Jebmh.

com Original Research Article

Comparison of Two Muscle Relaxants for Tracheal Intubation in

Patients Undergoing Surgery at Goa Medical College and Hospital
Anisha Deulker1, Rohini Bhat Pai2, Shaila Kamat3, Eufemia Dias4,
Rachel Botelho5, Gayatri Kamat6, Uma Sahakari7, Rukmi Pai Raiker8

1, 2, 3, 4, 5, 6, 7, 8
Department of Anaesthesiology, Goa Medical College, Bambolim, Goa, India.

A BS T R A C T

BACKGROUND
Cisatracurium and atracurium are intermediate acting muscle relaxants which do Corresponding Author:
not depend on renal or hepatic metabolism for elimination since they undergo Dr. Anisha Deulker,
Zantye Mansion bldg, Flat No. A-1,
Hofmann elimination. Despite the advantages of cisatracurium such as minimal
Calconda, Margao Goa, India.
effects on the cardiovascular system, no accumulative effects, no metabolite E-mail: [email protected]
toxicity, and metabolic product has no neuromuscular blocking effects, due to slow
onset and unsatisfactory intubating conditions, the use of cisatracurium is limited DOI: 10.18410/jebmh/2021/567
compared with those seen with equipotent doses of other neuromuscular blocking
agents. This study was undertaken to find onset time and intubating conditions How to Cite This Article:
with 3 × ED95 doses of atracurium versus cisatracurium. Deulker A, Pai RB, Kamat S, et al.
Comparison of two muscle relaxants for
tracheal intubation in patients
METHODS
undergoing surgery at Goa Medical
ASA grade 1 or 2 patients, (N = 220) were randomly allocated into 2 groups to College and Hospital. J Evid Based Med
receive equipotent doses of either atracurium or cisatracurium. Intubating Healthc 2021;8(33):3116-3122. DOI:
conditions were assessed using Cooper et al scale and neuromuscular monitoring 10.18410/jebmh/2021/567
done using TOF Watch SX. Haemodynamic responses and any adverse effects
were noted. Submission 14-04-2021,
Peer Review 24-04-2021,
RESULTS Acceptance 22-06-2021,
Published 16-08-2021.
The onset time was 167.36 ± 75.41 seconds (2.78 ± 1.25 minutes) in atracurium
group whereas in cisatracurium group, onset time was 249.26 ± 75.90 seconds Copyright © 2021 Anisha Deulker et al.
(4.15 ± 1.26) and the difference was statistically significant with p value of < This is an open access article distributed
0.001. The difference in intubating conditions between the groups was statistically under Creative Commons Attribution
insignificant. However, atracurium produced a higher incidence of clinically License [Attribution 4.0 International (CC
acceptable conditions (excellent in 94.4 %) than cisatracurium (excellent in 87.3 BY 4.0)]
%). The incidence of adverse effects such as erythema, flushing and
bronchospasm was greater in Atracurium group though hypotension was observed
in both groups.

CONCLUSIONS
Onset time and intubating conditions are significantly better with equipotent doses
of atracurium compared to cisatracurium. But atracurium is associated with higher
incidence of adverse effects such as erythema, flushing and bronchospasm,
though the potential of cisatracurium to cause anaphylactoid reactions cannot be
ignored.

KEYWORDS
Cisatracurium, Atracurium, Muscle Relaxants, Neuromuscular Blocking Agents,
Erythema, Flushing, Bronchospasm, Hypotension, Anaphylactoid Reactions

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Jebmh.com Original Research Article
BACKGROUND Exclusion Criteria
 Any disorders of the cardiovascular, renal, hepatic or
Endotracheal intubation requires relaxation of laryngeal neuromuscular systems, ascertained either from
musculature leading to total inactivity of vocal cords. Hence medical history or clinical examination
muscle relaxants have become an essential part of the  Patients with anticipated difficult airway
anesthesiologist’s armamentarium. Various muscle relaxants  Patients on medications which interact with
used for endotracheal intubation vary in their onset and neuromuscular blocking drugs ; e.g. antibiotics
duration, mechanism of action, pharmacokinetics and (aminoglycosides and tetracyclines), anticonvulsants,
pharmacodynamics and side effects. Depending upon these antiarrhythmics (calcium channel blockers and
differences, they are used in clinical practice.1 quinidine), antidepressants and magnesium sulphate
Cisatracurium besylate is a relatively new  Pregnant or breastfeeding females
nondepolarizing neuromuscular blocking agent which is  Patients with bronchial asthma
approximately three times as potent as atracurium with an  Inadequately nil by mouth patients
ED95 of 0.05 mg / kg during balanced anaesthesia.2,3,4
Similar to atracurium, cisatracurium is also an intermediate
acting neuromuscular blocking agent that does not depend S a m p l e S i ze C a l c u l a t i o n
upon renal or liver function for elimination since it undergoes Sample size of 220 patients was calculated by using an α
Hofmann elimination and ester hydrolysis. The main error of 0.05, confidence interval of 95 % for an infinite
advantage of cisatracurium is that there has been no population, calculated power of 80 %. Standard deviation
evidence of histamine release at doses up to eight times the was calculated using a previous similar study.6
ED95 whereas with atracurium, histamine release has been The purpose of the study and study protocol was
observed in humans at doses greater than 2.5 times ED95.5 explained to the patient in a language the patient
Compared to equipotent doses of atracurium, 2 × ED95 understood and a written informed consent was obtained.
doses of cisatracurium (100 µg / kg) do not yield satisfactory The patient's age, sex, ASA status, weight and type of
intubating conditions. The recommended intubating dose of surgery were recorded.
cisatracurium is 3 × ED95.6 Hence this study was conducted Patients were randomly divided into 2 groups using an
to compare the intubating conditions and time to onset of online research randomizer (http : / / www. randomizer. Org
neuromuscular blocking action of equipotent doses (3 × / ) by the principal investigator. Patients who would receive
ED95) of cisatracurium versus atracurium. atracurium were allocated into group A (n = 110), and those
to be given cisatracurium were allocated to group C (n =
110).
O bj e c t i v e s Monitoring included electrocardiogram, non - invasive
1. To compare the intubating conditions in terms of jaw blood pressure monitoring, pulse oximetry, capnography,
relaxation, vocal cord paralysis and response to temperature monitoring and neuromuscular monitoring.
intubation. TOF - Watch SX was used to measure the onset of the
2. To compare time taken for onset of action of muscle neuromuscular block. To avoid hypothermia, the hand, wrist
relaxant after administration of equipotent doses (3 × and half of the forearm were wrapped with crepe bandage.
ED95) of cisatracurium versus atracurium. Patients were preoxygenated with 100 % oxygen for 3
min and premedicated using intravenous 0.03 mg / kg
midazolam. General anaesthesia was induced with fentanyl
(2 µg / kg), propofol (2 mg / kg) intravenously followed by
METHODS
an infusion of propofol at the rate of 100 µg / kg / min.
Ventilation was ascertained and Train of Four (TOF)
The study was carried out as a prospective randomized calibration done. Muscle function was monitored using a TOF
double blind trial over a period of 1 year from November - Watch SX monitor system. A sensor was attached to the
2017 to October 2018 and included patients of both sexes palmar thumb to measure the contraction velocity of the
who underwent surgery under general anaesthesia at our thumb adductor. A stimulating electrode was placed on the
tertiary care hospital. Ethical Committee Clearance was wrist surface, where the ulnar nerve was stimulated. TOF
obtained from the Institutional Ethical Committee bearing stimulation at 2 Hz, with a 0.2 ms wave width, and a 15 -
the reference number GMC / IEC / Appr - Nov 17 / 15. second interval, was used to stimulate the ulnar nerve on
the forearm. TOF monitoring was done every 15 seconds.
After a stable baseline period of at least 5 min, 3 × ED95 dose
Inclusion Criteria of cisatracurium (0.15 mg / kg) or atracurium (0.75 mg / kg)
 Patients aged between 18 to 60 years was administered over 5 - 10 seconds to patients in Group
 Classified by the American Society of Anaesthesiologists C and Group A respectively. Patients were ventilated with
as ASA I or II 100 % oxygen. The patient was intubated when TOF % was
 Scheduled to undergo general anaesthesia with oral 0. Laryngoscopy and intubation was done by skilled
endotracheal intubation anaesthesiologist who was blinded to the muscle relaxant
 Consent to participate in study administered. Male patients were intubated orally with 8mm
internal diameter PVC tube and female patients were

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Jebmh.com Original Research Article
intubated with 7mm internal diameter PVC tube. The Patients were monitored for any signs of histamine release
anaesthesiologist noting the findings was also blinded. clinically through skin changes such as
Vital parameters Heart rate (HR), systolic blood pressure ● Flush (if redness lasted > 120 s)
(SBP), diastolic blood pressure (DBP) and mean arterial ● Erythema, or wheals
pressure (MAP) and oxygen saturation (SpO2) were noted. ● Presence of any haemodynamic changes such as
The above were recorded at induction of anaesthesia, before hypotension (defined as decrease in MAP less than 60
giving muscle relaxant, before intubation, immediately after mm Hg).9
intubation and at 3 and 5 minutes after intubation. ● Bronchospasm
Intubating conditions were graded based on scoring Anaesthesia was maintained with a mixture of 50 % N2O
scale devised by Cooper et al.7,8 Conditions were classified in O2, propofol infusion, boluses of the muscle relaxant (10
as excellent (8 - 9), good (6 - 7), poor (3 - 5), or impossible % of the initial dose) and intravenous fentanyl. Ventilation
(0 - 2). was controlled by the Datex - Ohmeda™ ventilator with end
tidal CO2 maintained at 30 - 35 mmHg. Intra-operative
Score haemodynamic changes were continuously displayed on the
Criteria 3 2 1 0
Jaw relaxation Complete Moderate Minimal None
monitor including : heart rate (HR), mean arterial pressure
Vocal cord Status Open Slight Moving Closing Closed (MAP) every 5 min, oxygen saturation (SO2), and end tidal
Response to intubation None Slight Moving Coughing Bucking
carbon dioxide (CO2). At the end of operation, reversal was
Table 1. Cooper et al Scale
achieved by administration of neostigmine and
The onset time was determined as the interval from the glycopyrrolate and trachea was extubated when TOF - ratio
end of muscle relaxant injection until maximal suppression was > 0.9.
of T1 %.

Enrollment Assessed for eligibility (n = 220)

Excluded (n = 0)
 Declined to participate (n = 0)
 Other reasons (n = 0)

Randomized (n = 220)

Allocation

Group A Group C
Allocated to intervention (n = 110) Allocated to intervention (n = 110)
 Received allocated intervention (n = 110)  Received allocated intervention (n = 110)
 Did not receive allocated intervention (n = 0)  Did not receive allocated intervention (n = 0)

Analysis

Analysed (n = 108) Analysed (n = 102)

 Excluded from analysis  Excluded from analysis
n = 2 : onset time of muscle n = 6 : onset time of muscle relaxation more
relaxation more than 480 seconds than 480 seconds
n = 2 : unanticipated difficult intubation

Consort 2010 Flow Diagram

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Jebmh.com Original Research Article
Statistical Analysis Group A (n = 108) Group C (n = 102)
Adverse Atracurium Cisatracurium
The data was entered in Microsoft excel and analysed using P Value
Effects (Frequency and % (Frequency and %
SPSS. The outcome variables were expressed as percentage within group) within group)
for categorical variable and as mean with standard deviation Hypotension 24 (22.2 %) 20 (19.6 %) 0.642
Flushing 8 (7.4 %) 0 (0.0 %) 0.005
for numerical variable. The association between outcome Erythema 3 (2.8 %) 1 (1.0 %) 0.341
variable and the intervention were measured by Student T Bronchospasm 13 (12.0 %) 0 (0.0 %) < 0.001*
Table 5. Comparison of Adverse Effects between 2 Groups
test and Chi square test and statistical significance at 5 %
*indicates significant statistical difference
level of significance. The demographic variables were
compared using student t test and chi square test.

D I S C US S I O N
RESULTS
Cisatracurium is a new intermediate acting
benzylisoquinolinium neuromuscular blocking agent that is
Both groups were comparable in terms of age, gender, ASA
one of the ten stereoisomers contained in atracurium
grading and weight.
besylate.10 It is approximately 3 times as potent as
Group A Group C
atracurium. Similar to atracurium, it undergoes Hofmann
P elimination and ester hydrolysis and, therefore, does not
Parameters (n = 108) (n = 102)
Value
Atracurium Cisatracurium depend upon renal or liver function for elimination.5
Age in years (mean ± SD) 41.47 ± 13.778 40.49 ± 13.818 0.607
Gender (male / female) 55 / 53 50 / 52 0.782 Advantages of cisatracurium over other agents are it
Weight in kgs (mean ± SD) 57.21 ± 10.208 57.25 ± 11.028 0.983 does not release histamine11,12 at doses up to eight times the
ASA grades (1 / 2) 81 / 27 79 / 23 0.677
Table 2. Comparison of Age, Gender, Weight and ASA Grades ED95 (whereas atracurium causes histamine release in
humans at doses greater than 2.5 times ED95),5 has minimal
Group A Group C effects on the cardiovascular system, has no accumulative
Parameters
(n = 108) (n = 102) P effects, has no metabolite toxicity, and its metabolic product
Atracurium Cisatracurium Value has no neuromuscular blocking effects.11 Cisatracurium
(Mean ± SD) (Mean ± SD)
Pulse rate 80.14 ± 13.514 80.57 ± 14.522 0.824 produces laudanosine about five times less than Atracurium,
Systolic blood pressure 130.52 ± 15.674 132.31 ± 17.115 0.428 and accumulation of this metabolite is not thought to be of
Baseline Diastolic blood pressure 80.06 ± 8.949 79.15 ± 9.121 0.467
Mean arterial blood any consequence in clinical practice.
96.55 ± 10.405 97.24 ±11.262 0.645
pressure Despite these advantages, due to slow onset and
Pulse rate 76.4 ± 14.645 76.76 ± 13.288 0.85
Systolic blood pressure 104.78 ± 16.165 106.54 ± 16.929 0.441 unsatisfactory intubating conditions, the use of
After
Diastolic blood pressure 65.26 ± 12.418 64.53 ± 11.295 0.657 cisatracurium is limited compared with those seen with
induction
Mean arterial blood
78.22 ±13.139 78.73 ± 13.258 0.783
pressure equipotent doses of other neuromuscular blocking
Pulse rate 71.01 ± 14.897 73.02 ± 13.422 0.306
Systolic blood pressure 88.82 ± 15.047 94.75 ± 14.038 0.004
agents.13,14,15 Hence we conducted this prospective
Before
intubation
Diastolic blood pressure 53.95 ± 12.751 57.18 ± 9.934 0.043 randomized double blind study to compare the intubating
Mean arterial blood
pressure
66.04 ± 12.112 69.64 ±10.797 0.024 conditions, onset time, haemodynamics and adverse effects
Pulse rate 87.99 ± 15.545 84.75 ± 17.585 0.159 of Cisatracurium versus Atracurium for endotracheal
Systolic blood pressure 116.63 ± 21.356 122.14 ± 20.106 0.056
After
Diastolic blood pressure 74.44 ± 16.72 78.11 ± 16.051 0.106 intubation.
intubation
Mean arterial blood
88.4 ± 17.956 99.58 ± 69.698 0.109 Inhalational agents were not used for induction since
pressure
Pulse rate 81.1 ± 14.232 81.17 ±15.937 0.975 they interfere with onset of action of muscle relaxants. It is
Systolic blood pressure 108.3 ± 17.12 113.58 ± 20.077 0.041 seen that deep anaesthesia induced with potent volatile
At 3 min Diastolic blood pressure 68.02 ± 14.247 71.01 ± 15.032 0.14
Mean arterial blood anaesthetics (in the absence of neuromuscular blockade)
80.98 ± 13.683 84.83 ± 15.938 0.061
pressure causes a slight reduction of neuromuscular transmission, as
Pulse rate 77.64 ± 14.605 76.85 ± 14.765 0.699
Systolic blood pressure 104.89 ± 16.369 107.68 ± 17.949 0.241 measured by depression of sensitive indicators of clinical
At 5 min Diastolic blood pressure 65.69 ± 13.071 67.14 ± 13.374 0.43 neuromuscular function, such as TOF. Inhaled anaesthetics
Mean arterial blood
78.6 ± 13.252 80.63 ± 14.188 0.286 also enhance the neuromuscular blocking effects of
pressure
Table 3. Comparison of Pulse Rate, Systolic Blood Pressure, nondepolarizing NMBDs. Hence propofol infusion at the rate
Diastolic Blood Pressure and Mean Arterial Blood Pressure of 100 µ / kg / min was used to maintain the depth of
anaesthesia.16
Group A Group C
Parameters (n = 108) (n = 102)
P Intubating conditions were assessed according to scale
Value devised by Cooper at al.8 Both groups were comparable in
Atracurium Cisatracurium
< terms of age, gender, ASA grading and weight. The
Onset time in Seconds (mean ± SD) 167.36 ± 75.41 249.26 ± 75.902
0.001*
Intubating conditions excellent 102 (94.4 %) 89 (87.3 %) differences observed were statistically insignificant between
(frequency and % good 6 (5.6 %) 12 (11.8 %) 0.156
the two groups. In our study the heart rates in both groups
within group) poor 0 (0.0 %) 1 (1.0 %)
Table 4. Comparison of Onset Time and Intubating Conditions remained comparable throughout the monitoring period and
*indicates significant statistical difference the difference was not statistically significant. Tachycardia
was not observed in any group.
Baseline SBP, DBP and MAP between the 2 groups were
comparable and difference between them was statistically
not significant. There was fall in blood pressure after

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Jebmh.com Original Research Article
induction of anaesthesia. The fall in blood pressure dose of a less potent drug. Because of this lower
compared to baseline values may be attributed to concentration gradient, more time is required for enough
haemodynamic effect of propofol. Induction of anaesthesia molecules of a potent drug to be delivered to the
with propofol causes a reduction in systemic arterial neuromuscular junction. Thus, onset time is longer.16
pressure, reportedly because of decrease in cardiac output, This slower onset of action has been demonstrated in
decrease in systemic vascular resistance, or both.17 Just other studies too. Linda S. Bluestein et al5 compared
before intubation (after injection of muscle relaxant), atracurium with 3 different doses of cisatracurium during
comparison of mean systolic blood pressure, mean diastolic N20 / O2 / Propofol / fentanyl anaesthesia and concluded that
blood pressure and mean arterial blood pressure between increasing the initial dose of cisatracurium (from 0.1 to 0.15
two groups shows that the pressures are higher in group C and 0.2 mg / kg) decreased mean time of onset (from 4.6
compared to group A and the difference between the two to 3.4 and 2.8 min, respectively).
groups was statistically significant. This may be attributed to Similarly AM El - Kasaby et al6 compared atracurium (2
histamine releasing property of atracurium which results in × ED95) and different doses of cisatracurium (2 × ED95, 4 ×
fall in blood pressure18 along with the haemodynamic effects ED95, 6 × ED95) regarding onset time and found that onset
of propofol. time was 3.24 ± 0.55 min with atracurium whereas it was
Our findings are consistent with those of R. P. F. SCOTT 4.37 ± 0.46, 2.9 ± 1.4 and 2 ± 1.2 min with 2 × ED95, 4 ×
et al18 who concluded that atracurium 0.8 mg / kg will ED95 and 6 × ED95 doses of cisatracurium.
produce a significantly more rapid onset of blockade than The difference in intubating conditions between the
0.5 mg / kg with a similar intubation score 1 min earlier groups was statistically insignificant. However, atracurium
which may be associated with a transient but significant produced a higher incidence of clinically acceptable
decrease in mean arterial pressure. conditions (excellent in 94.4 %) than cisatracurium
Mean systolic blood pressure, mean diastolic blood (excellent in 87.3 %).
pressure and mean arterial blood pressure after In a study conducted by El - Kasaby A M et al, with
laryngoscopy and endotracheal intubation showed no regards to the conditions of intubation, it was estimated
statistical difference between the two groups but a rise in that only 6 × ED95 dose of cisatracurium showed a
blood pressure is observed after laryngoscopy and statistically significant difference versus the atracurium dose
endotracheal intubation which may be attributed to pressor with excellent conditions of intubation. 4 × ED95 and 6 ×
response.19 ED95 doses of cisatracurium were significantly better than 2
At 3 min, the difference in mean systolic blood pressure × ED95 dose of cisatracurium.6
between two groups was statistically significant. This may Similarly, Linda S. Bluestein et al in their study found that
be attributed to histamine releasing effect of Atracurium there were no differences in intubation scores in patients
which is transient lasting for 1 - 5 minutes. Comparison of treated with equipotent doses of cisatracurium or
the diastolic blood pressure and mean arterial blood atracurium.5
pressure at 3 min between the two groups showed no Besides binding to the nicotinic receptors at the
statistical significance between two groups. neuromuscular junction neuromuscular blocking drugs also
SBP, DBP and MAP between the 2 groups were interact with other acetylcholine receptors such as the
comparable at 5 min after intubation and difference between nicotinic receptors in autonomic ganglia and the carotid body
them was statistically not significant. This showed that chemoreceptors, as well as the muscarinic receptors of the
although there is a transient significant fall in blood pressure heart. Binding to these receptors results in adverse effects
after Atracurium, the effect is short lasting. The effect of that vary with the potency and specificity for the cholinergic
histamine release is usually of short duration (1 to 5 receptor in question.22
minutes), is dose related, and is clinically insignificant in Initially the adverse effects of aminosteroidal compounds
healthy patients.16 were vagolytic and the benzylisoquinolines often released
The onset time was 167.36 ± 75.41 seconds (2.78 ± histamine. However, newer NMBs do not necessarily display
1.25 minutes) in atracurium group whereas in cisatracurium the same adverse effects despite structural similarities.
group, onset time was 249.26 ± 75.90 seconds (4.15 ± Cisatracurium does not cause any dose‐dependent
1.26) and the difference was statistically significant with p increase in plasma histamine level, and rapid intravenous
value of < 0.001. The slower onset of action of cisatracurium administration does not cause cardiovascular changes,22
is probably due to its greater potency compared to whereas atracurium causes histamine release in humans at
atracurium, a mechanism that has been proposed for other doses greater than 2.5 times ED95.5
relaxants.20 There is an inverse relationship between onset In our study in group A, 8 patients (7.4 %) developed
and potency.21 flushing whereas none of patients in group C developed
This relationship can be explained on the basis of the flushing. This difference was statistically significant with p
density of receptors at the neuromuscular junction. value of 0.005. In 4 cases it was associated with
Irrespective of their potency, Neuromuscular Blocking Drugs hypotension, 1 case was associated with bronchospasm
(NMBDs) must bind to a critical number of acetylcholine whereas 1 case was associated with both hypotension as
receptors for blockade to occur. These receptors are well as bronchospasm. In all our cases flushing was short
concentrated at the neuromuscular junction where access is lived and subsided on its own without any intervention.
limited. When a potent NMBD is administered, fewer Flushing in atracurium group may be attributed to histamine
molecules are administered than in the case of an equipotent releasing property of atracurium.

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Jebmh.com Original Research Article
3 patients (2.8 %) in group A and 1 patient (1 %) in positive intradermal reaction to atracurium confirmed
group C developed erythema which was not statistically atracurium anaphylaxis.
significant. In group A, in one case erythema was associated Similarly, Maitra S, et al28 reported severe anaphylactic
with bronchospasm whereas 2 cases were associated with reaction after administration of atracurium 15 mg, patient
hypotension. Although the presence of rash after atracurium developed, tachycardia, hypotension and severe
administration has been taken as an indicator of significant bronchospasm which required management with 2 doses of
cardiovascular changes, Alfred Doenicke et al in their intravenous adrenaline (1: 10000), steroid and
experimental study found that this is not the case. chlorpheniramine.
Cutaneous manifestations of atracurium administration were
independent of systemic levels of plasma histamine and
cardiovascular effects in their study.23 C O N C L US I O N S
Krombach J et al in their study concluded that, the
anaphylactoid potential of cisatracurium may not be
Onset time and intubating conditions are significantly better
proportionally less although it is known to be a less potent
with equipotent doses of atracurium compared to
histamine liberator than atracurium.24 They observed
cisatracurium. But atracurium is associated with higher
anaphylactoid reactions in 6 patients manifesting as
incidence of adverse effects such as erythema, flushing and
wheezing, arterial hypotension, urticaria and flush. Three
bronchospasm, though the potential of cisatracurium to
patients developed wheezing with increased airway
cause anaphylactoid reactions cannot be ignored.
resistance that was associated with arterial hypoxemia in
one patient. Arterial hypotension was seen in five patients,
Data sharing statement provided by the authors is available with the
tachycardia in three, and bradycardia with ventricular full text of this article at jebmh.com.
conduction block in one. In one patient, urticaria and flush Financial or other competing interests: None.
were the only anaphylactoid manifestations. All patients Disclosure forms provided by the authors are available with the full
survived. They confirmed their findings by skin testing and text of this article at jebmh.com.
found that all patients reacted to the Cisatracurium solutions
1 : 100 or 1 : 1000.
This may be contrary to findings of Bryson HM et al25 RE F E R E N C E S
which state that cisatracurium does not release histamine in
doses up to 8 times ED95. In our study, 24 patients (22.2 %)
[1] Parikh K, Modh DB, Upadhyay MR. Comparison of
in group A had hypotension whereas 20 patients (19.6 %)
rocuronium bromide with suxamethonium chloride for
in group C had hypotension, but the difference was
tracheal intubation. Int J Med Sci Public Health
statistically insignificant with p value of 0.642. In our study,
2014;3(5):610-615.
in all the patients, hypotension was transient in both the
[2] Lien CA, Schmith VD, Belmont MR, et al.
groups and blood pressure (BP) improved after intubation
Pharmacokinetics of cisatracurium in patients receiving
and was thought to be due to BP lowering effect of inducing
nitrous oxide/opioid/barbiturate anesthesia. Anesthesiol
agents. The histamine release caused by atracurium or
1996;84(2):300-308.
cisatracurium may be a contributing factor.
[3] Lien CA, Belmont MR, Abalos A, et al. The
Signs of bronchospasm are high peak airway pressure,
cardiovascular effects and histamine-releasing
upsloping of the end - tidal carbon dioxide (EtCO2)
properties of 51W89 in patients receiving nitrous oxide/
waveform, wheezing, and desaturation. During surgery,
opioid/barbiturate anesthesia. Anesthesiology
bronchospasm may be due to several causes such as light
1995;82(5):1131-1138.
plane of anaesthesia, histamine release by drugs used, etc.26
[4] Lepage JY, Malinovsky JM, Malinge M, et al.
13 patients (12 %) in group A and none of the patients in
Pharmacodynamic dose- response and safety study of
group C developed bronchospasm. The difference between
cisatracurium (51W89) in adult surgical patients during
the 2 groups was statistically significant with p value of <
N2O-O2-opioid anesthesia. Anesth Analg
0.001. Comparison of the airway pressure between the two
1996;83(4):823-829.
groups immediately after intubation, at 3 minutes and 5
[5] Bluestein LS, Stinson LW, Lennon RL, et al. Evaluation
minutes after intubation showed that airway pressure in
of cisatracurium, a new neuromuscular blocking agent
atracurium group was higher than in cisatracurium group
for tracheal intubation. Can J Anaesth 1996;43(9):925-
and the differences were statistically significant. In all our
931.
cases bronchospasm subsided after deepening the plane of
[6] El-Kasaby AM, Atef HM, Helmy AM, et al. Cisatracurium
anaesthesia and administration of β2 - agonist via the ET
in different doses versus atracurium during general
tube except in one case where bronchospasm persisted
anesthesia for abdominal surgery. Saudi J Anaesth
despite all manoeuvres and resolved only after
2010;4(3):152-157.
subcutaneous adrenaline was administered.
[7] Gupta S, Kirubahar R. A comparative study of intubating
Miraj A et al27 reported a life - threatening anaphylactic
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