O uso de bloqueadores neuromusculares no Brasil

Maria Cristina Simões de Almeida

doi:10.1590/S0034-70942004000600016

Miscellaneous

O uso de bloqueadores neuromusculares no Brasil

Neuromuscular blockers in Brazil

Maria Cristina Simões de Almeida

http://dx.doi.org/10.1590/S0034-70942004000600016 Braz J Anesthesiol, vol.54, n6, p.850-864, 2004

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JUSTIFICATIVA E OBJETIVOS: Dados estatísticos referentes ao uso de bloqueadores neuromusculares no Brasil são desconhecidos. Este trabalho se propõe a análise estatística desse tópico. MÉTODO: Foram compiladas 831 respostas de um questionário preenchido em parte por anestesiologistas presentes ao 48º Congresso Brasileiro de Anestesiologia em Recife, 2001 e em parte via Internet, por anestesiologistas cujos endereços eletrônicos constam na página da Sociedade Brasileira de Anestesiologia (www.sba.com.br). Foram analisados os seguintes dados: tempo de contato com a especialidade, região onde atuam os anestesiologistas, uso de bloqueadores neuromusculares (BNM) em ordem de preferência, indicações do uso de succinilcolina, uso do monitor da transmissão neuromuscular, critérios para se considerar o paciente descurarizado, uso de neostigmina, forma de administração dos BNM e descrição de complicações observadas. RESULTADOS: A maioria dos anestesiologistas em questão exerce a profissão há mais de 11 anos e o maior número de respostas foi proveniente da região sudeste do Brasil. O BNM mais empregado é o atracúrio, seguido de pancurônio e succinilcolina. A succinilcolina é mais empregada na indução rápida e em crianças (80% e 25% respectivamente). Monitores da transmissão neuromuscular, 53% dos anestesiologistas nunca usam, e como critério de recuperação, 92% consideram o paciente descurarizado mediante sinais clínicos. Em 45% das vezes os profissionais empregam a neostigmina de forma rotineira, e 94% administra os BNM sob forma de bolus. Cerca de 30% registra ter havido complicação decorrente do uso de BNM. As complicações mais apontadas foram o bloqueio prolongado, o broncoespasmo grave e a curarização residual. CONCLUSÕES: O atracúrio é o bloqueador neuromuscular mais empregado no Brasil, há percentual alto de uso da succinilcolina em situações não emergenciais, o uso de monitores da transmissão neuromuscular é raro, e, como um corolário, um percentual significativo de uso de critérios eminentemente clínicos para considerar o paciente descurarizado. Registrou-se que, cerca de 30% dos anestesiologistas teve algum tipo de complicação decorrente do uso desses fármacos.

Palavras-chave

BLOQUEADORES NEUROMUSCULARES

Abstract

BACKGROUND AND OBJECTIVES: There are no statistical data on the use of neuromuscular blockers in Brazil. This study aimed at statistically analyzing this topic. METHODS: Our study has compiled 831 answers to a questionnaire filled by anesthesiologists attending the 48th Brazilian Congress of Anesthesiology in Recife, 2001, and via Internet by anesthesiologists whose e-mail addresses are in the Brazilian Society of Anesthesiology web page (www.sba.com.br). The following data were evaluated: years of experience with the specialty, region where anesthesiologists practice, neuromuscular blockers (NMB) usage in order of preference, indications for succinylcholine, neuromuscular transmission monitor usage, blockade recovery criteria, neostigmine usage, NMB administration routes and description of observed complications. RESULTS: Most anesthesiologists practice for more than 11 years and the highest number of answers have come from the Southeastern region of Brazil. Most common NMB is atracurium, followed by pancuronium and succinylcholine. Succinylcholine is more frequently used for rapid sequence induction and in children (80% and 25%, respectively). Neuromuscular transmission monitors are never used by 53% of anesthesiologists, and 92% of them use clinical signs as blockade recovery criteria. Neostigmine is routinely used by 45% of professionals and 94% of them administer NMB in bolus. Approximately 30% have referred NMB-related complications. Most frequent complications were prolonged blockade, severe bronchospasm and residual curarization. CONCLUSIONS: Atracurium is the most popular neuromuscular blocker in Brazil; there is a high percentage of succinylcholine usage in non-emergency situations; neuromuscular transmission monitors are seldom used and, as a corollary, there is a significant percentage of clinical criteria to consider patients recovered. We have observed that approximately 30% of anesthesiologists had some type of NMB-related complication.

Keywords

NEUROMUSCULAR BLOCKERS

Referencias

Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery. Annals of Surgery. 1954;140:2-34.

Berg H, Roed J, Viby-Mogensen J. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095-1103.

Viby-Mogensen J. Why should I change my practice of anaesthesia: neuromuscular blocking agents. Minerva Anestesiol. 2000;66:273-277.

Baillard C, Gehan G, Reboul-Marty J. Residual curarization in the recovery room after vecuronium. Br J Anaesth. 2000;84:394-395.

Basta SJ, Ali HH, Savarese JJ. Clinical pharmacology of atracurium besylate (BW 33A): a new non-depolarizing muscle relaxant. Anesth Analg. 1982;61:723-729.

Fisher DM, Canfell PC, Fahey MR. Elimination of atracurium in humans: contribution of Hofmann elimination and ester hydrolysis versus organ-based elimination. Anesthesiology. 1986;65:6-12.

Cooper RA, Mirakhur RK, Elliott P. Estimation of the potency of ORG 9426 using two different modes of nerve stimulation. Can J Anaesth. 1992;39:139-142.

Payne JP, Hughes R. Evaluation of atracurium in anaesthetized man. Br J Anaesth. 1981;53:45-54.

Hughes R, Chapple DJ. The pharmacology of atracurium: a new competitive neuromuscular blocking agent. Br J Anaesth. 1981;53:31-44.

Moore EW, Hunter JM. The new neuromuscular blocking agents: do they offer any advantages?. Br J Anaesth. 2001;87:912-925.

Warner DO. Intramuscular succinylcholine and laryngospasm. Anesthesiology. 2001;95:1039-1040.

Larson Jr CP. Laryngospasm - the best treatment. Anesthesiology. 1998;89:1293-1294.

Kopman AF. Neuromuscular blocking agents: new insights and old controversies. Seminars in Anesthesia, Perioperative Medicine and Pain. 2002;21:75-85.

Viby-Mogensen J. Is postoperative residual curarization still a problem?. Seminars in Anesthesia, Perioperative Medicine and Pain. 2002;21:130-134.

Sullivan M, Thompson WK, Hill GD. Succinylcholine-induced cardiac arrest in children with undiagnosed myopathy. Can J Anaesth. 1994;41:497-501.

Haeseler G, Petzold J, Hecker H. Succinylcholine metabolite succinic acid alters steady state activation in muscle sodium channels. Anesthesiology. 2000;92:1385-1391.

Rosenberg H, Gronert GA. Intractable cardiac arrest in children given succinylcholine. Anesthesiology. 1992;77:1054.

Gronert G. Succinylcholine hyperkalemia after burns. Anesthesiology. 1999;91:320-322.

Gronert GA. Cardiac arrest after succinylcholine: mortality greater with rhabdomyolysis than receptor upregulation. Anesthesiology. 2001;94:523-529.

Goudsouzian NG. Rapacuronium and bronchospasm. Anesthesiology. 2001;94:727-728.

Meakin GH, Pronske EH, Lerman J. Bronchospasm after rapacuronium in infants and children. Anesthesiology. 2001;94:926-927.

White PF. Rapacuronium: why did it fail as a replacement for succinylcholine?. Br J Anaesth. 2002;88:163-165.

Caldwell JE. Rapid sequence intubation: is rocuronium an alternative?. Seminars in Anaesthesia, Perioperative Medicine and Pain. 2002;212:99-103.

Meistelman C. Update on neuromuscular pharmacology. Curr Opin Anaesthesiol. 2001;14:399-404.

Heier T, Feiner JR, Lin J. Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesthesiology. 2001;94:754-759.

Hayes AH, Mirakhur RK, Breslin DS. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312-318.

Fisher DM. Neuromuscular blocking agents in paediatric anaesthesia. Br J Anaesth. 1999;83:58-64.

Plaud B, Goujard E, Orliaguet G. [Pharmacodynamics and safety of mivacurium in infants and children under halothane-nitrous oxide anesthesia]. Ann Fr Anesth Reanim. 1999;18:1047-1053.

Brandom BW, Gavin FF. Neuromuscular clocking drugs in pediatric anesthesia. Anesthesiology Clinics of North America. 2002;30:45-59.

Sarner JB, Brandom BW, Woelfel SK. Clinical pharmacology of mivacurium chloride (BW B1090U) in children during nitrous oxide-halothane and nitrous oxide-narcotic anesthesia. Anesth Analg. 1989;68:116-121.

Goudsouzian NG, Alifimoff JK, Eberly C. Neuromuscular and cardiovascular effects of mivacurium in children. Anesthesiology. 1989;70:237-242.

Miller RD, Rupp SM, Fisher DM. Clinical pharmacology of vecuronium and atracurium. Anesthesiology. 1984;61:444-453.

Splinter WM, Isaac LA. The pharmacoeconomics of neuromuscular blocking drugs: a perioperative cost- minimization strategy in children. Anesth Analg. 2001;93:339-344.

Caldwell JE. The problem with long-acting muscle relaxants? They cost more!. Anesth Analg. 1997;85:473-475.

Macario A, Vitez TS, Dunn B. Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology. 1995;83:1138-1144.

Bevan D. The hidden cost of anesthesia. Can J Anaesth. 2002;49:533-535.

Fawcett WJ, Dash A, Francis GA et al. Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions. Acta Anaesthesiol Scand. 1995;39:288-293.

Shorten GD, Merk H, Sieber T. Perioperative train-of-four monitoring and residual curarization. Can J Anaesth. 1995;42:711-715.

Brull SJ, Silverman DG. Neuromuscular monitoring and clinical applications: what to do, when, and why?. Seminars in Anesthesia, Perioperative Medicine and Pain. 2002;21:104-119.

Brand JB, Cullen DJ, Wilson NE. Spontaneous recovery from nondepolarizing neuromuscular blockade: correlation between clinical and evoked responses. Anesth Analg. 1977;56:55-58.

Ali HH, Wilson RS, Savarese JJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth. 1975;47:570-574.

Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86:765-771.

Mason LJ, Betts EK. Leg lift and maximum inspiratory force, clinical signs of neuromuscular blockade reversal in neonates and infants. Anesthesiology. 1980;52:441-442.

Whittaker M. Plasma cholinesterase variants and the anaesthetist. Anaesthesia. 1980;35:174-197.

Goudsouzian NG, dHollander AA, Viby-Mogensen J. Prolonged neuromuscular block from mivacurium in two patients with cholinesterase deficiency. Anesth Analg. 1993;77:183-185.

Benzer A, Luz G, Oswald E. Succinylcholine-induced prolonged apnea in a 3-week-old newborn: treatment with human plasma cholinesterase. Anesth Analg. 1992;74:137-138.

Rodriguez-Gonzalez MM, Arribas-Carrion C, Torre-Aznar C. Prolonged neuromuscular block with mivacurium. Rev Esp Anestesiol Reanim. 1997;44:328-329.

Naguib M, el-Gammal M, Daoud W. Human plasma cholinesterase for antagonism of prolonged mivacurium-induced neuromuscular blockade. Anesthesiology. 1995;82:1288-1292.

Vanderheyden BA, Reynolds HN, Gerold KB. Prolonged paralysis after long-term vecuronium infusion. Crit Care Med. 1992;20:304-307.

Partridge BL, Abrams JH, Bazemore C. Prolonged neuromuscular blockade after long-term infusion of vecuronium bromide in the intensive care unit. Crit Care Med. 1990;18:1177-1179.

Booij LH. The use of muscle relaxants in the intensive care unit. Acta Anaesthesiol Belg. 1997;48:35-44.

Sharpe MD. The use of muscle relaxants in the intensive care unit. Can J Anaesth. 1992;39:949-962.

Rossiter A, Souney PF, McGowan S. Pancuronium-induced prolonged neuromuscular blockade. Crit Care Med. 1991;19:1583-1587.

Head-Rapson AG, Devlin JC, Parker CJ. Pharmacokinetics of the three isomers of mivacurium and pharmacodynamics of the chiral mixture in hepatic cirrhosis. Br J Anaesth. 1994;73:613-618.

Eriksson LI, Lennmarken C, Wyon N. Attenuated ventilatory response to hypoxaemia at vecuronium-induced partial neuromuscular block. Acta Anaesthesiol Scand. 1992;36:710-715.

Pedersen T, Viby-Mogensen J, Ringsted C. Anaesthetic practice and postoperative pulmonary complications. Acta Anaesthesiol Scand. 1992;36:812-818.

Watkins J. Investigation of allergic and hypersensitivity reactions to anaesthetic agents. Br J Anaesth. 1987;59:104-111.

Watkins J, Wild G, Bex S. A case for co-ordinated investigation and reporting of hypersensitivity-type drug reactions in the UK. Anaesthesia. 2000;55:1127-1128.

Laxenaire MC. Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994-December 1996). Ann Fr Anesth Reanim. 1999;18:796-809.

Mertes PM, Laxenaire MC. Allergic reactions occurring during anaesthesia. Eur J Anaesthesiol. 2002;19:240-262.

Seed MJ, Ewan PW. Anaphylaxis caused by neostigmine. Anaesthesia. 2000;55:574-575.

McNicholas JJ, Harban FM. Anaphylaxis caused by neostigmine. Anaesthesia. 2000;55:1039.

Laake JH, Rottingen JA. Rocuronium and anaphylaxis - a statistical challenge. Acta Anaesthesiol Scand. 2001;45:1196-1203.

Heier T, Guttormsen AB. Anaphylactic reactions during induction of anaesthesia using rocuronium for muscle relaxation: a report including 3 cases. Acta Anaesthesiol Scand. 2000;44:775-781.

Barthelet Y, Ryckwaert Y, Plasse C. Severe anaphylactic reactions after administration of rocuronium. Ann Fr Anesth Reanim. 1999;18:896-900.

Moss J, Rosow CE. Histamine release by narcotics and muscle relaxants in humans. Anesthesiology. 1983;59:330-339.

Watkins J. Adverse reaction to neuromuscular blockers: frequency, investigation, and epidemiology. Acta Anaesthesiol Scand. 1994;102:6-10.

Escolano F, Sierra P. Allergic reactions during anesthesia. Rev Esp Anestesiol Reanim. 1996;43:17-26.

Naguib M, Magbou M. Adverse effects of neuromuscular blockers and their antagonists. M E J Anesth. 1998;14:341-373.

Bevan DR. Neuromuscular blockade. Inadvertent extubation of the partially paralyzed patient. Anesthesiol Clin North America. 2001;19:913-922.

Pleym H, Bathen J, Spigset O. Ventricular fibrillation related to reversal of the neuromuscular blockade in a patient with long QT syndrome. Acta Anaesthesiol Scand. 1999;43:352-355.

Delphin E, Jackson D, Rothstein P. Use of succinylcholine during elective pediatric anesthesia should be reevaluated. Anesth Analg. 1987;66:1190-1192.

Bowman WC. Non-relaxant properties of neuromuscular blocking drugs. Br J Anaesth. 1982;54:147-160.

Naguib M, Samarkandi AH, Bakhamees HS. Histamine-release haemodynamic changes produced by rocuronium, vecuronium, mivacurium, atracurium and tubocurarine. Br J Anaesth. 1995;75:588-592.

Durant NN, Marshall IG, Savage DS. The neuromuscular and autonomic blocking activities of pancuronium, Org NC 45, and other pancuronium analogues, in the cat. J Pharm Pharmacol. 1979;31:831-836.

Tassonyi E, Neidhart P, Pittet JF. Cardiovascular effects of pipecuronium and pancuronium in patients undergoing coronary artery bypass grafting. Anesthesiology. 1988;69:793-796.

Strazis KP, Fox AW. Malignant hyperthermia: a review of published cases. Anesth Analg. 1993;77:297-304.

O uso de bloqueadores neuromusculares no Brasil

Neuromuscular blockers in Brazil

Maria Cristina Simões de Almeida

Resumo

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Abstract

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