The level of neuromuscular block needed to suppress diaphragmatic movement during tracheal suction in patients with raised intracranial pressure: a study with vecuronium and atracurium.
The effects of tracheobronchial suction before and after neuromuscular blockade with vecuronium (0.12 mg.kg-1; ED95 x 2; group A) and atracurium (0.4 mg.kg-1; ED95 x 2; group B) on intracranial pressure were studied in 18 neurosurgical patients with a Glasgow Coma Scale < 7. Despite adequate sedation, moderate to severe diaphragmatic movements (bucking and coughing) in response to carinal stimulation with significant increases in intracranial pressure (A: 18 SD 7 to 24 SD 8 mmHg; B: 19 SD 7 to 27 SD 5 mmHg) and subsequent decreases in cerebral perfusion pressure (group A: 69 SD 11 to 63 SD 8 mmHg; group B: 63 SD 11 to 59 SD 17 mmHg) could be observed without muscle relaxation. After a bolus dose of vecuronium or atracurium, profound neuromuscular paralysis quantified by the post-tetanic count, was observed after an onset time of 253 SD 72 s (vecuronium) and 159 SD 54 s (atracurium). Slight diaphragmatic movements could be elicited in only two patients in group A and in two patients in group B during tracheal suction; intracranial pressure (group A: 20 SD 8 to 20 SD 8 mmHg; group B: 19 SD 7 to 19 SD 7 mmHg) and cerebral perfusion pressure (group A: 65 SD 13 to 65 SD 13 mmHg; group B: 66 SD 12 to 65 SD 11 mmHg) remained unchanged. When coordinating respiratory therapy in neurosurgical intensive care patients, profound neuromuscular block, quantified by a post-tetanic count of at least 5 for vecuronium and 1 for atracurium, it is necessary to rule out any impact of diaphragmatic movement on intracranial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)
Werba
A
A
Department of Anaesthesia and General Intensive Care, University of Vienna, Austria.
Klezl
M
M
Schramm
W
W
Langenecker
S
S
Müller
C
C
Gosch
M
M
Spiss
C K
CK
D000328:Adult; D001279:Atracurium / Q000494:pharmacology*; D003128:Coma / Q000503:physiopathology; D003964:Diaphragm / Q000187:drug effects* / Q000502:physiology; D005260:Female; D006801:Humans; D008297:Male; D009068:Movement / Q000187:drug effects; D011559:Pseudotumor Cerebri / Q000517:prevention & control*; D013396:Suction; D014132:Trachea; D014673:Vecuronium Bromide / Q000494:pharmacology*
D001279:Atracurium; D014673:Vecuronium Bromide