Postoperative Resistenzentwicklung gegenüber Atracurium

Abstract

Supported by two case reports we show that resistance to atracurium can develop postoperatively. Both patients had septic complications after elective thoracic surgery. A 39-year-old patient developed a bronchial fistula and a superinfection of the remaining thoracic cavity after pneumonectomy. At the time of rethoracotomy the neuromuscular blocking potency of atracurium had changed drastically: onset time was lengthened (7 vs. 3.5 min), recovery period (DUR 10%) was reduced (14 vs. 28 min) and the maintenance dose had to be tripled (14.3 vs. 5.0 micrograms/kg per minute). Following superior lobe resection in a 56-year-old patient, middle lobe gangrene occurred which had to be removed. In contrast to the first anaesthesia the intubation dose of atracurium had to be increased significantly (70 vs. 40 mg), and even with this amount the neuromuscular blocking effect was not complete. Furthermore to accomplish a convenient state of relaxation the maintenance dose had to be raised considerably (11.8-16.5 vs. 5.5 micrograms/kg per minute). These reports show that even within a short period of time resistance to atracurium can develop and we must suppose that the severe inflammatory reaction caused these changes.

Effect of acute peritonitis on rocuronium-induced intraperitoneal pressure reduction and the uptake function of the sarcoplasmic reticulum

“…Pharmacodynamic changes include altered AChR physiology or sensitivity, inhibition of serum cholinesterase activity, interactions with plasma constituents, alterations in distribution volume and protein binding. Clearance may also contribute to resistance in several disease stages, as previously described (6–8). However, calcium overload in the cell and the dysregulation of intracellular Ca 2+ may also induce uncoordinated contraction of myocytes.…”

“…In a previous study, 98% of patients undergoing radical retropubic prostatectomy with neuromuscular blockade had acceptable surgical conditions compared with 72% of patients who had not received a neuromuscular blockade (5). However, during emergency surgery for acute peritonitis (AP) and other septic progresses, tetanic contraction of the abdominal wall muscles has been observed (6–8), and in this surgery the incomplete muscle relaxation effect of neuromuscular blockers and increased dosage of myorelaxant drugs is a serious problem that affects the success of the surgery. A number of pharmacokinetic and pharmacodynamic factors, including acetylcholine receptors (AChRs) could potentially contribute to this effect (6–8).…”

“…However, during emergency surgery for acute peritonitis (AP) and other septic progresses, tetanic contraction of the abdominal wall muscles has been observed (6–8), and in this surgery the incomplete muscle relaxation effect of neuromuscular blockers and increased dosage of myorelaxant drugs is a serious problem that affects the success of the surgery. A number of pharmacokinetic and pharmacodynamic factors, including acetylcholine receptors (AChRs) could potentially contribute to this effect (6–8). Studies on the effects of neuromuscular blockers have primarily focused on neuromuscular transmission in systemic inflammation models (6).…”