Muscle relaxants in critical illness

2016 ◽  
Author(s):  
Brian J. Pollard
Keyword(s):  
Muscle Relaxant ◽  
Rapid Onset ◽  
Hepatic Disease ◽  
Neuromuscular Blocking ◽  
Nerve Stimulator ◽  
Neurological Assessment ◽  
Onset Of Action ◽  
Increased Risk ◽  
Rapid Reversal ◽  
Train Of Four

The place of neuromuscular blocking agents in the intensive care unit (ICU) has changed markedly over the last 20 years. Originally regarded as a mainstay of the process of ‘sedation’, they are now only used for specific indications. The principal disadvantage is probably the difficulty in neurological assessment when a muscle relaxant is used coupled with the increased risk of awareness, because inadequate sedation will be masked. Of the available agents, the intermediate acting ones are the most popular. The degree of relaxation can be readily controlled and they have few side effects. In the presence of renal and/or hepatic disease atracurium or cisatracurium are preferred. Succinylcholine is only used for securing the airway due to its very rapid onset of action. Rocuronium given in a higher dose also possesses a rapid onset in situations when succinylcholine might be contraindicated. When using a muscle relaxant, its effect should always be monitored with a simple train of four pattern of stimulation from a hand-held nerve stimulator. This will ensure that an adequate and not excessive block is secured. If a more rapid reversal is required then a dose of neostigmine with glycopyrrolate may be used. Alternatively, if rocuronium is the relaxant in use then the new agent sugammadex is effective.

Neuromuscular blockade and reversal

2017 ◽  
Author(s):  
Jennifer M. Hunter ◽  
Thomas Fuchs-Buder
Keyword(s):  
Neuromuscular Block ◽  
Neuromuscular Disorders ◽  
Upper Airway ◽  
Blocking Agent ◽  
Rapid Onset ◽  
Neuromuscular Blocking ◽  
Onset Of Action ◽  
Disease States ◽  
Train Of Four ◽  
Residual Block

Over the past 70 years since the introduction of d-tubocurarine, the search for an ideal neuromuscular blocking agent has led to the development of the depolarizing drug, succinylcholine (suxamethonium), with its rapid onset of action and plasma metabolism, and a series of non-depolarizing agents of which there are two groups: benzylisoquinoliniums (e.g. atracurium, cisatracurium and mivacurium) and aminosteroidal agents (e.g. pancuronium, vecuronium and rocuronium). The need to monitor neuromuscular block perioperatively to ensure the appropriate dose of any neuromuscular blocking drug is given has led to the development of several nerve stimulation techniques. Particularly useful clinically are the train-of-four twitch response, double-burst stimulation, and the post-tetanic count. Their benefits and limitations are considered in this chapter. The most suitable equipment to monitor neuromuscular block and the appropriate anatomical sites for stimulation are discussed. To prevent residual block with its pathophysiological consequences such as upper airway and pharyngeal dysfunction and potential respiratory failure at the end of surgery, antagonizing agents are used. These are of two types: anticholinesterases such as neostigmine and edrophonium, and the γ‎-cyclodextrin, sugammadex. The pharmacodynamics and pharmacokinetics of neuromuscular blocking drugs and their antagonists are altered by the extremes of age, obesity, and several disease states including renal and hepatic failure, neuromuscular disorders, and critical illness. The altered response to all these drugs in these pathologies, which is related to their metabolism and excretion, is considered in detail, together with their other side-effects including the particular disadvantages to the use of succinylcholine.

Use of peripheral nerve stimulators to monitor patients with neuromuscular blockade in the ICU

1996 ◽  
Vol 5 (6) ◽  
pp. 449-454 ◽  
Author(s):  
R Kleinpell ◽  
C Bedrosian ◽  
L McCormick ◽  
M Kremer ◽  
L Bujalski ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
National Sample ◽  
Neuromuscular Blocking ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Number Of Patients ◽  
Train Of Four ◽  
Current Monitoring ◽  
Prolonged Neuromuscular Blockade

BACKGROUND: Neuromuscular blockade is a frequently used therapy in the ICU. However, recent reports of prolonged paralysis and general muscular weakness in patients treated with this procedure have raised concerns about its use in intensive care. OBJECTIVE: The purpose of this study was to assess current monitoring practices of nurses who care for patients treated with neuromuscular blockade. METHODS: In January 1995, questionnaires were mailed to a random national sample of 2000 critical care nurses. Of the 2000 questionnaires mailed, 744 were returned. RESULTS: The number of patients per month who were treated with neuromuscular blockade in ICU settings ranged from 0 to 75 (mean = 6.82, SD = 9.15). For each patient, the average number of days of blockade ranged from less than 1 to 63 (mean = 4.12, SD = 3.36). The most common indications for neuromuscular blockade were to assist in mechanical ventilation, reduce oxygen consumption, and treat agitation. Only 41% of respondents (n = 306) reported using train-of-four stimuli and a peripheral nerve stimulator to monitor patients. Depth of neuromuscular blockade was routinely monitored by using clinical assessment (31%), a peripheral nerve stimulator (16%), or both (52%). CONCLUSIONS: Among the respondents, variations existed in monitoring practices and in the use of peripheral nerve stimulators, including the frequency of monitoring and use of the baseline milliamperage. Appropriate monitoring and titration of neuromuscular blocking agents by ICU nurses may aid in preventing adverse effects, including the potential for prolonged neuromuscular blockade. The existing variations in practice may affect patients' outcomes.

Evaluation of Neuromuscular and Cardiovascular Effects of Two Doses of Rapacuronium (ORG 9487) versus Mivacurium and Succinylcholine 

1999 ◽  
Vol 91 (6) ◽  
pp. 1648-1648 ◽  
Author(s):  
Rafael Miguel ◽  
Thomas Witkowski ◽  
Hideo Nagashima ◽  
Robert Fragen ◽  
Richard Bartkowski ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Cardiovascular Effects ◽  
Rapid Onset ◽  
Neuromuscular Blocking ◽  
Open Label ◽  
Org 9487 ◽  
Train Of Four ◽  
Pressure Changes ◽  
To Receive ◽  
Nondepolarizing Muscle Relaxant

Background This study compares the neuromuscular blocking and cardiovascular effects of rapacuronium (ORG 9487), a new aminosteroid nondepolarizing muscle relaxant, to recommended intubating doses of succinylcholine and mivacurium. Methods Adult patients were randomized in an open-label fashion to receive 1-5 microg/kg fentanyl before 1.5 mg/kg propofol induction followed by 1.5 or 2.5 mg/kg rapacuronium, 1.0 mg/kg succinylcholine, or 0.25 mg/kg mivacurium (i.e., 0.15 mg/kg followed by 0.1 mg/kg 30 s later). Results Patient neuromuscular blockade status was monitored by measuring the train-of-four response to a supramaximal stimulus at the ulnar nerve every 12 s. Percentage of the first twitch of the train-of-four (T1) at 60 s was similar in patients receiving 1.5 mg/kg rapacuronium, 2.5 mg/kg rapacuronium, and succinylcholine and was significantly less than in patients in the mivacurium group (26, 16, and 18%, respectively, vs. 48%; P < 0.01). Times to 80% T1 depression were also similar among patients in the 1.5 mg/kg rapacuronium, 2.5 mg/kg rapacuronium, and succinylcholine groups and significantly longer in the mivacurium group (62, 54, and 54 s, respectively, vs. 112 s; P < 0.01). Clinical duration was longer in all groups compared with the succinylcholine group; however, clinical duration in the 1.5 mg/kg rapacuronium group was shorter compared with the mivacurium group (15 vs. 21 min, respectively; P < 0.01). Heart rate changes were mild in the 1.5 mg/kg rapacuronium, succinylcholine, and mivacurium groups. The patients in the 2.5 mg/kg rapacuronium group had significantly higher heart rates compared with patients in the mivacurium group. No differences were found in blood pressure changes among patients in the four groups. Conclusions Rapacuronium, 1.5 and 2.5 mg/kg, produced neuromuscular blockade as rapidly as succinylcholine and significantly faster than mivacurium. Although succinylcholine continued to show the shortest duration, 1.5 mg/kg rapacuronium used a rapid onset and a relatively short duration and may be considered an alternative to succinylcholine.

Pharyngeal Function and Breathing Pattern during Partial Neuromuscular Block in the Elderly

2014 ◽  
Vol 120 (2) ◽  
pp. 312-325 ◽  
Author(s):  
Anna I. Hårdemark Cedborg ◽  
Eva Sundman ◽  
Katarina Bodén ◽  
Hanne Witt Hedström ◽  
Richard Kuylenstierna ◽  
...  
Keyword(s):  
Neuromuscular Block ◽  
The Elderly ◽  
Pulmonary Complications ◽  
Neuromuscular Blocking ◽  
Residual Effects ◽  
Airway Protection ◽  
Healthy Elderly ◽  
Increased Risk ◽  
Train Of Four ◽  
Pharyngeal Function

Abstract Background: Intact pharyngeal function and coordination of breathing and swallowing are essential for airway protection and to avoid respiratory complications. Postoperative pulmonary complications caused by residual effects of neuromuscular-blocking agents occur more frequently in the elderly. Moreover, elderly have altered pharyngeal function which is associated with increased risk of aspiration. The purpose of this study was to evaluate effects of partial neuromuscular block on pharyngeal function, coordination of breathing and swallowing, and airway protection in individuals older than 65 yr. Methods: Pharyngeal function and coordination of breathing and swallowing were assessed by manometry and videoradiography in 17 volunteers, mean age 73.5 yr. After control recordings, rocuronium was administered to obtain steady-state train-of-four ratios of 0.70 and 0.80 followed by spontaneous recovery to greater than 0.90. Results: Pharyngeal dysfunction increased significantly at train-of-four ratios 0.70 and 0.80 to 67 and 71%, respectively, compared with 37% at control recordings, and swallowing showed a more severe degree of dysfunction during partial neuromuscular block. After recovery to train-of-four ratio of greater than 0.90, pharyngeal dysfunction was not significantly different from the control state. Resting pressure in the upper esophageal sphincter was lower at all levels of partial neuromuscular block compared with control recordings. The authors were unable to demonstrate impaired coordination of breathing and swallowing. Conclusion: Partial neuromuscular block in healthy elderly individuals causes an increased incidence of pharyngeal dysfunction from 37 to 71%, with impaired ability to protect the airway; however, the authors were unable to detect an effect of partial neuromuscular block on coordination of breathing and swallowing.

Comparative Clinical Pharmacology of Rocuronium, Cisatracurium, and Their Combination 

1998 ◽  
Vol 89 (5) ◽  
pp. 1116-1124 ◽  
Author(s):  
Mohamed Naguib ◽  
Abdulhamid H. Samarkandi ◽  
Adel Ammar ◽  
S. R. Elfaqih ◽  
Salem Al-Zahrani ◽  
...  
Keyword(s):  
Clinical Pharmacology ◽  
Time Course ◽  
Time Profile ◽  
Neuromuscular Blocking ◽  
Combination Group ◽  
Onset Of Action ◽  
Recovery Times ◽  
Train Of Four ◽  
American Society ◽  
American Society Of Anesthesiologists

Background The comparative clinical pharmacology of cisatracurium and rocuronium and their combinations has not been reported. In this study, the authors compared the relative potency and the clinical profile and characterized the interaction of both drugs. Methods Two hundred twenty adults classified as American Society of Anesthesiologists physical status I and anesthetized with propofol-fentanyl-nitrous oxide were studied. In part 1, the neuromuscular-blocking effects of cisatracurium and rocuronium were assessed after administration of bolus doses of 20-50 microg/kg and 100-300 microg/kg, respectively. In part 2, we compared the time course of 1xED50, 1, 1.5, and 2xED95 doses of both drugs (where ED50 and ED95 are, respectively, the doses producing 50% and 95% depression of the first twitch height [T1]). In part 3, equieffective combinations of both drugs were studied to characterize their interaction. Results The calculated ED50 values and their 95% confidence intervals were 111 (107-115) and 26.2 (25.8-26.5) microg/kg [corrected] for rocuronium and cisatracurium, respectively. Compared with equipotent doses of cisatracurium, rocuronium had a faster onset, and a faster spontaneous T1 and train-of-four recovery times that were significant except at maximum recovery with the 2xED95 dose. The interaction between rocuronium and cisatracurium was synergistic, and the time profile of the combination group was different from that of the single-dose groups. Conclusions Cisatracurium is four to five times more potent than rocuronium. Rocuronium had a faster onset of action, a shorter clinical duration, and a faster spontaneous recovery rate compared with equipotent doses of cisatracurium.

Comparison of the Intubation Conditions Provided by Rapacuronium (ORG 9487) or Succinylcholine in Humans during Anesthesia with Fentanyl and Propofol 

1999 ◽  
Vol 91 (5) ◽  
pp. 1311-1311 ◽  
Author(s):  
Neal W. Fleming ◽  
Frances Chung ◽  
Peter S. A. Glass ◽  
John B. Kitts ◽  
Hans Kirkegaard-Nielsen ◽  
...  
Keyword(s):  
Tracheal Intubation ◽  
Short Duration ◽  
Rapid Onset ◽  
Neuromuscular Function ◽  
Neuromuscular Blocking ◽  
Blocking Drug ◽  
Duration Of Action ◽  
Prospective Randomized Clinical Trial ◽  
Org 9487 ◽  
Train Of Four

Background Currently, the only approved muscle relaxant with a rapid onset and short duration of action is succinylcholine, a drug with some undesirable effects. Rapacuronium is an investigational nondepolarizing relaxant that also has a rapid onset and short duration and consequently should be compared with succinylcholine in its ability to facilitate rapid tracheal intubation. Methods This prospective, randomized clinical trial involved 336 patients. Anesthesia was induced with fentanyl and propofol and either 1.5 mg/kg rapacuronium or 1.0 mg/kg succinylcholine. The goal was to accomplish tracheal intubation by 60 s after administration of the neuromuscular blocking drug. Endotracheal intubation was performed, and conditions were graded by a blinded investigator. Recovery of neuromuscular function was assessed by electromyography. Results Intubation conditions were evaluated in 236 patients. Intubation by 60 s after drug administration occurred in 100% of patients with rapacuronium and in 98% with succinylcholine. Intubation conditions were excellent or good in 87% of patients with rapacuronium and in 95% with succinylcholine (P < 0.05). The time (median and range) to the first recovery of the train-of-four response was 8.0 (2.8-20.0) min with rapacuronium and 5.7 (1.8-17.7) min with succinylcholine (P < 0.05). The overall incidence of adverse effects was similar with both drugs. Conclusions A 1.5-mg/kg dose of rapacuronium effectively facilitates rapid tracheal intubation. It can be considered a valid alternative to 1.0 mg/kg succinylcholine for this purpose.

scholarly journals Rocuronium for intubation in parturients undergoing caesarean section

2018 ◽  
Vol 6 (10) ◽  
pp. 3441
Author(s):  
Sajina M. ◽  
Medha A. Sangawar ◽  
Sangawar A. V. ◽  
Niraj Bannore
Keyword(s):  
Muscle Relaxant ◽  
Rapid Sequence Induction ◽  
Anaesthetic Management ◽  
Neuromuscular Blocking ◽  
Onset Of Action ◽  
Promising Alternative ◽  
Intubating Conditions ◽  
Rapid Sequence ◽  
Sequence Induction ◽  
The Mean

Background: Anaesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Succinylcholine, a depolarizing muscle relaxant is most commonly used and considered “The Gold Standard’’ for tracheal intubation. Among currently available non-depolarizing neuromuscular blocking agent rocuronium bromide is the only agent that has rapid onset of action which is comparable to succinylcholine. Thus, rocuronium may provide alternative to succinylcholine for rapid sequence induction of anaesthesia wherever succinylcholine is contraindicated.Methods: In a control trial, 60 parturients of ASA grade I and II were randomly allocated in two groups of 30 patients each (group R and group S). After preoxygenation for a period of 5minutes rapid sequence induction done with thiopentone 5mg/kg for all patients. Muscle relaxant rocuronium (0.6mg/kg) was administered for group R. Succinylcholine was given in similar dosage (0.6mg/kg) for group S. The intubation was tried after 90 seconds in group R (rocuronium group) but after 60 seconds in group S (succinylcholie group). The intubating conditions were assessed and compared among the groups using criteria suggested by Cooper et al.Results: The mean intubation time was 98.3 seconds in group R and 67.9 seconds in group S. Rocuronium produced clinically acceptable intubating conditions in 28 out 30 patients (93.33%). Among these 28 patients 70% had excellent intubating conditions and 23.33% had good intubating conditions. Clinically acceptable intubating conditions were present in all 30 patients (100%-90% excellent and 10% good) who were administered succinylcholine. Succinylcholine produced excellent intubating conditions at 60 seconds (90 percent) compared to rocuronium (70 percent). However, this difference was statistically insignificant (p= 0.053). The mean Apgar score at 1 min and 5 min in group R was 8.1 and 8.83 as against 8.06 and 8.96 in babies born to mother in group S.Conclusions: Rocuronium (0.6mg/kg) provided acceptable intubation conditions after a waiting period of 90 seconds in 93.33% patients as against 100% patients in succinylcholine administered patients in equivalent dosage. So rocuronium is a promising alternative for rapid sequence induction in parturients in whom succinylcholine is not advisable or contraindicated.

Prasugrel in the treatment of acute coronary syndrome

2020 ◽  
Author(s):  
Michael Spartalis ◽  
Eleni Tzatzaki ◽  
Eleftherios Spartalis ◽  
Stavroula A Paschou ◽  
Antonios Athanasiou ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Rapid Onset ◽  
Cardiovascular Death ◽  
Major Adverse Cardiovascular Events ◽  
Onset Of Action ◽  
Action Current ◽  
P2y12 Inhibitor ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
Increased Risk

Dual antiplatelet therapy is the mainstay therapy in patients with acute coronary syndrome. The combination of aspirin and a P2Y12 inhibitor in patients who receive a coronary stent reduces the rate of stent thrombosis and the rates of major adverse cardiovascular events. The newer P2Y12 inhibitors (prasugrel and ticagrelor) have better efficacy than clopidogrel. Prasugrel provides greater inhibition of platelet aggregation and has a rapid onset of action. Current acute coronary syndrome guidelines recommend the use of both newer P2Y12 inhibitors. However, emerging data have shown that prasugrel is more efficient than ticagrelor in reducing the incidence of nonfatal myocardial infarction, stroke or cardiovascular death, without increased risk of major bleeding.

Measurement of the activity of neuromuscular blocking agents by train-of-four and their effect on the coagulation profiles of dogs undergoing and ovariohysterectomy

2019 ◽  
Author(s):  
Zulfikar Kadir Saritas ◽  
Musa Korkmaz ◽  
Oktay Yilmaz ◽  
C. Cagri Cingi ◽  
Tuba Berra Saritas ◽  
...  
Keyword(s):  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Thrombin Time ◽  
Onset Of Action ◽  
Inhalation Anesthesia ◽  
Group V ◽  
Short Acting ◽  
Blocking Agents ◽  
Reversal Time ◽  
Train Of Four

Atracurium and vecuronium, which are short-acting non-depolarising neuromuscular blocking agents, were introduced into clinical use after 1980. These two drugs, which have a short-acting duration and fewer adverse side effects, have found widespread use.The aims of this study were to determine the onset of action and duration of three neuromuscular-blocking drugs. A total of 18 dogs 1-3 years of age and weighing 17.6 kg on average were evaluated in the study. The animals were divided equally into the three drug groups: Group A = atracurium, Group V = vecuronium and Group R = rocuronium. Atracurium, rocuronium and vecuronium were administered at 0.2 mg/kg, 0.2 mg/kg and 0.4 mg/kg, respectively via the IV route. After the operation was completed, the animals in the vecuronium group were treated with 2-4 mg/kg IV sugammadex and the reversal time of the drug effect was recorded. Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT) and fibrinogen (FP) values were measured. The PT showed significant differences between the atracurium and rocuronium groups (p less than 0.05).TOF neuromuscular blockage time displayed significant differences between the atracurium (35.6±7.7 min) and rocuronium groups (26.1±2.1 min) (p less than 0.05). The onset of neuromuscular blockage time for all three agents was similar; however, rocuronium had a shorter neuromuscular blockage time. As a conclusion, our results suggest that all three neuromuscular blocking agents can be administered routinely with inhalation anesthesia for patients undergoing surgical procedures in which muscular relaxation is needed.

scholarly journals Acute Vision Loss Following Endoscopic Sinus Surgery

2017 ◽  
Vol 2017 ◽  
pp. 1-3
Author(s):  
Serena Byrd ◽  
Adnan S. Hussaini ◽  
Jastin Antisdel
Keyword(s):  
Endoscopic Sinus Surgery ◽  
Vision Loss ◽  
Nasal Congestion ◽  
Uterine Cancer ◽  
Rapid Onset ◽  
Sinus Surgery ◽  
Onset Of Action ◽  
Increased Risk ◽  
Arterial Vasospasm ◽  
History Of

A 41-year-old female with a history of uterine cancer and Celiac and Raynaud’s Disease presented to our institution with frequent migraines and nasal congestion. She underwent functional endoscopic sinus surgery (FESS) and experienced acute unilateral vision loss postoperatively. Rapid recognition of the etiology and effective treatment are paramount given the permanent and irreversible vision loss that can result. Arterial vasospasm following FESS is rare. Patients with autoimmune diseases have perhaps an increased risk for vasospasm secondary to an increased vasoreactive profile. We present the first documented case of nitroglycerin sublingual therapy to successfully treat ophthalmic artery vasospasm following FESS. Nitroglycerin sublingual therapy is a promising treatment for ophthalmic vasospasm secondary to its ability to cross the blood-ocular barrier, its rapid onset of action, and its ability to promote relaxation of vascular smooth muscle.

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