Abstarct
Train-of-four stimulation can shorten the apparent onset time of neuromuscular blocking drugs. This study was designed to verify whether the same occurred with neostigmine-assisted recovery, and whether this apparent acceleration could explain the previously reported effectiveness of the priming technique for reversal agents. Fourteen adults received atracurium, 0.5 mg · kg-1, during a thiopentone-nitrous oxide-enflurane anaesthetic. The ulnar nerves of both arms were stimulated with train-of-four stimulation every 12 seconds until 1 per cent recovery of first twitch, at which time stimulation in one arm was switched to single twitch. When mean first twitch height reached 10 per cent of control, neostigmine, 0.04 mg · kg-1, was administered either as a single bolus, or as a “priming” dose of 0.01 mg · kg-1, followed 3 min later by 0.03mg · kg-1. No statistically significant differences were observed between single twitch in one arm and first twitch height of the train-of-four in the other arm for the next 10 min. With priming, first twitch height was 45 ± (SEM) 5 per cent at 5 min and 85 ± 6 per cent at 10 min, compared with 72 ± 5 per cent (p < 0.05) and 91 ± 2 per cent (NS) respectively without priming. Train-of-four ratio was 28 ± 3 per cent at 5 min and 65 ± 5 per cent at 10 min with priming, versus 53 ± 4 per cent (P < 0.05) and 73 ± 3 per cent (NS) respectively without priming. It is concluded that with neostigmine to reverse atracurium blockade, the response of the first twitch of the train-of-four follows the same time course as single twitch, and priming does not accelerate recovery when reversal is attempted at 90 per cent blockade.
Résumé
La stimulation en train-de-quatre peut raccourcir le délai mesuré ďaction des curares. Cette étude avait pour but de vérifier si ce phénomène se produisait lors de la neutralisation du bloc par la néostigmine, et si ceci pouvait expliquer ľefficacité déjà décrite de la technique de ľamorce pour les anticholinestérasiques. On a donné 0.5 mg · kg-1 ďatracurium à 14 adultes au cours ďune anesthésie au thiopental, protoxyde ďazote et enflurane. On a stimulé le nerf cubital de chaque bras en utilisant le train-de-quatre toutes les 12 secondes, jusqu’à ce que la réponse au premier twitch récupère à un pour cent. Alors, on a changé le mode de stimulation de ľun des bras pour appliquer une stimulation unique toutes les 12 secondes. Lorsque la moyenne de la réponse mesurée dans les deux extrémités atteignait dix pour cent, on administrait de la n·ostigmine, soit en une seule dose de 0.04 mg · kg-1, soit en une dose ďamorce de 0.01 mg · kg-1, suivie trois minutes plus tard de 0.03 mg · kg-1. Pendant les dix minutes suivantes, on n’a pas noté de différences significatives entre le twitch unique enregistré dans un bras et le premier twitch du train-de-quatre dans ľautre bras. Avec la dose ďamorce, le premier twitch était de 45 ± (ETM) 5 pour cent après cinq minutes et 85 ± 6 pour cent après dix minutes. Après une dose unique, ces valeurs étaient de 75 ±5 pour cent (p < 0.05) et de 91 ± 2 pour cent (N.S.), respectivement. Avec ľamorce, le rapport du quatrième au premier twitch était de 28 ± 3 pour cent après cinq minutes et de 65 ± 5 pour cent après dix minutes. Sans amorce, ce rapport s’établissait à 53 ± 4 pour cent (p < 0.05) et 73 ± 3 pour cent (N.S.), respectivement. On en conclut que lorsque la néostigmine est utilisée pour neutraliser le bloc neuromusculaire produit par ľatracurium, la réponse du premier twitch du train-de-quatre est semblable à celle du twitch unique. De plus, le principe de ľamorce appliqué à la néostigmine n’ accélère pas la récupération, lorsqu’on donne cet anticholinestérasique pour neutraliser un bloc de 90 pour cent.
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Donati, F., Smith, C.E., Wiesel, S. et al. “Priming” with neostigmine: failure to accelerate reversal of single twitch and train-of-four responses. Can J Anaesth 36, 30–34 (1989). https://doi.org/10.1007/BF03010883
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DOI: https://doi.org/10.1007/BF03010883