under sevoflurane(SB) or propofol TIVA(PB).The bispectral index(BIS) was between 40 and 50 during maintenance of anesthesia.Thumb adductorius contractile response was monitored with TOF stimulation.Neuromuscular blocking variables included onset time(T0),no-response time(TR0),the time to recovery of T1 to 5%,25%,75% and 95% of control(T5,T25,T75,T95),the TOF ratio to70%(TR70) and recovery index(RI) were monitored.Results No difference was found in the onset time between groups PA and SA,and groups PB and SB(P0.05).The unresponsive time was prolonged by 62% in group SA compared with PA,and 26% in group SB compared with PB(P0.05).The time of T1 recovering 75% of the control(T75) was prolonged by 45% in group SA compared with PA,and 29% in group SB compared with PB(P0.05).The time of T1 recovering 95% of the control value(T95) was prolonged by 47% in group SA compared with PA,and 36% in group SB compared with PB(P0.05).The recovery index(RI) was prolonged by 33% in group SA compared with PA,and 48% in group SB compared with PB(P0.05).Conclusion Compared with propofol TIVA,sevoflurane anesthesia may enhance the neuromuscular block effect of cisatracurium and significantly prolong the clinical recovery duration of cisatracurium.
Bispectral index
Neuromuscular monitoring
Neuromuscular transmission
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Objective To investigate the influence of gender on the enmcement of neuromuscular blocking effects of cisatracurium or rocuronium by sevoflurane. Methods Two hundred and forty ASA Ⅰ or Ⅱ patients, aged 20-60 yr, weighing 45-85 kg, scheduled for elective surgery under general anesthesia were assigned into 2 groups ( n = 120 each): cisatracurium group and rocuronium group. Each group were divided into 4 subgroups according to gender and anesthetics ( n = 30 each): female propofol group, male propofol group, female sevoflurane group and male sevoflurane group. Anesthesia was induced with midazolam, propofol and fentanyl. After loss of consciousness, the laryngeal mask was inserted and the patients were mechanically ventilated. Propofol groups received target-controlled infusion (TCI) of propofol (target plasma concentration 2-6 μg/ml), and sevoflurane groups inhalation of sevoflurane. Cisatracurium 0.15 mg/kg or rocuronium 0.6 mg/kg was injected intravenously 5 min after propofol infusion or after the end-tidal concentrion of sevoflurane was maintained at 1.71% (1 MAC) for 5 min. Neuromuscular block was assessed with accelerograph F (TOF-watch SX). Train-of-four (TOF) stimulation of ulnar nerve was used. The onset time, duration of peak effect and times for recovery of T1 to 25% and TOF ratio (TOFR) to 25% were recorded.Results Compared with propofol groups, the time for recovery of TOFR to 25 % for rocuronium, and the duration of peak effect and times for recovery of T1 to 25 % and TOFR to 25% for cisatracurium were significantly prolonged in female sevoflurane group, the onset time of rocuronium was significantly shortened, while the duration of peak effect and times for recovery of T1 to 25% and TOFR to 25% for rocuronium and cisatracurium were significantly prolonged in male sevoflurane group ( P ＜ 0.05 or 0.01 ). The times for recovery of T1 to 25% and TOFR to 25% for rocuronium and onset time of cisatracurium were significantly shorter in female than in male during sevoflurane anesthesia (P ＜ 0. 05 or 0.01 ). Conclusion The enhancement of rocuronium-induced neuromuscular block by sevoflurane is stronger in male than in female,but there is no gender variation in the enhancement of cisatracurium-induced neuromuscular block by sevoflurane.
Key words:
Anesthetics, inhalation; Atracurium; Androstanols; Sex factors; Neuromuscular blockade
Midazolam
Neuromuscular monitoring
Neuromuscular transmission
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