title: The clinical neuromuscular pharmacology of cisatracurium versus vecuronium during outpatient anesthesia.
abstract: Neither comparisons of the clinical neuromuscular effects of cisatracurium and vecuronium nor comparative studies of their antagonism by neostigmine have been reported. In addition, the efficacy of administering cisatracurium in divided doses has not been investigated. Accordingly, we applied supramaximal electrical stimuli to the ulnar nerve of 165 ASA physical status I and II patients receiving nitrous oxide/alfentanil/propofol anesthesia. Forty-five patients received cisatracurium 5, 10, or 15 microg/kg, and the evoked response at the adductor pollicis was recorded for 15 min. One hundred-twenty patients received cisatracurium 5, 10, or 15 microg/kg or normal saline placebo followed 5 min later by either cisatracurium 100 microg/kg or vecuronium 100 microg/kg (always after placebo). Time to clinical onset (maximal ablation of single twitch response) was measured. When the evoked response spontaneously recovered to 10% of control height, neostigmine 5, 10, 30, or 50 microg/kg or placebo was administered, and recovery of neuromuscular function was recorded for the next 15 min. The clinical onset of vecuronium without priming (2.8 +/- 0.8 min) (mean +/- SD) was significantly (P < 0.05) faster than the onset of cisatracurium without priming (4.6 +/- 1.4 min). Cisatracurium 5, 10, or 15 microg/kg administered before cisatracurium 100 microg/kg significantly (P < 0.05) accelerated the time to complete ablation of the evoked response (3.9 +/- 0.9, 2.9 +/- 0.8, or 3.0 +/- 0.9 min, respectively) compared with cisatracurium 100 microg/kg without priming. The dose of neostigmine required to achieve 50% assisted recovery of the train-of-four ratio at 5 min was significantly (P < 0.05) smaller in patients who received vecuronium (29.1 [17.9-55.3] microg/kg) (mean [95% confidence interval]) compared with those who received cisatracurium (53.7 [31.6-131.5] microg/kg). Given its faster clinical onset and greater sensitivity to antagonism by neostigmine, we conclude that vecuronium may be more suitable than cisatracurium for use in outpatient anesthesia.
  
  
  CONCLUSIONS
  We investigated the onset of muscle relaxation using intravenous vecuronium and cisatracurium and assessed the ability of neostigmine to antagonize (reverse) this effect. Our results suggest that vecuronium works faster than cisatracurium and is more sensitive to neostigmine. Vecuronium therefore may be more useful than cisatracurium in outpatient anesthesia.
authors.affiliation: Department of Anesthesiology, Brooke Army Medical Center, San Antonio, Texas 78234, USA. jwpcat@aol.com
authors.forename: J B
authors.initials: JB
authors.lastname: Stevens
authors.forename: S C
authors.initials: SC
authors.lastname: Walker
authors.forename: J P
authors.initials: JP
authors.lastname: Fontenot
mesh_terms: D000293:Adolescent; D000328:Adult; D000556:Ambulatory Surgical Procedures; D000758:Anesthesia; D001279:Atracurium / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000037:antagonists & inhibitors / Q000494:pharmacology; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004558:Electric Stimulation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction / Q000187:drug effects; D009126:Muscle Relaxation / Q000187:drug effects; D009388:Neostigmine / Q000494:pharmacology; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage / Q000037:antagonists & inhibitors / Q000494:pharmacology*; D009469:Neuromuscular Junction / Q000187:drug effects* / Q000502:physiology; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage / Q000037:antagonists & inhibitors / Q000494:pharmacology*; D009435:Synaptic Transmission / Q000187:drug effects*; D014459:Ulnar Nerve / Q000502:physiology; D014673:Vecuronium Bromide / Q000008:administration & dosage / Q000037:antagonists & inhibitors / Q000494:pharmacology*
chemical_list: D009466:Neuromuscular Blocking Agents; D003473:Neuromuscular Nondepolarizing Agents; D001279:Atracurium; D009388:Neostigmine; D014673:Vecuronium Bromide; C101584:cisatracurium