COMPARATIVE STUDY OF THE RESIDUAL NEUROMUSCULAR BLOCKADE BETWEEN PANCURONIUM, VECURONIUM & ROCURONIUM USING TOF (TRAIN OF FOUR) AND DBS (DOUBLE BURST STIMULATION)” :1 COMPARATIVE STUDY OF THE RESIDUAL NEUROMUSCULAR BLOCKADE BETWEEN PANCURONIUM, VECURONIUM & ROCURONIUM USING TOF (TRAIN OF FOUR) AND DBS (DOUBLE BURST STIMULATION)” Presented By: Dr. Swastika Swaro P.G. (Second Year) Department of Anaesthesiology V.S.S. Medical College, Burla Guided By: Prof. R. C. Samantaray


AIM :2 AIM Comparison for residual neuromuscular blockade between pancuronium, vecuronium and rocuronium by TOF (Train of four) DBS (Double Burst stimulation) using peripheral nerve stimulator


INTRODUCTION :3 INTRODUCTION Residual postoperative neuromuscular block causes ? Chemoreceptor sensitivity to hypoxia. Functional impairment of muscles of pharynx. Impaired ability to maintain airway. ? risk of post operative pulmonary complications.


INTRODUCTION :4 INTRODUCTION So restoration of full muscle strength is essential to achieve adequate ventillation & maintain patent airway. Diaphragm recovers from effects of neuromuscular blocking drugs earlier than adductor pollicis whose recovery is parallel to smaller muscle of airway. So using peripheral nerve stimulator at ulnar nerve site & assessing the adductor pollicis response to TOF & DBS, we can assess the state of reversal.


MATERIAL & METHODS :5 MATERIAL & METHODS Departmental approval & written consent from patients was obtained. A prospective randomized trial was conducted on 60 patients (ASA – I, II) who have received muscle relaxant during GA. Patients with Hepatic / renal disease Neuromuscular disease Taking drugs known to interact with neuromuscular blocking agents. Were excluded from study.


Slide 6:6 Premedicated with Inj. Glycopyrollate (0.005 mg/kg) IV Inj. Midazolam (0.03 mg/kg) IV Inj. Pentozocine (0.5 mg / kg) IV Induction – Thiopentone sodium (2.5%, 5 mg/kg) IV Intubation done with Succinylcholine (1.5 mg/kg) IV Maintenance with N2O:O2 (66:33%) & nondepolarising muscle relaxants. Rocuronium (0.8 mg/kg) – ‘R’ Group – 20 patients Vecuronium (0.1 mg/kg) – ‘V’ group – 20 patients Pancuronium (0.1 mg/kg) – ‘P’ group – 20 patients


Slide 7:7 At end of surgery, after clinical signs of partial recovery, reversal of neuromuscular blockade done with : Inj. Neostigmine (0.05 mg/kg) + glycopyrollate (0.008 mg/kg) IV. Then RNMB was assessed by peripheral nerve stimulator using TOF & DBS. Detection of fade done by visual & tactile evaluation In our study, we have assumed if there is no detectable fade during DBS ? TOF ratio is likely to be > 0.6* *(Ind. J. Anaesth. Feb-2005;49(1):40-43)


RESULTS :8 RESULTS There was no significant statistical difference between these 3 groups.


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Slide 10:10 In our study during TOF (after reversal) all the 4 twitches are present in all patients. But some of them have detectable fade.


Slide 11:11 If fade detected in DBS ? TOF ratio < 0.6 33% in group (R), 17% in group (V) and 39% in group (P) exhibited RNMB as defined by Fade in DBS & TOF.


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DISCUSSION :13 DISCUSSION Presence of adequate spontaneous ventillation postoperatively doesnot guarantee either restoration of complete skeletal muscle strength / complete reversal of residual neuro muscular blockade. So reversal of RNMB must be monitored by observing recovery of small muscles such as adductor pollicis. In our study detection of fade during DBS & TOF was more in group P > R > V means, RNMB was more in group P > R > V.


CONCLUSION :14 CONCLUSION Use of long acting pancuronium was associated with a significantly higher incidence of postoperative RNMB than intermediate acting rocuronium which was more than vecuronium.


REFERENCE :15 REFERENCE Sachin Patil, J. V. Divatia ; Detection of Residual neuromuscular blockade after use of NDMR : utility of DBS comparing with TOF . Ind. J. Anaeth. 2005: 4(1): 40-43. S. Khan, J.V. Divatia, R. Sareen; Comparison of residual neuromuscular blockade between two intermediate acting nondepolarizing neuromuscular blocking agents – rocuronium & vecuronium : utility of DBS comparing with TOF. Ind. J. Anaeth. 2005: 4(1): 40-43. Ali HH, Savarese JJ. Monitoring of neuromuscular function. Anesthesiology 1976; 45: 216-49. Bevan D, Smith C, Donai F. Postoperative neuromuscular blockade: A comparison between atracurium, vecuronium & pancuronium. Anesthesiolgy 1988; 69: 272-76. McEwin L, Merrick PM, Bevan DR. Residual neuromuscular blockade after cardiac surgery: pancuronium vs rocuronium. Can J Anaesth 1997; 44: 891-95. Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate acting neuromuscular blocking drugs. Anaesthesia 2001; 56: 312-18.


Slide 16:16 THANK YOU