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ANESTHETIC PHARMACOLOGY

A Multicenter Evaluation of the Time-Course of Action of Two Doses of Rapacuronium After Early and Late Reversal with Neostigmine

Ghassem E. Larijani, PharmD^*, Francois Donati, MD, George Bikhazi, MD, Richard Bartkowski, MD, PhD, Charbel A. Kenaan, MD, Benoit Plaud, MD, and Michael E. Goldberg, MD^*

Departments of Anesthesiology, *University of Medicine and Dentistry of New Jersey, Camden, New Jersey; University of Montreal, Montreal, Quebec; University of Miami, Miami, Florida; and Jefferson Medical College, Philadelphia, Pennsylvania

Address correspondence and reprint requests to Ghassem E. Larijani, PharmD, Department of Anesthesiology, University of Medicine and Dentistry of New Jersey, One Cooper Plaza, Camden, NJ 08103. Address e-mail to larijage{at}umdnj.edu

Early reversal of rapacuronium may accelerate return of neuromuscular function. This study was designed to compare early (2 min after rapacuronium) or late (at 25% recovery of the first twitch [T1] of train-of-four) reversal of rapacuronium with neostigmine. We studied 119 subjects between the ages of 18 and 75 yr. Anesthesia was induced with fentanyl and thiopental and maintained with nitrous oxide, propofol, and fentanyl. Mechanomyographic neuromuscular monitoring was performed by using train-of-four stimulation of the ulnar nerve. Two groups received 1.5 mg/kg rapacuronium followed by neostigmine (50 µg/kg) and glycopyrrolate (10 µg/kg) either at 2 min after rapacuronium bolus or at 25% T1 recovery. The other two groups received 2.0 mg/kg rapacuronium, after which neostigmine was similarly given. For each rapacuronium dose, the time from the administration of rapacuronium to the start of T1 recovery or 25% T1 recovery was significantly shorter in subjects who received the reversal 2 min after rapacuronium. However, late recovery, defined by times from administration of rapacuronium to 70%, or 80% T4/T1 recovery, was not influenced by early reversal administration. We conclude that initial recovery is accelerated by early administration of neostigmine. Time to full recovery after rapacuronium administration is, however, dose-dependent and not significantly altered by early administration of neostigmine.

IMPLICATIONS: "Rescue reversal," which includes the administration of neostigmine shortly after the administration of rapacuronium, may accelerate the return of spontaneous breathing (early recovery), but does not shorten the time to complete recovery of upper airway function.

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999