(Acta Anaesth. Belg., 2006, 57, 157-159) Long-lasting potentiation of a single-dose of rocuronium byamikacin : case report V. GILLIARD (*), B. DELVAUX (**), K. RUSSELL (*) and Ph. E. DUBOIS (*) Abstract : We report for the first time to our knowledge
tained with desflurane. She received 2 g cefazoline long-lasting (4 hours) potentiation of single intubating as antibioprophylaxis. Total duration was 140 min- dose of rocuronium by a single bolus of amikacin given utes and there was no residual neuromuscular 55 minutes later in a woman having no precipitating fac- blockade (NMB) at the end of the procedure (train- tor (renal failure, hepatic failure, ionic disorder, other of-four ratio (TOF) above 0,9, ulnar nerve stimula- drugs influencing neuromuscular function). This patient tion at the wrist, thumb adduction measured by had received the same rocuronium dose one month acceleromyography ; TOF-Watch®, Organon, Oss, sooner in similar circumstances (without aminoglycoside The Nederlands). The patient could be then safely antibiotic drug) and had not presented any prolongedneuromuscular blockade at this time.
Neuromuscular blockade should be monitored in every Our patient didn’t leave hospital and had to be patient receiving aminoglycoside antibiotic with even a reoperated one month later because of local infec- single intubating dose of neuromuscular blocking drug.
tion at the scar site. Before reoperation, shereceived a ten days course of amoxicilline-clavu- Key words : Neuromuscular blockade ; rocuronium ;
lanate (2 g every 8 hours). Two days before opera- tion serum creatinine was 1,18 mg/dl, CRP 37,GOT 76, GPT 34, gammaGT 37. Serum ions werenormal, including calcium and magnesium.
general anesthesia induced by exactly the same drugs including 40 mg rocuronium (a single induc- multiple drug interactions that can lead to clinically tion bolus), and maintained by propofol (50 mg/ significant potentiation. We report a case of long- hour) and sufentanil (5 to 10 mcg every 30-45 min- lasting neuromuscular blockade due to synergism utes). 55 minutes after induction of GA, patient between a single dose of rocuronium and an received amikacin (1 gram over 30 minutes), by request of the surgeon. Surgery was without prob-lem. Body temperature was kept above 35,5°C. Atthe end of the procedure, 120 minutes after induc- tion of GA, she received 2 gram of propacetamoland 100 mg of tramadol (and no NSAID), but A 62 year old female was scheduled for a lum- bar athrodesis. She had a Launois-Bensaude disease(subcutaneous fat deposition, thought to be genetic; can be associated to alcoholic liver disease, with V. GILLIARD, M.D., resident in Anesthesiology ; B. DELVAUX, megaloblastic anaemia and polyneuropathy). She M.D., anesthesiologist, resident in Intensive Care ; had history of hypertension, alcohol abuse but no evidence of polyneuropathy, gastro-duodenal ulcer, UBOIS, M.D., staff anesthesiologist.
(*) Service d’Anesthésiologie, Cliniques Universitaires de treated asthma and obesity (90 kg, 158 cm, BMI Mont-Godinne, Avenue G. Therasse, 1, B-5530 Yvoir, 36). No known allergy. She was taking beta- blocker, sartan, inhaled beta-2 mimetics and corti- (**) Acute Medicine Department, Cliniques Universitaires Saint Luc, Avenue Hippocrate, 10, B-1200 Brussels, costeroids, oral theophylline. Preop lab, EKG and chest X-ray were without particularity. The proce- Corresponding author : Philippe E. Dubois, Service
dure was performed under general anesthesia d’Anesthésiologie, Cliniques Universitaires de Mont-Godinne, Avenue G. Therasse, 1, B-5530 Yvoir, Belgium.
induced with 200 mg propofol, 25 µg sufentanil, Tel. : +32-81-42-39-11. Fax : +32-81-42-39-20.
45 mg ketamine, 40 mg rocuronium, and main- E-mail : [email protected].
Acta Anæsthesiologica Belgica, 2006, 57, n° 2 0,6 mg/kg dose, which clinical duration is 31 minu- muscular blockade. We had to wait 230 minutes to tes (15-85). The drug should then have been signi- recover the first response to TOF stimulation, and ficantly eliminated at the time of starting amikacin, 18 more minutes to recover 4 responses but still 55 minutes later. This shows how powerful can be with residual NMB (fading). We reversed NMB the potentiation between these two drugs. (2 mg neostigmine and 0,4 mg glycopyrrolate) and Amikacin-rocuronium interactions has never 10 minutes later, TOF ratio rise above 0,9 and the been reported to our knowledge. Although inter- patient could be safely extubated. Blood samples actions between aminoglycoside and neuromuscu- taken 210 minutes after injection of rocuronium lar blockade are known to be possible, there are showed serum creatinine 0,8 mg/dl and serum inconsistent. For instance, Dupuis et al found that amikacin 88 mcg/dl. Those results were obtained gentamycin and tobramycin prolonged the neuro- 210 minutes after initial bolus of rocuronium, muscular actions of vecuronium but not that of 125 minutes after the end of infusion of amikacin, atracurium (11). The long duration of NMB and 10 minutes before observing the first response (4 hours) after a single doses of amikacin and rocuronium not given concomitantly, in a patientwho did not have any precipitating factors, makethis case even more interesting. Launois-Bensaude disease doesn’t seem to be responsible of this, sinceno effect on neuromuscular junction has been Many drugs are known to interact with neuro- muscular blocking drugs (1). They include antibi- Although literature shows that neostigmine otics, inhaled anesthetics, magnesium, lithium, produce only a partial reversal of aminoglycoside- local anesthetics, antiepileptic drugs, some diuretics induced block, we were able to fully reverse it with (furosemide) and some other drugs. Some antibi- this drug. Calcium (chloride or gluconate) has been otics have been proved to be very safe (e.g. beta- shown even more effective than cholinesterase lactams) while others have proved to have neuro- inhibitors for reversal of this type of NMB, but its muscular properties by themselves (e.g. clin- use is not recommended because the antagonism damycine). Aminoglycoside can interfere with neu- that it produces is not sustained, and it may prevent romuscular transmission by inhibition of the cholin- the antibacterial effect of the antibiotic (1, 2). 4- ergic activity at a pre- and post-synaptic level (2). aminopyridine has been used for research purpose In experimental animal studies, amikacin has but is not easily available for clinical use (2).
been shown to induce NMB by itself at very high Recent data’s show that there is a high inci- doses (80 to 200 mg/kg) (3-5) and to induce NMB dence of residual NMB in clinical daily practice at clinical doses (20 mg/kg) after subthreshold until 2 hours after a single intubating dose of non- doses of d-tubocarine (0,05 mg/kg) (3). Hashimoto depolarinzing muscle relaxant with an intermediate et al documented interaction of amikacin with d- duration of action (12). Our case emphazise the tubocarine in man, and showed significant potenti- need to monitor every NMB, especially when ation of NMB at low doses (200 mg), but for a short potentiating drugs such as aminoglycoside anti- time (a few minutes) (6). KRONENFELD et al. report- biotics are administered concomitantly, which is ed a recurrence of NMB after reversal of vecuroni- frequently the case in daily practice.
um NMB, to a patient who had undergone sternalirrigation with polymyxin and amikacin (7).
However polymyxin could have played an important References
role in this recurrent NMB, as its powerfull neuro-muscular blocking properties have been well docu- 1. Naguib M., Lien C. A., Pharmacology of muscle relaxants and their antagonists. In : Miller R. D., ed., Miller’s mented (8, 9). Hasfurther and Bailey reported the Anesthesia. 6th ed., p. 481-572, Philadelphia : Elsevier case of a patient who needed tracheal reintubation and overnight mechanical ventilation in the ICU 2. Sokoll M. D., Gergis S. D., Antibiotics and neuromuscular probably due to rocuronium and neomycin interac- function, ANESTHESIOLOGY, 55, 148-59, 1981.
3. Singh Y. N., Marshall I. G., Harvey A. L., Some effects of tion (10). However, their patient received several the aminoglycoside antibiotic amikacin on neuromuscular preoperative doses of neomycin and several boluses and autonomic transmission, BR. J. ANAESTH., 50, 109-17,
of rocuronium during the surgical procedure.
4. Yamada S., Kuno Y., Iwanga H., Effects of aminoglycoside antibiotics on the neuromuscular junction : part I, INT. J.
Body Mass Index 25), our patient received a CLIN. PHARMACOL. THER. TOXICOL., 24, 130-8, 1986.
Acta Anæsthesiologica Belgica, 2006, 57, n° 2 LONG-LASTING POTENTIATION OF A SINGLE-DOSE OF ROCURONIUM BY AMIKACIN 5. Renna G., Siro-Brigiani G., Cuomo V., Comparative eval- 9. Lee C., Chen D., Nagel E. L., Neuromuscular block by uation of the neuromuscular blocking activity of three new antibiotics : polymyxin B, ANESTH. ANALG., 56, 373-77,
aminoglycoside antibiotics in rats, TOXICOL. LETT., 9, 107-
10. Hasfurther D., Bailey P., Failure of neuromuscular block- 6. Hashimoto Y., Shima T., Matsukawa S., Satou M., ade reversal after rocuronium in a patient who received Neuromuscular blocking property of amikacin in man, oral neomycin, CAN. J. ANAESTH., 43, 617-20, 1996.
TOHOKU J. EXP. MED., 125, 71-75, 1978.
11. Dupuis J. Y., Martin R., Tetrault J. P., Atracurium and 7. Kronenfeld M. A., Thomas S. J., Turndorf H., Recurrence vecuronium interaction with gentamicin and tobramycin, of neuromuscular blockade of vecuronium in a patient CAN. J. ANAESTH., 36, 107-11, 1989.
receiving polymyxin/amikacin sternal irrigation, ANESTHE- 12. Debaene B., Plaud B., Dilly M. P., Donati F., Residual SIOLOGY, 65, 93-94, 1986.
paralysis in the PACU after a single intubating dose of non- 8. Fogdall R. P., Miller R. D., Prolongation of pancuronium- depolarizing muscle relaxant with an intermediate duration induced neuromuscular blockade by polymyxin, ANESTHE- of action, ANESTHESIOLOGY, 98, 1042-8, 2003.
SIOLOGY, 40, 84-87, 1974.
Acta Anæsthesiologica Belgica, 2006, 57, n° 2

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EIS Clinical Pre-Study of Stress-Related Erectile Dysfunction Clinical Investigator Professor Giuseppe Tritto Andrology Department St. Louis Hospital Paris, France Sponsor and Monitor Mr. Albert Maarek Site of Investigation St. Louis Hospital Paris, France Final Report May 15, 2005 Summary A test group of 37 male patients with erectile dysfunction (ED) undergoing consultation i

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Demonstrate knowledge of honey grading, creaming, and packing Level 3 Credits 2 Purpose People credited with this unit standard are able to demonstrate knowledge of: the techniques and criteria used for honey grading; honey granulation, and creaming; and the process of honey packing. Subfield Status date Date version published Planned review date Entry informati

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