Efeitos neuromusculares e cardiovasculares do pipecurônio: estudo comparativo entre diferentes doses

Angélica de Fátima de Assunção Braga; Leandro Yoshioka; Franklin Sarmento da Silva Braga; Gloria Maria Braga Potério; José Aristeu F. Frias; Rita de Cássia Rodrigues

doi:10.1590/S0034-70942008000600003

Scientific Article

Efeitos neuromusculares e cardiovasculares do pipecurônio: estudo comparativo entre diferentes doses

Neuromuscular and cardiovascular effects of pipecuronium. A comparative study between different doses

Angélica de Fátima de Assunção Braga; Leandro Yoshioka; Franklin Sarmento da Silva Braga; Gloria Maria Braga Potério; José Aristeu F. Frias; Rita de Cássia Rodrigues

http://dx.doi.org/10.1590/S0034-70942008000600003 Braz J Anesthesiol, vol.58, n6, p.582-592, 2008

PDF

Downloads: 0

Resumo

JUSTIFICATIVA E OBJETIVOS: O pipecurônio é um bloqueador neuromuscular não-despolarizante, com propriedades similares as do pancurônio, mas desprovido de efeitos cardiovasculares. Foram avaliados os efeitos neuromusculares, as condições de intubação traqueal e as repercussões hemodinâmicas de duas diferentes doses de pipecurônio. MÉTODO: Pacientes foram distribuídos em dois grupos de acordo com a dose de pipecurônio: Grupo I (0,04 mg.kg-1) e Grupo II (0,05 mg.kg-1). A medicação pré-anestésica consistiu em midazolam (0,1 mg.kg-1) por via muscular, 30 minutos antes da operação. A indução anestésica foi obtida com propofol (2,5 mg.kg-1) precedido de fentanil (5 µg.kg-1) e pipecurônio nas doses de 0,04 e 0,05 mg.kg-1 para os Grupos I e II, respectivamente. Os pacientes foram ventilados com O2 a 100% sob máscara até a redução de 75% da amplitude da resposta a estímulo isolado (1 Hz), quando foram realizadas a laringoscopia e intubação traqueal. O isoflurano (0,5 a 1%) em mistura de O2 e N(2)0 a 50% para a manutenção da anestesia, foi introduzido logo após a intubação traqueal. Os pacientes foram ventilados mecanicamente para manter P ET CO2 entre 32 e 36 mmHg. A farmacodinâmica do pipecurônio foi avaliada por aceleromiografia. RESULTADOS: Os tempos médios e desvios-padrão para o início de ação, duração clínica (T1(25%)) e índice de recuperação (T1(25-75%)) foram: Grupo I (122,10 ± 4,18 s, 49,63 ± 9,54 min e 48,21 ± 6,72 min) e Grupo II (95,78 ± 8,91 s, 64,84 ± 13,13 min e 48,52 ± 4,95 min). O início de ação, a duração clínica e as condições de intubação traqueal foram significativamente diferentes entre os grupos. CONCLUSÕES: O pipecurônio na dose 0,05 mg.kg-1 pode ser usado em procedimentos de longa duração, nos quais é desejável evitar alterações cardiocirculatórias.

Palavras-chave

BLOQUEADORES NEUROMUSCULARES, Não-Despolarizantes, FARMACOLOGIA, FARMACOLOGIA

Abstract

BACKGROUND AND OBJECTIVES: Pipecuronium is a non-depolarizing neuromuscular blocker with similar properties to pancuronium, but without cardiovascular effects. Neuromuscular effects, conditions of tracheal intubation, and hemodynamic repercussions of two different doses of pipecuronium were evaluated.
METHOD: Patients were divided into two groups according to the dose of pipecuronium: Group I (0.04 mg.kg^-1) and Group II (0.05 mg.kg^-1). Intramuscular midazolam (0.1 mg.kg^-1) was administered 30 minutes before the surgery. Propofol (2.5 mg.kg^-1), preceded by fentanyl (5 µg.kg^-1) and pipecuronium (0.04 and 0.05 mg.kg^-1 for Groups I and II, respectively), was administered for anesthetic induction. Patients were ventilated with 100% oxygen via a face mask until a 75% reduction in the amplitude of the response to an isolated stimulus (1 Hz) is achieved, at which time laryngoscopy and intubation were carried out. Anesthetic maintenance was achieved with isoflurane (0.5 to 1%) with a mixture of 50% O₂ and N₂O. Mechanical ventilation was used to maintain P_ETCO₂ between 32 and 36 mmHg. The pharmacodynamics of pipecuronium was evaluated by acceleromyography.
RESULTS: Mean times and standard deviation for the onset of action, clinical duration (T1_25%), and recovery index (T1_25-75%) were: Group I (122.10 ± 4.18 sec, 49.63 ± 9.54 min, and 48.21 ± 6.72 min), and Group II (95.78 ± 8.91 sec, 64.84 ± 13.13 min, and 48.52 ± 4.95 min). Onset of action, clinical duration, and conditions of tracheal intubation were significantly different for both groups.
CONCLUSIONS: Pipecuronium at a dose of 0.05 mg.kg^-1 can be used in prolonged procedures in which cardiovascular changes should be avoided.

Keywords

NEUROMUSCULAR BLOCKERS, Non-depolarizing, Pipecuronium; PHARMACOLOGY: Pharmacodynamics, Pharmacokinetics.

Referências

Diefenbach C, Mellinghoff H, Buzello W. Variability of pipecuronium neuromuscular blockade. Acta Anaesthesiol Scand. 1993;37:189-191.

Larijani GE, Bartkowski RR, Azad SS. Clinical pharmacology of pipecuronium bromide. Anesth Analg. 1989;68:734-739.

Pittet JF, Tassonyi E, Morel DR. Pipecuronium-induced neuromuscular blockade during nitrous oxide-fentanyl, isoflurane, and halothane anesthesia in adults and children. Anesthesiology. 1989;71:210-213.

Boros M, Szenohradszky J, Kertesz A. Clinical experiences with pipecuronium bromide. Acta Chir Hung. 1983;24:207-214.

Melloni C. Clinical pharmacology of pipecuronium: a comparative study of its duration of action in balanced anesthesia (propofol/fentanyl) vs isoflurane. Minerva Anestesiol. 1995;61:491-500.

Sanfilippo M, Fierro G, Vilardi V. Clinical evaluation of different doses of pipecuronium bromide during nitrous-oxide-fentanyl anaesthesia in adult surgical patients. Eur J Anaesthesiol. 1992;9:49-53.

Wierda JM, Richardson FJ, Agoston S. Dose-response relation and time course of action of pipecuronium bromide in humans anesthetized with nitrous oxide and isoflurane, halothane, or droperidol and fentanyl. Anesth Analg. 1989;68:208-213.

Atherton DP, Hunter JM. Clinical pharmacokinetics of the newer neuromuscular blocking drugs. Clin Pharmacokinet. 1999;36:169-189.

Foldes FF, Nagashima H, Nguyen HD. Neuromuscular and cardiovascular effects of pipecuronium. Can J Anaesth. 1990;37:549-555.

Denman WT, Goudsouzian NG, Gelb C. Comparison of neuromuscular, cardiovascular, and histamine-releasing properties of doxacurium and pipecuronium. J Clin Anesth. 1996;8:113-118.

Mallampati SR, Gatt SP, Gugino LD. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434.

Goldberg ME, Larijani GE, Azad SS. Comparison of tracheal intubating conditions and neuromuscular blocking profiles after intubating doses of mivacurium chloride or succinylcholine in surgical outpatients. Anesth Analg. 1989;69:93-99.

Donati F. Onset of action of relaxants. Can J Anaesth. 1988;35:S52-58.

Iwasaki H, Igarashi M, Yamauchi M. The effect of cardiac output on the onset of neuromuscular block by vecuronium. Anaesthesia. 1995;50:361-362.

Kopman AF. Molar potency and the onset of action of rocuronium. Anesth Analg. 1994;78:815-816.

Puhringer FK, Mitterschiffthaler G, Khuenl-Brady KS. The onset of pipecuronium following application of the priming principle. Eur J Anaesthesiol. 1996;13:478-482.

Canga JC, Lehn CN, Tonelli D. Efeito do priming na redução da latência do pipecurônio, novo bloqueador neuromuscular não-despolarizante. Rev Bras Anestesiol. 2005;55:381-386.

Ueda N, Masuda Y, Muteki T. Dose-response relation and time course of action of pipecuronium in patients anesthetized with nitrous oxide and sevoflurane. J Anesth. 1993;7:151-156.

Stanley JC, Mirakhur RK, Bell PF. Neuromuscular effects of pipecuronium bromide. Eur J Anaesthesiol. 1991;8:151-156.

Caldwell JE, Castagnoli KP, Canfell PC. Pipecuronium and pancuronium: comparison of pharmacokinetics and duration of action. Br J Anaesth. 1988;61:693-697.

Viby-Mogensen J, Engbaek J, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents. Acta Anaesthesiol Scand. 1996;40:59-74.

England AJ, Wu X, Richards KM. The influence of cold on the recovery of three neuromuscular blocking agents in man. Anaesthesia. 1996;51:236-240.

Gencarelli PJ, Swen J, Koot HW. The effects of hypercarbia and hypocarbia on pancuronium and vecuronium neuromuscular blockades in anesthetized humans. Anesthesiology. 1983;59:376-380.

Braga AFA, Potério GMB, Braga FSS. Influência do sevoflurano e do isoflurano na duração do bloqueio neuromuscular produzido pelo rocurônio. Rev Bras Anestesiol. 2001;51:2-9.

Braga AFA, Braga FSS, Potério GMB. Influência do sevoflurano e do isoflurano na recuperação do bloqueio neuromuscular produzido pelo cisatracúrio. Rev Bras Anestesiol. 2002;52:517-524.

Cardoso LSM, Martins CR, Tardelli MA. Efeitos da lidocaína por via venosa sobre a farmacodinâmica do rocurônio. Rev Bras Anestesiol. 2005;55:371-380.

Smith DC, Booth JV. Influence of muscle temperature and forearm position on evoked electromyography in the hand. Br J Anaesth. 1994;72:407-410.

Miller RD, Way WL, Dolan WM. The dependence of pancuronium- and d-tubocurarine-induced neuromuscular blockades on alveolar concentrations of halothane and forane. Anesthesiology. 1972;37:573-581.

Brett RS, Dilger JP, Yland KF. Isoflurane causes "flickering" of the acetylcholine receptor channel: observations using the patch clamp. Anesthesiology. 1988;69:161-170.

Vitez TS, Miller RD, Eger EI 2nd. Comparison in vitro of isoflurane and halothane potentiation of d-tubocurarine and succinylcholine neuromuscular blockades. Anesthesiology. 1974;41:53-56.

Waud BE, Waud DR. The effects of diethyl ether, enflurane, and isoflurane at the neuromuscular junction. Anesthesiology. 1975;42:275-280.

Williams NE, Webb SN, Calvey TN. Differential effects of myoneural blocking drugs on neuromuscular transmission. Br J Anaesth. 1980;52:1111-1115.

Shanks CA. Pharmacokinetics of the nondepolarizing neuromuscular relaxants applied to calculation of bolus and infusion dosage regimens. Anesthesiology. 1986;64:72-86.

Fisher DM, Rosen JI. A pharmacokinetic explanation for increasing recovery time following larger or repeated doses of nondepolarizing muscle relaxants. Anesthesiology. 1986;65:286-291.

Ginsberg B, Glass PS, Quill T. Onset and duration of neuromuscular blockade following high-dose vecuronium administration. Anesthesiology. 1989;71:201-205.

Stanley JC, Carson IW, Gibson FM. Comparison of the haemodynamic effects of pipecuronium and pancuronium during fentanyl anaesthesia. Acta Anaesthesiol Scand. 1991;35:262-266.

Sarner JB, Brandom BW, Dong ML. Clinical pharmacology of pipecuronium in infants and children during halothane anesthesia. Anesth Analg. 1990;71:362-366.

Vizi ES, Kobayashi O, Torocsik A. Heterogeneity of presynaptic muscarinic receptors involved in modulation of transmitter release. Neuroscience. 1989;31:259-267.

Kerr WJ, Baird WL. Clinical studies on Org NC 45: comparison with pancuronium. Br J Anaesth. 1982;54:1159-1165.

Efeitos neuromusculares e cardiovasculares do pipecurônio: estudo comparativo entre diferentes doses

Neuromuscular and cardiovascular effects of pipecuronium. A comparative study between different doses

Angélica de Fátima de Assunção Braga; Leandro Yoshioka; Franklin Sarmento da Silva Braga; Gloria Maria Braga Potério; José Aristeu F. Frias; Rita de Cássia Rodrigues

Resumo

Palavras-chave

Abstract

Keywords

Referências

Links

Compartilhar

Braz J Anesthesiol