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Anesth Analg 2000;91:1250-1255
© 2000 International Anesthesia Research Society

GENERAL ARTICLES

Recovery from Neuromuscular Blockade After Either Bolus and Prolonged Infusions of Cisatracurium or Rocuronium Using Either Isoflurane or Propofol-Based Anesthetics

W. Scott Jellish, MD, PhD, Michael Brody, MD, Kristina Sawicki, RN, and Stephen Slogoff, MD

Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois

Address correspondence and reprint requests to W. Scott Jellish, MD, PhD, Department of Anesthesiology, Loyola University Medical Center, 2160 South First Ave., Maywood, IL 60153. Address e-mail to wjellis{at}luc.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
We examined the recovery characteristics of cisatracurium or rocuronium after bolus or prolonged infusion under either isoflurane or propofol anesthesia. Sixty patients undergoing neurosurgical procedures of at least 5 h were randomized to receive either isoflurane with fentanyl (Groups 1and 2) or propofol and fentanyl (Groups 3 and 4) as their anesthetic. Groups 1 and 3 received cisatracurium 0.2 mg/kg IV bolus, spontaneously recovered, after which time an infusion was begun. Groups 2 and 4 received rocuronium 0.6 mg/kg IV, spontaneously recovered, and an infusion was begun. Before the end of surgery, the infusion was stopped and recovery of first twitch (T1), recovery index, clinical duration, and train-of-four (TOF) recovery was recorded and compared among groups by using appropriate statistical methods. Clinical duration was shorter for rocuronium compared with cisatracurium using either anesthetic. Cisatracurium T1 75% recovery after the infusion was shorter with propofol compared with isoflurane. Cisatracurium TOF 75% recovery was similar after either bolus or infusion, but rocuronium TOF 75% recovery after the infusion was delayed. Infusion rates decreased for cisatracurium but remained relatively constant for rocuronium regardless of the anesthetic used. Isoflurane enhances the effect of both muscle relaxants but prolonged cisatracurium recovery more than rocuronium. Of the two muscle relaxants studied, rocuronium’s recovery was most affected by length of the infusion. Cisatracurium may be a more desired muscle relaxant for prolonged procedures because recovery was least affected by prolonged infusion.

Implications: This study describes the effect of different anesthetic techniques on the recovery of two different muscle relaxants, cisatracurium and rocuronium, when administered as either a single bolus or prolonged infusion during neurosurgery. This study demonstrates the feasibility of using these relaxants for these prolonged procedures.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
The recovery characteristics of rocuronium and cisatracurium have been extensively studied. The duration of action of rocuronium using a 0.6 mg/kg dose is approximately 30–40 min and its recovery index (RI), defined as the time required for the first twitch (T1) of the train-of-four (TOF) to recovery from 25% to 75% of baseline, is approximately 20 min (1). Cisatracurium has a duration of action of 45 min after a 0.1 mg/kg dose and approximately 68 min after 0.2 mg/kg (2). The RI for cisatracurium is approximately 14 min, and is similar to atracurium. Rocuronium may (3) or may not (4) have a shorter recovery time compared with cisatracurium after bolus administration under total IV anesthesia (TIVA). Both muscle relaxants appear to have little difference in their recovery characteristics when given either as a bolus or infusion (5,6). The RI for rocuronium was 16.7 min after a mean infusion time of 138 min, which is similar to that obtained after bolus dosing (7). Likewise, cisatracurium has a similar RI after bolus administration and infusions of approximately 1- to 2-h duration (2). Inhaled anesthetics may enhance the effect of rocuronium by increasing its RI and reducing infusion requirements (8), but this finding is not consistent from study to study (9). Inhaled anesthetics enhance the effect of cisatracurium more than does propofol (10).

Most previous studies conclude that accumulation of these muscle relaxants does not occur after an infusion; however, none has examined the recovery characteristics of both drugs when administered as a prolonged infusion during clinical anesthesia. We examined the recovery characteristics of both cisatracurium and rocuronium when given as a bolus or prolonged infusion under either TIVA with propofol or isoflurane. We also examined whether prolonged infusions of at least 5 h will result in a progressive increase in recovery time, and whether prolonged exposure to propofol potentiates neuromuscular blockade to the same degree as inhaled anesthetics.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After obtaining informed written consent approved by the institutional review board, 60 patients, ASA physical status II–IV, undergoing neurosurgical procedures of at least 5 h, were admitted into the study. All patients were neurologically intact before surgery. Twelve of 60 patients underwent supratentorial tumor resection and were on phenytoin 2 to 3 days before the procedure. These patients were evenly divided among the four groups. The remaining patients underwent posterior fossa surgery and were not on anticonvulsant therapy. Patients who were pregnant or breast-feeding were excluded from the study, as were those with a history of malignant hyperthermia, hypersensitivity to neuromuscular blocking drugs, alcoholism, drug addiction, psychiatric, neuromuscular, cardiovascular, renal, or hepatic impairments. Patients were also excluded if they had recently taken antibiotics known to affect the neuromuscular junction, antidepressants, or antihistamines.

Thirty minutes before surgery, each patient was given midazolam 2–4 mg IV, and during surgery, standard monitors were used. An arterial catheter was also placed in all patients for direct measurement of blood pressure and arterial blood gas tensions. Tidal volume and respiratory rate were controlled to maintain end-tidal carbon dioxide tension between 25 and 30 mm Hg. Heating pads and blankets were used to maintain esophageal temperature between 35° and 37°C. The hand from which neuromuscular transmission was assessed was wrapped in cotton wool to minimize heat loss and was immobilized with the thumb abducted. A crystallineTM skin temperature trend indicator (Sharon Inc., Tampa, FL) was placed on the inner aspect of the wrist, and skin temperature was maintained at approximately 34°C.

Before arriving in the operating room, the patients were randomized into four separate groups. As part of their anesthetics, all patients received a 70% N2O in O2 gas mixture and were given succinylcholine 1.5 mg/kg IV to facilitate intubation. Patients in Groups 1 and 2 received thiopental 5 mg/kg IV and fentanyl 2 mg · kg-1 IV for anesthetic induction. Isoflurane 0.4%–0.8% end-tidal concentration and a fentanyl infusion of 2 to 4 µg · kg-1 · h-1 were used for maintenance anesthesia. Patients randomized to Groups 3 and 4 received propofol 2 mg · kg-1 IV and fentanyl 2 mg · kg-1 IV for induction of anesthesia with propofol 100–200 µg · kg-1 · min-1 and fentanyl 2–4 µg · kg-1 · h-1 IV as a maintenance anesthetic. Both Groups 1 and 3 received cisatracurium 0.2 mg · kg-1 IV as a bolus dose. After recording spontaneous recovery times to 95% baseline electromyelogram values, a cisatracurium infusion was initiated and titrated to maintain a 90%–95% neuromuscular blockade. Groups 2 and 4 received rocuronium 0.6 mg/kg IV bolus with spontaneous recovery recorded to 95% baseline, after which an infusion of rocuronium was begun and titrated to maintain a 90%–95% neuromuscular blockade. Ninety minutes before the end of the surgical procedure, during stable anesthetic conditions, at a first twitch recovery of 5% baseline, the infusion was discontinued and the patient was allowed to spontaneously recover from the neuromuscular blockade.

The specific sequence of relaxant administration was as follows. Thirty minutes after endotracheal intubation, during stable anesthetic conditions, an evoked compound electromyogram (ECEMG) of the adductor pollicis brevis muscle was run for 3 to 10 min until a stable baseline was established. Neuromuscular transmission was monitored with a Puritan-Bennett/Datex monitor (Datex Instrumentarium, Helsinki, Finland). The ulnar nerve was stimulated supramaximally with repeated TOF stimuli (2 Hz for 2 s at 10-s intervals) by using surface electrodes placed on the medial aspect of the forearm above the wrist. The ECEMG of the adductor pollicis brevis muscle was recorded using surface electrodes placed on the radial surface of the palm between the first and second metacarpals.

The designated muscle relaxant was then given as a bolus dose and the patient was allowed to spontaneously recover to 95% baseline value, after which the infusion of muscle relaxant was begun and adjusted every 10 min until a stable 90%–95% level of neuromuscular blockade was achieved. The first six 10-min periods were used for infusion adjustment. In all patients, the block was stable within the desired range by the fifth or sixth 10-min period. This first hour was discarded from analysis. After each subsequent hour, the amount of relaxant delivered was divided by time, and the infusion rate was calculated. The ECEMG was recorded and calculated as T1 (strength of the first twitch of TOF/baseline first twitch) and TOF ratio (strength of the fourth twitch/first twitch x 100).

After bolus administration, time for T1 to recover to 25% of baseline, considered the clinical duration, was recorded. Times to T1 recovery of 10%, 15%, 20%, 25%, 50%, and 75% of baseline response were compared between bolus and infusion dosing of the same muscle relaxant using the same anesthetic technique and between like dosing using different anesthetics. Recovery times were also compared between the different muscle relaxants. The T1 5% time point was considered the zero point for recovery comparisons between bolus and infusion dosing schemes. TOF ratio times to 75% recovery of baseline values were also compared in like manner. RI, measured as the time of recovery from T1 25% to T1 75% was recorded and comparisons were made among the four different groups.

Demographic data were recorded and compared by using analysis of variance. Intergroup differences in T1 and TOF recovery times were determined using the Kolmogorov-Smirnov two sample test. This same statistical method was used to compare recovery times and RI between bolus and infusion dosing under the same anesthetic conditions. Clinical duration was compared among the different groups by using analysis of variance. All demographic and clinical duration values were expressed as mean ± SD. All recovery times were expressed as median and range values. Comparative differences of P < 0.05 were considered significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Demographic data were similar among the four groups of 15 patients each (Table 1). Infusion times ranged from 390 to 645 min.


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  		Table 1. Demographic Data and Clinical Duration Comparisons Among Groups
 
Clinical duration after bolus administration was shorter for rocuronium under both anesthetic techniques (propofol: 43.4 ± 14.9 min, isoflurane: 40.9 ± 15.9 min) than that seen with cisatracurium (propofol: 69.3 ± 15.2 min, isoflurane: 76.3 ± 16.3 min) (P < 0.05). The rate of T1 recovery, calculated by using the T1 5% value as baseline, for either muscle relaxant was compared under the two anesthetic techniques using the same dosing scheme, i.e., bolus or infusion. Cisatracurium had a shorter T1 recovery time after both bolus and infusion with propofol anesthesia compared with isoflurane (Figure 1). Rocuronium recovery was minimally affected by anesthetic technique. Within the same anesthetic group, however, infusions of relaxant were always associated with a prolonged T1 recovery when compared with bolus administration (Table 2). The RI was also longer after the infusion compared with bolus dosing with both muscle relaxants regardless of anesthetic technique (Table 2). Infusions of rocuronium seemed to prolong its RI more than that of cisatracurium.



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  		Figure 1. T1 percent recovery times compared among the four groups after bolus and infusion dosing of muscle relaxant. Iso/Cis = patients receiving isoflurane and cisatracurium, Prop/Cis = patients receiving total IV anesthesia (TIVA) with propofol and cisatracurium, Iso/Roc = patients receiving isoflurane and rocuronium, Prop/Roc = patients receiving TIVA with propofol and rocuronium. *P < 0.05 compared with Iso/Cis.

 

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  		Table 2. Median Times to Twitch (T1) and TOF Recovery to Baseline Levels After Bolus or Infusion Dosing
 
TOF ratio recovery after the infusion of cisatracurium was similar to that seen after bolus administration during either anesthetic technique (Table 2). Rocuronium, however, was associated with a significantly longer recovery after the infusion versus bolus administration during both anesthetics (Table 2).

Infusion rates after the first hour decreased over time in patients receiving cisatracurium, particularly during isoflurane anesthesia (Table 3). Mean infusion rates for rocuronium remained stable throughout the entire study in patients receiving isoflurane and decreased slightly in patients receiving TIVA with propofol (Table 3).


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  		Table 3. Mean Infusion Rates Compared Among Groups Over Time
 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Cisatracurium and rocuronium are two intermediate-duration muscle relaxants whose pharmacokinetic properties make them suitable for administration by either bolus or continuous infusion. Some neuromuscular blocking drugs given for prolonged periods may show a progressive decrease in infusion requirements because of accumulation of drug. Vecuronium for example, has been shown to accumulate during infusions lasting two to five hours (11). This was manifested by a progressive decrease in infusion requirements throughout the length of the infusion. This accumulation was thought to be attributed to the large elimination half-life for vecuronium (70 min). Recovery from neuromuscular blockade after a single dose is primarily attributed to redistribution. Long infusions will reduce the ability to redistribute drug because the peripheral compartment will become saturated over time, making recovery totally dependent on elimination. Repeated bolus dosing, rather than infusion, produces similar results (12). Recovery after repeated doses of vecuronium was slower than that of atracurium. In addition to the pharmacokinetic differences mentioned, these investigators hypothesized that vecuronium affected the prejunctional receptor to a greater degree than atracurium, and this was an additional factor in prolonging recovery of the TOF ratio after repeated doses of the drug (12). Accumulation has not been confirmed for either cisatracurium or rocuronium. This study was designed to assess the recovery characteristics of both of these drugs after bolus or prolonged infusion under clinical neurosurgical conditions using different anesthetic techniques.

After bolus administration of these relaxants, their clinical duration was unaffected by anesthetic, an observation predicted for rocuronium (9,13). Though the rate of recovery, as reflected by RI, was similar for the two drugs, clinical duration was more prolonged with cisatracurium as a result of a more prolonged duration of profound relaxation at this dose, thus confirming a previous report (3). As previously observed (8,13), neither anesthetic significantly delayed TOF recovery for rocuronium after bolus administration. TOF recovery of cisatracurium was longer under isoflurane anesthesia compared with propofol, as predicted (10), but the difference was smaller, probably as a result of the smaller concentrations of isoflurane used here (14,15).

Infusion always caused a slower recovery for each relaxant during the same anesthetic, although the mechanism for delay was not always the same. During isoflurane anesthesia, T1 recovery of both relaxants was delayed throughout recovery; during propofol, recovery was delayed by a flatter slope of RI. Our data differ from those of others, who observed no difference in recovery between bolus and infusion dosing (2,5–7). Our T1 75% median value of 38 minutes for rocuronium during isoflurane anesthesia is less than the 50 minutes reported by Shanks et al. (8), which may be explained by their significantly larger doses of isoflurane. However, our T1 75% median time for rocuronium of 39 minutes during propofol is longer than the 32 minutes reported by the same authors. Recovery characteristics for cisatracurium after the infusion also differed from other studies. We noted a prolonged RI after the infusion compared with bolus dosing under TIVA anesthesia. This is in contrast to the results obtained by Belmont et al. (2) who demonstrated no difference in RI between bolus or continuous infusion. Our value of 14 minutes is similar to their RI value after bolus administration but the 19 minutes observed after the infusion is longer than the RI noted by their group, although it is identical to that found by Mellinghoff et al. (6). These differences in RI, though not clinically important, may represent differences in infusion times between the studies. Our infusion times were all more than 300 minutes compared with other studies that used infusion times as short as 11 minutes to no longer than 200 minutes (6,8). The longer administration of muscle relaxant will saturate the peripheral compartment and concentrations of the drug will be more dependent on elimination rather than redistribution.

Comparisons of TOF recovery between bolus and infusion dosing under similar anesthetic conditions revealed significant prolongation of rocuronium after the infusion with smaller TOF recovery time increases after the infusion with cisatracurium. This difference between the muscle relaxants in TOF recovery after the infusion may be attributed to the differences in metabolism between the two drugs. Cisatracurium has been shown to be primarily cleared from the body (77%) by Hoffman degradation with a 16% renal excretion (16). This is in contrast to the almost total liver clearance of rocuronium (17). This difference in metabolism could account for the prolonged effect of rocuronium after the infusion.

A large intragroup variability was noted in recovery times for both muscle relaxants under differing anesthetic conditions. This variability may be attributed to the fact that some patients in each group were taking anticonvulsants, which are known to potentiate recovery for most nondepolarizing neuromuscular drugs (18). In addition, our population was unique because of the type and duration of surgery. These neurosurgical procedures required administration of mannitol and furosemide. Thus, these patients were volume contracted and hemoconcentrated, which could effectively change the volume of distribution of some of the drugs and increase plasma concentrations. Because each patient’s response to these diuretics is different, this may explain some of the variability noted among the groups. Hypokalemia, induced by diuresis and hyperventilation, may also antagonize neuromuscular blockade (19). The degree of hypokalemia induced in each patient was variable and could have affected recovery times to some extent. Finally, body temperature may also affect recovery from muscle relaxants. Each patient was maintained within 0.5°C of initial body temperature and no large variations were noted in extremity temperature that could explain the variability observed.

Mean infusion rates to maintain 90%–95% neuromuscular blockade were similar to values obtained in other studies (1–3 µg · kg-1 · min-1 for cisatracurium and 6–8 µg · kg-1 · min-1for rocuronium) (5–9). However, mean infusion rates were smaller for the muscle relaxants under isoflurane anesthesia compared with TIVA with propofol. This might reflect the potentiation of muscle relaxants by inhaled anesthetics not noted with anesthetic techniques using propofol (8,10,12,20). Further, reduction of infusion rate over time was more pronounced with cisatracurium, which adds to the presumption of accumulation over prolonged administration. Infusion rates of rocuronium remained constant or decreased slightly over time, which is in contrast with findings from other studies that demonstrated that vecuronium infusion requirements decreased over time (11). Though both drugs have similar properties, our results might differ because of population characteristics, age differences, or variables listed above. Recovery characteristics for cisatracurium after the infusion must also be considered even more important in light of the continuously reduced drug requirement consequent to possible accumulation.

In conclusion, both rocuronium and cisatracurium are suitable muscle relaxants for prolonged neurosurgical procedures. Rates of T1 recovery after the infusion were not affected by anesthetic technique, though potentiation of effect was noted by infusion over time for both muscle relaxants. Rocuronium’s effect was more potentiated by prolonged infusion, which was manifested by increased TOF recovery times compared with bolus administration. The RI noted for both rocuronium and cisatracurium increased after prolonged infusion compared with bolus administration, but the 20- and 24-minute median times for cisatracurium and rocuronium, respectively, were not as long as those RI times noted for the longer-acting muscle relaxants pipecuronium, pancuronium, or metocurine, which have RI times between 25 and 40 minutes. Though clinical duration is shorter for rocuronium after bolus administration, long infusions affect the recovery of rocuronium to a greater extent with some patients having TOF 75% recovery times of 70 minutes or more. Thus, some patients undergoing prolonged infusion of these muscle relaxants may need anticholinesterase supplemented reversal of neuromuscular blockade. Though the difference in RI between the two muscle relaxants after the infusion may be clinically insignificant, cisatracurium may be the muscle relaxant of choice for prolonged procedures because its recovery is least affected by length of infusion.


   Acknowledgments
 
This work was supported in part by a grant from Glaxo-Wellcome, Inc.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Agoston S. The pharmacodynamics and pharmacokinetics of Org 9426, a new nondepolarizing neuromuscular blocking agent, in patients anesthetized with nitrous oxide and halothane. Can J Anaesth 1991; 38: 430–5.
  2. Belmont M, Lien CA, Quessy S, et al. The clinical neuromuscular pharmacology of 51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology 1995; 82: 1139–45.[ISI][Medline]
  3. Naguib M, Abdul Hamid HS, Ammar A, et al. Comparative clinical pharmacology of rocuronium, cisatracurium and their combination. Anesthesiology 1998; 89: 1116–24.[ISI][Medline]
  4. Carroll MT, Mirakhur RK, Lowry DW, et al. Neuromuscular blocking effects and train of four fade with cisatracurium: comparison with other nondepolarizing relaxants. Anaesthesia 1998; 53: 1169–73.[ISI][Medline]
  5. Sparr HJ, Khuenl-Brady KS, Eriksson LT. Pharmacodynamic and pharmakokinetics of rocuronium following continuous infusion in patients during intravenous anesthesia. Eur J Anaesthesiol 1994; 11: 63–5.
  6. Mellinghoff H, Radbruch L, Diefenbach C, Buzello W. A comparison of cisatracurium and atracurium: onset of neuromuscular block after bolus injection and recovery after subsequent infusion. Anesth Analg 1996; 83: 1072–5.[Abstract]
  7. McCoy EP, Mirakhur RK, Maddineni VR, et al. Pharmacokinetics of rocuronium after bolus and continuous infusion during halothane anaesthesia. Br J Anaesth 1996; 76: 29–33.[Abstract/Free Full Text]
  8. Shanks CA, Fragen RJ, Ling D. Continuous intravenous infusion of rocuronium (ORG 9426) in patients receiving balanced enflurane or isoflurane anesthesia. Anesthesiology 1993; 78: 649–51.[ISI][Medline]
  9. Wierda JMKH, Proost JH, Shiere S, Hommes FD. Pharmacokinetics and pharmacokinetic/dynamic relationship of rocuronium bromide in humans. Eur J Anaesth 1994; 11: 66–74.
  10. Tran TV, Fiset P, Varin F. Pharmacokinetics and pharmacodynamics of cisatracurium after a short infusion in patients under propofol anesthesia. Anesth Analg 1998; 87: 1158–63.[Abstract/Free Full Text]
  11. Martineau RJ, St-Jean B, Kitts JB, et al. Cumulation and reversal with prolonged infusion of atracurium and vecuronium. Can J Anaesth 1992; 39: 670–6.[Abstract/Free Full Text]
  12. Erkola O, Karhunen U, Sandelin-Hellqvist E. Spontaneous recovery of residual neuromuscular blockade after atracurium or vecuronium during isoflurane anaesthesia. Acta Anaesthesiol Scand 1989; 33: 290–4.[ISI][Medline]
  13. Lowry DW, Mirakhur RK, McCarthy GJ, et al. Neuromuscular effects of rocuronium during sevoflurane, isoflurane and intravenous anesthesia. Anesth Analg 1998; 87: 936–40.[Abstract/Free Full Text]
  14. De Wolf AM, Freeman JA, Scott VL, et al. Pharmacokinetics and pharmacodynamics of cisatracurium in patients with end-stage liver disease undergoing liver transplantation. Br J Anaesth 1996; 76: 624–8.[Abstract/Free Full Text]
  15. Sorooshian SS, Stafford MA, Eastwood NB, et al. Pharmacokinetics and pharmacodynamics of cisatracurium in young and elderly adult patients. Anesthesiology 1996; 84: 1083–91.[ISI][Medline]
  16. Kisor DF, Schmith VD, Wargin WA, et al. Importance of the organ-independent elimination of cisatracurium. Anesth Analg 1996; 63: 1065–71.[Abstract/Free Full Text]
  17. Agoston S, Houwertjes MC, Salt PJ. A new method for studying the relationship between hepatic uptake of drugs and their pharmacodynamic effects in anaesthetized cats. Br J Pharmacol 1980; 68: 637–43.[ISI][Medline]
  18. Tempelhoff R, Modica PA, Jellish WS, Spitznagel EL. Resistance to atracurium-induced neuromuscular blockade in patients with intractable seizure disorders treated with anticonvulsants. Anesth Analg 1990; 71: 665–9.[Abstract/Free Full Text]
  19. Hill GE, Wong KC, Shaw CL, Blatnick RA. Acute and chronic changes in intra-and extracellular potassium and responses to neuromuscular blocking agents. Anesth Analg 1978; 57: 417–21.[Abstract/Free Full Text]
  20. Olkkola KT, Tammisto T. Quantitation of the interaction of rocuronium bromide with etomidate, fentanyl, midazolam, propofol, thiopentone and isoflurane using closed-loop feedback control of infusion of rocuronium. Eur J Anaesth 1994; 11: 99–100.
Accepted for publication June 19, 2000.




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Lippincott, Williams & Wilkins 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 HighWire Press