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A Comparative Study of Neuromuscular Blocking Effects

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A Comparative Study of Neuromuscular Blocking Effects IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle January–February2020;7(1)(Part-I):58-63 DOI:http://dx.doi.org/10.21088/ijaa.2349.8471.7120.9 AComparativeStudyofNeuromuscularBlockingEffectsandReversibility ofCisatracuriumandVecuronium DivyaNKheskani1,HeenaSChhanwal2,BhaktiSJain3 1AssistantProfessor,2ProfessorandHead,3rdYearResident,DepartmentofAnaesthesia,GCSMedicalCollege,Hospital&Research Centre,NearChamundaBridge,Ahmedabad,Gujarat380025,India. Abstract Context: Cisatracurium is a cis isomer of parent compound atracurium, devoid of histamine release, thus possessing hemodynamic & cardiovascular stability. Aims: We compared the intubating conditions, hemodynamic stability & recovery of atracurium & vecuronium. Settings and Design: We carried out prospective, double blind randomized study after approval of ethical committee. 100 adult patients of ASA 1 &2with comparable demographicdatawereselected. Dividedin TwoGroupsC(Cisatracurium) &V(Vecuronium).Standardmonitoringwasdone&followingroutinepremedication&inductionagents, patientswereintubatedat2minsafteradministrationofcisatracurium0.15mg/kg&vecuronium0.1mg/ kgrespectively,maintainedonintermittentdoseofcisatracurium:0.03mg/kg&vecuronium:0.02mg/kg. IntubationconditionswereassessedaccordingtoTimeto25%recoveryoft1/tcfollowinginitialdoses,Time to25%recoveryoft1/tcfollowingrepeatedboluses,Timeto25%recoveryoft1/tcfollowinglastdose,Return oft4/t1ratio0.8spontaneousrecoveryatendofoperation.Statisticalanalysisused:Theresultswereevaluated byapplyingpairedt-testandp-valueusingSPSSStatisticalSoftware.Results:Intubatingconditionsat2mins followingadministrationappearedsatisfactory&laryngoscopyconditionwasgoodin98%inGroupC&97% inGroupV,Timetakenfor25%recoveryfollowingFirstDose&SubsequentDoseswaslongerforGroupC thanGroupV.Timetakento25%recoveryoft1/tcfollowingLastDosewasshorterinGroupCpatientsas comparedtoGroupV,durationofactionofGroupCwaslongerthanGroupV,bothdemonstratedequal hemodynamic & cardiovascular effect. Conclusions: Cisatracurium is intermediate onset nondepolarizing musclerelaxantdevoidofhistaminereleasewithlongerdurationofaction&fasterrecovery. Keywords:Cisatracurium;Vecuronium;Intubatingconditions;Recovery;Hemodynamicprofile. Howtocitethisarticle: DivyaNKheskani,HeenaSChhanwal,BhaktiSJain.AComparativeStudyofNeuromuscularBlockingEffectsandReversibility ofCisatracuriumandVecuronium.IndianJAnesthAnalg.2020;7(1Part-I):58–63. Introduction performing endotracheal intubation depends on thedegreeofmusclerelaxation,depthofanesthesia 2 Rapidandsafeendotrachealintubationisofprime and skill of anesthesiologist. The onset time, importanceingeneralanesthesia.Theroleofmuscle durationofmusclerelaxation,typeofpatientand relaxantservestofacilitateendotrachealintubation surgery are factors in choosing the appropriate and provides surgical relaxation.1–3 The ease of muscle relaxant to achieve rapid, successful CorrespondingAuthor:HeenaSChhanwal,ProfessorandHead,DepartmentofAnaesthesia,GCSMedicalCollege,Hospital& ResearchCentre,NearChamundaBridge,Ahmedabad,Gujarat380025,India. E-mail:[email protected] Receivedon12.09.2019,Acceptedon23.10.2019 ©RedFlowerPublicationPvt.Ltd. DivyaNKheskani,HeenaSChhanwal,BhaktiSJain/AComparativeStudyofNeuromuscularBlocking 59 EffectsandReversibilityofCisatracuriumandVecuronium 4 trachealintubation. Cisatracuriumisacisisomerof andthepreinductionSystolicBloodPressure(SBP), parentcompoundatracurium.However,itismore Diastolic Blood Pressure (DBP), Heart Rate (HR), appealingasitisdevoidofhistaminereleaseand Oxygen Saturation (SpO2), ECG were recorded. In thuspossessinghemodynamicandcardiovascular theoperationtheatrethepatientswerepremedicated stability.ItpossessesorganindependentHoffman withInjondansetron4mgIVInjGlycopyrollate0.2 elimination and intermediate duration of action. mg IV, Inj midazolam 0.1 mg/kg IV, Inj fentanyl Vecuronium is nondepolarizing muscle relaxant 10microgram/kgIV,justbeforeinduction.Patient withintermediatedurationofaction,metabolizesin werepreoxygenatedwith100%oxygenat10litre/ liver andhepatorenalorgan dependent clearance. minfreshgasowfor3minutesusingclosedcircuit, Hence, forth considering the above properties induced with IV propofol 2 mg/kg followed by of cisatracurium in this study we compared the cisatracurium or vecuronium and IPPV wih 100% intubatingconditions,hemodynamicstabilityand oxygenonbagandmaskaftertheywererandomly recoveryofthesetwoagents. allocated to Group C (Cisatracurium) or Group V (Vecuronium). After adequate relaxation for 2 MaterialsandMethods minutes patient were intubated with appropriate sizedendotrachealtubeandwasxedafterchecking equalairentrybilaterally. We carried out prospective, double blind randomized study after approval of ethical GrroupC:Cisatracuriumintubatingdose0.15mg/ committee. Written and informed consent was kg; obtained from all the participating patients. We studied100adultpatientsofphysicalstatusASA1 GroupV:Vecuroniumintubatingdose0.1mg/kg. and2,ofeithersex,agerangingfrom18to65years, Intubation conditions were assessed according weighing40to70kg,postedforelectivesurgeries tothecriteria:Laryngoscopycondition,vocalcord underGeneralanesthesialastingformaximumof2 position,vocalcordmovementallbeingexcellent to3hours.Adetailedandformalairwayevaluation orscarceandiftherewasreactiontoEndotracheal wasdonepreoperativelyandpatientswithmpg1 tubeinsertionofcuffinationbylimbmovementor andmpg2wereincluded. coughshownin(Table2).Patientweremaintained Patientsexcludedwerewithgradingscore3and on controlled mechanical ventilation with 50% 4 according to Sampson and young modication oxygen, 50% nitrous oxide (N2O) Inhalational of mallampati grading, anticipated difcult mask agent (sevourane 3%) and maintainance dose of ventilation and airway, Patient refusal, patients nondepolarizing muscle relaxant (Cisatracurium: of ASA 3 and 4, on therapy with drugs known 0.03 mg/kg and Vecuronium: 0.02 mg/kg). The to interfere with neuromuscular transmission, Adductor Policies muscle evoked response (AP), suspected pregnancy, liver or renal disease, TrainofFour(TOF)stimulationaftersupramaximal prolonged preoperative bed rest, Uncontrolled ulnar nerve stimulation were measured. With hypertension, History of reactive airway disease, TOF the time for recording baseline response historyofallergyorsensitivitytoanymedication, was standard 5 mins prior to administration of latex or egg, emergency surgical intervention musclerelaxant.Repeatedconsequentdoseswere or obesity (BMI ≥ 25). All patients were given T administered when AP response recovered to Alprazolam 0.5 mg on night prior to the surgery 25%ofcontroltwitchheight,attheendofsurgery andwerekeptnilbymouthfor8hrs. monitoringwascontinueduntil95%ofT1andT4/ Patientswillberandomlydividedinto2Groups T1(80%attheendofsurgery). of50each: Attheendoftheoperation,anestheticagentswere • GroupC(50patients)forCisatracurium; discontinued and adequate oral suctioning was done.PtwerethenreversedwithinjGlycopyrollate • GroupV(50patients)forVecuronium. (0.008 mg/kg) and inj neostigmine (0.05 mg/kg) Awrittenandinformedconsentwastakenfrom and extubated after regains consciousness and thepatient.Onthedayofsurgery,Inthepreoperative responded to verbal command. All patients were room base line vital parameters (pulse, blood monitoredforHR(HeartRate),SBP(SystolicBlood pressure, respiratory rate, SpO2 and temperature) Pressure), DBP (Diastolic Blood Pressure), SPO2, wererecorded.Alargebore18gaugeIVperipheral ETCO2 and uid requirement was calculated and linewassecured,aslowinfusionoflactatedRinger’s replacedaccordingly.Thefollowingvariableswere solution was started. All resuscitation equipments recorded in minutes: (1) Time to 25% recovery werekeptready.Standardmonitorswereconnected of t1/tc following initial doses (2) Time to 25% IJAA/Volume7Number1(Part-I)/January-February2020 60 IndianJournalofAnesthesiaandAnalgesia recovery of t1/tc following repeated boluses (3) female ratio,weight and age of patients between Timeto25%recoveryoft1/tcfollowinglastdose both the groups. Intubating conditions at 2 mins (4)Returnoft4/t1ratio0.8spontaneousrecoveryat following administration appeared satisfactory endofoperation(SpontaneousCompleteRecovery, & laryngoscopy condition wasgood in 98% in (SCRT). group C & 97% in Group V, shown as in Figs. 1–2, both demonstrated equal hemodynamic & cardiovasculareffect,Figs.3–4,Timetakenfor25% Results recovery following rst dose & subsequent doses waslongerforGroupCthanGroupV,Timetaken After studying 100 cases, observation and results to25%recoveryoft1/tcfollowingLastDosewas are summarized in tabulated form and described shorterinGroupCpatientsascomparedtoGroup below.Bothgroupscomprisedof50patients,(Table V,durationofactionofGroupCwaslongerthan 1). No signicant difference was seen in male- GroupV,(Table2). Table1:DemographicData Parameters GroupC(n=50) GroupV(n=50) p-value Inference Sex(M/F) 38:12 40:10 >0.05 NS Age(Years) 30.96±7.68 32.4±10.01 >0.05 NS Weight(kg) 56.72±8.5 60.04±6.943 >0.05 NS Height(cm) 165.6±4 168±7.1 >0.05 NS ASAGrade1 ASAGrade2 44:6 40:10 – – Durationofsurgery(min) 100±10 110±15 – – Table2:Recoverycharacteristicsofbothgroups(n-100) Parameters GroupC GroupV p-value Time(mins)to25%recovery 57.3±11.2 41.2±7.0 <0.0001 oft1/tcfollowinginitial doses Time(mins)to25%recovery 35.5±8.49 30.02±3.9 <0.0002 oft1/tcfollowingrepeated boluses Time(mins)to25%recovery 36.75±4.8 31.6±4.71 <0.0001 oft1/tcfollowinglastdose Returnoft4/t1ratio0.8 43.5±4.6 46.5±7.25 <0.015 spontaneousrecoveryat endofoperation(mins) Cisatracurium 6% 98% 92% Laryngoscopy:excellent/good Vocalcordposition:excellent/good
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