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Antagonism of intense atracurium-induced neuromuscular block in children
C L Gwinnutt1, R W Walker, G Meakin
1Department of Anaesthesia, Hope Hospital, Salford.
Insights
Early administration of neostigmine or edrophonium does not speed recovery from intense neuromuscular block in children. Neostigmine provided faster recovery than edrophonium, but higher doses offered no benefit.
Area of Science:
- Anesthesiology
- Pediatric Pharmacology
- Neuromuscular Blockade
Background:
- Atracurium is commonly used for neuromuscular blockade in pediatric anesthesia.
- Antagonizing deep neuromuscular block requires careful timing and drug selection.
- Understanding the efficacy of different reversal agents is crucial for patient safety.
Purpose of the Study:
- To evaluate the efficacy of early administration of neostigmine and edrophonium in antagonizing intense neuromuscular block in children.
- To compare the recovery times and variability between neostigmine and edrophonium at different doses.
- To determine if increased doses of these agents offer clinical advantages.
Main Methods:
- Four groups of six children received either neostigmine (0.05 or 0.1 mg kg-1) or edrophonium (0.5 or 1.0 mg kg-1) to reverse atracurium-induced block when post-tetanic count (PTC1) reached 10% of control.
- A fifth group received conventional neostigmine (0.05 mg kg-1) at T1 10% for comparison.
- Recovery time to a train-of-four ratio of 0.8 was measured.
Main Results:
- Early administration of anticholinesterases did not shorten the total recovery time compared to conventional neostigmine.
- Recovery from intense block was significantly faster with neostigmine than with edrophonium (P < 0.01).
- Doubling the doses of neostigmine or edrophonium did not reduce recovery time and increased variability.
Conclusions:
- There is no clinical benefit to attempting to antagonize intense neuromuscular block in children with early or increased doses of neostigmine or edrophonium.
- Neostigmine demonstrates superior efficacy over edrophonium for reversing deep neuromuscular blockade in pediatric patients.
- Current reversal strategies for profound neuromuscular blockade in children may require re-evaluation.
Abstract:
Antagonism of intense neuromuscular block induced by atracurium 0.5 mg kg-1 was attempted in four groups of six children using one of two doses of neostigmine (0.05 mg kg-1 and 0.1 mg kg-1) or of edrophonium (0.5 mg kg-1 and 1.0 mg kg-1) when the first twitch of the post-tetanic count (PTC1) was 10% of control. For comparison with normal practice, a fifth group received neostigmine 0.05 mg kg-1 when the first twitch of the train-of-four was 10% of control. Total recovery time from PTC1 10% to a train-of-four ratio of 0.8 was not reduced by early administration of the anticholinesterases, compared with conventional administration of neostigmine at T1 10%. However, recovery from intense block was faster after neostigmine than edrophonium (P less than 0.01). Doubling the doses of the anticholinesterases did not reduce the recovery time and had the effect of increasing variability. We conclude that there is no clinical advantage in attempting to antagonize intense neuromuscular block in children using normal or increased doses of neostigmine or edrophonium.