pancuronium and Status-Asthmaticus

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

To compare recovery times from neuromuscular blockade between two groups of critically ill patients in whom pancuronium was administered by continuous infusion or intermittent bolus injection. To compare the mean pancuronium requirements (milligrams per kilogram per hour) and to assess the incidence of prolonged recovery times (>12 hrs) and residual muscle weakness.. Prospective, observational cohort.. Intensive care unit in a university-affiliated hospital.. A total of 30 mechanically ventilated patients who required pharmacologic paralysis. Patients were excluded if they had renal failure (creatinine clearance <30 mL/min), heart rate >130 beats/min, hepatic failure, peripheral nerve disease or myopathy, stroke, spinal cord damage, or myasthenia gravis.. Patients were assigned to receive pancuronium either by continuous infusion (n = 14) or intermittent bolus (n = 16). Depth of paralysis was titrated to maintain one or two responses to Train-of-Four stimulation with an accelerograph and desired clinical goals. Recovery time was defined as time from discontinuation of muscle relaxant until the amplitude of the fourth twitch, measured every 15-30 min using an accelerograph, was 70% the amplitude of the first twitch (Train-of-Four > or = 0.7).. These patients included the only three patients with status asthmaticus in our study. The groups were similar with respect to age, sex, weight, Acute Physiology and Chronic Health Evaluation II score, mode of ventilation, creatinine clearance, indications for paralysis, and duration of pancuronium administration. The median time for patients to recover from paralysis was 3.5 hrs (95% confidence interval, 1.82-5.18) in the infusion group vs. 6.3 hrs (95% confidence interval, 3.40-9.19) in the intermittent bolus group (p = .10). Less drug was administered in the intermittent group (mean, 0.02+/-0.01 mg/kg/hr) than by infusion (mean, 0.04+/-0.01 mg/kg/hr; p < .001). Six patients (five in the infusion group and one in the intermittent group) developed persistent severe muscle weakness. In addition, six different patients (three from each group) had prolonged recovery >12 hrs.. Our study suggests that recovery time after paralysis with continuous infusion is faster than that after intermittent bolus injection. Although more pancuronium was administered in the continuous-infusion group, recovery time was not prolonged as a consequence. It is uncertain whether pancuronium given by infusion increases the risk of persistent muscle weakness.

Topics: Adult; Algorithms; APACHE; Critical Illness; Female; Humans; Injections; Male; Middle Aged; Muscle Relaxation; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Pancuronium; Paralysis; Prospective Studies; Respiration, Artificial; Respiratory Distress Syndrome; Shock, Septic; Status Asthmaticus; Time Factors

A 30-year-old man was admitted because of status asthmaticus. He required 7 days of artificial ventilation and was treated with hydrocortisone 1.2 g.day-1 and bronchodilaters. Pancuronium bromide 0.08 mg.kg-1.hr-1 was given for 64 hours for the ease of artificial ventilation. On day 3, severely elevated airway pressure resulted in left pneumothorax and isoflurane 1% was given for the following 2 days. Respiratory muscle weakness was evident 24 hours after discontinuation of pancuronium infusion on day 5 while full 4 twitches of TOF on the adductor pollicis muscle were seen at the time. The respiratory muscle weakness continued for another 3 days and he was extubated on day 8. Serum creatine kinase concentration rose to 2178 U.l-1 on day 6 and returned to normal on day 11. Hematurea, hyperpyrexia and metabolic acidosis were never seen during the course. Acute corticosteroid myopathy was suspected to be the cause of the prolonged respiratory muscle weakness.

Topics: Acute Disease; Adult; Anti-Inflammatory Agents; Drug Therapy, Combination; Humans; Hydrocortisone; Male; Muscle Weakness; Neuromuscular Nondepolarizing Agents; Pancuronium; Respiratory Muscles; Status Asthmaticus; Time Factors

Prolonged neuromuscular weakness has been identified after neuromuscular blockade in intensive care unit patients on mechanical ventilation. Previously reported electromyographic studies in these patients documented both neurogenic features and features consistent with a myopathy. We recorded sequential electrophysiological parameters during recovery from neuromuscular blockade in 5 patients with clinical weakness. An evolving pattern was identified. The early features were in keeping with previous reports of neurogenic changes, and this evolved into features consistent with a primary myopathy. Several potential underlying mechanisms are discussed.

Topics: Adult; Electromyography; Female; Glucocorticoids; Humans; Male; Methylprednisolone; Middle Aged; Muscles; Neuromuscular Blocking Agents; Pancuronium; Status Asthmaticus

A case is reported of a 74-year-old man who developed rhabdomyolysis during treatment for status asthmaticus. This patient had a history of asthma. He was admitted after a cardiac arrest during a severe asthma attack. Continuous muscle relaxation (4 mg.h-1 of pancuronium for 10 days; total dose 960 mg) was required to carry out mechanical ventilation. Bronchodilators and high doses of steroids (300 mg.day-1 of methylprednisolone for 10 days) were also given. After the administration of muscle relaxant had been discontinued, the patient displayed a severe, predominantly proximal, quadriplegia as well as a raised blood creatinine kinase concentration. The urine was brown coloured over a 24 h period. Rhabdomyolysis was confirmed by muscle biopsy. The patient recovered over a period of one month. This case is discussed in the light of some other similar reports in the literature. It seems that the combination of muscle relaxant with high doses of steroids is to be incriminated.

Topics: Acute Disease; Aged; Creatine Kinase; Critical Care; Drug Therapy, Combination; Humans; Male; Methylprednisolone; Pancuronium; Rhabdomyolysis; Status Asthmaticus

Topics: Asthma; Bronchial Spasm; Conscious Sedation; Female; Humans; Infusions, Intravenous; Ketamine; Midazolam; Middle Aged; Myocardial Infarction; Pancuronium; Respiration, Artificial; Status Asthmaticus

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: Acute Disease; Adult; Drug Therapy, Combination; Female; Humans; Hydrocortisone; Methylprednisolone; Pancuronium; Rhabdomyolysis; Status Asthmaticus; Vecuronium Bromide

Topics: Asthma; Female; Humans; Hydrocortisone; Middle Aged; Muscular Atrophy; Pancuronium; Status Asthmaticus

Topics: Adult; Aged; Asthma; Female; Humans; Hydrocortisone; Male; Muscular Dystrophies; Pancuronium; Status Asthmaticus

Topics: Adult; Asthma; Female; Humans; Muscular Atrophy; Neuromuscular Junction; Pancuronium; Respiration, Artificial; Respiratory Care Units; Status Asthmaticus; Time Factors