Abstract
A randomized, doubleblind study was undertaken to compare the tendencies for cumulation, and reversal characteristics of atracurium (ATR) and vecuronium (VEC) when administered by continuous infusionfor long surgical procedures under balanced anaesthesia. Eligible subjects were between 50 and 75 yr of age and were free of neuromuscular disease. Patients in the ATR group (n = 25) received a loading dose of atracurium 0.25 mg· kg−1, followed by an infusion initially set at 5.0 μg · kg−1 · min−1. In the VEC group (n = 25) patients received a loading dose of vecuronium 0.05 mg · kg−1, followed by an infusion at 1.0 μg · kg−1 · min−1. During surgery, the infusions of both ATR and VEC were titrated in increments or decrements of 12.5% to maintain first twitch (TI) suppression of 90–95%. Neuromuscular block was measured by recording the integrated evoked electromyographic response (EMG) of the first dorsal interosseous muscle in response to supramaximal TOF stimuli on the ulnar nerve. The durations of infusion were similar for the two groups (164 ± 42 and 183 ± 67 min for ATR and VEC, respectively). The infusion rates of ATR (mean ± SD) remained between 4.0 ± 0.7 and 5.0 ± 1.0 μg · kg− 1 · min− 1 throughout the study period. In contrast, a progressive decrease (P < 0.05) in the infusion rate of VEC, from 1.0 to 0.47 ± 0.13 μg · kg−1 · min−1, was observed during the study period. The number of adjustments required to maintain 90–95% TI suppression decreased between the second and fourth hours of administration, but were similar at corresponding times when comparing the two groups. The times to recover to a TOF ratio >70% following reversal with neostigmine 40 μg· kg−1 and atropine 15 μg · kg−1 were also similar for the two groups (13.4 ± 4.9 and 14.4 ± 8.0 min for ATR and VEC, respectively). We conclude that a constant infusion of vecuronium adjusted to maintain TI suppression of 90–95% results in cumulation which is manifest after the second hour of administration. In contrast, atracurium shows little tendency for cumulation during infusions lasting between two and five hours. When titrated according to individual patient response, infusions of both atracurium and vecuronium are characterized by their ease of administration and their ability to be readily reversed with appropriate doses of neostigmine.
Résumé
Cette éetude à double insu compare les propriétés cumulatives et la reversibilité de l’atracurium (ATR) et du vécuronium (VEC) administrés en perfusion continue pour des interventions de longue durée sous anesthésie balancée. Les sujets de l’étude sont âgés de 50 à 70 ans et ne souffrent pas de maladie neuromusculaires. Les patients due groupe ATR reçoivent une dose d’attaque de 0.25 mg · kg−1 suivie par une perfusion réglée au départ à 5 μg · kg · min−1. Dans le groupe VEC (n = 25), les patients recoivent une dose d’attaque de vécuronium de 0.05 mg · kg−1 suivie par une perfusion titrée à 1.0 μg · kg−1 min−1. Pendant la chirugie, la perfusion est augmentée ou diminuée par paliers de 12,5% pour maintenir la suppression a 90–95% du premier twicht (TI). L’évaluation de block neuromusculaire se fait par l’analyse du tracé de la réponse électromyographique (EMG) du premier interoseux dorsal de la main en réponse aux stimuli supramaximaux appliqués au nerf cubital. La durée de la perfusion est la même pour les deux groupes (164 ± 42 min pour l’ATR et 183 ± 67 min pour VEC). La vitesse de perfusion pour ATR (moyenne ± ET) se situe entre 4.0 ± 07 et 5.0 ± 1,0 μg · kg−1 · min−1. Par contre une baisse progressive (P < 0.05) de la quantite perfusee de VEC passant de 1.0 a 0.47 ± 0.13 μg · kg−1· min−1 est observée au cours de l’étude. Le nombre d’ajustements requis pour maintenir la suppression à 90–95% de TI a diminué entre la seconde et la quatrieme heure de perfusion mais est similaire lorsqu’on compare les deux groupes à des moments correspondants. La vitesse de récupération du rapport du train-dequatre > 70% après le renversement avec la niostigmine 40 μg · kg−1 et l’atropine 15μg · kg−1 est identique dans les deux groupes. Nous concluons qu’une perfusion continue de vicuronium réglée pour maintenir la suppression de 90–95% de TI produit une accumulation appréciable après deux heures. Par contre, l’atracurium ne montre pas cette tendance à l’accumulation pendant des perfusions continues d’une durée de deux à cinq heures. Lorsque titrées d’après la réponse, les perfusions d’atracurium et de vécuronium sont faciles à administrer et à renverser lorsque la dose de néostigmine est adéquate.
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Supported by a Research Grant from Burroughs-Wellcome Inc.
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Martineau, R.J., St.-Jean, B., Kitts, J.B. et al. Cumulation and reversal with prolonged infusions of atracurium and vecuronium. Can J Anaesth 39, 670–676 (1992). https://doi.org/10.1007/BF03008228
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DOI: https://doi.org/10.1007/BF03008228