mivacurium and Pain--Postoperative

After myorelaxants, myalgia and residual curarization may complicate recovery. Local anaesthesia and minimally invasive airway management make myorelaxants disputable in many outpatient procedures; nevertheless, neuromuscular blockade may be necessary to facilitate intubation or maintain muscle relaxation. Agent selection criteria are discussed.. Reduced hospital time is not associated with central neuraxial or peripheral nerve block. To reduce the risk for residual block, neuromuscular monitoring is mandatory. Use of reversal agents should not be restricted, although studies have shown higher incidence of postoperative nausea and vomiting following their use. Higher succinylcholine dosage is followed by lower incidence of myalgia. The relationship between fasciculation and myalgia is unclear. Sodium channel blockers or nonsteroidal antiinflammatory drugs may prevent myalgia. Sugammadex functions as a chelating agent.. Ear-nose-throat, open eye surgery and laparoscopy may demand myoresolution. Regional and minimally invasive anaesthesia are alternative solutions. Central and peripheral nerve blocks are associated with increased induction time, reduced pain scores, and decreased need for analgesics. Central neuraxial block, however, is associated with prolonged outpatient unit stay. Bad intubating conditions may cause pharyngo-laryngeal complications: the decision to avoid myorelaxants for tracheal intubation appears illogical. Incidence of postoperative residual curarization remains very high. Sugammadex offers new perspectives.

Topics: Ambulatory Surgical Procedures; Anesthesia, Conduction; Anesthesia, General; Benzylisoquinolines; Cholinesterase Inhibitors; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Isoquinolines; Mivacurium; Muscle Relaxants, Central; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Paralysis; Postoperative Nausea and Vomiting; Practice Guidelines as Topic; Risk Assessment; Steroids; Succinylcholine; Sugammadex

Surgical conditions in laparoscopic surgery are largely determined by the depth of neuromuscular relaxation. Especially in procedures that are confined to a narrow working field, such as retroperitoneal laparoscopic surgery, deep neuromuscular relaxation may be beneficial. Until recently, though, deep neuromuscular block (NMB) came at the expense of a variety of issues that conflicted with its use. However, with the introduction of sugammadex, rapid reversal of a deep NMB is feasible. In the current protocol, the association between the depth of NMB and rating of surgical conditions by the surgeon and anesthesiologist is studied.. This is a single-center, prospective, randomized, blinded, parallel group and controlled trial. Eligible patients are randomly assigned to one of two groups: (1) deep NMB (post-tetanic count, one or two twitches; n = 12) and (2) moderate NMB (train-of-four, 1 to 2 twitches, n = 12) by administration of high-dose rocuronium in Group 1 and a combination of atracurium and mivacurium in Group 2. The NMB in Group 1 is reversed by 4 mg/kg sugammadex; the NMB in Group 2 by 1 mg neostigmine and 0.5 mg atropine. Patients are eligible if they are over 18 years, willing to sign the informed consent form, and are scheduled to undergo an elective laparoscopic renal procedure or laparoscopic prostatectomy. A single surgeon performs the surgeries and rates the surgical conditions on a five-point surgical rating scale (SRS) ranging from 1 (poor surgical conditions) to 5 (excellent surgical conditions). The intra-abdominal part of the surgeries is captured on video and a group of five anesthesiologists and ten surgical experts will rate the videos using the same SRS. The primary analysis will be an intention-to-treat analysis. Evaluation will include the association between the level of NMB and SRS, as obtained by the surgeon performing the procedure and the agreement between the scoring of the images by anesthesiologists and surgeons.. We aim to show that under the right conditions the perceived opposing goals of surgeons and anesthesiologists (optimal surgical conditions vs. optimal postoperative conditions) may be met without compromise to either.. ClinicalTrials.gov identifier NCT01631149.

Topics: Academic Medical Centers; Androstanols; Anesthesia Department, Hospital; Atracurium; Atropine; Attitude of Health Personnel; Clinical Protocols; Female; gamma-Cyclodextrins; Health Knowledge, Attitudes, Practice; Humans; Intention to Treat Analysis; Isoquinolines; Kidney; Laparoscopy; Male; Medical Staff, Hospital; Mivacurium; Neostigmine; Netherlands; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Perception; Prospective Studies; Prostatectomy; Research Design; Rocuronium; Sugammadex; Surgery Department, Hospital; Task Performance and Analysis; Treatment Outcome; Video Recording

To assess the effectiveness of intravenous steroids at induction of anaesthetic to reduce post-operative nausea and vomiting and pain after adult tonsillectomy.. Prospective, double-blind, randomized, placebo controlled trial, with ethical approval, following Consolidated Standards of Reporting Trials guidelines.. District General Hospital in Scotland, UK.. Seventy-two adults between 16 and 70 years, American Association of Anaethetists (ASA) 1, listed for elective tonsillectomy.. Single dose of either 10 mg of dexamethasone or 2 mL of saline after induction with a consistent anaesthetic technique.. Patients filled in a visual analogue scale relating to pain and post-operative nausea and vomiting for the day of operation and 7 days after operation. The time to first ingestion of food and drink after operation was also noted.. Data completion rate of 64% (46 of 72 patients enrolled). Statistically significant relative decrease (62%P = 0.001) in the incidence of post-operative nausea and vomiting was seen in those treated with dexamethasone. Statistically significant relative decrease (23%P = 0.016) in post-operative pain scores for the day of operation was seen in those treated with dexamethasone. Significant decrease (17.5%, P < 0.001) in mean pain score for seven post-operative days was seen in those treated with dexamethasone. No adverse effects were seen.. Dexamethasone given as a single dose of 10 mg at induction of anaesthesia for adult tonsillectomy is an effective, safe and inexpensive method for reducing morbidity in adult tonsillectomy.

Topics: Adolescent; Adult; Aged; Anesthetics, Intravenous; Anti-Inflammatory Agents; Antiemetics; Dexamethasone; Double-Blind Method; Female; Glucocorticoids; Humans; Injections, Intravenous; Isoquinolines; Male; Middle Aged; Mivacurium; Neuromuscular Nondepolarizing Agents; Pain Measurement; Pain, Postoperative; Postoperative Nausea and Vomiting; Propofol; Tonsillectomy; Treatment Outcome

To determine if pretreatment with either gallamine or mivacurium before succinylcholine in children is associated with reduction in fasciculations; postoperative myalgias; or serum levels of potassium, creatinine phosphokinase (CPK), and myoglobin.. Prospective, randomized, double-blinded study.. Operating room at a children's hospital.. 45 ASA physical status IE children, aged 3 to 15 years, scheduled for emergency surgery.. The children received either normal saline 0.5 mL, mivacurium chloride 0.03 mg. kg(-1), or gallamine triethiodide 0.04 mg. kg(-1)2 minutes prior to rapid sequence induction (RSI) using thiopental sodium 5 mg. kg(-1), fentanyl 2 microg. kg(-1), and succinylcholine 2 mg. kg(-1).. Serum potassium concentration (0, 3, 5, 7.5, and 15 min), myoglobin concentration (5 and 15 min), and CPK concentration (0 min and 24 hr). Fasciculation and myalgia were rated on a 0 to 3 score.. There was no difference between groups for fasciculation (p = 0.87) or myalgia score (p = 0.52). The mivacurium group had significantly less increase in potassium at 5 minutes (0.45 vs. 0.0, p = 0.01), myoglobin at 5 minutes (56 vs. 2, p < 0.001), myoglobin at 15 minutes (128 vs. 2.5, p < 0.001), and CPK at 24 hours (399 vs. 138, p < 0.001) following succinylcholine when compared with normal saline. Additionally, we found a significant level of association (p < 0.001) between fasciculation and myoglobin levels and fasciculation and CPK levels (p < 0.001). Gallamine was not effective in reducing the increase of potassium, myoglobin, or CPK. However, the dose of gallamine used for pretreatment was 13 times less than the dose of mivacurium.. Administration of mivacurium 0.03 mg. kg(-1) intravenously 2 minutes before administration of succinylcholine 2 mg. kg(-1) in children is effective in reducing the increase in serum potassium at 5 minutes, the increase in myoglobin at 5 minutes and 15 minutes, and the increase in CPK at 24 hours.

Topics: Adolescent; Anesthesia; Child; Child, Preschool; Creatine Kinase; Double-Blind Method; Emergency Medical Services; Female; Gallamine Triethiodide; Humans; Isoquinolines; Male; Mivacurium; Myoglobin; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Potassium; Prospective Studies; Succinylcholine

Ninety-four patients undergoing elective outpatient third molar extraction were recruited into a double-blind, randomized, prospective trial comparing mivacurium (group M) with succinylcholine (Group S) for conditions for endotracheal intubation and the occurrence of postoperative myalgia. Anaesthesia was induced with fentanyl 1 microgram.kg-1 and propofol 2.5 micrograms.kg-1 in all patients. Group S patients were given gallamine 20 mg while group M patients were given mivacurium 0.2 mg.kg-1. Manual ventilation was commenced and anaesthesia maintained with nitrous oxide 70% and isoflurane 1 to 2% in oxygen. After two minutes, group S patients were given succinylcholine 1.5 mg.kg-1 and group M patients 0.9% saline. Nasotracheal intubation was performed 30 seconds later. Intubating conditions in group M were significantly better than those in group S (P < 0.001). The incidence of postoperative myalgia was 9.5% in group M and 26% in group S but this was not statistically significant (P = 0.09). We propose that mivacurium is a suitable neuromuscular blocker to use for endotracheal intubation in outpatient dental surgery.

Topics: Adolescent; Adult; Ambulatory Surgical Procedures; Anesthesia, Dental; Double-Blind Method; Female; Humans; Intubation, Intratracheal; Isoquinolines; Male; Middle Aged; Mivacurium; Molar, Third; Muscular Diseases; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Prospective Studies; Succinylcholine; Tooth Extraction

Because succinylcholine has obvious advantages for facilitating endotracheal intubation in the ambulatory setting (e.g., low cost, fast onset, and no need for reversal of neuromuscular block), it is important to determine whether this muscle relaxant is indeed associated with an increased incidence of postoperative myalgias, compared with alternative but more expensive nondepolarizing muscle relaxants. We studied 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. The anesthetic technique consisted of propofol/lidocaine for induction, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed by using a fiberscope. Patients were randomly assigned to one of two muscle relaxant groups. Group 1 patients received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Group 2 patients received mivacurium 0.2 mg/kg. After recovery from anesthesia, patients were asked whether they had any muscle pain and/or stiffness. Pain was categorized by location and quantified by using a verbal scale (from 0 to 10). Analgesic usage and myalgias limiting ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on Postoperative Day 1. If patients complained of myalgias, they were contacted by telephone on Days 2 and 3. Only one patient (in the mivacurium-treated group) reported myalgia as a limiting factor in ambulation or resumption of normal activity. There were no differences between groups with respect to the incidence (21% in the succinylcholine-treated group and 18% in the mivacurium-treated group), location, or severity of myalgia. In conclusion, succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) is not associated with an increased incidence of myalgias, compared with mivacurium, when used to facilitate tracheal intubation in patients undergoing ambulatory nasal surgery.. The results of this study show that the frequency of muscle pains after surgery in outpatients is approximately 20%, regardless of whether succinylcholine (after precurarization) or mivacurium is used to assist in insertion of the breathing tube.

Topics: Adult; Ambulatory Surgical Procedures; Anesthesia Recovery Period; Anesthetics, Local; Contraindications; Female; Humans; Intubation, Intratracheal; Isoquinolines; Lidocaine; Male; Mivacurium; Muscular Diseases; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Paranasal Sinuses; Succinylcholine; Surveys and Questionnaires; Tubocurarine

Suxamethonium in the doses of 1.0, 0.5 and 0.25 mg/kg was compared with mivacurium 0.15 mg/kg in 80 patients requiring nasotracheal intubation for maxillofacial surgery in a double-blind randomized controlled trial. Anaesthesia was induced with thiopentone 5 mg/kg and alfentanil 15 micrograms/kg. Patients were randomly allocated to one of the four relaxant groups. Anaesthesia was maintained with enflurane in 70% nitrous oxide and 30% oxygen and analgesia provided with intravenous pethidine 0.5 to 1.5 mg/kg and rectal indomethacin 100mg. All patients given mivacurium or suxamethonium 1 mg/kg had acceptable intubating conditions. Significantly fewer patients given suxamethonium 0.5 mg or 0.25 mg/kg had acceptable intubating conditions (90% and 70% respectively) (P = 0.003). Poor intubating conditions requiring additional relaxation were seen in two patients given suxamethonium 0.25 mg/kg and two given 0.5 mg/kg, while no patients given suxamethonium 1.0 mg/kg or mivacurium 0.15 mg/kg required additional relaxation (P = 0.004). Only four patients had postoperative myalgia, all of whom were given suxamethonium 0.5 mg/kg or more but no significant difference between groups could be demonstrated.

Topics: Adult; Double-Blind Method; Female; Humans; Intubation, Intratracheal; Isoquinolines; Male; Mivacurium; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Oral Surgical Procedures; Pain, Postoperative; Succinylcholine

Preoperatively administered midazolam may contribute to postoperative sedation and delayed recovery from brief outpatient general anesthesia, particularly in patients who receive significant postoperative opioid analgesics. We evaluated the effects of midazolam premedication (0.04 mg/kg) on postoperative sedation and recovery times after laparoscopic tubal sterilization (Falope rings) in 30 healthy women in a randomized, double-blind, placebo-controlled study. Patients received midazolam or saline-placebo intravenously 10 min before anesthesia. General anesthesia was induced with fentanyl, propofol, and mivacurium and was maintained with N2O and isoflurane. Sedation was quantified before and after premedication and 15, 30, and 60 min after emergence from anesthesia, using the digit-symbol substitution (DSST) and Trieger dot (TDT) tests. Management of postoperative pain and nausea and discharge criteria were standardized. Groups were similar with respect to age, weight, and duration of surgery and anesthesia. Midazolam was associated with impairment of performance on the TDT and DSST after premedication administration and 15 (TDT and DSST) and 30 (DSST) min after postanesthesia care unit (PACU) arrival. There were no differences in PACU time and time to discharge-readiness. In conclusion, midazolam premedication augments postoperative sedation in this population but does not prolong recovery times.

Topics: Adult; Age Factors; Ambulatory Surgical Procedures; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Antiemetics; Body Weight; Double-Blind Method; Female; Fentanyl; Humans; Hypnotics and Sedatives; Injections, Intravenous; Isoflurane; Isoquinolines; Laparoscopy; Midazolam; Mivacurium; Nausea; Neuromuscular Nondepolarizing Agents; Nitrous Oxide; Pain, Postoperative; Patient Discharge; Placebos; Preanesthetic Medication; Propofol; Prospective Studies; Psychomotor Performance; Sterilization, Tubal; Time Factors