pancuronium and Muscular-Diseases

Critically ill patients represent a very different population from that of the operating theatre, but much of our knowledge of many of the neuromuscular blocking drugs is derived from intraoperative use. The diversity of clinical-practice and case-mix differences in intensive care are probably responsible for the absence of a formal consensus about the use of neuromuscular blocking drugs in the intensive care unit (ICU). Various surveys suggest that these drugs are used comparatively infrequently, but we do not know whether current usage is either safe or appropriate. In addition to the adverse effects which inevitably accompany prolonged paralysis and immobility, the steroidal relaxants, pancuronium and vecuronium, have also been associated with myopathy. This seems to be aggravated by concurrent use of pharmacologic doses of corticosteroids or the aminoglycoside antibiotics. Neither the mechanism nor the validity of the association with steroidal relaxants is known at present. Muscle dysfunction is a common feature of critical illness, and it is possible that neuromuscular blocking drugs interfere with muscle repair and regrowth. Patients with multiple organ failure present a particular challenge both because of the extent of tissue injury and because drug clearance via the liver or kidneys is generally impaired.

Topics: Adrenal Cortex Hormones; Aminoglycosides; Anti-Bacterial Agents; Critical Care; Critical Illness; Diagnosis-Related Groups; Drug Interactions; Humans; Immobilization; Kidney; Liver; Multiple Organ Failure; Muscle, Skeletal; Muscular Diseases; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Pancuronium; Regeneration; Safety; Vecuronium Bromide

A case of acute myopathy was observed in the course of treatment of respiratory failure with mechanical ventilation combined with prolonged neuromuscular blockade and administration of corticosteroids. A muscle biopsy revealed degeneration of muscle fibres. Electron microscopy showed loss of thick filaments as well as nemaline rods, vacuoles and cytoplasmic bodies. The mitochondria were increased in number, many harbouring paracrystalline inclusions, which were hitherto unknown in this condition.

Topics: Combined Modality Therapy; Humans; Male; Methylprednisolone; Middle Aged; Mitochondria, Muscle; Muscular Diseases; Pancuronium; Respiration, Artificial; Respiratory Insufficiency

A female patient treated by mechanical ventilation with high doses of pancuronium and methylprednisolone for status asthmaticus presented with acute total areflexic and severe amyotrophic tetraplegia; she died after multiple organ failure. Muscle biopsy confirmed the clinical diagnosis of "acute corticosteroid myopathy", precipitated by a corticosteroid "disuse hypersensitivity" after pancuronium. The electromyogram showed a critical illness polyneuropathy, secondary to multiple organ failure. Nerve biopsy was normal. The respective parts played by corticosteroids, curare-like derivatives and intensive care in the genesis of unexplained difficulty in weaning from the ventilator are discussed.

Topics: Acute Disease; Aged; Fatal Outcome; Female; Humans; Methylprednisolone; Multiple Organ Failure; Muscular Diseases; Nervous System Diseases; Neural Conduction; Pancuronium; Respiration, Artificial; Resuscitation; Status Asthmaticus

Topics: Bradycardia; Cholinesterases; Gallamine Triethiodide; Heart Arrest; Humans; Hyperkalemia; Infant; Infant, Newborn; Intraocular Pressure; Monitoring, Physiologic; Muscular Diseases; Myotonia; Neuromuscular Blocking Agents; Neuromuscular Depolarizing Agents; Neuromuscular Junction; Pancuronium; Postoperative Complications; Succinylcholine; Time Factors; Tubocurarine

The incidence of myalgia after suxamethonium was determined in 200 fit military male dental patients of European, Chinese and Nepalese descent. Half received pancuronium 1 mg and the other half received saline pretreatment on a randomised double-blind basis. The percentage incidence of postsuxamethonium myalgia after saline or pancuronium was found to be: Europeans 26%, 13%; Chinese 13%, 7%; Nepalese 20%, 14%. Although pancuronium reduced the incidence of myalgia by about 50% overall, these values were not significantly different from each other. The recovery of spontaneous ventilation following suxamethonium was quicker in the Europeans than in the Asians (p < 0.05). Pancuronium pretreatment also delayed the recovery of spontaneous ventilation and recovery from neuromuscular block (p < 0.05) but this was independent of ethnicity. The Europeans recovered from anaesthesia more quickly than the Asians. It was concluded that ethnicity affected recovery from suxamethonium and from anaesthesia but was not of clinical relevance to the incidence of myalgia in male Asians and Europeans.

Topics: Adolescent; Adult; Anesthesia Recovery Period; Anesthesia, Dental; China; Double-Blind Method; Europe; Humans; Male; Middle Aged; Muscular Diseases; Nepal; Pain; Pancuronium; Postoperative Complications; Succinylcholine; Time Factors

Two matched groups of patients with Hodgkin's disease undergoing a staging laparotomy received thiopentone, pancuronium bromide or suxamethonium 1.0 mg kg-1 (group 2) to facilitate tracheal intubation. There were no differences in the sites or degree of postoperative myalgia between the groups. It is concluded that efforts to reduce the frequency of suxamethonium muscle pains in patients having major abdominal operations are not justified.

Topics: Abdomen; Adolescent; Adult; Female; Hodgkin Disease; Humans; Male; Middle Aged; Muscular Diseases; Pain, Postoperative; Pancuronium; Succinylcholine; Time Factors

The authors studied certain effects in the male subject of precurarisation using different doses of pancuronium. The results obtained show that the maximum doses used, corresponding to 0.01 Omg/kg of pancuronium, were associated with subjective symptoms which were well tolerated by the conscious patient, a decreases in the incidence of fasciculations, antagonistic effects against succinylcholine and a decreases in postoperative myalgia. In their conclusion, the authors confirm that the maximum doses of pancuronium used require an increase in doses of succinylcholine in order to avoid the antagonism phenomenon, and that doses ranging from 0.010 to 0.020 mg/kg of pancuronium could be used in order to completely eliminate postoperative myalgia related to succinylcholine.

Topics: Adult; Aged; Dose-Response Relationship, Drug; Fatigue; Humans; Male; Middle Aged; Muscle Contraction; Muscular Diseases; Pain, Postoperative; Pancuronium; Succinylcholine; Vital Capacity

The mechanisms underlying acute quadriplegic myopathy (AQM) are poorly understood, partly as a result of the fact that patients are generally diagnosed at a late stage of the disease. Accordingly, there is a need for relevant experimental animal models aimed at identifying underlying mechanisms.. Pigs were mechanically ventilated and exposed to various combinations of agents, i.e. pharmacological neuromuscular blockade, corticosteroids and/or sepsis, for a period of 5 days. Electromyography and myofibrillar protein and mRNA expression were analysed using sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), confocal microscopy, histochemistry and real-time polymerase chain reaction (PCR).. A decreased compound muscle action potential, normal motor nerve conduction velocities, and intact sensory nerve function were observed. Messenger RNA expression, determined by real-time PCR, of the myofibrillar proteins myosin and actin decreased in spinal and cranial nerve innervated muscles, suggesting that the loss of myosin observed in AQM patients is not solely the result of myofibrillar protein degradation.. The present porcine AQM model demonstrated findings largely in accordance with results previously reported in patients and offers a feasible approach to future mechanistic studies aimed at identifying underlying mechanisms and developing improved diagnostic tests and intervention strategies.

Topics: Adrenal Cortex Hormones; Animals; Betamethasone; Disease Models, Animal; DNA, Complementary; Electric Stimulation; Electrophoresis, Polyacrylamide Gel; Electrophysiology; Endotoxins; Feasibility Studies; Female; Histocytochemistry; Masseter Muscle; Muscle, Skeletal; Muscular Diseases; Neuromuscular Nondepolarizing Agents; Pancuronium; Peroneal Nerve; Quadriplegia; Respiration, Artificial; Reverse Transcriptase Polymerase Chain Reaction; RNA; RNA, Messenger; Sepsis; Spinal Nerves; Swine

Patients who undergo mechanical ventilation for severe asthma are at risk of developing diffuse muscle weakness because of acute myopathy. The relative importance of corticosteroids and neuromuscular paralysis in causing the myopathy is controversial, and it is uncertain whether the chemical structure of the drug used to induce paralysis influences the risk of myopathy. Using a retrospective cohort study design, we evaluated 107 consecutive episodes of mechanical ventilation for severe asthma to assess (1) the incidence of clinically significant weakness in patients treated with corticosteroids alone versus corticosteroids with neuromuscular paralysis, (2) the influence of the duration of paralysis on the incidence of muscle weakness, and (3) the relative risk of weakness in patients paralyzed with the nonsteroidal drug atracurium versus an aminosteroid paralytic agent (pancuronium, vecuronium). The use of corticosteroids and a neuromuscular blocking agent was associated with a much higher incidence of muscle weakness as compared with the use of corticosteroids alone (20 of 69 versus O of 38, p < 0.001). The 20 weak patients were paralyzed significantly longer than the 49 patients who received a neuromuscular blocking agent without subsequent weakness (3.4 +/- 2.4 versus 0.6 +/- 0.7 d, p < 0.001). Eighteen of the 20 weak patients had been paralyzed for more than 24 h. The incidence of weakness was not reduced when paralysis was achieved with atracurium as opposed to an aminosteroid neuromuscular blocking agent. In conclusion, corticosteroid-treated patients with severe asthma who undergo prolonged neuromuscular paralysis are at significant risk for the development of muscle weakness, and the risk of weakness is not reduced by use of atracurium.

Topics: Acute Disease; Adolescent; Adult; Aged; Albuterol; Asthma; Atracurium; Bronchodilator Agents; Cohort Studies; Female; Glucocorticoids; Humans; Incidence; Male; Methylprednisolone; Middle Aged; Muscle Weakness; Muscular Diseases; Neuromuscular Nondepolarizing Agents; Pancuronium; Respiration, Artificial; Retrospective Studies; Risk Factors; Time Factors; Vecuronium Bromide

A series of recent reports have identified cases of a quadriplegic myopathy characterized by myofiber necrosis and loss of myosin filaments associated with the use of nondepolarizing muscle blocking agents and glucocorticoids. We report electrophysiological findings in 7 intensive care unit patients who developed evidence of an acute myopathy in association with the use of nondepolarizing muscle blocking agents. Several important features were identified: (i) a neuromuscular transmission deficit was observed in 3 patients up to 7 days following withdrawal of vecuronium; (ii) motor M potentials were of low amplitude, there was mild abnormal spontaneous activity on needle electromyography, and sensory conduction was relatively preserved; (iii) not all patients received glucocorticoids or were asthmatic; (iv) 2 patients given vecuronium had very high creatine kinase levels and developed acute renal failure associated with myoglobinuria; and (v) rises in motor M potentials accompanied clinical recovery. This complication of intensive care may be severe, but is reversible and possibly avoidable. Our findings implicate nondepolarizing muscle blocking agents in the development of the myopathy. Electrophysiological studies provide important prognostic guidance.

Topics: Action Potentials; Adult; Aged; Creatine Kinase; Critical Care; Critical Illness; Female; Humans; Hydrocortisone; Male; Median Nerve; Methylprednisolone; Middle Aged; Muscular Diseases; Necrosis; Neural Conduction; Neuromuscular Junction; Pancuronium; Synaptic Transmission; Ulnar Nerve; Vecuronium Bromide

Two patients with status asthmaticus (a 30-year-old female and a 48-year-old male) who developed flaccid quadriplegia and sensory impairment of glove and stocking type after treatment with halothane, muscle relaxants (pancuronium and vecuronium) and steroid are described. They noted motor and sensory impairment immediately after recovery from control ventilation for treatment of status asthmaticus. Histochemical examinations of biopsied muscle demonstrated the necrosis and regeneration of muscle fibers and small diameters in type I fibers. These results suggested that the involvement of muscle (myopathy) was a consequence of the harmful action of halothane and muscle relaxants together with steroids on muscle fibers with subclinical fragility. The sensory impairment (neuropathy) was considered to have been produced mainly by the halothane together with muscle relaxants and aminoglycosides.

Topics: Adult; Anesthesia; Female; Halothane; Humans; Male; Middle Aged; Muscular Diseases; Nervous System Diseases; Pancuronium; Status Asthmaticus; Vecuronium Bromide

Topics: Adrenal Cortex Hormones; Humans; Male; Muscular Diseases; Ophthalmoplegia; Pancuronium; Quadriplegia

We report acute complete external ophthalmoplegia and severe myopathy in a patient treated with high doses of IV methylprednisolone and pancuronium. Awareness of this rare syndrome in a common clinical setting can lead to prompt recognition and avoid confusion with other causes of acute weakness and ophthalmoparesis.

Topics: Acute Disease; Humans; Male; Methylprednisolone; Middle Aged; Muscular Diseases; Ophthalmoplegia; Pancuronium

Topics: Autopsy; Humans; Infant, Newborn; Male; Muscles; Muscular Atrophy; Muscular Diseases; Pancuronium; Respiratory Distress Syndrome, Newborn

Topics: Adolescent; Anesthesia; Female; Humans; Muscle Contraction; Muscular Diseases; Myofibrils; Neuromuscular Junction; Pancuronium; Succinylcholine; Synaptic Transmission; Ulnar Nerve

Topics: Action Potentials; Adult; Humans; Male; Masseter Muscle; Masticatory Muscles; Muscular Diseases; Neuromuscular Junction; Pancuronium; Spasm; Synaptic Transmission

Topics: Adjuvants, Anesthesia; Adult; Humans; Muscles; Muscular Diseases; Pain, Postoperative; Pancuronium; Preanesthetic Medication; Succinylcholine

The effectiveness of pancuronium (1.0 to 1.5 mg), d-tubocurarine (3 mg), and gallamine (20 mg) administered three minutes before succinylcholine (1 mg/kg) in preventing muscle fasciculations and postoperative muscle pains was compared in 100 patients. Pretreatment with pancuronium abolished fasciculations and produced rapid and excellent muscle relaxation for endotracheal intubation. Both d-tubocurarine (dTc) and gallamine administered prior to succinylcholine (SCh) were inconsistent in prevention fasciculations. Muscle relaxation was significantly delayed in onset, shorter in duration, and was inadequate for intubation in the majority of patients. The 45% incidence of postoperative muscle pains in the control group decreased after pretreatment with gallamine, dTc, and pancuronium to 20%, 15%, and less than 5%, respectively. It was concluded from the present study that pancuronium is superior to dTc and gallamine for preventing SCh-induced fasciculations and postoperative muscle pains without compromising the muscle relaxation for intubation. However, pancuronium administered for pretreatment may significantly prolong the action of succinylcholine and caution is to be exercised in patients having short surgical procedures and when additional doses of muscle relaxants may be required.

Topics: Adolescent; Adult; Aged; Female; Gallamine Triethiodide; Humans; Male; Middle Aged; Muscle Contraction; Muscular Diseases; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Pancuronium; Succinylcholine; Tubocurarine

Topics: Anesthesia; Atropine; Cholinesterases; Electromyography; Halothane; Humans; Male; Melanoma; Middle Aged; Muscular Diseases; Myotonia; Myotonia Congenita; Myotonic Dystrophy; Neoplasms; Neostigmine; Pancuronium; Preanesthetic Medication; Spectrophotometry; Succinylcholine; Temperature; Time Factors