thiopental and cisatracurium

The aims of the present study were to determine the tracheal intubating conditions, onset time, duration of action, and hemodynamic responses following the administration of cisatracurium 0.15 mg x kg(-1) to infants and children.. One hundred and eighty-one infants and children aged 1 month to 12 years were randomized to two groups to receive anesthesia with nitrous oxide-oxygen-halothane (group H) or nitrous oxide-oxygen-thiopental-fentanyl (group TF). Intubation conditions were assessed 120 s after cisatracurium administration using a 4-part scale. Neuromuscular transmission was monitored by recording the evoked compound electromyogram of the adductor pollicis.. The proportion of patients with excellent or good intubating conditions was similar in both groups (88 of 90, 98% in group H; 85 of 90, 94% in group TF). However, there was a significantly greater proportion of excellent intubating conditions in group H (79 of 90, 88%) compared with group TF (65 of 90, 72%) (P = 0.01) and recovery time was significantly longer in group H compared with group TF (P < 0.001). There was also a higher proportion of excellent intubating conditions in infants compared with older subjects (P = 0.02) and a shorter onset time (P < 0.001) and longer recovery time (P < 0.001) in younger compared with older patients. Changes in heart rate and arterial pressure were negligible 1 min following the cisatracurium administration.. Cisatracurium 0.15 mg x kg(-1) produces acceptable intubating conditions at 120 s in the great majority of infants and children. Anesthesia background and age have significant effects on intubating conditions and duration of action of cisatracurium.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Atracurium; Blood Pressure; Child; Child, Preschool; Electromyography; Female; Fentanyl; Halothane; Heart Rate; Humans; Infant; Intubation, Intratracheal; Male; Neuromuscular Blocking Agents; Nitrous Oxide; Oxygen; Thiopental; Time Factors; Treatment Outcome

Many anaesthesiologists still interpret haemodynamic responses as signs of insufficient cortical suppression. The aim was to illustrate how haemodynamics may only poorly reflect the level of cortical suppression and that electroencephalographic monitoring could indicate different relationships between cortical effects and haemodynamics.. Anaesthesia was induced with thiopental (7 mg kg(-1)), and fentanyl (2 microg kg(-1)) with succinylcholine (1.5 mg kg(-1)) for neuromuscular blockade in the 11 patients of Group 1. In Group 2 (n = 15), thiopental (7 mg kg(-1)) and succinylcholine (1.5 mg kg(-1)) were given. In Group 3, the patients (n = 13) received thiopental (7 mg kg(-1)), fentanyl (2 microg kg(-1)) and cisatracurium (0.1 mg kg(-1)), and they were intubated 3 min later than the patients in Groups 1 and 2. We determined conventional electroencephalographic (EEG) variables and classified 14 EEG stages in real-time ranging from A (= 1), indicating full wakefulness, to F1 (= 14), at profound cortical suppression.. All groups had profound cortical suppression 45 s after thiopental administration, which rapidly decreased (EEG stage, 11 (6-13) versus 7 (2-13) at 4 min, P < 0.0001). Decreasing EEG stages were associated with increasing SEF 95, relative alpha and beta power and decreasing relative delta power. During tracheal intubation, profound cortical suppression remained unchanged in Groups 1 and 2. In Group 3, cortical suppression had decreased before laryngoscopy (P < 0.005). In Group 2, 11 patients had heart rate responses to tracheal intubation, whereas only two responded in Group 1 (P = 0.015) and three in Group 3 (P = 0.02). Thirteen patients in Group 2 had arterial pressure responses, and five in Group 1 (P = 0.038). Circulatory responses did not differ between Groups 1 and 3.. Electroencephalographic monitoring was suitable to indicate in real-time that haemodynamics only poorly reflect rapidly changing levels of cortical suppression, and how haemodynamics and cortical activity depend on the applied combination of hypnotic and analgesic drugs during anaesthesia induction with thiopental.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthetics, Intravenous; Atracurium; Cerebral Cortex; Electroencephalography; Female; Fentanyl; Hemodynamics; Humans; Intubation, Intratracheal; Male; Middle Aged; Monitoring, Intraoperative; Neuromuscular Blocking Agents; Signal Processing, Computer-Assisted; Succinylcholine; Thiopental

A prospective, randomized, double-blind study was performed in 62 patients (ASA Classes I and II) treated with either 0.15 or 0.25 mg/kg cisatracurium or 0.15 mg/kg vecuronium administered as a rapid bolus. We wished to determine whether the muscle relaxants caused cutaneous, systemic, or chemical evidence of histamine release. Six minutes after induction of anesthesia with thiopental, patients received one of the muscle relaxants over 5 s. Plasma histamine levels were measured by radioimmunoassay after thiopental administration and 3 and 5 min after the administration of the relaxant. Additionally, plasma was assayed for tryptase, a marker of mast cell release. Cutaneous manifestations to both thiopental and the muscle relaxant were graded by an independent observer. Arterial blood pressure and heart rate were measured every minute. Although systolic and diastolic blood pressure decreased and heart rate increased significantly after thiopental administration (P < 0.0001), there were no further hemodynamic changes after either cisatracurium or vecuronium. One patient who received 0.25 mg/kg cisatracurium exhibited a slight elevation in plasma histamine level 5 min after hemodynamic changes. Cutaneous signs of histamine release were noted in five patients after thiopental administration (flush in four, erythema in one), but no further cutaneous reactions were observed after administration of either cisatracurium or vecuronium. We conclude that cisatracurium and vecuronium do not cause systemic or cutaneous histamine release. Tryptase levels showed no evidence of mast cell degranulation.

Topics: Atracurium; Blood Pressure; Double-Blind Method; Heart Rate; Histamine Release; Humans; Prospective Studies; Thiopental; Vecuronium Bromide

Cisatracurium, 51W89, is one of the ten stereoisomers of Tracrium which, unlike atracurium, has been reported to have a lack of histamine mediated cardiovascular effects at doses as high as 8 x ED95 in adults. We compared the time-course of neuromuscular effects of 80 micrograms.kg-1 or 100 micrograms.kg-1 cisatracurium during N2O-O2-halothane or N2O-O2-opioid anaesthesia, respectively, in 32 children 2-12 years old. Neuromuscular function was monitored by evoked adductor pollicis EMG. Even-numbered patients (n = 16) were allowed to obtain full spontaneous recovery of neuromuscular function and odd-numbered patients (n = 16) received neostigmine 45 micrograms.kg-1 together with glycopyrrolate at the time of 25% EMG recovery. Data are expressed as median with 10th to 90th percentile range. Cisatracurium had an onset time (time from administration to maximal effect) of 2.2 (1.7-3.8) or 2.3 (1.8-4.9) min, a clinical duration (time to 25% EMG recovery) of 34 (22-40) or 27 (24-33) min, and a spontaneous 25-75% recovery time (time from 25 to 75% EMG recovery) of 11 (9-13) or 11 (7-12) min during halothane or balanced anaesthesia, respectively (NS). Train-of-four ratio recovered to 0.70 in 2.5 (1.8-3.0) or 3.2 (2.1-4.3) min following neostigmine during halothane or balanced anaesthesia, respectively (NS). Changes in blood pressure or heart rate following cisatracurium were negligible. We regard cisatracurium as a safe and promising intermediate duration muscle relaxant the effects of which can easily be reversed with neostigmine.

Topics: Anesthesia; Anesthesia, Inhalation; Anesthetics, Combined; Anesthetics, Inhalation; Atracurium; Blood Pressure; Child; Child, Preschool; Electromyography; Female; Fentanyl; Halothane; Heart Rate; Humans; Male; Neostigmine; Neuromuscular Blockade; Neuromuscular Blocking Agents; Neuromuscular Junction; Nitrous Oxide; Thiopental

The suicide of a 43-year-old male by intravenous injection of cisatracurium, a non-depolarizing neuromuscular blocking agent, and thiopental, an ultra-short-acting barbiturate, is presented. Systematic toxicological screening by gas chromatography-mass spectrometry (GC-MS), liquid chromatography (LC)-diode-array detection, and LC-MS-MS confirmed the presence of thiopental. A large peak in the GC-MS chromatogram was matched by the Pfleger-Maurer library as corlumine, but neither atracurium neither its metabolite, laudanosine, were detected. To confirm the absence or the presence of laudanosine in the blood sample, an ultra-performance liquid chromatography-MS-MS method for cisatracurium and laudanosine quantification was developed. The calibration range was 2.5-500 ng/mL for laudanosine and 10-500 ng/mL for cisatracurium. The biases were lower than 12.3%. Intraday and interday precisions, expressed as coefficient of variation, were lower than 13.3%. This method allowed to confirm the presence of laudanosine and measurement of laudanosine in all samples. The femoral blood concentration was therapeutic (0.46 μg/mL). This case report documents a possible analytical pitfall and describes a simple and fast method for cisatracurium determination. Moreover, the purpose of this case report was to document the postmortem redistribution of cisatracurium and laudanosine, which could help make it possible to interpret tissue or cardiac blood concentrations in forensic cases where femoral blood is not available.

Topics: Adult; Atracurium; Drug Overdose; Fatal Outcome; Humans; Hypnotics and Sedatives; Injections, Intravenous; Male; Neuromuscular Blocking Agents; Suicide; Thiopental

Topics: Adolescent; alpha-Mannosidosis; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Atracurium; Catheters, Indwelling; Child; Humans; Intubation, Intratracheal; Magnetic Resonance Imaging; Methyl Ethers; Neuromuscular Blocking Agents; Propofol; Sevoflurane; Thiopental

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient.

Topics: Adenomatous Polyps; Adult; Analgesia, Epidural; Anesthesia, Epidural; Arrhythmogenic Right Ventricular Dysplasia; Ascites; Atracurium; Catheter Ablation; Colectomy; Colitis, Ulcerative; Colonic Neoplasms; Colonic Polyps; Defibrillators, Implantable; Equipment Failure; Fentanyl; Humans; Isoflurane; Male; Monitoring, Intraoperative; Pain, Postoperative; Postoperative Care; Postoperative Complications; Preanesthetic Medication; Respiration, Artificial; Thiopental

Alagille syndrome (syndromic paucity of interlobular bile ducts) is the most common form of familial intrahepatic cholestasis. We describe the perioperative management of a pediatric patient with Alagille syndrome undergoing ileal exclusion and the specific issues associated with epidural anesthesia with this syndrome.

Topics: Alagille Syndrome; Anesthesia, Epidural; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Atracurium; Bupivacaine; Child, Preschool; Colostomy; Fentanyl; Humans; Ileum; Intubation, Intratracheal; Isoflurane; Male; Midazolam; Neuromuscular Blocking Agents; Thiopental

A 6-year-old boy presented for surgery for phimosis. The anaesthetic technique included intravenous induction with thiopentone and neuromuscular blockade with cisatracurium. Severe persistent bronchospasm and central cyanosis followed the administration of these drugs. A continuous i.v. infusion of epinephrine at 0.2 microg. kg(-1) x min(-1) was necessary to break the severe refractory bronchial hyperresponsiveness. There was no previous exposure to anaesthetic drugs and no definite family history of allergy. Through increased serum eosinophil cationic protein, tryptase and histamine levels and IgE levels specific to cisatracurium, we demonstrated an IgE-mediated anaphylactic reaction to cisatracurium in the child's first exposure to this new neuromuscular blocking agent. Anaphylactic reactions to new anaesthetic drugs may be challenging to recognize and treat during general anaesthesia in children. The pathogenesis, diagnosis and management of life threatening persistent allergic reactions to intravenous anaesthetics are discussed.

Topics: Adrenergic Agonists; Anaphylaxis; Anesthetics, Intravenous; Atracurium; Blood Proteins; Bronchial Hyperreactivity; Bronchial Spasm; Child; Chymases; Cyanosis; Eosinophil Granule Proteins; Epinephrine; Histamine; Humans; Immunoglobulin E; Inflammation Mediators; Male; Mast Cells; Neuromuscular Blockade; Neuromuscular Blocking Agents; Phimosis; Ribonucleases; Serine Endopeptidases; Thiopental; Tryptases

After administration of doses ranging from 0.025 to 0.25 mg/kg, the neuromuscular blocking effect of cisatracurium was assessed in 119 adult surgical patients receiving N2O-opioid-midazolam-thiopental anesthesia. The calculated 95% effective dose (ED95) for inhibition of adductor pollicis twitch evoked at 0.1 Hz was 0.053 mg/kg. With 0.10 mg/kg injected over 5-10 and 20-30 s, median onset times (range) were 5.8 (3.0-7.7) and 4.8 (1.2-10.2) min, respectively, and median times to 5% and 95% recovery (range) were 27 (19-46) and 48 (25-68) min, respectively. For doses of 0.10, 0.20, and 0.25 mg/kg, median 5%-95% and 25%-75% recovery indexes ranged from 48 to 90 min and 8 to 9 min, respectively. After administration of neostigmine (0.06 mg/kg) at 10%-15% or 16%-30% recovery, the median times to 95% recovery (range) were 6 (2-22) and 4 (2-5) min, respectively. There were no changes in heart rate, blood pressure, or plasma histamine concentrations during the first 5 min after administration of cisatracurium at doses up to 5 x ED95 injected over 5-10 s. No cutaneous flushing or bronchospasm was noted. In summary, cisatracurium is a potent neuromuscular blocking drug with an intermediate duration of action, characterized by excellent cardiovascular stability, with no apparent histamine release.

Topics: Adolescent; Adult; Aged; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Atracurium; Dose-Response Relationship, Drug; Electric Stimulation; Female; Histamine Release; Humans; Isomerism; Male; Midazolam; Middle Aged; Muscle Contraction; Muscle, Skeletal; Narcotic Antagonists; Narcotics; Neostigmine; Neuromuscular Nondepolarizing Agents; Nitrous Oxide; Oxygen; Safety; Surgical Procedures, Operative; Thiopental