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Metaclopramide is not safe as premedication in patients with torsion dystonia undergoing surgery
- Ravindra Kumar Pandey, V.Darlong, Jyotsna Punj (26 February 2007)
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Caesarean section for torsion dystonia
- Adeyemi J Olufolabi, Michael Wee (26 May 2006)
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Caesarean section in a patient with torsion dystonia - a response
- James Geoghegan (10 May 2006)
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Ravindra Kumar Pandey, doctor , V.Darlong, Jyotsna Punj
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To The Editor-in-chief British Journal of Anaesthesia Dear Editor, We read with interest the case report regarding caesarian section in a patient with known torsion dystonia [1]. We feel appropriate precautions were taken regarding potential difficult intubation, dystonic movements and intensive care for any post operative respiratory compromise. The author in this case has given metaclopramide, ranitidine & sodium citrate for antacid prophylaxis to the patient with torsion dystonia undergoing elective caesarian section. It is a well-established fact that metaclopramide causes secondary adult dystonia [2,3], as has also been recognised by the authors of this report. Thus knowing the fact that metaclopramide is not safe in torsion dystonia we recommend that some other prokinetic & antiemetic drug like domperidone should be used for premedication in these patients as it has no central nervous system reaction owing to relative lack of penetration of the blood brain barrier [4]. Dr Ravindra Kr Pandey, MD Dr V Darlong, MD Dr Jyotsana Punj, MD Asst. Professors Dept of Anesthesiology & critical care AIIMS, New Delhi-29 India E- mail: ppandey@smxtech.net E-mail: darlongv@yahoo.com References: 1. References 1.A.J.Olufolabi & M.Y.K Wee. Caesarian section in a patient with torsion dystonia. British Journal of Anaesthesia 96 (5): 611-13 (2006). 2. Ganzini L, Daniel E Casey, William F Hoffman, Anthony L Mc Call (1993). The prevalence of metoclopramide-induced tardive dyskinesia and acute extrapyramidal movement disorders. Arch Intern Med 153: 1469-1475. 3. Shaffer D, Butterfield M, Tamer C, Mackey AC (2004). Tardive dyskinesia risks and metoclopramide use before and after U.S. market withdrawal of cisapride. J Am Pharm Assoc. (Wash DC) 44: 661-665. 4. Irfan Soykan, Irene Sorosiek, Richard W Ma Callum (1997). The effect of chronic oral domperidone therapy on gastrointestinal symptoms, gastric emptying, and quality of life in patients with gastroparesis. Am J Gastroenterol 92: 976-980. Conflict of Interest:We are of the opinion that when other safer alternative drugs like domperidone is available, it could have been used in a patient of torsion dystonia |
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Adeyemi J Olufolabi , Michael Wee
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Thank you for allowing us to respond to Dr Geoghegan’s comments. We acknowledge his reservations concerning our use of mivacurium instead of rocuronium and there is good evidence of rocuronium adequately substituting succinylcholine as a drug for rapid sequence induction. Our primary aim was to choose a muscle relaxant of relatively short duration of action with potentially less incidence of residual motor blockade due to the possibility of a difficult intubation and the patient’s clinical condition. Mivacurium despite its slightly less suitability for rapid sequence induction fulfilled this criteria better than rocuronium. It has to be shown that intubating conditions were noted to be good or excellent with the method of administration used 1,2. Neostigmine is still the most common drug utilized for reversal and the patient may have been adequately reversed without any anticholinesterase agent. However, because of the condition of the patient and the need to optimize her respiratory effort postoperatively, we decided to give half the usual dose recommended. 1. Naguib B, Samarkandi H, Ammer A, et al. Comparison of suxamethonium and different combinations of rocuronium and mivacuronium for rapid tracheal intubation in children. Br J Anaesth 1997; 79:450–5 2. Pino RM, Hassan HA, Denham WT, et al. Comparison of the intubation conditions between mivacuronium and rocuronium during balanced anaesthesia. Anesthesiology 1998; 88:673–8 Conflict of Interest:None declared |
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James Geoghegan Birmingham, UK
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Olufolabi and Wee’s excellent case report1 emphasises the need for good communication and early referral from our obstetric colleagues. Their patient obviously presented a difficult anaesthetic dilemma. The ability to have all appropriate preoperative investigations and a balanced discussion with a challenging patient in an outpatient setting makes planning their anaesthetic considerably easier. One could imagine the difficulties had this lady presented de novo in labour requiring an emergency caesarean section. There are however two points that arise from their management that perhaps could be challenged, namely: The use of mivacurium for a rapid sequence induction (RSI). The authors quote Naguib et al.2 for suggesting that mivacurium is a suitable alternative to succinycholine for RSI. However in that paper Naguib et al. stated that it was the combination of rocuronium 0.45mg/Kg and mivacurium 0.15mg/Kg that could be considered as an alternative, not mivacurium on its own (which had slower onset than succinycholine, high dose rocuronium or mivacurium and rocuronium together) While Pino et al. suggest that mivacurium in divided doses provides good or excellent intubation conditions, this is at 90 seconds3. In their paper, rocuronium at higher doses (0.9 and 1.2 mg/Kg) provided faster onset. Ali et al. specifically state that although mivacurium in divided doses does provide good to excellent intubation conditions after 90 seconds, their conclusion does not apply to RSI4. While the patient wished to avoid succinycholine; given her poor respiratory function and reduced functional residual capacity, from pregnancy and pre-existing disease, it would seem appropriate to minimise the apnoea time as much as possible. A Cochrane review suggested that there was no statistical difference between Rocuronium and succinycholine in providing clinically acceptable conditions for RSI intubation5. The use of neostigmine for reversal of a mivacurium induced neuromuscular blockade. The data for the use of neostigmine in reversal of mivacurium induced neuromuscular blockade is conflicting with some studies showing an increase in block duration6 and some a reduction7. Given that the usual duration of an uncomplicated caesarean section is approximately 30 minutes and the duration of a mivacurium block is between 10-20 minutes it would seem reasonable to have used edrophonium instead6 or avoided reversal entirely. References 1 Olufolabi AJ, Wee MYK. Caesarean section in a patient with torsion dystonia. Br J Anaesth 2006; 96: 611-613 2 Naguib B, Samarkandi H, Ammer A, et al. Comparison of suxamethonium and different combinations of rocuronium and mivacuronium for rapid tracheal intubation in children. Br J Anaesth 1997; 79:450–5 3 Pino RM, Hassan HA, Denham WT, et al. Comparison of the intubation conditions between mivacuronium and rocuronium during balanced anaesthesia. Anesthesiology 1998; 88:673–8 4 Ali HH, Lien CA, Witowski T, et al. Efficacy and safety of divided dose administration of mivacurium for a 90-second tracheal intubation. J Clin Anesth 1996; 8:276–81 5 Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002788. DOI: 10.1002/14651858.CD002788. 6 Abdulatif M: Recovery characteristics after early administration of anticholinesterases during intense mivacurium-induced neuromuscular block. Br J Anaesth 1995; 74:20-5. 7 Fleming NW and Lewis BK: Cholinesterase inhibitors do not prolong neuromuscular block produced by mivacurium. Br J Anaesth 1994; 73:241-3. Conflict of Interest:None declared |
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