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Vecuronium : New Perspective for Cardiovascular Anesthesia

Dr. Hisbullah, SpAnDramatic changes in cardiac surgical practice Anaesthesiologists to re-think their perioperative strategies a faster recovery to normal function requires anaesthetic techniques which avoid a long-lasting impact on physiological functionsHow to manage airwaysWhat sort of techniques to use for maintaining anaesthesiaProvide perioperative analgesiaUse of muscle relaxantsPerioperative Strategies can be Influenced byCardiac surgery has undergone revolutionary changes over the last two decades OP- CABGMIDCABGFast-track AnesthTECABRobotic surgeryNMB :Rapid onsetShort duration of actionEasy to titrate Post op residul MR

NMBDs in CV surgeryTachycardiaInteraction with magnesium, inhalation agent, ABAllergic reactionPost op residual curarisation

HISTORY

Kurare dipakai untuk pelemah otot dari hewan yang diburu sehingga mudah untuk ditangkapHistory of NMBA in Clinical Use1932: d-tubocurarine in patients with tetanus1940: d-tubocurarine for electroshock therapy1942: d-tubocurarine for general anesthesia1949: Succinylcholine1972: Pancuronium1980s: Vecuronium, Atracurium1990s: Mivacurium, Rocuronium, Cisatracurium8

8Publikasi pada tahun 1942 yang ditulis oleh Dr. Griffith terlihat pemakaian kurare sebagai relaksasi otot untuk anestesia umum

Morgan GE, Mikhail MS, Murray MJ. Neuromuscular blocking agents. In : Clinical Anesthesiology. 2006: 4 th edition. 205-2610Na+Na+K+K+Na+Na+Na+Na+Na+Na+Na+K+K+K+K+K+K+K+K+Junctional CleftK+K+Na+Na+Depolarizing NMBAsMuscleCell10Saat ini ada dua jenis Neuro Muscular Blocking Agents (NMBAs) yaitu :1. Yang bekerja secara depolarisasi2. Yang bekerja secara non depolarisasi

Berikut ini adalah gambaran dari cara kerja NMBA depolarisasi yaitu : berkompetisi dengan asetilkolin untuk berikatan dengan reseptor kolinergik. Dengan terikatnya reseptor asetilkolin dengan NMBA maka rangsangan kontraksi otot akan dapat dihambat sehingga otot akan terelaksasi, penggunaan NMBA tersebut juga akan membuka saluran (channel) natrium / kalium sehingga terjadi masuknya natrium ke dalam sel otot dan sebagai gantinya adalah dikeluarkannya kalium ke luar dari sel otot.

11Nondepolarizing NMBAsK+K+Na+Na+Na+Na+K+MuscleCellK+Na+K+K+Junctional Cleft11Non depolarisasi NMBA secara umum sama dengan NMBA depolarisasi yaitu berkompetisi dengan asetilkolin untuk berikatan dengan reseptor kolinergik. Dengan terikatnya reseptor asetilkolin dengan NMBA maka rangsangan kontraksi otot akan dapat dihambat sehingga otot akan relaksasi. Tetapi NMBA ini tidak menyebabkan terjadinya pertukaran elektrolit (natrium / kalium) dari dan ke dalam sel otot.

Antikolinergik menghambat kolinesterase dan meningkatkan kadar asetilkolinsehingga dapat berkompetisi dengan NMBA. Dengan demikian maka pemberian antikolinergik seperti neostigmin akan dapat menghilangkan efek penghambatan dari NMBA.Clinical Characteristics of Neuromuscular Block Drugs

Hunter, J.M.,New England Journal Medicine; Vol 332 No. 25:1691-1699

Hemmerling TM, Russo G, Bracco D. Neuromuscular blockade in cardiac surgery : an update for clinicians. Annals of Cardiac Anaesthesia 2008; 11 (2): 79-89The Ideal NMBNon-depolarizing mechanism of actionRapid onset of actionShort duration of actionRapid recoveryNon cumulativeNo cardiovascular side effectsNo histamine releaseReversible by cholinesterase inhibitorsHigh potencyPharmacologically inactive metabolites

Munford B. Practical Pharmacology of Neuromuscular Blockade. Air Medical Journal 1998: 17 (4)Vecuronium

Vecuronium is pancuronium minus a quaternary methyl group (a monoquaternary relaxant). This minor structural change beneficially alters side effects without affecting potencyMorgan GE, Mikhail MS, Murray MJ. Neuromuscular blocking agents. In : Clinical Anesthesiology. 2006: 4 th edition. 205-26Cardiovascular effects of non-depolarizing neuromuscular blockers in patients with aortic valve disease

Dosis :Vecuronium: 0,12 mg/KgAtracurium: 0,4 mg/Kg* P < 0,01 *Sethna, D.H., et al.,Canadian Journal Anaesthesia:1987:34 (8) : 582-8Vecuronium, in general, permitted the most stable cardiovascular course in patients with aortic stenosis, with no significant haemodynamic changes being observed at any measurement time.

VecuroniumGenerally, the most stable cardiovascular course in patients with aortic stenosisNo significant haemodynamic changes

Hemmerling TM, Russo G, Bracco D. Neuromuscular blockade in cardiac surgery : an update for clinicians. Annals of Cardiac Anaesthesia 2008; 11 (2): 79-89Comparison of effects of atracurium and vecuronium in cardiac surgical patientsAtracurium a statistically significant decrease in blood pressure at 2 minutes and increase in cardiac output and decrease in systemic vascular resistance at 2, 5, and 10 minutesVecuronium no statistically significant changes in any hemodynamic variable measured other than a decrease in pulmonary capillary wedge pressure 10 minutes after the drug was administered

The hemodynamic changes seen with atracurium were closely related to changes in serum histamine levels, whereas histamine level did not change after vecuroniumVecuronium may be advantageous over use of atracurium when hemodynamic stability is crucial in the anesthetic management of cardiac surgical patientsJA Gallo J.A. et al., Anesthesia & Analgesia, Vol 67, 161-165

Histamine-release Haemodynamic Change Produced by NMBA

Dosis :Vecuronium: 0,1 mg/KgAtracurium: 0,6 mg/KgN : 75 adult* P < 0,01Naguib, M., et al., British Journal Anaesthesia, 1995; 75: 588-592 *VecuroniumRelease histamine Show autonomic effectsGenerally associated with the most stable haemodynamic course in the patientsComparison of Recovery in Outpatient Arthroscopy

N : 40 adultDosis :Vecuronium : 0,1 mg/KgAtracurium : 0,5 mg/KgP < 0.01Zuurmond, W.W.A. et al., Canadian Journal of Anaesthesia, 1988; 35:2: 139-42Vecuronium Satisfactory relaxation Rapid recoveryMinimal required neostigmine for reversal of NMB Residual NMBA

N : 107 adultDosis :Vecuronium : 0,1 mg/KgRocuronium : 0.12 mg/Kg

Shabana Khan et al. Indian Journal Anaesth 2006;50(2):115-117Residual neuromuscular blockade Present in a significant proportion of patients receiving NMBAThe incidence is significant lower with Vecuronium compared rocuroniumAdvantages of NMBCV neutrality : Vecuronium, rocuronium,cisatracurium +++ Atracurium ++Intermeiate duration of action : Atracurium, cisatracurium, Vecuronium, rocuroniumLack of accumulation : Ataracurium, cisatracurium +++ Vecuronium, rocuronium ++

Vecuronium most stable cardiovascular course with no significant change of haemodynamic Vecuronium, which does not release histamineVecuronium provide satisfactory relaxation and rapid recoveryVecuronium , lower residual neuromuscular blockadeCONCLUSION

TERIMA KASIH