Rapacuronium is an aminosteroidal nondepolarising neuromuscular blocking agent (NMBA). Its neuromuscular blocking effects have a different time course to those of most currently available agents. It also has lower potency than many of the other NMBAs. In doses consistent with short to medium duration of action, rapacuronium has rapid and complete onset. In some doses it gives tracheal intubating conditions that compare favourably with those produced by suxamethonium (succinylcholine) during rapid sequence induction of anaesthesia. Tracheal intubating conditions improve as dose increases, but adverse effects (including potentially severe bronchospasm) become more prominent. Rapacuronium has an active metabolite that is at least as potent as the parent compound and is eliminated much less efficiently. Consequently, the time course of action of rapacuronium is prolonged after multiple doses or an infusion. Its potency is similar across age ranges and its time course after single doses is little altered in patients with hepatic or renal insufficiency. At least in part because of its active metabolite, rapacuronium is highly cumulative in renal failure. In keeping with its rapid onset and short to medium duration of action, rapacuronium has a more rapid clearance than most other NMBAs. Values for clearance are in the range 0.26-0.67 L/h/kg, with most studies giving a value of approximately 0.45 L/h/kg. There is some evidence that clearance declines marginally with advanced age, and it is also reduced in children. A typical value for steady-state volume of distribution is 0.3 L/kg. This is similar to that of many other NMBAs, but is small compared with many other drugs, as expected with a highly polar compound. Pharmacokinetic parameters do not appear to differ markedly in hepatic insufficiency, but clearance is reduced by approximately 30% in renal failure. Rapacuronium equilibrates very rapidly between the plasma and the site of effect. This is the principal explanation behind its unusually rapid onset. It also appears to have a similar potency at the larynx compared with the adductor pollicis; most other NMBAs are less effective at the larynx. Because it gives rapid onset in a dose consistent with brief duration of action, it was hoped that rapacuronium might be a suitable alternative to suxamethonium. It does not have the problems associated with suxamethonium, but its use is associated with bronchospasm, the incidence of which is dose-related. Rapacuronium has been withdrawn from sale because of this adverse effect, and its future availability is uncertain.
We read with interest Dr Bogod's editorial highlighting the potential link between the use of chlorhexidine and alcohol based skin antiseptics and the development of adhesive arachnoiditis [1].Along with many other institutions we changed our skin antiseptic use for neuraxial blocks following NAP3 guidance (from 10% povidone iodine to 0.5% chlorhexidine in 70% isopropyl alcohol). Our guidelines advocate the spraying of the skin by an assistant before opening the sterile packaging of the spinal or epidural kits and allowing the skin to air dry for at least 2 min before palpating the skin. However, it is noticeable that droplets of cleaning solution can often be seen adhering to the hairs of the skin overlying the lumbar spine well beyond the 2-min interval, that may need to be wiped away by a sterile swab before commencing the procedure, whilst meticulously avoiding contamination of the gloves.Our hospital guidance still recommends 2% chlorhexidine in 70% isopropyl alcohol as the skin antiseptic before peripheral nerve blockade. However, given the current concerns expressed about the use of antiseptics for neuraxial block, should we be recommending that 0.5% chlorhexidine be used for all procedures involving proximity to nerves?
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