title: A method of rapid-sequence induction using high-dose narcotics with vecuronium or vecuronium and pancuronium in patients with coronary artery disease.
abstract: A method of rapid-sequence induction was studied in 18 patients undergoing coronary artery bypass grafting (CABG) to assess the adequacy of relaxation for endotracheal intubation without resulting in major changes in heart rate (HR). Ten patients received vercuronium, 0.2 mg/kg (V); and eight patients received vecuronium, 0.1 mg/kg, and pancuronium, 0.1 mg/kg (V + P). All patients then received fentanyl, 50 to 70 microg/kg, or sufentanil, 5 to 7 microg/kg, followed 60 seconds later by intubation. Patients were assessed for ulnar and mandibular nerve response to train-of-four (TOF) and tetanic (T) stimulation at 60 seconds; presence or absence of coughing or bucking; degree of vocal cord relaxation (1=none, 2=some, 3=complete relaxation); ability to intubate at 60 seconds; and changes in HR. At the time of intubation, 17 patients had four twitches to TOF and a positive response to T stimulation of the ulnar nerve, while all 18 patients had zero or one twitch to TOF and only four had a positive response to T stimulation of the mandibular nerve (P < .0001 for T and TOF, ulnar v mandibular). Coughing and bucking were not observed in any patient. Vocal cord position was "3" in 14 patients and "2" in four patients. All patients were intubated without difficulty. The mean change in HR was -4.1 beats/min for patients receiving V and +16.4 beats/min for those receiving V + P (P < .002 for change in HR), with two V + P patients developing tachycardia. It is concluded that the onset of neuromuscular blockade is more rapid in the distribution of the mandibular nerve than at the ulnar nerve; mandibular nerve stimulation is a better predictor of adequate intubating conditions; good intubating conditions can be attained with either V or V + P; and, rapid-sequence induction with V is safe from a cardiac standpoint as measured by changes in HR, but the addition of pancuronium is unnecessary.
authors.affiliation: Department of Anesthesiology, Medical College of Virginia, and McGuire Veterans Administration Medical Center, Richmond, USA.
authors.forename: M
authors.initials: M
authors.lastname: Nakatsuka
authors.forename: P
authors.initials: P
authors.lastname: Franks
authors.forename: R L
authors.initials: RL
authors.lastname: Keenan
mesh_terms: D019162:Anesthetics, Combined / Q000008:administration & dosage* / Q000009:adverse effects; D001026:Coronary Artery Bypass / Q000379:methods; D003324:Coronary Artery Disease / Q000601:surgery*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods; D008297:Male; D008340:Mandibular Nerve / Q000187:drug effects; D008875:Middle Aged; D009126:Muscle Relaxation / Q000187:drug effects; D009294:Narcotics / Q000008:administration & dosage*; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage* / Q000009:adverse effects; D010197:Pancuronium / Q000008:administration & dosage* / Q000009:adverse effects; D017409:Sufentanil / Q000008:administration & dosage; D013997:Time Factors; D014459:Ulnar Nerve / Q000187:drug effects; D014673:Vecuronium Bromide / Q000008:administration & dosage* / Q000009:adverse effects; D014827:Vocal Cords / Q000187:drug effects
chemical_list: D019162:Anesthetics, Combined; D009294:Narcotics; D003473:Neuromuscular Nondepolarizing Agents; D014673:Vecuronium Bromide; D017409:Sufentanil; D010197:Pancuronium; D005283:Fentanyl