Residual Paralysis in the PACU after a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action

Background Residual neuromuscular blockade remains a problem even after short surgical procedures. The train-of-four (TOF) ratio at the adductor pollicis required to avoid residual paralysis is now considered to be at least 0.9. The incidence of residual paralysis using this new threshold is not known, especially after a single intubating dose of intermediate-duration nondepolarizing relaxant. Therefore, the aim of the study was to determine the incidence of residual paralysis in the postanesthesia care unit after a single intubating dose of twice the ED(95) of a nondepolarizing muscle relaxant with an intermediate duration of action. Methods Five hundred twenty-six patients were enrolled. They received a single dose of vecuronium, rocuronium, or atracurium to facilitate tracheal intubation and received no more relaxant thereafter. Neuromuscular blockade was not reversed at the end of the procedure. On arrival in the postanesthesia care unit, the TOF ratio was measured at the adductor pollicis, using acceleromyography. Head lift, tongue depressor test, and manual assessment of TOF and DBS fade were also performed. The time delay between the injection of muscle relaxant and quantitative measurement of neuromuscular blockade was calculated from computerized anesthetic records. Results The TOF ratios less than 0.7 and 0.9 were observed in 16% and 45% of the patients, respectively. Two hundred thirty-nine patients were tested 2 h or more after the administration of the muscle relaxant. Ten percent of these patients had a TOF ratio less than 0.7, and 37% had a TOF ratio less than 0.9. Clinical tests (head lift and tongue depressor) and manual assessment of fade showed a poor sensitivity (11-14%) to detect residual blockade (TOF < 0.9). Conclusion After a single dose of intermediate-duration muscle relaxant and no reversal, residual paralysis is common, even more than 2 h after the administration of muscle relaxant. Quantitative measurement of neuromuscular transmission is the only recommended method to diagnose residual block.

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Intraoperative Neuromuscular Monitoring Site and Residual Paralysis

Anesthesiology ◽

10.1097/aln.0b013e31826f8fdd ◽

2012 ◽

Vol 117 (5) ◽

pp. 964-972 ◽

Cited By ~ 48

Author(s):

Stephan R. Thilen ◽

Bradley E. Hansen ◽

Ramesh Ramaiah ◽

Christopher D. Kent ◽

Miriam M. Treggiari ◽

...

Keyword(s):

Odds Ratio ◽

Elective Surgery ◽

Adductor Pollicis ◽

Postanesthesia Care Unit ◽

Time Interval ◽

Monitoring Site ◽

Residual Paralysis ◽

Crude Odds Ratio ◽

Eye Muscles ◽

Duration Of Surgery

Background Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis. Methods This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates. Results 150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8-8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1-14.5). Conclusions Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.

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Neuromuscular Pharmacology of TAAC3, a New Nondepolarizing Muscle Relaxant with Rapid Onset and Ultrashort Duration of Action

Anesthesia & Analgesia ◽

10.1097/00000539-200204000-00020 ◽

2002 ◽

Vol 94 (4) ◽

pp. 879-885 ◽

Cited By ~ 18

Author(s):

Laszlo Gyermek ◽

Chingmuh Lee ◽

Young-Moon Cho ◽

N. Nguyen ◽

S. K. Tsai

Keyword(s):

Muscle Relaxant ◽

Rapid Onset ◽

Duration Of Action ◽

Nondepolarizing Muscle Relaxant

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Faculty Opinions recommendation of Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1119815.580208 ◽

2008 ◽

Author(s):

Mark Nunnally

Keyword(s):

Neuromuscular Blockade ◽

Postanesthesia Care Unit ◽

Residual Neuromuscular Blockade ◽

Respiratory Events

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Neuromuscular blockade effects of cisatracurium in 11 cats undergoing ophthalmological surgery anaesthetised with isoflurane

Journal of Feline Medicine and Surgery ◽

10.1177/1098612x211021829 ◽

2021 ◽

pp. 1098612X2110218

Author(s):

Anne-Sophie Van Wijnsberghe ◽

Keila K Ida ◽

Petra Dmitrovic ◽

Alexandru Tutunaru ◽

Charlotte Sandersen

Keyword(s):

Neuromuscular Blockade ◽

Case Series ◽

Neuromuscular Function ◽

Duration Of Action ◽

Cardiovascular Side Effects ◽

Train Of Four ◽

Physical Classification ◽

The Mean ◽

American Society ◽

American Society Of Anesthesiologists

Case series summary This case series describes the neuromuscular blockade (NMB) following 0.15 mg/kg intravenous (IV) cisatracurium administration in 11 cats undergoing ophthalmological surgery and anaesthetised with isoflurane. Anaesthetic records were analysed retrospectively. Neuromuscular function was assessed by a calibrated train-of-four (TOF) monitor. Cats were 73 ± 53 months old, weighed 4 ± 1 kg and were of American Society of Anesthesiologists’ physical classification 2. Duration of anaesthesia and surgery were 144 ± 27 and 94 ± 24 mins, respectively. The lowest TOF count was zero in four cats, four in six cats and for one cat the TOF ratio never decreased below 31%. The time of onset was between 1 and 6 mins after the administration of cisatracurium and the mean duration of action was 20.4 ± 10.1 mins. Relevance and novel information Cisatracurium at a dose of 0.15 mg/kg IV did not consistently induce a TOF count of zero in all cats. The dose used in these cats did not produce any remarkable cardiovascular side effects. Although the NMB was not complete, the dose given was sufficient to produce central eyeball position, which was the goal of the ophthalmic surgeries.

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Preclinical Pharmacology in the Rhesus Monkey of CW 1759-50, a New Ultra-short Acting Nondepolarizing Neuromuscular Blocking Agent, Degraded and Antagonized by L-Cysteine

Anesthesiology ◽

10.1097/aln.0000000000002408 ◽

2018 ◽

Vol 129 (5) ◽

pp. 970-988 ◽

Cited By ~ 2

Author(s):

John J. Savarese ◽

Hiroshi Sunaga ◽

Jeff D. McGilvra ◽

Matthew R. Belmont ◽

Matthew T. Murrell ◽

...

Keyword(s):

Heart Rate ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Neuromuscular Blockade ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agent ◽

Duration Of Action ◽

Short Acting ◽

Circulatory Effects

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Structure–activity studies were performed to identify a new neuromuscular blocking agent retaining the ultra-short acting characteristics of gantacurium, including degradation and reversal by l-cysteine, but lacking its histaminoid properties in man. CW 1759-50 has emerged from this program. Methods Adduction of CW 1759-50 with l-cysteine was studied by high-performance liquid chromatography and mass spectrometry. Institutional Animal Care and Use Committee–approved comparisons of CW 1759-50 to gantacurium were performed in rhesus monkeys. ED95 for neuromuscular blockade was established. Spontaneous recovery was compared to reversal by l-cysteine in paired studies of boluses or infusions. In addition, changes in mean arterial pressure and heart rate after very large doses of 15 to 60 × ED95 were compared. Results The half-time of adduction of l-cysteine to CW 1759-50 in vitro was 2.3 min. The ED95 of CW 1759-50 was 0.069 ± 0.02 mg/kg; ED95 of gantacurium was 0.081 ± 0.05 mg/kg (P = 0.006). Duration of action (recovery to 95% twitch height after 98 to 99% blockade) was as follows: CW 1759-50, 8.2 ± 1.5 min; and gantacurium, 7.4 ± 1.9 min; (n = 8 and 9, P = 0.355). Administration of l-cysteine (30 mg/kg) shortened recovery (i.e., induced reversal) from CW 1759-50 after boluses or infusions (P always less than 0.0001). Recovery intervals (5 to 95% twitch) ranged from 6.1 to 6.7 min (and did not differ significantly) after boluses of 0.10 to 0.50 mg/kg, as well as control infusions (P = 0.426 by analysis of variance). Dose ratios comparing changes of 30% in mean arterial pressure or heart rate to ED95 for neuromuscular blockade (ED 30% Δ [mean arterial pressure or heart rate]/ED95) were higher for CW 1759-50 than for gantacurium. Conclusions CW 1759-50, similar to gantacurium, is an ultra-short acting neuromuscular blocking agent, antagonized by l-cysteine, in the monkey. The circulatory effects, however, are much reduced in comparison with gantacurium, suggesting a trial in humans.

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Pharmacokinetics and Pharmacodynamics of Cisatracurium in Young and Elderly Adult Patients

Anesthesiology ◽

10.1097/00000542-199605000-00010 ◽

1996 ◽

Vol 84 (5) ◽

pp. 1083-1091 ◽

Cited By ~ 67

Author(s):

Shahpoor S. Sorooshian ◽

Michael A. Stafford ◽

Nigel B. Eastwood ◽

Alastair H. Boyd ◽

Christopher J. Hull ◽

...

Keyword(s):

Muscle Relaxant ◽

Time Course ◽

Venous Blood ◽

The Elderly ◽

Adult Patients ◽

Pharmacodynamic Modeling ◽

Population Pharmacokinetic ◽

Elderly Adult ◽

Elderly Adults ◽

Duration Of Action

Background The effects of a muscle relaxant may differ in elderly compared with young adult patients for a variety of reasons. The authors compared the effects of a new muscle relaxant (cisatracurium) in young and elderly adults and used pharmacokinetic/pharmacodynamic modeling to identify factors explaining differences in time course of effect. Methods Thirty-one young (18-50 yr) and 33 elderly ( > 65 yr) patients anesthetized with nitrous oxide, isoflurane, and fetanyl were studied. Cisatracurium (0.1 mg/kg) was given after induction of anesthesia and later additional boluses of 0.025 mg/kg or an infusion of cisatracurium was given. Neuromuscular transmission was measured using the first twitch of the train-of-four response at the adductor pollicis after supramaximal stimulation of the ulnar nerve at 2 Hz every 15 s. Five venous blood samples were obtained for plasma drug concentration at intervals ranging from 2 to 120 min from every patient. Three additional samples were obtained from those who received an infusion. A population pharmacokinetic/pharmacodynamic model was fitted to the plasma concentration and effect data. The parameters of the model were permitted to vary with age to identify where differences existed between young and elderly adults. Results Onset of block was delayed in the elderly; values being mean 3.0 (95% confidence interval 1.75-11.4) min and 4.0 (2.4-6.5) min in the young and elderly, respectively (P < 0.01). Duration of action was similar in the two groups. Plasma clearance was 319 (293-345) ml/min in the study population and did not differ between young and elderly patients. Apparent volume of distribution was 13.28 (9.9-16.7) 1 and 9.6 (7.6-11.7) 1 in the elderly and young adults, respectively (P < 0.05). There also were differences in pharmacodynamic parameters between the young and elderly; the predominant change being a slower rate of biophase equilibration (ke0) in the elderly (0.060 [0.052-0.068])/min compared with the young (0.071 [0.065-0.077]/min; P < 0.05). Conclusions The pharmacokinetics of cisatracurium differ only marginally between young and elderly adults. Onset is delayed in the elderly because of slower biophase equilibration.

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THE RATE OF RESIDUAL NEUROMUSCULAR BLOCKADE AFTER LAPAROSCOPIC APPENDECTOMY SURGERY AT NGUYEN TRI PHUONG HOSPITAL

Tạp chí Y học Cộng đồng ◽

10.52163/vjcm.v62i6.186 ◽

2021 ◽

Vol 62 (6) ◽

Author(s):

Doan Minh Nhut ◽

Nguyen Van Chinh

Keyword(s):

Neuromuscular Blockade ◽

Laparoscopic Appendectomy ◽

Muscle Relaxant ◽

Muscle Relaxation ◽

Cross Sectional Study ◽

Cross Sectional ◽

Residual Rate ◽

Residual Neuromuscular Blockade ◽

Study Results

Introduction: In Vietnam, using a muscle accelerator to measure the TOF index to monitor residue neuromuscular blockade has not been performed routinely, extubation is mainly based on subjective clinical assessments. Methods: A cross-sectional study on 96 patients undergoing laparoscopic appendectomy at Nguyen Tri Phuong Hospital, from November 2020 to May 2021. Objectives: The study was conducted with 2 objectives including (1) Determine the progression of TOF index at 7 time points: immediately after arriving in the recovery room, after extubation, 15 minutes, 30 minutes, 60 minutes, 90 minutes, 120 minutes after extubation; (2) Determination of residual muscle relaxant rate of patients undergoing laparoscopic appendectomy at Nguyen Tri Phuong Hospital. Results: The average TOF ≥ 0,9 index after laparoscopic appendectomy at the time of resuscitation was 88.11%, extubation was 90.53% and at 120 minutes after extubation. is 99.88%. Residual muscle relaxation after surgery when TOF index < 0.9. At the time of resuscitation, the highest residual rate of muscle relaxant accounted for 58.33%, followed by the time of extubation 39.58%, 15 minutes after extubation was 21.88%. Until 120 after extubation, there is no case that has residue neuromuscular blockade. Conclusion: Through the study results, it is necessary to monitor patients undergoing laparoscopic appendectomy with quantitative devices to more accurately assess the clinical index of muscle relaxation.

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