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Etlrophoniuni. a rcvcrsible cholinesterase inhibitor, has been proposed as a n alternative to neostigmine for antago n i m of non-dcpolarising neuromuscular blockade in children. Advantages claimed for edrophonium are a faster onset of rcversal and fewer muscarinic effects compared with neostigminc.' Glycopyrronium has advantages over iitropinc as a n anticholinergic agcnt to antagonise the muscarinic effects of ncostigmine; these advantages include greater stability o f heart rate. a lower incidence of dysrhythmias,3 and faster arousal and return of cognitivc function after general anaesthesia." -O The combination of edrophoniiim and glycopyrronium may therefore have ;id\,antages over that of neostigmine and atropine. It is especially uscful to prevent bradycardia in children. and the longer dur;ztion of glycopyrronium compared with edrophonium may be considered 14n advantage.The combination of edrophonium and glycopyrronium has been examined in adults.'.* In both these studies thc glycopyrroniurn was administered simultaneously with thc cdrophonium, and prior injection of glycopyrronium was not investigated. We believed that the optimum combination might involvc the administration of glycopyrronium before edrophonium because of the more rapid onset of the effects of edrophonium.An initial study in adults who reccivcd edrophonium 1 mg/kg for reversal '' showcd that glycopyrronium 5 /&kg administcrcd one minute before thc anticholinesterase resulted in the bcst cardiovascular stability. Children oftcn have faster bascline heart rates ( I IR) than adults. arc commonly prcnicdicated with an anticholinergic agent, and may not react in the same way as adults to drugs that affect the heart. Consequently. we decided 10 invcstigatc the combination of edrophonium and glycopyrronium in childrcn. with the aim of defining a dose and administration sequence that minimises cardiovascular changes. MethodsEighty children who underwent a wide rnnpc of surgical procedures were studied after approval from the local ethics committee and informed parental consent (Tables 1 and 2). Prcnicdication was routine for our institution and consisted of a n anticholinergic (atropine 01-hyoscinc). and forpatients hcavicr than 7 kg m opioid (pethidine compound injection o r papavcrctum). Induction was gaseous (cyclopropane or nitrous oxide/halothane). or intravenous (thiopentone). Trizclical intubation was performed after adniinistration of suxamethonium. Anacsthesia was rnaintairietl with 66% inspired nitrous oxide and halothanc in all but six children in whom iaoflurane was substituted for halothane. In addition, 15 children received small doscs of Tentanyl shortly after induction. Curarc was adiuinistered to provide neuroniusculai-blockade.
Etlrophoniuni. a rcvcrsible cholinesterase inhibitor, has been proposed as a n alternative to neostigmine for antago n i m of non-dcpolarising neuromuscular blockade in children. Advantages claimed for edrophonium are a faster onset of rcversal and fewer muscarinic effects compared with neostigminc.' Glycopyrronium has advantages over iitropinc as a n anticholinergic agcnt to antagonise the muscarinic effects of ncostigmine; these advantages include greater stability o f heart rate. a lower incidence of dysrhythmias,3 and faster arousal and return of cognitivc function after general anaesthesia." -O The combination of edrophoniiim and glycopyrronium may therefore have ;id\,antages over that of neostigmine and atropine. It is especially uscful to prevent bradycardia in children. and the longer dur;ztion of glycopyrronium compared with edrophonium may be considered 14n advantage.The combination of edrophonium and glycopyrronium has been examined in adults.'.* In both these studies thc glycopyrroniurn was administered simultaneously with thc cdrophonium, and prior injection of glycopyrronium was not investigated. We believed that the optimum combination might involvc the administration of glycopyrronium before edrophonium because of the more rapid onset of the effects of edrophonium.An initial study in adults who reccivcd edrophonium 1 mg/kg for reversal '' showcd that glycopyrronium 5 /&kg administcrcd one minute before thc anticholinesterase resulted in the bcst cardiovascular stability. Children oftcn have faster bascline heart rates ( I IR) than adults. arc commonly prcnicdicated with an anticholinergic agent, and may not react in the same way as adults to drugs that affect the heart. Consequently. we decided 10 invcstigatc the combination of edrophonium and glycopyrronium in childrcn. with the aim of defining a dose and administration sequence that minimises cardiovascular changes. MethodsEighty children who underwent a wide rnnpc of surgical procedures were studied after approval from the local ethics committee and informed parental consent (Tables 1 and 2). Prcnicdication was routine for our institution and consisted of a n anticholinergic (atropine 01-hyoscinc). and forpatients hcavicr than 7 kg m opioid (pethidine compound injection o r papavcrctum). Induction was gaseous (cyclopropane or nitrous oxide/halothane). or intravenous (thiopentone). Trizclical intubation was performed after adniinistration of suxamethonium. Anacsthesia was rnaintairietl with 66% inspired nitrous oxide and halothanc in all but six children in whom iaoflurane was substituted for halothane. In addition, 15 children received small doscs of Tentanyl shortly after induction. Curarc was adiuinistered to provide neuroniusculai-blockade.
SummaryThe cardiovascular changes in the 10 minutes fo/lowing antagonism of an atracurium-induced block were studied in 32 patients. A :
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