1
|
Prediction of Clearance in Children from Adults Following Drug-Drug Interaction Studies: Application of Age-Dependent Exponent Model. Drugs R D 2020; 20:47-54. [PMID: 32056156 PMCID: PMC7067713 DOI: 10.1007/s40268-020-00295-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background and Objective Pharmacokinetic drug–drug interaction (DDI) studies are conducted in adult subjects during drug development but there are limited studies that have characterized pharmacokinetic DDI studies in children. The objective of this study was to evaluate if the DDI clearance values from adults can be allometrically extrapolated from adults to children. Methods Fifteen drugs were included in this study and the age of the children ranged from premature neonates to adolescents (30 observations across the age groups). The age-dependent exponent (ADE) model was used to predict the clearance of drugs in children from adults following DDI studies. Results The prediction error of drug clearances following DDIs in children ranged from 4 to 67%. Of 30 observations, 17 (57%) and 27 (90%) observations had a prediction error ≤ 30% and ≤ 50%, respectively. Conclusion This study indicates that it is possible to predict the clearance of drugs with reasonable accuracy in children from adults following DDI studies using an ADE model. The method is simple, robust, and reliable and can replace other complex empirical models.
Collapse
|
2
|
Park SY, Kim HJ, Choi YS, Yun SH, Park JC. Estimation of the effect-site equilibration rate constant using the time-to-peak effect of muscle
relaxants measured by train-of-four stimulation during general anesthesia induction. Korean J Anesthesiol 2018; 71:113-119. [PMID: 29619783 PMCID: PMC5903116 DOI: 10.4097/kjae.2018.71.2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 05/17/2017] [Accepted: 05/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background The concept of the effect-site concentration of anesthetic agents is important. The effect compartment model can be explained using the concepts of effect-site concentration and effect-site equilibration rate constant (ke0). This study confirms that the time-to-peak effect (tpe) can be measured easily in clinical practice by applying a priming dose and train-of-four (TOF) during general anesthesia induction, and ke0 can be calculated from the tpe of the four muscle relaxants that are commonly used in general anesthesia. Methods Eighty patients who received general anesthesia were divided into the succinylcholine, rocuronium, atracurium, or vecuronium groups. Priming doses of muscle relaxants were administered. The effects of muscle relaxants were quantified by recording the twitch response of the adductor pollicis muscle after stimulating the ulnar nerve. The tpe was measured at the lowest TOF value. ke0 was calculated from the measured tpe. Results The ke0 values of the succinylcholine, rocuronium, atracurium, and vecuronium groups were 0.076 (0.030)/min, 0.228 (0.122)/min, 0.062 (0.011)/min, and 0.077 (0.019)/min, respectively. Conclusions It is possible to estimate ke0 from the tpe of muscle relaxants using a priming dose and TOF during general anesthesia induction.
Collapse
|
3
|
Abstract
BACKGROUND The onset time for paralysis varies 3-fold among nondepolarizing muscle relaxants. Possible explanations include: (a) pharmacokinetic differences among drugs and (b) buffering of drug molecules by acetylcholine receptors as they diffuse into the neuromuscular junction. Although some pharmacokinetic models consider buffered diffusion, these models do not account for either the high density of receptors or synapse geometry. Here, I used computer simulations to calculate the kinetics of buffered diffusion. The goal was to determine the conditions under which buffered diffusion could account for differences in onset time among nondepolarizing muscle relaxants. METHODS Monte Carlo simulation was used along with a realistic 3-dimensional model of the rat neuromuscular junction. Simulations determined the time dependence of the number of drug-bound receptors. A 1000-fold range of drug potency was examined. In some simulations, the drug concentration outside the junction was changed instantaneously. In other simulations, the concentration changed according to predictions of pharmacokinetic models assuming time-dependent changes in plasma drug concentration. The rate constant for equilibration of drug between plasma and muscle, keo, was varied between 0.15 and 0.6 min(-1). Twitch amplitude was calculated from receptor occupancy assuming a high safety margin for neuromuscular transmission. Some simulations used a synaptic model with an increased nerve-muscle contact width. RESULTS Simulations with instantaneous changes in drug concentration at the synapse, indicated that the time to 50% twitch depression (onset time) was 0.1 to 30 seconds and was proportional to drug potency. This corresponds to iontophoretic application of drug to isolated neuromuscular junctions, but is too fast to explain onset times in humans. When pharmacokinetic models were used to calculate the drug concentration outside the synapse, buffered diffusion increased onset times of potent drugs (drugs for which the effective concentration at 50% twitch height is <600 nM). Simulations using keo = 0.6 min(-1) and a model with a 2- to 3-fold wider nerve-muscle contact width indicated that buffered diffusion could account for the differences in clinical onset times among the nondepolarizing muscle relaxants. CONCLUSION Monte Carlo simulation provides a biophysically appropriate way to incorporate buffered diffusion into pharmacokinetic modeling. The simulations indicated that buffered diffusion could account for differences in onset time among drugs. However, a better understanding of the geometry of the human neuromuscular junction is needed before the magnitude of the effect of buffered diffusion can be quantified.
Collapse
|
4
|
Muscle relaxant use during intraoperative neurophysiologic monitoring. J Clin Monit Comput 2012; 27:35-46. [DOI: 10.1007/s10877-012-9399-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 09/15/2012] [Indexed: 12/17/2022]
|
5
|
Feasibility of Microdialysis to Determine Interstitial Rocuronium Concentration in the Muscle Tissue of Anesthetized Neurosurgical Patients. J Neurosurg Anesthesiol 2010; 22:163-9. [DOI: 10.1097/ana.0b013e3181c80a68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Braga ADFDA, Barcelos CCD, Braga FSDS, Fernandes SCA, Franco YO, Mantovani M, Simioni LR. Phenobarbital influence on neuromuscular block produced by rocuronium in rats. Acta Cir Bras 2009; 23:343-7. [PMID: 18641804 DOI: 10.1590/s0102-86502008000400008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Accepted: 04/17/2008] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To evaluate in vitro and in vivo neuromuscular blockade produced by rocuronium in rats treated with Phenobarbital and to determine cytochrome P450 and cytochrome b5 concentrations in hepatic microsomes. METHODS Thirty rats were included in the study and distributed into 6 groups of 5 animals each. Rats were treated for seven days with phenobarbital (20 mg/kg) and the following parameters were evaluated: 1) the amplitude of muscle response in the preparation of rats exposed to phenobarbital; 2) rocuronium effect on rat preparation exposed or not to phenobarbital; 3) concentrations of cytochrome P450 and cytochrome b5 in hepatic microsomes isolated from rats exposed or not to phenobarbital. The concentration and dose of rocuronium used in vitro and in vivo experiments were 4 microg/mL and 0,6 mg/kg, respectively. RESULTS Phenobarbital in vitro and in vivo did not alter the amplitude of muscle response. The neuromuscular blockade in vitro produced by rocuronium was significantly different (p=0.019) between exposed (20%) and not exposed (60%) rats; the blockade in vivo was significantly greater (p=0.0081) in treated rats (93.4%). The enzymatic concentrations were significantly greater in rats exposed to phenobarbital. CONCLUSIONS Phenobarbital alone did not compromise neuromuscular transmission. It produced enzymatic induction, and neuromuscular blockade in vivo produced by rocuronium was potentiated by phenobarbital.
Collapse
|
7
|
Pedroviejo V, Ayuso M, Jiménez A. [Anesthesia for procedures other than neurosurgery in the adult with epilepsy]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:425-435. [PMID: 19856689 DOI: 10.1016/s0034-9356(09)70423-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Epilepsy is a common disease affecting between 1% and 2% of the general population. The incidence increases with age. Given the complicated etiology and pathogenesis of this disease, epileptic patients of all ages may require anesthesia. The perioperative care of these patients involves a number of special considerations, although the main issues to deal with are pharmacologic. This review gives an overview of the etiopathogenesis and pathophysiology of epilepsy and describes the general characteristics of antiepileptic drug therapy. The anesthetic implications of chronic treatment with antiepileptic agents and the interactions between these drugs and common anesthetics are discussed in more detail.
Collapse
Affiliation(s)
- V Pedroviejo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid.
| | | | | |
Collapse
|
8
|
Kim MS, Lee SH, Hwang JY, Kang SS. Anesthetic management for a cesarean section under regional anesthesia in a parturient with tuberous sclerosis - A case report -. Korean J Anesthesiol 2009; 57:123-126. [DOI: 10.4097/kjae.2009.57.1.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Min Soo Kim
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
| | - Jong Yun Hwang
- Department of Obstetrics and Gynecology, Kangwon National University Medical School, Chuncheon, Korea
| | - Seong Sik Kang
- Department of Anesthesiology and Pain Medicine, Kangwon National University Medical School, Chuncheon, Korea
| |
Collapse
|
9
|
Fernández-Candil J, Gambús PL, Trocóniz IF, Valero R, Carrero E, Bueno L, Fábregas N. Pharmacokinetic-pharmacodynamic modeling of the influence of chronic phenytoin therapy on the rocuronium bromide response in patients undergoing brain surgery. Eur J Clin Pharmacol 2008; 64:795-806. [PMID: 18521585 DOI: 10.1007/s00228-008-0485-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 03/06/2008] [Indexed: 01/30/2023]
Abstract
BACKGROUND Antiepileptic drugs decrease the intensity of the effect of neuromuscular blocking agents. The objective of this study was to evaluate the influence of chronic phenytoin therapy (CPT) on the pharmacokinetics (PK) and pharmacodynamics (PD) of rocuronium. METHODS A total of 21 patients undergoing intracranial surgery were enrolled in the study. Ten of these were under CPT. Rocuronium was administered intravenously. Arterial blood samples were drawn, and the T1% (percentage change from the response to the supramaximal stimulus) derived from electromyogram was continuously recorded. NONMEM: software was used to construct, evaluate and validate the PKPD models. RESULTS The PKPD of rocuronium was described using a three-compartment PK model and effect compartment model. The CPT therapy was found to increase the total plasma clearance from 0.26 to 0.75 L min(-1). The PD model parameter estimates were k(e0)= 0.073 min(-1), IC(50) (the steady-state plasma concentration eliciting half of the maximum response) = 836 ng mL(-1) and gamma = 3.13. CONCLUSIONS Chronic phenytoin therapy increases the clearance of rocuronium from 0.26 to 0.75 L min(-1) but has no effect on the k(e0), IC(50) or gamma parameters.
Collapse
Affiliation(s)
- Juan Fernández-Candil
- Anesthesiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | |
Collapse
|
10
|
Leelanukrom R, Wacharasint P, Kaewanuchit A. Perioperative management for surgical correction of frontoethmoidal encephalomeningocele in children: a review of 102 cases. Paediatr Anaesth 2007; 17:856-62. [PMID: 17683404 DOI: 10.1111/j.1460-9592.2007.02216.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube defect characterized by herniation of brain and meninges through an anterior skull defect. The extruding mass results in a cutaneous expanding lesion and facial deformity. The objective of this study was to review perioperative management for surgical correction of this condition. METHODS We reviewed the charts of FEEM children who were treated by surgical correction in King Chulalongkorn Memorial Hospital during 1995-2005. The collected data were categorized into preoperative, intraoperative and postoperative data. In addition, average blood loss was calculated. RESULTS A total of 102 charts were reviewed. Preoperative data: The mean age of the patients was 4.62 years. Forty-six patients (45%) were smaller than average weight or height. Preoperative-associated abnormal conditions were found in 69 cases (68%). Intraoperative data: The mean duration of the anesthesia and surgery were 6.35 h and 5.51 h, respectively. The estimated mean red cell mass loss was 13.04 ml.kg(-1). There is one case of difficult intubation. No major anesthetic complication was found. Postoperative data: The average intensive care unit stay and hospital stay were 1.55 days and 11.51 days, respectively. The main postoperative complications were tonic-clonic seizure and serious infection including septic shock from wound infection and meningitis. CONCLUSIONS We reported perioperative management in 102 FEEM children. Comprehensive care during preoperative, intraoperative and postoperative period is essential for successful outcome.
Collapse
Affiliation(s)
- Ruenreong Leelanukrom
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | | | | |
Collapse
|
11
|
Ryu KH. Anesthetic Drug Interactions. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Keon Hee Ryu
- Department of Anesthesiology and Pain Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
12
|
Affiliation(s)
- Jeffrey J Pasternak
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| | | |
Collapse
|
13
|
Abstract
Recent breakthroughs in molecular biology have enabled a reclassification of drug metabolising enzymes based on their amino acid sequence. This has led to a better understanding of drug metabolism and drug interactions. The majority of these drug metabolising enzymes may be either induced or inhibited by drugs or by extraneous substances including foodstuffs, cigarette smoke and environmental pollutants. Virtually all drugs used in anaesthesia are metabolised by either hepatic phase 1 or phase II enzymes. This review considers the classification of drug metabolising enzymes, explains the mechanisms of enzyme induction and inhibition, and also considers how the action of drugs commonly used by anaesthetists, including opioids and neuromuscular blocking drugs, may be altered by this mechanism.
Collapse
Affiliation(s)
- B P Sweeney
- Department of Anaesthesia, Poole and Royal Bournemouth Hospitals, Bournemouth BH7 7DW, UK.
| | | |
Collapse
|
14
|
Kim JU, Lee YK, Lee YM, Yang HO, Han SM, Yang HS. The effect of phenytoin on rocuronium-induced neuromuscular block in the rat phrenic nerve-hemidiaphragm preparation. J Neurosurg Anesthesiol 2005; 17:149-52. [PMID: 16037736 DOI: 10.1097/01.ana.0000171732.18138.ce] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anticonvulsant therapy alters the action of nondepolarizing muscle relaxants. We determined the effects of acute and chronic administration of phenytoin on rocuronium-induced neuromuscular block using the rat phrenic nerve-hemidiaphragm preparation. Rats were divided into 3 groups: a saline control group (n = 10), an acute phenytoin-treated group (n = 30), and a chronic phenytoin-pretreated group (n = 30). Phrenic nerve-hemidiaphragm was dissected, mounted in a bath containing oxygenated Krebs solution, and the nerve was stimulated at supramaximal intensity. Single twitch responses were recorded by physiogram. In the acute phenytoin-treated group, acute effects of phenytoin were determined based on the phenytoin concentration of 1, 10, or 100 microg/mL in the bath. The chronic effects of phenytoin were determined using phrenic nerve-diaphragms from rats pretreated with phenytoin (50 mg/kg/d) for 1, 7, or 28 days. In rats with phenytoin 100 microg/mL in the bath, all concentrations of rocuronium produced twitch depression significantly different from those of other groups (P < 0.05), and the concentration-response curve shifted to the left. In rats with phenytoin 10 microg/mL in the bath, the effective concentrations for 50%, 90%, and 95% twitch depression values were significantly different from those of the control group (P < 0.05). In chronically (28 days) phenytoin-pretreated rats, the concentration-response curve significantly shifted to the right (P < 0.05). These findings show that acute administration of phenytoin augmented the neuromuscular blocking effects of rocuronium, whereas chronic phenytoin treatment causes resistance to the neuromuscular blocking effects of rocuronium in target organs.
Collapse
Affiliation(s)
- Joung Uk Kim
- Department of Anesthesiology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | | | | | | | | | | |
Collapse
|
15
|
Richard A, Girard F, Girard DC, Boudreault D, Chouinard P, Moumdjian R, Bouthilier A, Ruel M, Couture J, Varin F. Cisatracurium-Induced Neuromuscular Blockade Is Affected by Chronic Phenytoin or Carbamazepine Treatment in Neurosurgical Patients. Anesth Analg 2005; 100:538-544. [PMID: 15673889 DOI: 10.1213/01.ane.0000143333.84988.50] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effect of chronic anticonvulsant therapy (CAT) on the maintenance and recovery profiles of cisatracurium-induced neuromuscular blockade has not been adequately studied. In this study, we compared the pharmacokinetics and pharmacodynamics of cisatracurium after a prolonged infusion in patients with or without CAT. Thirty patients undergoing intracranial surgery were enrolled in the study: 15 patients under CAT (carbamazepine and phenytoin, Group A) and 15 controls receiving no anticonvulsant therapy (Group C). Anesthesia was standardized and both groups received a bolus of cisatracurium followed by an infusion to maintain a 95% twitch depression. A steady-state was obtained and the infusion was kept constant for 2 additional hours. Neuromuscular blockade was then allowed to spontaneously recover. Blood samples were taken for measurement of cisatracurium plasma concentration during the steady-state period (Cp(ss)95) and at various times during recovery. Demographic and intraoperative data were similar. CAT resulted in faster 25% and 75% recovery of the first twitch. The rate of infusion of cisatracurium needed to maintain a 95% twitch depression at steady-state was 44% faster in Group A (P < 0.001). The clearance of cisatracurium was significantly faster in Group A when compared with Group C (7.12 +/- 1.87 versus 5.72 +/- 0.70 L . kg(-1) . min(-1), P = 0.01). The Cp(ss)95 was also significantly larger in Group A (191 +/- 45 versus 159 +/- 36 ng/mL, P = 0.04). In addition, patients receiving CAT had a 20% increase in the clearance of cisatracurium that, in turn, resulted in a faster recovery of neuromuscular blockade after an infusion of the drug. Also, patients under CAT had a 20% increase in their Cp(ss)95, indicating an increased resistance to the effect of cisatracurium.
Collapse
Affiliation(s)
- Anouk Richard
- *Department of Anesthesiology and †Neurosurgery Division, CHUM, Hôpital Notre-Dame; and ‡Faculty of Pharmacy, Université de Montréal, Montréal, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Roy JJ, Varin F. Physicochemical properties of neuromuscular blocking agents and their impact on the pharmacokinetic-pharmacodynamic relationship. Br J Anaesth 2004; 93:241-8. [PMID: 15169739 DOI: 10.1093/bja/aeh181] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Among the factors influencing the onset of action of neuromuscular blocking agents (NMBA), the potency (EC50) and the rate of equilibration between blood and the effect compartment (k(e0)) have been highlighted. Although these descriptors are intrinsically influenced by the physicochemical characteristics of the drug, the impact of lipid solubility, molecular weight and protein binding on pharmacokinetic-pharmacodynamic (PK-PD) descriptors has not been established for most NMBA. METHODS The octanol/phosphate buffer distribution coefficients (logD) of various NMBA (vecuronium, rocuronium, mivacurium isomers (cis-cis, cis-trans and trans-trans), doxacurium, cisatracurium, atracurium, succinylcholine) were determined. The free fraction for each drug was measured using an ultrafiltration technique. PK-PD descriptors were obtained from selected clinical studies. Correlations between physicochemical parameters (including molecular weight) and PK-PD descriptors were assessed by linear or multiple linear regression. RESULTS A wide range of log D (-4.15 for succinylcholine to 0.75 for vecuronium) and free fraction (from 31% for vecuronium to 80% for succinylcholine) is observed for NMBA. Molecular weight combined with either lipid solubility (r2=0.70; P=0.001) or free fraction (r2=0.84; P<0.001) were highly correlated with potency, while for k(e0) a greater degree of correlation was obtained when both lipid solubility and free fraction (r2=0.74; P=0.002) were included. CONCLUSIONS The basic characteristics of NMBAs, namely, molecular weight, lipid solubility and protein binding, are strongly associated with the kinetics of the drug response.
Collapse
Affiliation(s)
- J J Roy
- Faculté de pharmacie, Université de Montréal, 2900 boul. Edouard Montpetit, C.P. 6128, Succursale Centre-ville, Montréal (Québec), H3C 3J7, Canada
| | | |
Collapse
|
17
|
Abstract
Prolonged administration of antiepileptic drugs is associated with several drug interactions. In the field of anaesthesia and critical care, patients exhibit both sensitivity and resistance to non-depolarising neuromuscular blockers (NDNMBs) after acute and long-term administration of antiepileptic drugs, respectively. Although antiepileptic therapy alone has only mild neuromuscular effects, acutely administered antiepileptic drugs can potentiate the neuromuscular effects of NDNMBs as a result of direct pre- and post-junctional effects. Resistance to NDNMBs during long-term antiepileptic therapy is due to multiple factors operating alone or in combination, including induction of hepatic drug metabolism, increased protein binding of the NDNMBs and/or upregulation of acetylcholine receptors.
Collapse
Affiliation(s)
- Sulpicio G Soriano
- Harvard Medical School and Children's Hospital, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|
18
|
|
19
|
Hans P, Bonhomme V. Muscle relaxants in neurosurgical anaesthesia: a critical appraisal. Eur J Anaesthesiol 2003; 20:600-5. [PMID: 12932059 DOI: 10.1017/s0265021503000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The use of muscle relaxants, considered until recently as common practice in current neurosurgical anaesthesia protocols, becomes increasingly more questionable today. The reasons rely on the evolution of neurosurgery including the advent of new surgical techniques, the evolution of anaesthesia having the benefit of new drugs and devices, and the rationale for using muscle relaxants balanced against their potential side-effects and possible pharmacodynamic alterations in neurosurgical patients.
Collapse
Affiliation(s)
- P Hans
- Liege University Hospital, University Department of Anaesthesia and Intensive Care Medicine, CHR de la Citadelle, Liege, Belgium.
| | | |
Collapse
|
20
|
Naguib M, Koorn R. Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management. CNS Drugs 2002; 16:229-47. [PMID: 11945107 DOI: 10.2165/00023210-200216040-00003] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Despite many predictions that electroconvulsive therapy (ECT) would be replaced by pharmacotherapy, ECT has remained an invaluable adjunct in the management of severe psychiatric disease. Both pharmacotherapy and ECT continue to be used extensively, and will frequently be administered concurrently. The majority of patients requiring ECT will need anaesthesia; therefore, interactions could conceivably occur between the psychotropic drugs, ECT and the anaesthetic agents utilised. In managing an anaesthetic for ECT the effects of the anaesthetic agents and other medications on seizure intensity are important determinants influencing outcome. With regard to the antidepressants, tricyclic antidepressants (TCAs) and ECT can be combined safely and beneficially. More care is required when ECT is administered in the setting of a monoamine oxidase inhibitor (MAOI), especially the older irreversible varieties and in patients recently placed on MAOI therapy. Of the anticonvulsants and mood stabilisers, lithium and ECT given concurrently add significant risk of delirium and/or organic syndromes developing. Possible concerns with valproate, carbamazepine, lamotrigine, gabapentin and topiramate are that they may inhibit seizure activity. Additionally, carbamazepine may prolong the action of suxamethonium (succinylcholine). The combination of antipsychotics and ECT is well tolerated, and may in fact be beneficial. As regards the anxiolytics, benzodiazepines have anticonvulsant properties that might interfere with the therapeutic efficacy of ECT. CNS stimulants on the other hand may prolong seizures as well as produce dysrhythmias and elevate blood pressure. Calcium channel antagonists should be used with great care to avoid significant cardiovascular depression. The anaesthesiologist should therefore remain vigilant at all times, as untoward responses during ECT might occur suddenly due to interactions between psychotropics, anaesthetic agents and/or ECT.
Collapse
Affiliation(s)
- Mohamed Naguib
- Department of Anesthesia, University of Iowa College of Medicine, Iowa City, Iowa 52242-1009, USA.
| | | |
Collapse
|
21
|
May JA, White HC, Leonard-White A, Warltier DC, Pagel PS. The Patient Recovering from Alcohol or Drug Addiction: Special Issues for the Anesthesiologist. Anesth Analg 2001; 92:1601-8. [PMID: 11375854 DOI: 10.1097/00000539-200106000-00050] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J A May
- Department of Anesthesiology, Medicine, the Medical College of Wisconsin, Milwaukee, 53226, USA
| | | | | | | | | |
Collapse
|
22
|
Hernández-Palazón J, Tortosa JA, Martínez-Lage JF, Pérez-Ayala M. Rocuronium-induced neuromuscular blockade is affected by chronic phenytoin therapy. J Neurosurg Anesthesiol 2001; 13:79-82. [PMID: 11294462 DOI: 10.1097/00008506-200104000-00003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients receiving chronic anticonvulsant therapy have been reported to show resistance to certain nondepolarizing neuromuscular blockers. In this study, the effects of chronic phenytoin therapy on the onset, duration, and recovery of rocuronium action was assessed. Thirty-six patients scheduled for various neurosurgical procedures were studied: 18 receiving chronic phenytoin therapy (Group I) and 18 controls (Group II). Rocuronium 0.6 mg/kg (2 x DE95) was administered after induction of general anesthesia with 4-6 mg/kg thiopental sodium and 3-5 microg/kg intravenous (IV) fentanyl. Maintenance anesthesia consisted of N2O in O2, 0.5% end-tidal isoflurane, and a fentanyl infusion. Neuromuscular block was monitored with acceleromyography of the adductor pollicis-brevis muscle by using a TOF-GUARD Biometer monitor (Biometer International A/S, Odense, Denmark). According to the amplitude of the first response of train-of-four, neither the lag time nor the onset time differed between the two groups. However, the recovery index was significantly shorter in patients chronically treated with phenytoin (mean recovery index: control group, 8.3 +/- 1.7 minutes; phenytoin group, 6.7 +/- 2.3 minutes; P < .05). In addition, the times of recovery to 10%, 25%, 75%, and 90% of the baseline response were also significantly shorter in the phenytoin group than in the control group. We conclude that the duration of action of rocuronium and the recovery index were affected by chronic phenytoin therapy.
Collapse
Affiliation(s)
- J Hernández-Palazón
- Department of Anesthesia, Hospital Universitario, Virgen de la Arrixaca, Murcia, Spain
| | | | | | | |
Collapse
|
23
|
Soriano SG, Sullivan LJ, Venkatakrishnan K, Greenblatt DJ, Martyn JA. Pharmacokinetics and pharmacodynamics of vecuronium in children receiving phenytoin or carbamazepine for chronic anticonvulsant therapy. Br J Anaesth 2001; 86:223-9. [PMID: 11573664 DOI: 10.1093/bja/86.2.223] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The pharmacokinetics and time course of action of vecuronium in normal children and children receiving anticonvulsant drugs for prolonged periods were characterized. A bolus dose of vecuronium 0.15 mg kg(-1) was administered i.v. to 10 non-epileptic children and to 10 children on phenytoin and 10 children on carbamazepine, who were matched for age and weight. Plasma concentrations of vecuronium, 3-OH desacetylvecuronium (the primary metabolite of vecuronium) and alpha1-acid glycoprotein (AAG) were determined. Pharmacokinetic variables were derived from plasma samples collected before and after administration of vecuronium. Neuromuscular transmission was monitored by evoked compound electromyography. Recovery of the first twitch of the train-of-four (T1/T0) and the recovery index (RI), the time for 25-75% recovery of T1/T0, were determined. The elimination half-life of vecuronium was significantly reduced in both anticonvulsant groups compared with control [control 48.2 (SD 40.3), phenytoin 23.5 (13.1), carbamazepine 18.4 (16.6) min, P<0.05]. Vecuronium clearance was increased in both anticonvulsant groups [control 9.0 (3.6), phenytoin 15.1 (8.9), carbamazepine 18.8 (13.1) ml kg(-1) min(-1), 0.05<P<0.1]. Children on chronic anticonvulsant therapy had a significantly shorter RI than control [control 21.8 (11), phenytoin 12.5 (8.3), carbamazepine 10.6 (5.9) min, P<0.05]. Concentrations of vecuronium at different degrees of recovery of T1, volumes of distribution and AAG concentrations were not different between groups. Our data confirm anticonvulsant-induced resistance to vecuronium in children and support a pharmacokinetic component contributing to the resistance.
Collapse
Affiliation(s)
- S G Soriano
- Department of Anesthesia, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | |
Collapse
|
24
|
Viby-Mogensen J, Ostergaard D, Donati F, Fisher D, Hunter J, Kampmann JP, Kopman A, Proost JH, Rasmussen SN, Skovgaard LT, Varin F, Wright PM. Pharmacokinetic studies of neuromuscular blocking agents: good clinical research practice (GCRP). Acta Anaesthesiol Scand 2000; 44:1169-90. [PMID: 11065197 DOI: 10.1034/j.1399-6576.2000.441002.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In September 1997, an international consensus conference on standardization of studies of neuromuscular blocking agents was held in Copenhagen, Denmark. Based on the conference, a set of guidelines for good clinical research practice (GCRP) in pharmacokinetic studies of neuromuscular blocking agents is presented. Guidelines include: design of the study; relevant patient groups to investigate; test drug administration, sampling and analysis; pharmacokinetic analysis; pharmacokinetic/pharmacodynamic modeling; population pharmacokinetics; statistics; and presentation of pharmacokinetic data. The guidelines are intended to aid those working in this research area; it is hoped that they will assist researchers, editors of scientific papers, and pharmaceutical companies in improving the quality of pharmacokinetic studies.
Collapse
Affiliation(s)
- J Viby-Mogensen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Koenig MH, Edwards LT. Cisatracurium-induced neuromuscular blockade in anticonvulsant treated neurosurgical patients. J Neurosurg Anesthesiol 2000; 12:314-8. [PMID: 11147379 DOI: 10.1097/00008506-200010000-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients treated with the anticonvulsants phenytoin or carbamazepine are resistant to steroidal neuromuscular blocking agents. We studied the effect of cisatracurium on onset, duration, and speed of recovery from neuromuscular blockade (NMB) in acutely anticonvulsant treated patients ([< 2 weeks] [AA]), chronically anticonvulsant treated patients ([> 2 weeks] [CA]) and patients not on anticonvulsants ([controls] [C]). After Internal Review Board approval, 10 AA, 14 CA, and 14 C neurosurgical patients were studied. Anesthetic induction was midazolam, fentanyl, and thiopental, and maintenance was fentanyl and 0.5 MAC isoflurane in O2. The evoked compound electromyogram of the hypothenar eminence was monitored (TOF supramaximal stimulus at 2 Hz every 20 seconds). Baseline TOF was established, then cisatracurium (0.2 mg/kg) was administered IV. Onset (time to maximal paralysis), duration [time to recovery of first twitch (T1) to 25% of baseline] and speed of recovery (time of recovery from 10%-25% of baseline) were recorded. Data were analyzed using ANOVA. Onset (C = 4 +/- 2, AA = 3 +/- 1, CA = 3 +/- 1.5 minutes) and duration (C = 69 +/- 13, AA = 64 +/- 19, CA = 59 +/- 19 minutes) were not different among the groups (P > .7). Speed of recovery was significantly faster in both AA (6 +/- 2 minutes) and CA (6 +/- 3 minutes) than in C (12 +/- 9 minutes) patients (P < .05). (Data = mean +/- SD). Onset and duration of cisatracurium-induced neuromuscular relaxation was not affected by acute or chronic anticonvulsant treatment, but speed of recovery was significantly faster. Frequent NMB monitoring is necessary to detect the greater speed of recovery in anticonvulsant-treated patients during cisatracurium muscle relaxation.
Collapse
Affiliation(s)
- M H Koenig
- Department of Anesthesiology, University of Illinois at Chicago, 60612-7239, USA
| | | |
Collapse
|
26
|
Suzuki T, Nakamura T, Saeki S, Ogawa S. Vecuronium-induced neuromuscular blockade in a patient with cerebral palsy and hemiplegia. Anesth Analg 2000; 91:492-3. [PMID: 10910874 DOI: 10.1097/00000539-200008000-00049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated vecuronium-induced neuromuscular block in both arms of a patient with cerebral palsy and hemiplegia. A remarkable resistance to vecuronium was observed in the hemiplegia side compared with cerebral palsy side. Complete recovery from neuromuscular block should be assessed in the cerebral palsy side that shows a delayed recovery.
Collapse
Affiliation(s)
- T Suzuki
- Department of Anesthesiology, Surugadai Nihon University Hospital, Tokyo, Japan.
| | | | | | | |
Collapse
|
27
|
Suzuki T, Nakamura T, Saeki S, Ogawa S. Vecuronium-Induced Neuromuscular Blockade in a Patient with Cerebral Palsy and Hemiplegia. Anesth Analg 2000. [DOI: 10.1213/00000539-200008000-00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Soriano SG, Kaus SJ, Sullivan LJ, Martyn JA. Onset and duration of action of rocuronium in children receiving chronic anticonvulsant therapy. Paediatr Anaesth 2000; 10:133-6. [PMID: 10736074 DOI: 10.1046/j.1460-9592.2000.00472.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The onset and time course of action of rocuronium in normal children and children receiving anticonvulsant drugs for prolonged periods was characterized. A single bolus dose of 0.6 mg.kg-1 rocuronium was administered i.v. to seven nonepileptic patients on no medication, and eight patients on chronic anticonvulsant therapy consisting of either phenytoin, carbamazepine, or both who were age and weight matched. Neuromuscular transmission was monitored by the evoked compound electromyography of the thenar muscles using train of four stimulation every 20 s. Recovery times of the first twitch to 10%, 25%, 50%, 75% and 100% of baseline values and recovery index were obtained. The onset times were 1.05+/-0.5 and 1.41+/-0.5 min for the control and anticonvulsant groups respectively and were not significantly different. Children receiving chronic anticonvulsant therapy had significantly shorter recovery index than the control group (control 10.4+/-5.1 min, anticonvulsant 4.8+/-1.7 min, P<0.05). Furthermore, the duration of recovery to 10%, 50%, 75% and 100% of baseline T1 values was less in the anticonvulsant drug group. Our data confirm resistance to rocuronium in children on chronic anticonvulsant drugs.
Collapse
Affiliation(s)
- S G Soriano
- Department of Anesthesia, Harvard Medical School, at Children's Hospital, Boston, MA 02115, USA
| | | | | | | |
Collapse
|
29
|
|
30
|
Spacek A, Neiger FX, Spiss CK, Kress HG. Atracurium-induced neuromuscular block is not affected by chronic anticonvulsant therapy with carbamazepine. Acta Anaesthesiol Scand 1997; 41:1308-11. [PMID: 9422297 DOI: 10.1111/j.1399-6576.1997.tb04649.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients on chronic anticonvulsant therapy are relatively resistant to some nondepolarizing neuromuscular blockers. Because of the controversial reports on atracurium, the purpose of the present study was to determine the effect of long-term carbamazepine treatment on the neuromuscular block produced by this muscle relaxant. METHODS Eighteen otherwise healthy individuals scheduled for neurosurgical interventions were studied. Eight patients had received carbamazepine for an average of 41 weeks (range 4-156 weeks) prior to surgery. Ten patients without carbamazepine exposure served as controls. After premedication with oral diazepam, anaesthesia was induced with fentanyl and thiopental and maintained with nitrous oxide and isoflurane in oxygen. Atracurium was given for neuromuscular blockade and the evoked electromyogram (EMG) was recorded with a Datex Monitor NMT. RESULTS The lag time, the onset time, the duration 10%, 25%, 50%, 75% and the interval 25-75% did not differ between the groups. CONCLUSION Our results with atracurium differ from previous data demonstrating an influence of carbamazepine therapy on the pharmacokinetics and/or pharmacodynamics of other non-depolarizing muscle relaxants. As documented in this study, atracurium produces adequate neuromuscular block in patients chronically exposed to carbamazepine. Chronic carbamazepine therapy does not influence the onset time and duration of action of atracurium-induced neuromuscular block.
Collapse
Affiliation(s)
- A Spacek
- Department B of Anesthesia and General Intensive Care, University of Vienna, Austria
| | | | | | | |
Collapse
|
31
|
Nguyen A, Ramzan I. Acute In Vitro Neuromuscular Effects of Carbamazepine and Carbamazepine-10,11-Epoxide. Anesth Analg 1997. [DOI: 10.1213/00000539-199704000-00034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
32
|
Nguyen A, Ramzan I. Acute in vitro neuromuscular effects of carbamazepine and carbamazepine-10,11-epoxide. Anesth Analg 1997; 84:886-90. [PMID: 9085976 DOI: 10.1097/00000539-199704000-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We examined the acute neuromuscular effects of the anticonvulsant, carbamazepine, and its major metabolite, carbamazepine-10,11-epoxide, using the in vitro rat phrenic nerve-hemidiaphragm muscle preparation. Carbamazepine produced 8.8% +/- 2.2% (n = 12) neuromuscular paralysis as its concentration was increased from 1 to 50 microg/mL (4.2-210 microM). In contrast, carbamazepine-10,11-epoxide produced maximum paralysis of 65% +/- 8% (n = 10) in the concentration range 1-100 microg/mL (4-400 microM) and the concentration required to produce half this paralysis was 36 +/- 7 microg/mL (144 +/- 28 microM). Carbamazepine 10 microg/mL (42 microM) shifted the response-concentration curve for both a depolarizing (succinylcholine) and a nondepolarizing (atracurium) neuromuscular blocker, reducing their concentrations required for 50% paralysis by approximately 30%. In contrast, the metabolite, which was a more potent neuromuscular blocker by itself, failed to alter either succinylcholine or atracurium effect. These results concur with previous clinical reports where anticonvulsants have acutely reduced neuromuscular blocker dose requirements.
Collapse
Affiliation(s)
- A Nguyen
- Department of Pharmacy, The University of Sydney, New South Wales, Australia
| | | |
Collapse
|
33
|
Brandom BW, Yellon RF, Lloyd ME, Gronert BJ, Theroux MC, Simhi E, Chakravorti S, Venkataraman S, Dohar JE, Shapiro AM, Rimell FL, Reilly JS. Recovery from Doxacurium Infusion Administered to Produce Immobility for More Than Four Days in Pediatric Patients in the Intensive Care Unit. Anesth Analg 1997. [DOI: 10.1213/00000539-199702000-00012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
34
|
Brandom BW, Yellon RF, Lloyd ME, Gronert BJ, Theroux MC, Simhi E, Chakravorti S, Venkataraman S, Dohar JE, Shapiro AM, Rimell FL, Reilly JS. Recovery from doxacurium infusion administered to produce immobility for more than four days in pediatric patients in the intensive care unit. Anesth Analg 1997; 84:307-14. [PMID: 9024019 DOI: 10.1097/00000539-199702000-00012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Doxacurium was administered by titrated infusion to 14 pediatric patients for 4.7-12.3 days after laryngotracheal reconstruction to produce minimum spontaneous movement and less than five posttetanic movements of the first toe after stimulation of the posterior tibial nerve. Recovery was documented by stimulation of the ulnar nerve with 2 Hz for 2 s (train-of-four [TOF]) at intervals of 1 min and measurement of the ratio of the fourth to the first response (TOF ratio) at the adductor pollicis. During spontaneous recovery, the TOF ratio was between 0.4 and 0.7 for 0.6-3.3 h, mean (SEM) 2.2 (0.31) h. The TOF ratio equaled 1 between 4.7 and 23.0 h, mean (SEM) 11.0 (2.1) h after termination of doxacurium infusion. In six of the patients, weakness and decreased coordination were noted for a few days to weeks postoperatively. There were no complications related to impairment of upper airway function or ventilation in those patients who had recovery of neuromuscular transmission to the extent of TOF ratio equal to 1 prior to extubation or in those patients in whom weakness or lack of coordination was noted after tracheal extubation.
Collapse
Affiliation(s)
- B W Brandom
- Department of Anesthesiology/Critical Care Medicine, Children's Hospital of Pittsburgh, Pennsylvania 15213-2583, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|