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Synergism between atracurium and vecuronium in children
O A Meretoja1, B W Brandom, T Taivainen
1Department of Anaesthesiology, Children's Hospital University of Helsinki, Finland.
Insights
Combining atracurium and vecuronium in pediatric anesthesia demonstrates supra-additive effects, significantly reducing drug requirements by up to 40%. This neuromuscular blockade combination offers enhanced potency and efficiency in pediatric surgical settings.
Area of Science:
- Anesthesiology
- Pharmacology
- Pediatric Medicine
Background:
- Neuromuscular blocking agents are crucial in pediatric anesthesia for facilitating intubation and surgical procedures.
- Understanding the synergistic or additive effects of combining different neuromuscular blockers is essential for optimizing dosage and minimizing side effects.
- Atracurium and vecuronium are commonly used neuromuscular blockers, but their combined effects in pediatric populations require further elucidation.
Purpose of the Study:
- To determine the dose-response curves and maintenance requirements for various combinations of atracurium and vecuronium in pediatric patients.
- To investigate the potential for supra-additive effects when combining atracurium and vecuronium.
- To assess the impact of these combinations on neuromuscular block characteristics and recovery.
Main Methods:
- Thirty pediatric patients under balanced anesthesia were studied.
- Dose-response curves and maintenance requirements were evaluated for three atracurium:vecuronium dose ratios (10:1, 4:1, 1.6:1).
- Neuromuscular block was monitored using adductor pollicis electromyography (EMG).
Main Results:
- The equipotent dose ratio of 4:1 (atracurium:vecuronium) was found to be the most potent, with an ED95 of 95 (6) µg/kg for atracurium and 24 (1) µg/kg for vecuronium.
- The combined ED95 was 58% of the ED95 for either agent alone (P = 0.0001), indicating supra-additive effects.
- Hourly maintenance requirement was 2.0 (0.1) times the individual ED95 dose of the combination, and the recovery index was 8.9 (0.5) minutes.
Conclusions:
- Combinations of atracurium and vecuronium exhibit supra-additive neuromuscular blocking effects in children, leading to a significant reduction in total drug requirement (up to 40%).
- While supra-additive, these combinations maintained an intermediate character of neuromuscular block.
- These findings suggest that combining atracurium and vecuronium can be an effective strategy for optimizing neuromuscular blockade in pediatric anesthesia.
Abstract:
In 30 children under balanced anaesthesia, we have determined dose-response curves and maintenance requirement of three dose ratio combinations of atracurium and vecuronium (10:1, 4:1 or 1.6:1 on a microgram:microgram basis). Neuromuscular block was monitored by adductor pollicis EMG. An equipotent dose ratio (4:1) was most potent, with a mean (SEM) ED95 of atracurium 95 (6) micrograms kg-1 with vecuronium 24 (1) micrograms kg-1. The sum of these doses is only 58% of an ED95 value of one agent (P = 0.0001). The hourly requirement to maintain a 90-95% neuromuscular block was 2.0 (0.1) times an individual ED95 dose of any combination. Recovery index was 8.9 (0.5) min. These results indicate that a combination of atracurium and vecuronium is supra-additive compared with the effects of each drug alone. However, all combinations maintained an intermediate character of neuromuscular block. Combining atracurium with vecuronium may reduce drug requirement by 40%.