Comparison of cis-atracurium with atracurium for balanced general anaesthesia: A randomized double blinded controlled study

 

Shyamlal Thukral¹, Mridul Panditrao^2*, Minnu Panditrao³, Shalu Punia⁴

 

 

Abstract               Background: Atracurium and Csatracurium are intermediate acting muscle relaxants without any much side effects and recovery due to non-organ dependent elimination. This study was conducted to compare the differences between them. Aim and Objective: To compare difference between Atracurium and Cis Atracrium regarding terms of onset, duration of action of first dose, 25% recovery from last supplemental dose and neostigmine reversal Material and Methods: Our study conducted was a prospective randomised observational study conducted 60 ASA Grade I, II patients. Patients were divided into two groups of 30 each. Group A (Atracurium), patients were administered atracurium 0.5 mg/kg while Group B (Cisatracurium) patients received cisatracurium 0.2 mg/kg as loading dose. The onset time, duration of block and recovery index were recorded using Train of Four (TOF) response along with the haemodynamic profile. Results: Mean duration of action (DOA) of 1ST dose in Cisatracurium group was significantly more (72.5± 2.3 min)as compared to atracurium group (40.23± 8.3mins). The mean 25% recovery in Atracurium group was 32.11±3.2 . The mean 25% recovery in Cisatracurium besylate group was 51.61±2.5. The mean 25% recovery in Atracurium and cis atracurium were statistically significantly different.(P<0.05) . 

Key Words: Non Depolarising Neuro Muscular Blockers, Benzylisoquionolium, Cis Atracurium, Atracurium, Cmparative Study, iIntermediate Acting.

 

 

 

 

 

INTRODUCTION

The neuromuscular blocking drugs (NMBDs) have revolutionized management of balanced General Anaesthesia (GA). Since the introduction of d tubocurarine and succinyl choline, there have been significant advances in the field of neuromuscular blockade. The NMBDs offer many advantages during the conduct of General Anaesthesia viz; Long Surgeries can be performed without voluntary and reflex movements, They don’t cross blood brain barrier, hence no increase of ICP (except succinyl choline). Reduction of intra operative awareness and recall, allows proper muscle relaxation for prolonged period of time, facilitates complete control of airways, breathing and circulation, maintainance of stable Haeamodynamics, lack cerebral side effects hence can be used in cerebral trauma cases also .These drugs have minimal side effects, rapid metabolism to inactive products, action confined to neuromuscular junctions only can be used in liver and renal diseases also, they don’t cross placenta can be used in obstetrtic cases. They are not without dis advantages like cardiovascular effects by benzyl iso quonololinium agents other than doxa curium can cause histamine release, Miva curium cause maximum histamine release can result into broncho constriction, flushing . Pancronium and Gallamine can cause tachycardia, Tubo curarine causes vasodilation and hypotension .Now with the introduction of newer Benzyl isoquonolinium derivatives like Atracurium and Cis Atra curium duration of action is maximum as compared to Doxa curium and Miva curium more than 30 to 40 minutes, Their elimination is through ester hydrolysis and holfman elimination a process dependant on pH and temperature whereas steroid derivativtes like Pancuronium and Vecronium, Rocuronium, Piercoronium have elimination through renal or hepatic route. Cisatracurium is a new intermediate duration, non-depolarizing, benzylisoquinolinium neuromuscular blocking drug which is a stereoisomer of atracurium with a potency of approximately 3 to 4 times greater than that of atracurium^{1, 2}. Despite the higher potency, cisatracurium is associated with more stable hemodynamics than atracurium and does not cause histamine release even at doses of up to 0.4mg/kg (8×ED₉₅).³ The same dose (2×ED₉₅) atracurium is more effective neuromuscular blocking agent than cisatracurium. However, higher doses of cisatracurium 0.2mg/kg (4×ED₉₅) and 0.3mg/kg (6×ED₉₅) provide more effective, more rapid neuromuscular blocking with longer duration of action, stable hemodynamic status and no signs of histamine release clinically during abdominal surgery.^4,5 This study was conducted to compare the atracurium and cis atracurium with respect to neuromuscular blockade and recovery characterstics.

AIM AND OBJECTIVE

To compare difference between Atracurium and Cis Atracrium with 2*ED 95 regarding terms of onset, intubating conditions after three minutes of 1_st dose, safety and efficacy of both the drugs, Heamodynamic effects, signs any adverse reaction, duration of action of first dose, 25% recovery from last supplemental dose and neostigmine reversal . Because of its intermediate, onset of action, cisatracurium is not recommended for rapid sequence endotracheal intubation in emrgancy cases (i.e., where intubation is uregently and rapidly required to minimize the time the airway is unprotected) Our study was a prospective double blinded randomized controlled study conducted in the Department of 
Anaesthesia, Adesh institute of medical sciences and research, Bathinda (Punjab). In this prospective study 60 patients undergoing all types of surgeries under balanced general anesthesia were studied.

Inclusion Criteria

1. ASA I and II
2. Age of 18 to 75 years
3. Elective surgery patients

Exclusion Criteria

1. Age above 75and below 18 yrs
2. Emergency surgery patients
3. Patient not willing to participate in study.
4. Patients with any previous history of hypersensitivity or any known side effect of drug
5. Patients at risk for gastric aspiration
6. 6. anticipated difficult airway cases
7. Pregnant and lactating mothers
8. Patients taking drugs that known to interfere with neuromuscular function like amino glycides, antibiotics anti deprresants, anti convulsants, anti arrthymic drugs
9. Patients with electrolyte Imbalance

Study was approved by ethical committee of the institute . a written valid consent was taken from patients after explaining the study to them. All cases of ASA Grade I and II were selected. 30 patients were allocated in each group randomly. 
Premedication: Premedication was given half hour before surgery. Each patient were given premedication with analgesic like Inj. Butorphanol 1 mg, Inj. Midzolam 1 mg, and Inj. Glycopyrrolate 0.2 mg half hour before surgery. 

 

MATERIAL AND METHODS

All cases were were given Ringer lactate before induction for all type of surgeries. Standard monitoring were performned with multi para monitor for ECG, HR, Spo2 Temperature, Capnograpgy before anaesthsia and during anaesthesia and neuromuscular monitoring for TOF. Patients age, sex, weight, type of surgery, informed consent and expected duration of surgery were recorded preoperatively .. Group A of 30 patients received injection Cis Atra curium 0.2mg /kg as loading for intubation as well as for conducting surgeries and maintenance dose 0.03 mg /kg. Group B patients were given injection Atracurium 0.5 mg /kg as loading dose and 0.1 mg /kg as maintenance dose. In both groups these muscle relaxants were given after premedication and induction agents like Inj. Propofol 2 mg /kg IV and inhalational agents like Oxygen 100 % 3 litres / N₂O 3 litres and Isoflurane 0.5% to 1% were given to all patients till the intubation and onset time was noted from the time of first dose of muscle relaxant to TOF 0 Zero. After intubation Oxygen and N₂O low flow 1: 1.5 L/ minute were given . Hemodynamic parameters including systolic blood pressure, diastolic blood pressure, MAP and heart rate, side effects in any were monitored one minutes, after three minutes at the time of intubation, after one minutes, three minutes at the time of intubation, after 5 minutes after administration of the first dose and then every 10 minutes throughout the surgery. Recovery profile were concluded. Using Train of Four (TOF) response with nerve stimulator using 50 Ma 2HZ power through electrodes to stimulate ulnar nerve every 15 seconds. Subsequent dose of Muscle relaxant were given when TOF was 2 . when at the end of surgery when TOF recovery was 25% from the last dose, reversal was achieved by administration of neostigmine and glycopyrrolate mixture (0.05 mg/kg neostigmine and 8µk/kg glycopyrrolate ) through slow IV injection.

RESULTS

The onset of action time was fixed as 3 minutes for intubation for both the groups . During intubation after first dose of muscle relaxant, we observed condition of larnygoscopy, vocal cords, reaction 1to intubation as under

 

Table 1:

 

Table 1: Results of in tubating condition within 3 minutes

 

Table 2: Comparison of Atracurium and Cis atracurium group according to variables