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From the Department of Anesthesiology, Dokkyo University School of Medicine, Mibu, Tochigi 321-0293, Japan.
Address correspondence to: Shigeki Yamaguchi MD PhD. Phone: 81-282-861111; Fax: 81-282-860478; E-mail: sigeki{at}peach.ocn.ne.jp
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Methods: Patients were allocated to three groups: (1) group I: anesthesia was induced and maintained with propofol and fentanyl (n=15), (2) group II: anesthesia was induced with propofol and maintained with N2O(66%)-O2-sevoflurane 2% (n=15), (3) group III: anesthesia was induced with sevoflurane 8% using a vital capacity inhalation induction and maintained with N2O(66%)-O2-sevoflurane 2% (n=15). 0.1 mg•kg–1 vecuronium was used for paralysis three minutes after anesthetic induction and reversed using intravenous 0.04 mg•kg–1 neostigmine with 0.02 mg•kg–1 atropine when the train-of-four (TOF) ratio returned to 25%.
Results: The onset time from initial administration of vecuronium to maximal block in the group III was shorter than that in the groups I and II (139 ± 35, 193 ± 35 and 188 ± 47s, respectively: P < 0.05). The clinical duration from maximal block to 25% recovery of TOF ratio in group II and III was longer than that in the group I (47 ± 15, 48 ± 14 and 36 ± 10 min, respectively: P < 0.05). The reversal times from administration of neostigmine to 75% of TOF ratio in groups II and III were longer than that in the group I (196 ± 53, 208 ± 64 and 136 ± 28s, respectively: P < 0.05).
Conclusions: Vital capacity inhalation induction of anesthesia with sevoflurane accelerates onset and prolongs duration of vecuronium neuromuscular block compared with propofol-fentanyl anesthesia.
VITAL capacity inhalation with a high concentration of sevoflurane has been described for the rapid induction of anesthesia.1,2 A vital capacity induction technique with approximately 8% sevoflurane provides more rapid induction and reduced side effects compared with other intravenous or inhaled anesthetics.1–5
Since sevoflurane increases both intensity and duration of a non-depolarizing muscle relaxant,6–8 anesthetic induction with a high concentration of sevoflurane followed by maintenance with sevoflurane may induce a more rapid onset time and longer duration of action of non-depolarizing muscle relaxants.
The purpose of this study was to clarify the onset and duration of action of vecuronium after a high concentration sevoflurane induction of anesthesia using the vital capacity induction technique compared with the conventional techniques using propofol or propofol-sevoflurane anesthesia.
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Patients were premedicated with 0.5 mg atropine and 50 mg hydroxyzine one hour before surgery. After arriving in the operating room, the cutaneous electrodes of an accelerograph (TOF-Guard®, Organon Teknika B.V., Netherlands) were applied to the right wrist and the acceleration transducer was fastened to the right thumb. Venous cannulation was performed on the dorsum of the left hand. Indirect arterial blood pressure and pulse oximetry were monitored in the left arm. Electrocardiography, capnography and rectal temperature were also used as monitors.
Patients were randomly allocated to three groups (Table I
). In the propofol-sevoflurane and sevoflurane 8% groups, the circle system of the anesthetic machine (A-VSEVO; Aladin Cassette for Sevoflurane with Quik FilTM, Datex-Omeda, Sweden) was primed for five minutes with sevoflurane 2 or 8% in oxygen mixture at 6 l•min–1 fresh gas flow, respectively.
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The ulnar nerve was stimulated at a frequency of 2 Hz in trains lasting two seconds every 15 sec. The train-of four (TOF) stimulus was used to give single twitch height. The accelerograph was adjusted to supramaximal stimulation and the baseline response was obtained three minutes after the start of anesthetic induction in the three groups. Immediately after obtaining the baseline value, 0.1 mg•kg–1 vecuronium was administered intravenously in all groups. Ventilation was controlled after tracheal intubation, and PETCO2 was maintained between 35 to 40 mmHg during the study.
Neuromuscular block was reversed using 0.04 mg•kg–1 neostigmine with 0.02 mg•kg–1 atropine when the TOF ratio had returned to 25%.
Measurements were made of (1) onset time (T0) from initial administration of vecuronium to maximal block, (2) clinical duration (T25) from maximal block to 25% recovery of the twitch height, and (3) reversal time (TOF25–75) from the administration of neostigmine to 75% of the TOF ratio.
Data were expressed as mean ± SD. Statistical analysis of the data was performed using one-way ANOVA, followed by Bonferroni correction. Statistical significance was assumed at P < 0.05.
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). No patient experienced hypothermia during anesthesia.
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).
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Discussion |
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Inhalation anesthetics enhance the potency of non-depolarizing muscle relaxants to a different degree. Sevoflurane appears to increase both intensity and duration of neuromuscular block induced by non-depolarizing muscle relaxants. However, Ahmed et al.6 reported that the maximum onset time produced by vecuronium was not shortened by an increase of sevoflurane exposure time under sevoflurane 2%. Lowry et al.7 reported that with 1.5 MAC sevoflurane the maximum onset time after administration of mivacurium did not differ from that during propofol infusion. Furthermore, Lowry et al.8 reported that intubating conditions after 0.6 mg•kg–1 rocuronium following anesthetic induction with a vital capacity induction technique with sevoflurane 8% in oxygen 100% or intravenous administration of 2-3 mg•kg–1 propofol were similar. They assessed intubating conditions one minute after intravenous rocuronium and patients received only two to three minutes of sevoflurane inhalation. In this study, we administered vecuronium intravenously three minutes after the start of anesthetic induction with sevoflurane, and the end-tidal concentration of sevoflurane was reached between 6 to 7% in the sevoflurane 8% group. Tracheal intubation could be performed approximately two minutes after administration of vecuronium. The time from the start of anesthesia to tracheal intubation in the present study was almost double that of Lowry et al.8 A longer duration of anesthetic induction with a high concentration of sevoflurane may induce easier intubating conditions. The speed of onset of paralysis after intravenous injection of a non-depolarizing muscle relaxant is related to age, circulation time, cardiac output and regional muscle blood flow.12–16 A high concentration of volatile anesthetics may also be associated with the onset time of non-depolarizing muscle relaxants.
Anesthetic induction with sevoflurane 8% and maintenance with sevoflurane 2% induced the prolonged duration of action of vecuronium and a longer reversal time compared with intravenous anesthesia with propofol and fentanyl. However, there were no differences in recovery time or the reversal time between the propofol-sevoflurane group and the sevoflurane 8% group. This suggests that anesthetic induction with a high concentration of sevoflurane followed by maintenance of sevoflurane does not induce a longer duration of action of a non-depolarizing muscle relaxant and prolonged reversal time compared with a conventional technique using propofol and sevoflurane.
In conclusion, a vital capacity anesthetic induction technique with sevoflurane 8% may induce a more rapid onset time and may not prolong the duration of action of vecuronium compared with conventional techniques using propofol-sevoflurane anesthesia.
Accepted for publication October 9, 2000.
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2 Yurino M, Kimura H. A comparison of vital capacity breath and tidal breathing techniques for induction of anaesthesia with high sevoflurane concentrations in nitrous oxide and oxygen. Anaesthesia 1995; 50: 308–11.[Medline]
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Ahmed AAK, Kumagai M, Otake T, Kurata Y, Amaki Y. Sevoflurane exposure time and the neuromuscular blocking effect of vecuronium. Can J Anesth 1999; 46: 429–32.
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Upton RN, Huang YF. Influence of cardiac output, injection time and injection volume on the initial mixing of drugs with venous blood after i.v. bolus administration to sheep. Br J Anaesth 1993; 70: 333–8.
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