Abstract
The purpose of the study was to determine the effect of non-depolarizing muscle relaxants and waiting time on muscle fasciculations after succinylcholine in anaesthetized patients. Adult men and women, 60–80 kg, received pretreatment doses of atracurium 5 mg (n = 160), pancuronium 1 mg (n = 123), d-tubocurarine 3 mg (n = 97), or vecuronium 1 mg (n = 62). Waiting times between pretreatment and succinylcholine, 100 mg, ranged between 0.6 and 5 min. Data points (presence or absence of fasciculations and waiting time) were entered for each patient. Waiting time response curves were obtained between the logit transformation of the probability of no fasciculations and the log waiting time for each drug. Statistical differences between wait time response curves were determined by non-overlapping of the associated 95% confidence intervals. The frequency of muscle fasciculations was reduced with increased waiting time for all nondepolarizers tested. Following wait times of three, four and five minutes, the probability of not fasciculating was greatest with d-tubocurarine (90, 97 and 99%, respectively) and atracurium (89, 93 and 96%). Corresponding values for pancuronium were 70, 82 and 88% and for vecuronium were 74, 82 and 86% Waiting times to prevent fasciculations in 80% and 90% of patients were shorter with d-tubocurarine (2.46 and 3.02 min, respectively) or atracurium (2.16 and 3.24 min) than pancuronium (3.77 and 5.35 min) or vecuronium (3.73 and 6.36 min). In a subgroup of 107 patients who did not fasciculate after succinylcholine, patients receiving d-tubocurarine pretreatment had the lowest frequency of coughing/bucking responses during tracheal intubation (22%), whereas patients receiving atracurium had the highest frequency (58%). The data suggest that pretreatment with d-tubocurarine 3 mg, using a 3.5 to 4 min wait time interval is the optimal method to prevent succinylcholine-induced fasciculations.
Résumé
L’objectif de ce travail est de mesurer l’effet des myorelaxants non dépolarisants sur la vitesse d’apparition des fasciculations musculaires et l’intervalle d’attente qui suit l’administration de succinylcholine chez le patient anesthésié. Des adultes des deux sexes, pesant de 60 à 80 kg, reçoivent en pré-traitement de l’atracurium 5 mg (n = 160), du pancuronium 1 mg (n = 123), de la d-tubocurarine 3 mg (n = 97) ou du vécuronium 1 mg (n = 62). L’intervalle entre le pré-traitement et l’administration de succinylcholine 100 mg se situe entre 0,6 et 5 min. Les données de recherche (présence ou absence de fasciculations et l’intervalle d’attente) sont enregistrées pour chacun des patients. Des courbes de réponse sont obtenues entre la probabilité transformée en logit de l’absence de fasciculation et le logarithme de l’intervalle d’attente. Les differences statistiques entre les courbes-réponses de l’intervalle d’attente sont déterminées avec le non-chevauchement des intervalles de confiance à 95%. La fréquence des fasciculations musculaires diminue avec l’augmentation de l’intervalle d’attente pour tous les non dépolarisants étudiés. Après un intervalle d’attente de trois, quatres et cinq minutes, la probabilité d’absence de fasciculations est plus élevée avec la d-tubocurarine (90, 97 et 99% respectivement) et l’atracurium (89, 93 et 96%). Les valeurs correspondantes pour le pancuronium sont de 70, 82 et 88% et pour le vécuronium de 74, 82 et 86%. Les intervalles d’attente nécessaires à la prévention des fasciculations chez 80 et 90% des patients sont plus courts avec la d-tubocurarine (2,46 et 3,02 min respectivement) ou l’atracurium (2,16 à 3,24 min) que le pancuronium (3,77 et 5,35 min) ou le vécuronium (3,73 et 6,36 min). Dans un sous-groupe de 107 patients sans fasciculations après succinylcholine, les patients qui reçoivent dtubocurarine ont la plus basse incidence de toux et de cabrdde à l’intubation (22%), alors que cewc qui reçoivent de l’atracurium ont l’incidence la plus élevée (58%). Ces donriés suggèrent que la méthode optimale de prévention des fasciculations consiste à injecter de la d-tubocurarine 3 mg, 3,5 à 4 min avant la succinylcholine.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Erkola O, Salmenperd A, Kuoppamäki R. Five nondepolarizing muscle relaxants in precurarization. Acta Anaesthesiol Scand 1983; 27: 427–32.
Cullen DJ. The effect of pretreatment with nondepolarizing muscle relaxants on the neuromuscular blocking action of succinylcholine. Anesthesiology 1971; 35: 572–8.
Blitt CD, Carlson GL, Rolling GD, Hameroff SR, Otto CW. A comparative evaluation of pretreatment with nondepolarizing blockers prior to the adminstration of succinylcholine. Anesthesiology 1981; 55: 687–9.
Bennetts FE, Khalil KI. Reduction of postsuxamethonium pain by pretreatment with four nondepolarizing agents. Br J Anaesth 1981; 53: 531–6.
Miller RD, Way WL. Inhibition of succinylcholineinduced increased intragastric pressure by nondepolarizing muscle relaxants and lidocaine. Anesthesiology 1971; 34: 185–8.
Stirt JA, Grosslight KR, Bedford RF, Vollmer D. “Defasciculation” with metocurine prevents succinylcholineinduced increases in intracranial pressure. Anesthesiology 1987; 67: 50–3.
Bevan DR, Bevan JC, Donati F. Muscle Relaxants in Clinical Anesthesia. Chicago: Year Book Medical Publishers, 1988.
Horrow JC, Lambert DH. The search for an optimal interval between pretreatment dose of d-tubocurarine and succinylcholine. Can Anaesth Soc J 1984; 31: 528–33.
Miller RD, Way WL. The interaction between succinylcholine and subparalyzing doses of d-tubocurarine and gallamine in man. Anesthesiology 1971; 35: 567–71.
McLoughlin C, Elliott P, McCarthy G, Mirakhur RK. Muscle pains and biochemical changes following suxamethonium administration after six pretreatment regimens. Anaesthesia 1992; 47: 202–6.
Manchikanti L, Grow JB, Colliver JA, Canella MG, Hadley CH. Atracurium pretreatment for succinylcholineinduced fasciculations and postoperative myalgia. Anesth Analg 1985; 64: 1010–4.
Domaoal AM, Weniger FC, Wolfson B. “Precurarization” using pancuronium. Anesth Analg 1975; 54: 71–5.
White DC. Observations on the prevention of muscle pains after suxamethonium. Br J Anaesth 1962; 34: 332–5.
Pace NL. Prevention of succinylcholine myalgias: a metaanalysis. Anesth Analg 1990; 70: 477–83.
Sosis M, Broad T, Larijani GE, Man AT. Comparison of atracurium and d-tubocurare for prevention of succinylcholine myalgias. Anesth Analg 1987; 66: 657–9.
Zahl K, Apfelbaum JL. Muscle pain occurs after outpatient laparoscopy despite the substitution of vecuronium for succinylcholine. Anesthesiology 1989; 70: 408–11.
Collins KM, Docherty PW, Plantevin OM. Postoperative morbidity following gynaecological outpatient laparoscopy. A reappraisal of the service. Anaesthesia 1984; 39: 819–22.
Hosmer DW Jr., Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons, 1989.
Smith CE, Donati F, Bevan DR. Cumulative doseresponse with infusioin: a technique to determine neuromuscular blocking potency of atracurium and vecuronium. Clin Pharmacol Ther 1988; 44: 56–64.
Smith CE, Donati F, Bevan DR. Differential effects of pancuronium on masseter and adductor pollicis muscles in humans. Anesthesiology 1989; 71: 57–61.
Bartowski RB,Epstein RH. The influence of receptor binding on the onset of neuromuscular blockade. (Abstract). Fourth International Neuromuscular Meeting, Montreal, 1992 2C.
Law Min JC, Bekavac I, Glavinovic MI, Donati F, Bevan DR. Iontophoretic study of speed of action of various muscle relaxants. Anesthesiology 1992; 77: 351–6.
Donlon JV, Ali HH, Savarese JJ. A new approach to the study of four nondepolarizing relaxants in man. Anesth Analg 1974; 53: 934–9.
Virtue RW. Comparison of gallamine with d-tubocurarine effects on fasciculation after succinylcholine. Anesth Analg 1975; 54: 81–2.
Ferres CJ, Mirakhur RK, Craig HJL, Browne ES, Clarke RSJ. Pretreatment with vecuronium as a prophylactic against post-suxamethonium muscle pain. Comparison with other non-depolarizing neuromuscular blocking drugs. Br J Anaesth 1983; 55: 735–40.
Bowman WC. Prejunctional and postjunctional cholinoceptors at the neuromuscular junction. Anesth Analg 1980; 59: 935–43.
Gibson FM, Mirakhur RK. Train-of-four fade during onset of neuromuscular block with nondepolarizing neuromuscular blocking agents. Acta Anaesthesiol Scand 1989; 33: 204–6.
Hartman GS, Fiamengo SA, Riker WF Jr. Succinylcholine: mechanism of fasciculations and their prevention by dtubocurarine or diphenylhydantoin. Anesthesiology 1986; 65:405–13.
Fahmy NR, Malek MS, Lappas DG. Diazepam prevents some adverse effects of succinylcholine. Clin Pharmacol Ther 1979; 26: 395–8.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Pinchak, A.C., Smith, C.E., Shepard, L.S. et al. Waiting time after non-depolarizing relaxants alter muscle fasciculation response to succinylcholine. Can J Anaesth 41, 206–212 (1994). https://doi.org/10.1007/BF03009832
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03009832