Abstract
Recovery after doxacurium and pancuronium neuromuscular blockade and their acceleration by neostigmine have not been compared in children. Therefore, 60 paediatric surgical patients aged 2–10 yr (ASA 1–2) were studied. They were randomized to receive doxacurium 30 μg · kg−1 or pancuronium 70 μg · kg−1 iv during propofol, fentanyl, isoflurane and nitrous oxide anaesthesia. Electromyographic (EMG) responses of the adductor pollicis to train-of-four (TOF) stimulation of the ulnar nerve were recorded every ten seconds using a Datex NMT monitor. Six patients in each relaxant group received neostigmine (0, 5, 10, 20 or 40 μg · kg−1) with atropine by random allocation when first twitch height (TI) had recovered to 25% of control. Spontaneous recovery after ten minutes was similar following doxacurium (mean ± SEM values of 45.0 ± 3.9 vs 49.5 ± 10.0 % for TI and 25.2 ± 3.8 vs 14.8 ± 3.6% for TOF ratios). Dose-responses to neostigmine were calculated from the log dose vs logit of TI or TOF ratio after ten minutes. Neostigmine-assisted recovery was not different in the two groups, with ED70 and ED90 doses for TI of 14.3 ± 1.8 and 25.7 ± 2.7 μg·kg−1 for doxacurium and 12.5 ± 1.7 and 25.3 ± 2.3 μg· kg−1 for pancuronium. Time to recovery of TOF ratio to 70% after neostigmine 40 ng · kg−1 was 2.3 ± 1.0 and 4.2 ± 1.7 min (P = NS) following pancuronium and doxacurium, respectively. Adjusted recovery due to neostigmine alone (spontaneous recovery subtracted from the total) required two to three times higher doses of neostigmine. Thus, in children, the spontaneous recovery and reversal of neuromuscular blockade is similar with doxacurium and pancuronium. However, compared with previous adult studies, they recover twice as quickly from doxacurium neuromuscular blockade and neostigmine antagonism is achieved at 25–50% of the adult doses.
Résumé
On n’a jamais comparé chez l’enfant l’antagonisme du bloc neuromusculaire produit par le doxacurium avec celui du pancuronium et son accélération par la néostigmine. Dans ce but, 60 patients pédiatriques programmés pour la chirurgie sont étudiés. Ils sont répartis au hasard pour recevoir soit du doxacurium 30 μg · kg−1 ou du pancuronium 70 μg · kg−1 pendant une anesthésie générale au propofol, fentanyl, isoflurane et protoxyde d’azote. La réponse électromyographique à la stimulation par train de quatre (TOF) du nerf cubital est enregistrée toutes les dix secondes sur un moniteur NMT de Datex. Six patients dans chacun des groupes reçoivent néostigmine (0, 5, 10, 20 ou 40) avec de l’atropine au moment du retour de l’amplitude de la première secousse (TI) à 25% du contrôle. Après dix minutes, la décurarisation spontanée est identique après le doxacurium (moyenne ± SEM, 45.0 ± 3,9 vs 49,5 ± 10,0% pour le TI et 25,2 ± 3,8 vs 14,8 ± 3,6% pour le rapport TOF). Les relations dose-effet de la néostigmine sont calculées avec le log de la dose vs le logit de TI ou la rapport TOF après dix minutes. Avec des ED70 et ED90, la décurarisation assistée par la néostigmine ne diffère pas entre les deux groupes au regard du TI: de 14,3 ± 1,8 et 25,7 ± 2,7 μg · kg−1 pour le doxacurium et de 12,5 ± 1,7 et 25,3 ± 2,3 μg · kg−1 pour le pancuronium. Le délai de retour du rapport TOF à 70% après néostigmine 40 μg · kg−1 est de 2,3 ± 1,0 après le pancuronium et de 4,2 ± 1,7 min (P = NS) après le doxacurium. La décurarisation ajustée pour la néostigmine seule (la décurarisation spontanée soustraite du total) nécessite des doses de deux à trois fois plus importantes de néostigmine. Chez l’enfant, la décurarisation spontanée et l’antagonisme du bloc neuromusculaire sont identiques pour le doxacurium et le pancuronium. Cependant, comparativement aux adultes, les enfants récupèrent deux fois plus rapidement du bloc neuromusculaire produit par le doxacurium et l’antagonisme de la néostigmine est complet à doses de 25–50% inférieures à celles de l’adulte.
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Bevan, J.C., Purday, J.P., Reimer, E.J. et al. Reversal of doxacurium and pancuronium neuromuscular blockade with neostigmine in children. Can J Anaesth 41, 1074–1080 (1994). https://doi.org/10.1007/BF03015657
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DOI: https://doi.org/10.1007/BF03015657