Etomidate Vecuronium

Answer This feature of bradycardia is typical of patients who take (3-blockers, which should be continued so they result ultimately in better anesthetic management. The drugs given could have been modified (i.e., etomidate instead of propofol, which does not raise or may cause a slower heart rate). The potent opioids in the fentanyl family all cause vagal transmitted bradycardia. The muscle relaxant vecuronium (norcuron) has no effect on heart rate and could have been replaced by pancuronium, which has a vagolytic effect and will counter bradycardia in the usual induction bolus doses. 

In 113 patients undergoing general anesthesia, intravenous midazolam 15 mg slowed recovery of the twitch height after vecuronium and atracurium compared with diazepam. The recovery index was not altered (162). However, in another study in 20 patients, midazolam 0.3 mg/kg did not affect the duration of blockade, recovery time, intensity of fasciculations, or adequacy of relaxation for tracheal intubation produced by suxamethonium 1 mg/kg, nor the duration of blockade and adequacy of relaxation for tracheal intubation produced by pancuronium 0.025 mg/kg in incremental doses until 99% depression of muscle-twitch tension was obtained (161). Furthermore, in 60 patients undergoing maintenance anesthesia randomly assigned to one of six regimens (etomidate, fentanyl, midazolam, propofol, thiopental plus nitrous oxide, or isoflurane plus nitrous oxide), midazolam did not alter rocuronium dosage requirements (165). 

Ulsamer B. Vecuroniumbromid Beeinflussung der Pharmakodynamik durch Etomidat, Cimetidin und Ranitidin. [Vecuronium bromide modification of its pharmacodynamics by etomidate, cimetidine and ranitidine.] Anaesthesist 1988 37(8) 504-9. 

Etomidate is the indnction agent of choice in atopic patients, in whom etomidate, fentanyl, and vecuronium comprise the safest combination of drugs for general anesthesia. However, non-allergic anaphylactic (anaphylactoid) reactions have been observed, even with this combination (23,24), and it can even be life-threatening one patient also had a myocardial infarction (24). 

Bradycardia occurring during anaesthetic induction with vecuronium and etomidate, or to a iesser extent thiopental, has also been reported, particularly in patients also receiving fentanyl, see also Neuromuscular blockers + Opioids , p.l30. 

Inoue K, El-Banayo A, Stolarski L, Reichelt W. Vecuronium induced bradycardia following induction of anaesthesia with etomidate or thiopentone, with or widiout fentanyl. BrJ AnaesOi (1988) 60,10-17. 

Noninterfering alfentanil, aprotinin, atropine, bupivacaine, chlorpromazine, dalteparin, dexamethasone, diazepam, dopamine, droperidol, etomidate, fentanyl, furosemide, gallamine, haloperidol, midazolam, morphine, neostigmine, nitroglycerin, nitroprusside, oxytocin, pancuronium, pentobarbital, phenylephrine, phenytoin, pipecuronium, piperacillin, promethazine, propofol, ranitidine, succinylcholine, sufentanil, terbutaline, thiopental, vecuronium, verapamil... 

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