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G. Pavel. Nebraska Methodist College.

In reality buy discount combivir 300mg, the response of lymphoid and bone marrow to ionizing radiation cause the greatest problems best 300mg combivir. Patients who present with nausea purchase combivir overnight, vomiting, diarrhea, and fever are likely to have severe acute radiation syndrome. Long-term effects include thyroid cancer and psychological injury, as has been documented many times in the past. Of most importance, depending on the type of catastrophe, would be the immediate evacuation of the area. If evacuation, is impossible, a safe place should be sought within the home or building. The principles of disaster management always involve containment (avoid 4259 bringing patients with material emitting ionizing radiation to the hospital). Therefore, as part of the containment process, to the extent possible, patients should be decontaminated at the site. Rather than guess whether radiation is still present, it is best to disrobe patients. In previous mass casualty situations, maintenance of casualties’ privacy has been a concern, but not one with an easy solution. Depending on the number of casualties, decontamination areas may have to be set up outside of hospitals, especially because individuals will arrive by private vehicles or on foot. Take care to isolate patients’ personal belongings, giving the same consideration to biologic fluids—including saliva, blood, urine, and stool (all of which may be contaminated with radioisotopes and may therefore require special precautions when being handled)—as for clothing. Potassium iodide can attenuate most of the radiation-induced thyroid effects, but must be given as quickly as possible because there is little protective effect if it is given more than 24 hours after exposure. Treatment is largely supportive, as these patients will develop acute radiation syndrome manifested by bleeding and sepsis. Treatment guidelines for management of postirradiation sepsis have been developed and advocated by the military. Mobilizing agents include ammonium chloride, calcium gluconate, and diuretics, which may enhance renal excretion. Granulocyte57 macrophage colony–stimulating factor and thrombopoietin or interleukin-11, though postulated, have not been proven to be of benefit. Unfortunately, in this situation, there is also the possibility that there may be the combined effects of a radiation-releasing event and the use of either chemical or biologic agents. Patients have burns, fractures, lacerations, multiple shrapnel injuries, soft tissue trauma, and traumatic amputations. As the weapons have become more sophisticated and powerful, the extent of injuries has increased significantly. Patients should be intubated, awake if possible, because a significant number of these patients will have mild-to- moderate glottic edema at the time of intubation. Those patients with burns must be managed aggressively with respect to fluid resuscitation. With polytrauma and no third-degree burns, “damage control resuscitation/surgery” is the norm. The patient’s body temperature is62 maintained and surgery is performed as soon as possible to stop the bleeding, thereby decreasing the need for blood products and the chances of developing a dilutional coagulopathy. Patients who do develop a coagulopathy appear to benefit from a ratio of packed red blood cells to fresh frozen plasma to platelets of 1:1:1. In patients with crush injury and markedly elevated creatine phosphokinase, alkalinization of the urine- forced diuresis may attenuate renal failure from myoglobinuria. Conclusion Although it is unlikely that an anesthesiologist will be at the initial site of a natural or intentional disaster, it could happen. Most likely, anesthesiologists will become involved if the hospital at which they work provides care for a number of these patients. As suggested for several of these situations,65 4261 airway management and ventilator management may be critical, as would the establishment of intravascular access and volume resuscitation. Obviously, it is critical to have a high index of suspicion if you are managing the index case, or two or more patients, with presenting signs and symptoms that are suggestive of the use of a biologic weapon. The individual who is the point of contact for the index case should notify the hospital infectious disease specialist and the local and state health departments. Factors that might indicate the intentional release of a biologic agent would include unusual temporal or geographic clustering of cases, an uncommon age distribution, or a significant number of cases (more than one) of acute flaccid paralysis that might suggest use of botulinum toxin. If called to the hospital to be involved in managing such a catastrophe, the anesthesiologist must review basic decontamination and isolation techniques and, as mentioned previously, must follow those guidelines scrupulously. It is clear that anesthesiologists have the requisite training and experience to be of vital importance in managing such casualties. However, based on their training, they may not be emotionally prepared to manage these patients. They must remember that unlike their normal practice, they may have to triage patients, accept the fact that the standard of care may be different, and focus their efforts on interventions that will carry the greatest benefit for the greatest number of casualties. This process begins when the anesthesiologist gets the call at home or in the hospital regarding an impending mass casualty event. One must also develop one’s own family care plan in anticipation of absence from the home for extended periods of time. Ensuring one’s own safety through the appropriate use of protective devices to serve as barriers against radiologic, biologic, and chemical weapons is also of vital importance. Preparing to deliver care under austere circumstances, developing creative responses, and practicing (simulations) regularly will mitigate the effects of a disaster and increase resilience for individuals, teams, and institutions. Engendering enthusiasm for sustainable disaster critical care response: why this is of consequence to critical care professionals? Disaster preparedness of Canadian trauma centres: the perspective of medical directors of trauma. A survey assessment of the level of preparedness for domestic terrorism and mass casualty incidents among eastern association for the surgery of trauma members. Willingness to respond: Of emergency department personnel and their predicted participation in mass casualty terrorist events. Health care at the crossroads: strategies for creating and sustaining community-wide 4265 emergency preparedness systems. Implementing the hospital emergency incident command system: an integrated delivery system’s experience. Mass casualties and healthcare following the release of toxic chemicals or radioactive material: contribution of modern biotechnology. Operative trauma in low-resource settings: the experience of Medicins Sans Frontieres in environments of conflict, post conflict, and disaster. A comparison of the neuroprotective efficacy of newly developed oximes (K117, K127) and currently available oxime (obidoxime) in tabun-poisoned rats. Primary brain targets of nerve agents: the role of the amygdala in comparison to the hippocampus. Responding to a small-scale bioterrorist anthrax attack: cost-effectiveness analysis comparing pre-attack vaccination with postattack antibiotic treatment and vaccination.

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The38 dobutamine (−) isomer progressively stimulates the α -adrenoceptor as1 infusion rates increase above 5 μg⋅kg−1⋅min−1 combivir 300mg overnight delivery. The α -1 823 adrenoceptor agonist effect of higher doses of dobutamine also serves to blunt the baroreceptor reflex-mediated tachycardia that might otherwise occur generic combivir 300mg line. Nevertheless purchase generic combivir line, dobutamine often increases heart rate by direct β -1 adrenoceptor-mediated positive chronotropic and dromotropic effects. In fact, dobutamine produced significantly higher heart rates than epinephrine at equivalent values of cardiac index in patients after coronary artery surgery. This is the underlying principle behind dobutamine stress echocardiography as a diagnostic tool for the detection of coronary artery disease because regional wall motion abnormalities in the affected coronary perfusion territories occur in response to the myocardial oxygen supply–demand mismatch during transient infusion of the drug. Conversely, dobutamine often reduces heart39 rate in patients with heart failure because increases in cardiac output and oxygen delivery improve tissue perfusion and reduce chronically elevated sympathetic nervous system tone. Dobutamine modestly decreases pulmonary arterial pressures and pulmonary vascular resistance through β -adrenoceptor stimulation. Thus,2 dobutamine may be a useful positive inotropic drug in intensive care unit patients with pulmonary arterial hypertension. However, this dobutamine-induced pulmonary vasodilation has the potential to exacerbate ventilation–perfusion mismatch, increase transpulmonary shunt, and contribute to relative hypoxemia. Nevertheless, dobutamine remains a useful drug for the treatment of depressed myocardial contractility in patients with 824 sepsis. Isoproterenol has a low affinity for and does not exert activity at the α-adrenoceptor. As a result, isoproterenol increases heart rate and myocardial contractility and decreases arterial pressure through β - and β -adrenoceptor agonist effects, respectively. Isoproterenol was also used during cardiac transplantation to increase heart rate and enhance myocardial contractility in the deneverated donor organ. However, transcutaneous or transvenous pacing has largely replaced the catecholamine for heart rate control in modern practice, especially in view of the drug’s propensity to precipitate adverse supraventricular and ventricular tachyarrhythmias. Thus, although the clinical applicability of isoproterenol is quite limited at present, the comparison of the pharmacology of isoproterenol with other catecholamines merits continued discussion. Isoproterenol causes β -adrenoceptor–mediated arteriolar vasodilation in2 renal, mesenteric, splenic, and skeletal muscle circulations. Isoproterenol causes direct positive chronotropic and dromotropic effects and increases heart rate because of β -adrenoceptor activation. Tachycardia also1 occurs because hypotension stimulates baroreceptor reflex-mediated increases in heart rate. For example,2 isoproterenol, unlike dobutamine, did not increase cardiac output in patients undergoing coronary artery or valve replacement surgery. Predictably, the hemodynamic effects of isoproterenol cause dose-related increases in myocardial oxygen consumption. The synthetic catecholamine also reduces coronary perfusion pressure and decreases diastolic filling time. These alterations in myocardial oxygen supply–demand relations may contribute to the development of acute myocardial ischemia or cause subendocardial 825 necrosis, even in the absence of coronary artery disease. Thus, isoproterenol may be especially deleterious in patients with flow-limiting coronary stenoses. Selective β -Adrenoceptor Agonists2 A number of short- and long-acting selective β -adrenoceptor agonists,2 including metaproterenol, albuterol, salmeterol, and fenoterol, are currently in clinical use for treatment of asthma and chronic obstructive pulmonary disease. A hydroxyl substitution on the phenyl ring or a large moiety attached to the amino group of a catecholamine’s basic chemical structure increases the molecule’s relative β -adrenoceptor affinity. These drugs stimulate β -2 2 adrenoceptors in bronchial smooth muscle to produce bronchodilation, reduce airway resistance, and improve obstructive symptoms. Reductions in histamine and leukotriene release from pulmonary mast cells, and improvements in mucociliary function may also contribute to beneficial effects of selective β -adrenoceptor agonists in patients with reactive airway2 disease. However, the β -adrenoceptor2 selectivity of these drugs progressively decreases and β -adrenoceptor–1 mediated adverse effects (e. Terbutaline is another β -adrenoceptor2 agonist that is administered subcutaneously or intramuscularly and may be useful in the management of status asthmaticus. The drug dilates35 mesenteric, splenic, and renal arterioles, increases renal blood flow, decreases renal vascular resistance, reduces systemic vascular resistance, improves creatinine clearance, and promotes both natriuretic and diuretic effects. Fenoldopam was initially developed as an antihypertensive medication because of its actions as a vasodilator, but the drug may also be capable of46 protecting the kidney against radiographic contrast-induced nephropathy, presumably by virtue of enhanced renal blood flow. For example, a large meta-analysis based primarily on small single center studies suggested that fenoldopam may reduce the risk of acute tubular necrosis, the need for renal replacement therapy, and overall 826 mortality in patients with or at risk for acute kidney injury. Unfortunately,49 large randomized controlled clinical trials have failed to support these promising early results. Thus, despite the fact that fenoldopam is a52 potent direct renal vasodilator and promotes increased urine output, the drug does not appear to exert clinically meaningful protection against renal injury. Intravenous fenoldopam has a rapid onset of action as an antihypertensive medication. Unlike the findings with intravenous nitrovasodilators (see below), tolerance to fenoldopam’s antihypertensive effects does not appear to occur. Rebound hypertension has also not been observed with abrupt discontinuation of the drug. The most common adverse effects of fenoldopam are related to its effects as a vasodilator and include hypotension, tachycardia, flushing, dizziness, headache, tachycardia, and nausea. Sympathomimetics Ephedrine The sympathomimetic drug ephedrine exerts both direct and indirect actions on adrenoceptors. Endocytosis of ephedrine into α - and β -adrenoceptor1 1 presynaptic postganglionic nerve terminals displaces norepinephrine from the synaptic vesicles. The displaced norepinephrine is then released to activate the corresponding postsynaptic receptors to cause arterial and venous vasoconstriction and increased myocardial contractility, respectively. Indeed, ephedrine’s initial cardiovascular effects resemble those of epinephrine because dose-related increases in heart rate, cardiac output, and systemic vascular resistance are observed. However, ephedrine is less potent than epinephrine, and the indirect acting sympathomimetic’s duration of action is longer than that of the endogenous catecholamine. Ephedrine also directly stimulates β -adrenoceptors, which limits the increases in arterial pressure2 that occur as a result of α -adrenoceptor activation. Tachyphylaxis to1 ephedrine’s hemodynamic effects occurs with repetitive administration of the drug because presynaptic norepinephrine stores are quickly depleted and ephedrine is released from synaptic vesicles as a false neurotransmitter instead. In contrast, tachyphylaxis does not occur with epinephrine because 827 the endogenous catecholamine directly stimulates α- and β-adrenoceptors independent of norepinephrine displacement and release. The most common clinical use of ephedrine during anesthesia is treatment of acute decreases in arterial pressure concomitant with bradycardia. Ephedrine was previously used for the treatment of hypotension in laboring parturients because the drug increases uterine blood flow, but phenylephrine may be preferred in this setting because ephedrine crosses the placenta and may cause fetal acidosis. As a result of this minor structural difference, phenylephrine almost exclusively stimulates α -adrenoceptors to1 increase venous and arterial vasomotor tone while exerting little or no effect on β-adrenoceptors. In contrast to ephedrine, phenylephrine acts directly on the α -adrenoceptor and is not dependent on presynaptic norepinephrine1 displacement to produce its cardiovascular effects. Phenylephrine constricts venous capacitance vessels and causes cutaneous, skeletal muscle, mesenteric, splenic, and renal vasoconstriction.

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Depth of Anesthetic Monitoring Recent reports of awareness in up to 1% of children who received general anesthesia for elective surgery have attracted considerable attention order combivir overnight. To reduce the risk of awareness order generic combivir canada, the anesthetic concentration of sevoflurane should be neither interrupted nor dramatically decreased early in anesthesia or during surgical stimulation; at least 0 purchase combivir pills in toronto. Emergency Drugs Emergency drugs should always be available before inducing anesthesia. In the latter situations, preloaded syringes of phenylephrine (10 μg/mL) and epinephrine (10 μg/mL) should also be available. Full Stomach and Rapid Sequence Induction The term full stomach refers to the presence of residual solid or liquid foods in the stomach at induction of anesthesia, a condition that places the child at risk for regurgitation and aspiration. A full stomach is assumed to be present in children who require emergency surgery, in those with gastric dysmotility syndromes, and in those with diabetes. A full stomach may be caused by the trauma, pain, and stress of the injury as well as by the administration of opioids, which increase gastric and intestinal paresis and further delay emptying of food from the stomach. In emergency surgery, the only time interval that correlates with the risk of food remaining in the stomach is the interval between ingestion of food and the trauma or opioid administration. Induction of anesthesia may include propofol (2 to 4 mg/kg), ketamine (1 to 2 mg/kg), or etomidate (0. If an inhalational induction is performed, unexpected regurgitation may necessitate rotating the child quickly into the left lateral decubitus position and pharyngeal suctioning to prevent aspiration. However, there are some concerns regarding the application of cricoid pressure in infants. In both infants and children, the cricoid ring and trachea are mobile and deformable, and as little as 5 N force can compress the infant’s airway by 50%. Cricoid pressure may also increase the level of difficulty of tracheal intubation by distorting tracheal anatomy or compressing the cricoid ring. Very few assistants are trained properly in locating the cricoid ring and in how much force is required to occlude the esophagus. The practitioner should understand the advantages and disadvantages of cricoid pressure in infants and children in order to make an informed decision regarding its use. Preoperative Preparation 3092 Anxiolysis It is important to reduce anxiety in children undergoing anesthesia and surgery. Anxiety is greater when preschool age and withdrawn children are separated from their parents, when anxious parents accompany their children, and when multiple personnel, bright lights, and loud noises are present at induction of anesthesia. Each of these factors should be addressed on an institutional basis to reduce the overall anxiety in young children scheduled for surgery. Goal-directed therapy for the child should primarily attenuate the child’s anxiety preoperatively and anticipate more anxiety at induction of anesthesia and, secondarily, address the parental anxiety. Parents who are most insistent on being present at induction of anesthesia are often the most disruptive, least likely to calm their child, and actually promote further noncompliant behavior in their child. Parents should never be invited to accompany their child for induction, lest both the hospital and the medical personnel find themselves responsible for any untoward sequelae that occur. Some cognitively challenged adolescents and children may resist the transfer to the operating room. Distraction Techniques Preoperative coloring books, stories, videos, and websites may be used to help children of all ages learn about surgery and anesthesia and the equipment that will be used for induction of anesthesia. Child-life providers may help children defuse anxiety on the day of surgery by having the children play with the mask and flavor the inside using lip balm. Other 3093 distraction techniques including video games, earphones, and portable Internet devices as well as music and clowns all reduce children’s anxiety. Once the child enters the operating room, the anesthesiologist should establish rapport (distract) with the child by telling a story, engaging them in conversation about a recent birthday, holiday, or vacation, or by singing as they prepare for induction of anesthesia. Pharmacologic Sedation For some, a premedication may be required to facilitate smooth separation from their parents. It should be noted that most premedications do not delay recovery and/or hospital discharge for surgeries at least 30 minutes in duration. The dose of oral midazolam increases with decreasing age, although few bother to consider this very important factor. To minimize the aftertaste, the dose should be swallowed in a single bolus and then followed with a small volume of water. For children too young to swallow midazolam from a cup, it should be instilled into the lateral gutters of the mouth using a needleless syringe to prevent the child from spitting it out. Judgment should be exercised when considering oral midazolam premedication for a child who is crying continuously as few strategies, including parental presence at induction, may provide anxiolysis. Alternative oral premedications include ketamine (5 to 6 mg/kg),108 clonidine (2 μg/kg),253 and dexmedetomidine (2 μg/kg). Some have combined oral midazolam and ketamine in a 50:50 mixture with good success. Both clonidine and dexmedetomidine take 60 to 3094 90 minutes to effect sedation and anxiolysis. They may produce bradycardia and sedation that persist beyond the duration of the anesthetic. By this route, ketamine has an onset of action of 3 to 5 minutes and a duration of 30 to 40 minutes. Induction Techniques Inhalational Induction In North America, the most common technique for inducing anesthesia in children undergoing elective surgery is an inhalational induction. Infants and children of all ages, including those who are crying and upset, can be successfully anesthetized using this approach. Distracting upset and crying children using a warm, reassuring, and calm manner often permits a successful induction of anesthesia by face mask. The notion that distraught children should be treated with “brutane” by holding children down and forcing a mask on their face with 8% sevoflurane flowing has no place in pediatric anesthesia and may psychologically scar the child for life. If the child had a poor previous experience with anesthesia, it is important to understand the nature of the past experience and design an anesthetic to minimize their anxiety. In preschool-age children, distraction techniques and premedication are key strategies to minimize the anxiety associated with separating from their 3095 parents and undergoing induction of anesthesia. The author offers children (>3 years of age) a choice of several flavored lip balms to mark inside the mask. For younger children (<3 years of age), the author flavors the face mask for them. The smell obscures the plastic smell of the mask but more importantly it distracts the child and offers a topic for discussion. Troposmia, which means a distorted perception of an odor, is an interesting strategy in which the child is told that the flavor that was applied to the mask will transform into his/her favorite flavor as anesthesia is induced. Using this approach, 80% of children interviewed postoperatively confirmed that they smelled their favorite flavor as they were anesthetized.

A comparison of remifentanil patient- controlled analgesia with epidural analgesia during labour combivir 300 mg on-line. Timing of intravenous patient- 1351 controlled remifentanil bolus during early labor cheap combivir amex. Remifentanil patient controlled analgesia versus epidural analgesia in labour: a randomised multicentre equivalence trial generic combivir 300 mg free shipping. Differences in maternal temperature during labour with remifentanil patient-controlled analgesia or epidural analgesia: a randomised controlled trial. Sex-related differences in the influence of morphine on ventilatory control in humans. Side effects of opioids during short- term administration: effects of age, gender and race. Opioid-related side-effects in children undergoing surgery: Unequal burden on younger girls with higher doses of opioids. Clinical testing (such as 5-second head-lift, grip strength, vital capacity, tidal volume) is notoriously inaccurate, and despite its wide clinical use, does not exclude residual neuromuscular block. When using subjective and clinical methods of assessment, the incidence of postoperative residual paralysis is 30% to 40%. This restores normal neuromuscular transmission, but the reversal of nondepolarizing block is limited (cholinesterase inhibitors have a ceiling effect). Physiology and Pharmacology Morphology of the Neuromuscular Junction Lower motor neurons, whose cell bodies are located in the ventral horn of the spinal cord and the motor nuclei of cranial nerves, project their axons via the ventral roots to control effector organs (muscles and glands). The somatic motor neurons are typically large-diameter, myelinated, and fast conducting; as the axons approach their endings, they lose their myelin sheaths before branching into terminal fibers. The number of muscle fibers 1355 that each neuron innervates (innervation ratio) determines the precision of the muscle contraction: for muscle groups that require very fine control (e. For large muscles that require coarse, powerful movement (thigh or back muscles), the innervation ratio approaches 1:2,000. The initial fetal receptor density is relatively low, approximately 1,000 receptors/ μm. The K channels in the nerve terminal+ area limit the extent of Ca2+ entry into the terminal, and regulate the transmitter quantal release, initiating nerve membrane repolarization. During the first 2 postnatal weeks, each2 postsynaptic motor site is innervated by multiple presynaptic nerve terminals. The central channel allows Na influx and K efflux, resulting in muscle cell+ + membrane depolarization. Voltage-gated Na channels on the muscle+ membrane propagate the action potential across the membrane, leading to the development of muscle tension (excitation–contraction coupling). Nondepolarizing agents can be classified further according to their chemical structure (benzylisoquinolinium or steroidal) or to their duration of action (short-, intermediate, or long-duration; see later). Potency of a drug is determined by the dose required to produce a certain effect and is calculated from the dose-response sigmoidal curve (Fig. Onset time is inversely related to dose, and can be affected by its rate of delivery to the site of action (blood flow, speed of injection, etc. This desensitization then leads to flaccid paralysis after the initial receptor activation (which is manifested clinically as muscle “fasciculations”). Additionally, after a brief period of high-frequency stimulation (tetanus), there is no increase (amplification) in the force of subsequent muscle contractions (no posttetanic potentiation—see later; Fig. This is characterized by fade of responses to repetitive stimulation and amplification of muscle responses after high- frequency stimulation (posttetanic potentiation—see later), similar to the changes observed during nondepolarizing block (Fig. Premature ventricular escape beats are also common; cardiac effects can be attenuated by pretreatment with anticholinergics. Myalgias are also very common 1 1362 to 2 days postoperatively and can occur in 50% to 60% of patients. Fasciculations have been considered a possible etiology for postoperative myalgia, but systematic reviews have not established a clear relationship. However, this technique may render susceptible patients at risk of regurgitation and pulmonary aspiration because of partial paralysis of pharyngeal muscles. Alternatively, because of large interindividual variability, pretreatment may be ineffective in some patients. In fact, otherwise innocuous settings, such as the 1363 Valsalva maneuver while playing wind instruments, can significantly (+9. It has the shortest clinical duration (5 to 10 minutes at 1 mg/kg dose), so most patients will resume some diaphragmatic function before significant apnea-induced hypoxia occurs; it has the shortest onset time (1 minute at 1. Intubating conditions are plotted against dose of remifentanil (in micrograms per kilogram). Results for succinylcholine (Sux), 1 mg/kg (with little opioid) are given for comparison. Patients with pseudocholinesterase (butyrylcholinesterase) deficiency are at risk of unintended intraoperative awareness and recall if they are awakened while paralyzed and neuromuscular monitoring is not used. In the intensive care setting, patients can be at increased risk of significant hyperkalemia (>6. Unlike depolarizing blockade, which is potentiated by the administration of anticholinesterases, the nondepolarizing block can be antagonized by these agents as long as the depth of block at the time of reversal is not excessive. They also can be classified based on their chemical structure as aminosteroid (vecuronium, rocuronium, pancuronium, pipecuronium) or benzylisoquinolinium (mivacurium, 1367 atracurium, cisatracurium, doxacurium) compounds. Pancuronium has vagolytic effects as well as direct sympathomimetic effects; it blocks norepinephrine presynaptic reuptake. It has traditionally been used in cardiac surgery, because its vagolytic effects counteract the bradycardic effects associated with high-dose opioid techniques. Anticholinesterase reversal of pancuronium-induced block is much less effective, but the reversal of shallow pancuronium block by the new agent sugammadex (see Selective Relaxant Binding Agents) appears to be effective. Today, many clinicians find pancuronium obsolete because of the19 significant risk of postoperative residual neuromuscular weakness. Figure 21-9 Neuromuscular blockade as a function of time for four neuromuscular 1371 blocking agents. Onset is faster for the less potent succinylcholine and rocuronium than for the more potent vecuronium and cisatracurium. Molar potency is predictive of the speed of onset of neuromuscular block for agents of intermediate, short, and ultrashort duration. It is structurally similar to pancuronium and vecuronium, and its antagonism of residual block by neostigmine is more effective than by edrophonium. It has been reported that vecuronium recovery time may be prolonged significantly in patients with diabetes mellitus. Because of its low potency, the high plasma concentration achieved after bolus administration decreases rapidly, such that its duration of action in patients with normal renal and hepatic function is determined mostly by its redistribution, and not its elimination. Similar to vecuronium, rocuronium does not cause significant hemodynamic perturbations and releases no histamine. In laparoscopic procedures, the duration of neuromuscular block produced by rocuronium is increased by approximately 25%; this increase is attributed to the effects of pneumoperitoneum on hepatic perfusion and blood flow, which may alter the pharmacokinetics of rocuronium.

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