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Muscle relaxing agents are clinically in use for general anaesthesia to optimize the conditions to the endotracheal intubation as well as the surgical conditions. Therefore different musclerelaxants with specific pharmacological characteristics are available. Many factors that depend on the condition of the patient and the used musclerelaxant agent influence the duration of the neuromuscular blockade. Rapid reversal of their effects, particularly in cases of profound blockades, proved to be difficult. In cases of postoperative residual paralysis hypoxic complications because of failure of the ventilation increase the morbidity and mortality of the perioperative period. To avoid these complications in cause of postoperative residual neuromuscular blockade it seems to be necessary to evaluate the status of the muscle function. For the tactile or visual assessment or the objective measurement of stimulation the train-of-four (TOF), double-burst (DBS) or tetanus-stimulation of peripheral nerves like the ulnar nerve may be used. Established methods for the objective monitoring of neuromuscular function is the mechanomyography (MMG), the acceleromyography (AMG), the electromyography (EMG), the kinemyography (KMG) and the phonomyography (PMG). A sufficient recovery of the neuromuscular transmission is reached to a TOF-ratio of 0,9 and should be aimed before the extubation at the end of surgery. No subjective evaluation of the neuromuscular recovery is able to identify residual paralysis above a TOF-ratio of 0,5. Recent studies suggest that objective methods should be used to monitor neuromuscular function to avoid postoperative residual blockades.

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OBJECTIVE: To assess the relative efficacy of a pacing esophageal stethoscope and intermittent boluses (40 mg) of gallamine in correcting sinus bradycardia (SB) during coronary artery surgery. DESIGN: The study was prospective, randomized, and controlled. SETTING: A community hospital. PARTICIPANTS: Fifty patients scheduled for elective coronary artery surgery. INTERVENTIONS: The patients were randomly allocated to receive treatment for an SB (less than 60 BPM) with either transesophageal atrial pacing (TAP) or gallamine. MEASUREMENTS AND MAIN RESULTS: Heart rate, blood pressure, and systemic hemodynamics were measured. The electrocardiogram was monitored for rate, rhythm, and conduction abnormalities. Twenty-four of the 25 TAP patients could be paced at a rate of 70 BPM after SB. Cardiac index increased from 1.90 to 2.56 L/min/m2. In the gallamine group, heart rate was increased from 50 to 66 BPM, but cardiac index only increased to 2.2 L/min/m2, and 2 patients developed nodal rhythms. Eight of these patients had peak heart rates over 80 BPM, and two were over 90 BPM. CONCLUSIONS: The ability to reliably and precisely control heart rate was superior with TAP compared with intermittent bolus dosing with gallamine.

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Rat neurons have shown an increase of spontaneously active fibers to systemically administered potassium channel blocking agents such as tetraethylammonium chloride (TEA) and gallamine. Neuroma formation and spontaneous activity have been associated with autotomy in rats and pain in humans. To evaluate the chemosensitivity of human neurons to potassium channel blocking agents, 9 subjects with neuroma pain underwent perineuromal injection in a single-blinded fashion of normal saline, gallamine, and lidocaine. Sodium had no effect on control pain levels, while gallamine significantly increased and lidocaine significantly decreased pain from control levels. Three of 4 patients with accompanying phantom limb pain noted an increase in pain after the injection of gallamine. The data suggest that peripheral input plays a modulating but not solitary role in both neuroma and phantom limb pain. Agents which increase potassium channel permeability or decrease sodium influx would be predicted to decreased perceived pain.

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Forty patients were investigated for serum myoglobin changes following induction of anaesthesia but before the commencement of surgery. Blood was drawn for potassium, creatinine kinase and serum myoglobin immediately prior to and 5, 10 and 20 minutes after administration of thiopentone 4 mg/kg and suxamethonium 1.2 mg/kg. Twenty patients were given either 2 mg alcuronium or 20 mg gallamine as pretreatment 2 to 3 minutes before the suxamethonium to reduce the fasciculations. Anaesthesia was maintained with artificial ventilation and alcuronium, or spontaneous ventilation with halothane. Serum myoglobin was assayed by radioimmunoassay. All pre-induction myoglobin levels were within the normal range. Of the 20 patients who were not pretreated, six showed a marked rise of serum myoglobin within 5 minutes, increasing to 150-200 micrograms/litre at 20 minutes. The remaining 14 patients had no such rise. No patients in the pretreatment group had any significant rise in serum myoglobin, suggesting that although the fasciculations were not completely abolished, there was protection against one of the effects of suxamethonium on the muscle. Although there was no clear relationship between intensity of fasciculations and increase in serum myoglobin, there was no marked rise in serum myoglobin values in any patient who did not have muscle fasciculations. There were no consistent changes in potassium or creatinine kinase in any group during the period of study.

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The cause of postoperative shivering is not known. The theories and possible remedies are reviewed. Five hundred patients were observed for the possible effect of lissive doses of gallamine, and of analgesic or benzodiazepine premedication. Diazepam premedication appeared to reduce the incidence of post-halothane shivering.

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The frequency of post-suxamethonium pain after pretreatment with small doses of non-depolarizing neuromuscular blocking agents was studied in 299 patients. Gallamine 10 and 20 mg, tubocurarine 5 mg and pancuronium 1 mg were equally effective when a 2-min interval was allowed between their injection and suxamethonium administration. Fazadinium was ineffective and caused difficulty with intubation. No evidence supporting the concept that dosage should be related to patient's weight was found. Inpatients suffered from post-suxamethonium pain as much as did outpatients.

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Eighty healthy adult patients randomly allocated to four groups received pancuronium 0.01, 0.015, 0.02 mg kg-1 or gallamine 0.3 mg kg-1 i.v. 3 min before induction. Just before induction of anaesthesia, the patients were examined for signs and symptoms of neuromuscular blockade. After induction of anaesthesia with thiopentone, suxamethonium 1.5 mg kg-1 was administered i.v. Five minutes later the second dose was injected. No serious arrhythmia was seen in any of the four groups following the repeated dose of suxamethonium. However, the highest dose of pancuronium (0.02 mg kg-1) caused an unacceptably high frequency of partial neuromuscular blockade.

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Eighty healthy patients were randomly allocated to four groups. Atropine 0.01 mg kg-1 i.v. (group I), gallamine 0.3 mg kg-1 i.v. (group II), atropine 0.01 mg kg-1 i.m. and gallamine 0.3 mg kg-1 i.v. (group III), or atropine 0.01 mg kg-1 i.v. and gallamine 0.3 mg kg-1 i.v. (group IV) were given before operation. After induction of anesthesia with thiopentone, suxamethonium 1 mg kg-1 was given i.v. The lungs were ventilated with halothane in nitrous oxide in oxygen. Five minutes later the same dose of suxamethonium was repeated. E.c.g. was monitored continuously. No serious bradycardia was observed following a second injection of suxamethonium in any group. The results suggest that thiopentone protects against suxamethonium-induced bradycardia during halothane anaesthesia.

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The effectiveness of pancuronium (1.0 to 1.5 mg), d-tubocurarine (3 mg), and gallamine (20 mg) administered three minutes before succinylcholine (1 mg/kg) in preventing muscle fasciculations and postoperative muscle pains was compared in 100 patients. Pretreatment with pancuronium abolished fasciculations and produced rapid and excellent muscle relaxation for endotracheal intubation. Both d-tubocurarine (dTc) and gallamine administered prior to succinylcholine (SCh) were inconsistent in prevention fasciculations. Muscle relaxation was significantly delayed in onset, shorter in duration, and was inadequate for intubation in the majority of patients. The 45% incidence of postoperative muscle pains in the control group decreased after pretreatment with gallamine, dTc, and pancuronium to 20%, 15%, and less than 5%, respectively. It was concluded from the present study that pancuronium is superior to dTc and gallamine for preventing SCh-induced fasciculations and postoperative muscle pains without compromising the muscle relaxation for intubation. However, pancuronium administered for pretreatment may significantly prolong the action of succinylcholine and caution is to be exercised in patients having short surgical procedures and when additional doses of muscle relaxants may be required.

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