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Edrophonium antagonism of vecuronium at varying degrees of fourth twitch recovery

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Abstract

The purpose of this study was to determine the optimal dose of edrophonium needed for successful antagonism (train-of-four ratio, or T4/T1 > 0.7) of vecuronium-induced blockade when all four twitches were visible in response to indirect train-offour (TOF) stimulation. Forty patients, scheduled for elective surgical procedures not exceeding 120 min, received vecuronium, 0.08 mg · kg−1, during thiopentone-N2O-isoflurane anaesthesia. Train-of-four stimulation was applied every 20 sec and the force of contraction of the adductor pollicis muscle was recorded. Increments of vecuronium, 0.015 mg · kg−1, were given as required. At the end of surgery, and provided that neuro-muscular activity had recovered to four visible twitches, edrophonium, 0.1 mg · kg−1, was given. Two minutes later, edrophonium, 0.1 mg · kg−1, was given if T4/T1 did not reach 0.7. After another two minutes, edrophonium, 0.2 mg · kg−1, was given if T4/T1 did not reach 0.7 or more. Finally, if T4/ T1 was still < 0.7, a dose of 0.4 mg · kg−1 was given. Seventeen patients (42.5%) required 0.1 mg · kg−1 of edrophonium for successful reversal, sixteen patients (40%) needed a cumulative dose of 0.2 mg · kg−1 and six patients (15%) required 0.4 mg · kg−1. Only one patient received 0.8 mg · kg−1. There was a good correlation between T4/ T1 two minutes after the first dose of edrophonium and pre-reversal T4/T1 (r = 0.6; P = 0.00014). All patients with pre-reversal T4/ T1 > 0.23 required at most 0.2 mg · kg−1 of edrophonium for successful reversal. We conclude that when all four twitches are clearly visible following train-of-four stimulation, small doses of edrophonium (0.1-0.2 mg · kg−1) might be sufficient to antagonize vecuronium neuromuscular blockade.

Résumé

Le but de cette étude était de déterminer la dose d’édrophonium requise pour la neutralisation de l’effet du vécuronium, lorsque les quatre éléments du train-de-quatre sont visibles. Le critère de récupération adéquate était un rapport quatrième:première réponse (T4/T1) > 0,7. On a donné 0,08 mg · kg−1 de vécuronium à quarante patients subissant une chirurgie non-urgente d’une durée inférieure à 120 minutes pendant une anesthésie au thiopental-N2O-isoflurane. On a enregistré la force de contraction de l’adducteur du pouce suite à une stimulation en train-de-quatre appliquée aux 20 secondes. Des doses additionnelles de 0,015 mg · kg−1 de vécuronium ont été administrées au besoin. A la fin de la chirurgie, les patients ont reçu 0,1 mg · kg−1 d’édrophonium, pourvu que les quatre éléments du train-de-quatre soient visibles. Deux minutes plus tard, on donnait encore 0,2 mg · kg−1 d’édrophonium si le T4/T1 < 0,7. On administrait une dose de 0,2 mg · kg−1 après un autre intervalle de deux minutes, si le T4/ T1 restait inférieur à 0,7. Enfin, une dernière injection de 0,4 mg · kg−1 d’édrophonium était donné après encore deux minutes si le seuil de T4/T1 = 0,7 n’était pas atteint. Ainsi, 17 patients (42,5%) n’ont reçu que 0,1 mg · kg−1, 16 autres (40%) ont eu besoin d’un total de 0,2 mg · kg−1, et il a fallu 0,4 mg · kg−1 chez six malades (15%). On a donné 0,8 mg · kg−1 à un seul patient. On a trouvé une bonne corrélation entre les valeurs de T4/ T1 deux minutes après et avant la première dose d’édrophonium (r = 0,6; P = 0,00014). Tous les sujets dont le T4/ T1 était supérieur à 0,23 n’ont eu besoin que de 0,2 mg · kg−1 d’édrophonium ou moins. On en conclut que lorsque les quatre éléments de train-dequatre sont bien visibles, de petites doses d’édrophonium (0,1-0,2 mg · kg−1)pourraient être suffisantes dans la neutralisation d’un bloc produit par le vécuronium.

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Correspondence to E. Donati.

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Salib, Y.M., Donati, E. & Bevan, D.R. Edrophonium antagonism of vecuronium at varying degrees of fourth twitch recovery. Can J Anaesth 40, 839 (1993). https://doi.org/10.1007/BF03009255

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Key words

  • antagonist, neuromuscular relaxants: edrophonium
  • monitoring: train-of-four
  • neuromuscular relaxants: vecuronium