Der Anaesthesist
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Cisatracurium (51W89) is one of the ten stereoisomers of atracurium, accounting for about 15% of the racemate. The ED95 of cisatracurium was determined to be about 50 micrograms/kg (cation, molecular weight 929), while the ED95 of atracurium (besylate salt, molecular weight 1245) was 250 micrograms/kg. Thus, on a molar basis in adult patients, cisatracurium is about 3.5 times as potent as the racemic atracurium mixture. ⋯ The recovery of neuromuscular transmission from a cisatracurium infusion of up to 145 h was investigated in intensive care unit patients. Their time from the end of infusion to a train-of-four ratio > 0.7 (68 +/- 18 min) was on average only some 70% longer than after an infusion of cisatracurium for 2 h in normal surgical patients. In another study, no signs of histamine release nor any clinically relevant cardiovascular effects of cisatracurium were found in doses up to eight times ED95.
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Bacteraemia and septicaemia are generally thought to be relative or absolute contraindications for central neural axis (CNA) blocks. Postulated mechanisms for haematogenous infection of the central nervous system (CNS) caused by subarachnoid or epidural puncture might be an accidental vessel puncture, a change of pressure in the subarachnoid space, and the induction of a "locus minoris resistentiae." Infectious complications of diagnostic lumbar puncture, spinal or epidural anaesthesia are very rare. Although in animals meningitis can be induced by subarachnoid puncture during bactaeremia, there is no study that proves an increased risk for bacteraemic patients. ⋯ Based on current knowledge, bacteraemia cannot be an absolute, but only a relative contraindication for CNA blocks. Antibiotic chemoprophylaxis should be given before the puncture and the patients must be closely followed after the anaesthesia, particularly for the development of spinal epidural abscess. Because of the possibly increased risk of infectious complications, informed consent should be obtained from the patient.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Cisatracurium--is the stereoisomer an "ideal" relaxant? Histamine liberation and tryptase determination after bolus administration of cistracurium: a comparison with vecuronium].
Cisatracurium (51W89, Nimbex, Glaxo-Wellcome), an intermediate-acting non-depolarizing neuromuscular blocking agent, is a stereoisomer of atracurium. Histamine releasing propensities and serum tryptase level have been investigated after administration of cisatracurium (3 x ED95, 5 x ED95) or vecuronium (3 x ED90) in surgical patients. ⋯ In this study, with the particular time course of drug administration, neither cisatracurium nor vecuronium increased plasma histamine levels. Only after 5 x ED95 cisatracurium was 1 elevated histamine level documented after 5 min. In several studies increased histamine levels have been described, but without clinical manifestations. It is known that cutaneous signs can occur without increased plasma histamine levels due to the structural heterogeneity of mast cells. The cutaneous reactions in this study were caused by thiopentone. The tryptase values were within normal limits even in the patient with histamine release. No relationship between the positive results in the prick test and the incidence of cutaneous reactions and/or histamine release for drugs used in the induction of anaesthesia was observed. Whether cisatracurium has a potential for immunologic release is unknown.
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Since the development of prognostic score systems in intensive care medicine in the 1980s score models have improved substantially and are now based on much larger databases. They have been validated in many multicenter and international studies all over the world. Prognostic scoring systems may be used for assessment of severity of illness, stratifying patients prior to randomization in clinical trials, evaluation and comparing outcome and survival (hospital mortality), quality assessment, cost-benefit analysis, and in clinical decision making. ⋯ Advances in computer technology should assist in achieving many of the future goals of prognostic scoring systems. Most of the physiological data are available from ICU monitors and computerized laboratory systems. By electronically interfacing with the ICU monitor an automated patient data entry is possible and will provide that prognostic scores can be made available to the clinician daily.