LETTER
Prolonged Weakness and Vecuronium
Victor L. Scott;
Judith A. Freeman; and
Andre M. DeWolf
1 April 1993 | Volume 118 Issue 7 | Pages 569-571
TO THE EDITOR:
We agree with Kupfer and colleagues' [1] comments about the necessity of monitoring neuromuscular transmission and feel that this prospective study would have been enhanced by titrating the dose of vecuronium to a monitored end point, thereby excluding the possibility of overdose as a cause for prolonged paralysis, as probably occurred in Patients 3 and 10. In addition, the 3-desacetylvecuronium metabolite is approximately 50% to 60% as potent as the parent compound and accumulates in the presence of hepatic and renal insufficiency [2]. Had the authors measured serum levels of both vecuronium and its metabolite, they might have been able to show more clearly an association between the residual drug or its metabolite and prolonged neuromuscular blockade.
Several reports in the literature [3, 4] have documented the development of polyneuropathy and myopathy in patients receiving both steroids, especially methylprednisolone, and prolonged infusions or multiple bolus doses of nondepolarizing neuromuscular blocking agents. Muscle biopsies have shown a myopathy, with type II muscle fiber atrophy, as well as a neuropathy [5]. Our reading of the patient presentations (for example, Patient 5) suggest that both a polyneuropathy and myopathy were present.
No studies to date have documented vecuronium or other muscle relaxants as the cause of demyelination or myopathy, when administered without steroids.
1. Kupfer Y, Namba T, Kaldawi E, Tessler S. Prolonged weakness after long-term infusion of vecuronium bromide. Ann Intern Med. 1992; 117:484-6.
2. Segredo V, Caldwell JE, Matthay MA, Sharma ML, Gruenke LD, Miller RD. Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med. 1992; 327:524-8.
3. Margolis BD, Khachikian D, Friedman Y, Garrard C. Prolonged reversible quadriparesis in mechanically ventilated patients who received long-term infusions of vecuronium. Chest. 1991; 100:877-8.
4. Subramony SH, Carpenter DE, Raju S, Pride M, Evans OB. Myopathy and prolonged neuromuscular blockade after lung transplant. Crit Care Med. 1991; 19:1580-2.
5. Danon MJ, Carpenter S. Myopathy with thick filament (myosin) loss following prolonged paralysis with vecuronium during steroid treatment. Muscle Nerve. 1991; 14:1131-9.
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