The Orbicularis Oculi and the Adductor Pollicis Muscles as Monitors of Atracuriurn Block of Laryngeal Muscles

Purpose: Mivacurium-rocuronium combinations have been demonstrated to be more potent than either drug given alone. Combinations were compared with mivacurium and rocuronium, with respect to onset, intubating conditions, and duration of action in young and elderly adults.Methods: Fentanyl-propofol-N 2 O-isoflurane anesthesia was given to ASA I and II adults aged 18-65 yr (45 patients) and over 66 yr (45 patients). In this blinded randomized study, we compared accelerographic adductor pollicis response and visual assessment of response to facial nerve stimulation after 0.25 mg·kg -1 mivacurium, 0.6 mg·kg -1 rocuronium, and a combination of 0.08 mg·kg -1 mivacurium plus 0.2 mg·kg -1 rocuronium. Intubating conditions at 2.5 min were rated as excellent, good, fair or poor.Results: Onset times were similar for all drugs regimens and for both age groups (204-276 sec at the thumb; 142-196 sec at the eye) (P < 0.05 between muscles). Intubating conditions were similar in all groups, and rated good or excellent, except in two subjects. In young patients duration to 25% recovery was longer (P < 0.05) for rocuronium (mean ± SD) (39 ± 11 min) than for either mivacurium (23 ± 6 min), or the combination (27 ± 7 min). Duration was prolonged in the elderly for rocuronium (54 ± 17 min), and the combination ( 35 ± 11 min), but not for mivacurium (24 ± 6 min).Conclusions: Mivacurium-rocuronium combinations yield onset times and intubating conditions similar to either parent agent with only two thirds as much total drug. Duration for such a mixture is similar to that of mivacurium in young adults and slightly prolonged in the elderly.Objectif : Le mélange de rocuronium et de mivacurium est plus puissant que l'un ou l'autre de ses composants donné seul. On a comparé ce mélange au mivacurium et au rocuronium quant au délai d'installation, aux conditions d'intubation et à la durée d'action chez des adultes jeunes et âgés.Méthode : Une anesthésie au fentanyl, propofol, N 2 O et isoflurane a été administrée à 45 patients de 18 à 65 ans et à 45 sujets de plus de 65 ans. De façon randomisée et aveugle, on a comparé la réponse accélérographique de l'adducteur du pouce et l'évaluation visuelle de la réponse à la stimulation du nerf facial après 0,25 mg·kg -1 de mivacurium, 0,6 mg·kg -1 de rocuronium ou un mélange de 0,08 mg·kg -1 de mivacurium et 0,2 mg·kg -1 de rocuronium. Les conditions d'intubation à 2,5 min ont été classifiées comme excellentes, bonnes, passables ou inadéquates.Résultats : Les délais d'installation étaient semblables pour tous les myorelaxants et pour les deux groupes d'âge (204-276 sec au pouce, 142-196 sec près de l'oeil (P < 0,05 entre les muscles). Les conditions d'intubation étaient semblables dans tous les groupes et cotées bonnes ou excellentes, excepté chez deux sujets. Chez les jeunes, la durée d'action jusqu'à 25 % de récupération était plus longue (P < 0,05) pour le rocuronium (moyenne ± ET) (39 ± 11 min) que pour le mivacurium (23 ± 6 min), ou le mélange (27 ± 7 min). Chez les sujets âgés, la durée était prolo...

Section: Discussionmentioning

confidence: 71%

Intubating conditions and blockade after mivacurium, rocuronium and their combination in young and elderly adults

Motamed

Donati

2000

“…71 Several studies have described the relationship between the response at the eyebrow and either diaphragmatic response or intubating conditions. 42,[72][73][74][75] The movement of the eyebrow was evaluated either visually or by electromyography. Donati et al 42 found a striking resemblance in the time course of neuromuscular block between the eyebrow and the diaphragm.…”

Section: Anatomy and Physiologymentioning

confidence: 99%

Neuromuscular blockade at the larynx, the diaphragm and the corrugator supercilii muscle: a review

Hemmerling

Donati

2003

P Pu ur rp po os se e: : To review recent findings concerning neuromuscular blockade and monitoring at the larynx, the diaphragm, and the corrugator supercilii muscle.S So ou ur rc ce e: : This narrative review is based on recent publications. P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : Neuromuscular blockade at the larynx and the diaphragm is less intense than at the adductor pollicis muscle; the onset and offset of neuromuscular blockade is more rapid. The corrugator supercilii muscle reflects better the time course of neuromuscular blockade of the larynx than the adductor pollicis muscle, is better suited to monitor the onset of neuromuscular blockade for intubation, and should give a better reflection of the time course and degree of neuromuscular blockade of the larynx or the diaphragm. Recovery of neuromuscular function at the end of any procedure is best reflected at the adductor pollicis muscle where neuromuscular transmission is last restored. Clinical monitoring of the larynx or the diaphragm is still limited by the absence of a simple method. Acceleromyography of the corrugator supercilii muscle is prone to artifacts that do not occur during monitoring of the adductor pollicis muscle. Phonomyography, a new method of monitoring that is currently being tested, is based on the phenomenon that muscle contraction creates low-frequency sound waves, which can be detected using special microphones to quantify neuromuscular blockade. This method seems promising because it can be easily used on all muscles of interest.C Co on nc cl lu us si io on n: : Research during the last 15 years has greatly enhanced our knowledge about how muscles react differently to muscle relaxants and has enabled us to achieve better surgical conditions with safer use of muscle relaxants. Interesting technologies have been developed to reliably monitor neuromuscular blockade at the larynx and the diaphragm, but are currently restricted to research settings. Our increased understanding should help us in ongoing efforts to develop the "ideal" muscle relaxant and the "ideal" method of neuromuscular monitoring. Objectif

“…Atracurium was chosen because its onset of action at the laryngeal and orbicularis oculi muscles had already been documented. 24 This value was considered to be similar between both muscle groups when it was reviewed recently. 25 Mean onset time after atracurium 0.5 mg·kg -1 observed in our study (166 ± 62 sec) was similar to that obtained in previous studies: 146 ± 55 sec, 24 141 ± 7 sec 26 and 129 ± 33 sec 27 after the same dose of atracurium.…”

Section: Discussionmentioning

confidence: 99%

Muscle relaxation and increasing doses of propofol improve intubating conditions

Lieutaud

Billard

Khalaf

et al. 2003

P Pu ur rp po os se e: : Muscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not clearly defined. This study was designed to determine, during intubation: i) the relative role of anesthetics and atracurium-induced neuromuscular block and; ii) the effect of different doses of propofol in the presence of complete muscle block.