Postoperative Myalgia Research Articles

Limitations to self-care in theambulatory surgical patient

Myalgia, or muscle pain, is a common postoperative phenomenon. Causes of myalgia include age, gender, medication, positioning, and abdominal insufflation for laparoscopic surgery. For some patients, myalgia may be more severe than surgically induced pain. This study explored postoperative myalgia from the perspective of self-care limitations. Sixty-three individuals were surveyed, and responses were analyzed using unidimensional and multidimensional scaling techniques. Subjects reported back pain and the inability to accomplish high-energy activities of daily living to be most incapacitating after surgery. Results of this investigation may be used to structure preoperative teaching and perianesthetic nursing interventions.

Succinylcholine-associated postoperative myalgia.

The subject of postoperative myalgia associated with the use of succinylcholine is reviewed. We discuss the mechanisms of succinylcholine-induced myalgia and the techniques available to prevent and treat the myalgia. In situations where patients are at risk of developing myalgia and succinylcholine is the neuromuscular blocker of choice, the use of a combination of techniques may prove to be a useful strategy.

Effects of pretreatment with cisatracurium, rocuronium, and d-tubocurarine on succinylcholine-induced fasciculations and myalgia: a comparison with placebo

Study Objective: To evaluate the efficacy of cisatracurium, rocuronium, and d-tubocurarine in preventing succinylcholine-induced fasciculations and postoperative myalgia in patients undergoing ambulatory surgery. Design: Randomized, prospective, placebo-controlled trial Setting: Teaching hospital. Subjects: 80 ASA physical status I and II patients scheduled for elective ambulatory surgery with general anesthesia. Intervention: A standardized balanced anesthetic technique was used for all patients. Measurements and Main Results: Patients were randomized to receive cisatracurium 0.01 mg/kg, rocuronium 0.06 mg/kg, d-tubocurarine 0.05 mg/kg, or saline, 3 minutes prior to intravenous (IV) succinylcholine 1.5 mg/kg. The intensity of fasciculations and intubating conditions were assessed using a four-point rating scale. In addition, the severity of myalgia was assessed using a four-point rating scale in the postanesthesia care unit and at 24 hours postoperatively. No patient complained of any side effects after the administration of the study drug. Fasciculations were observed less frequently ( p < 0.05) in the d-tubocurarine and rocuronium groups compared with the placebo and cisatracurium groups. However, there was no difference between the d-tubocurarine group and the rocuronium group (21% vs. 10%, respectively). Although fasciculations occurred less frequently in the cisatracurium group than in the placebo group (59% vs. 85%, respectively), this difference did not reach statistical significance. There was no difference among the four groups in the intubating conditions or the incidence of postoperative myalgia. Conclusion: Pretreatment with rocuronium and d-tubocurarine was superior to cisatracurium in preventing succinylcholine-induced fasciculations. However, pretreatment did not have any effect on the incidence of myalgia after ambulatory surgery.

Rocuronium Is the Best Non-Depolarizing Relaxant to Prevent Succinylcholine Fasciculations and Myalgia

ied. They were divided into six groups of 20 according to the non-depolarizing pretreatment used: NaCl 0.9%(control), 0.05 mg'kg -I d-tubocurarine, 0.01 mg'l~ I vecuronium, 0.05 mg'kg -I atracurium, 0.02 mg'kg -I mivacurium and 0.06 mg.kg -I rocuronium. Four minutes after the pretreatment, 1.5 mg.kg -I succinytcholine was injected. Side effects of the pretreatment, the presence and magnitude of fasciculations, the ease of tracheal intubation, myalgia I, 24 and 48 hr after surgery were observed. A Puritan Bennett Datex TM 221 NMT Relaxograph monitor was used to evaluate the neuromuscular block. Results: Muscle fasciculations were observed in 19 of the 20 patients in the control group and in 3 of the 20 patients in the rocuronium group, the best of the pretreatments in that aspect. Four patients in the mivacurium group were unable to sustain more than four seconds head-lift after pretreatment (P < 0.05). Tracheal intubation conditions were better and the onset of block was faster and longer after succinylcholine in the control group (P < 0.05). Myalgias were present in 71% of the patients 24 hr postoperatively and the frequency was not different among the groups. Conclusion: Among the pretreatments tested, 0.06 mg'kg -~ rocuronium was the best to prevent muscular fasciculations following succinylcholine injection. In the population studied, pretreatment did not prevent postoperative myalgia. Succinylcholine 1.5 mg-kg -~ was more effective without a non-depolarizing pretreatment. Objectif : D&erminer quel myorelaxant non d~polarisant, dont la d-tubocurarine, le v&uronium, I'atracurium, le mivacurium et le rocuronium, saura le mieux pr~venir ~les myofasciculations et les myalgies qui suivent I'utilisation de succinylcholine.

Pharmacoeconomic issues related to selection of neuromuscular blocking agents.

Pharmacoeconomic issues related to the selection of neuromuscular blocking agents are described. Five models of economic analysis are commonly used in health care: cost-minimization, cost-benefit, cost-effectiveness, cost-utility, and cost-of-illness. The model used most commonly in anesthesiology is the cost-effectiveness model, in which outcomes are measured in nonmonetary terms that are then translated into units of success or failure. The true cost of anesthetic drugs and techniques should include more than acquisition cost. Factors typically included in economic analyses include resources used and humanistic factors. Six specific indirect costs should be included in pharmacoeconomic analyses of neuromuscular blocking agents: cost of residual muscle blockade, cost of prolonged time to extubation, inability of patients to resume normal activities because of postoperative myalgia, cost of additional postoperative monitoring for arrhythmia associated with reversal drugs, and risk of nausea and vomiting associated with reversal drugs. The availability of rapid-onset, shorter-duration anesthetics, analgesics, and neuromuscular blocking agents with fewer adverse effects and the availability of less invasive surgical techniques have made it possible to accelerate the movement of patients in and out of the operating room and have shortened lengths of stay in the postanesthesia care unit (PACU) and the intensive care unit (ICU). Decreased length of stay in the PACU and the ICU can save hundreds of dollars per case because these areas have high personnel costs. If reversal drugs like neostigmine can be avoided, fewer patients may experience postoperative nausea and vomiting and the resulting complications. In searching for the best outcome at the most reasonable cost, practitioners should look for meaningful cost reductions, bearing in mind that the use of newer, shorter-acting drugs has led to improved perioperative efficiency in clinical practice.

Pharmacoeconomic issues related to selection of neuromuscular blocking agents

Pharmacoeconomic issues related to the selection of neuromuscular blocking agents are described. Five models of economic analysis are commonly used in health care: cost-minimization, cost-benefit, cost-effectiveness, cost-utility, and cost-of-illness. The model used most commonly in anesthesiology is the cost-effectiveness model, in which outcomes are measured in nonmonetary terms that are then translated into units of success or failure. The true cost of anesthetic drugs and techniques should include more than acquisition cost. Factors typically included in economic analyses include resources used and humanistic factors. Six specific indirect costs should be included in pharmacoeconomic analyses of neuromuscular blocking agents: cost of residual muscle blockade, cost of prolonged time to extubation, inability of patients to resume normal activities because of postoperative myalgia, cost of additional postoperative monitoring for arrhythmia associated with reversal drugs, and risk of nausea and vomiting associated with reversal drugs. The availability of rapid-onset, shorter-duration anesthetics, analgesics, and neuromuscular blocking agents with fewer adverse effects and the availability of less invasive surgical techniques have made it possible to accelerate the movement of patients in and out of the operating room and have shortened lengths of stay in the postanesthesia care unit (PACU) and the intensive care unit (ICU). Decreased length of stay in the PACU and the ICU can save hundreds of dollars per case because these areas have high personnel costs. If reversal drugs like neostigmine can be avoided, fewer patients may experience postoperative nausea and vomiting and the resulting complications. In searching for the best outcome at the most reasonable cost, practitioners should look for meaningful cost reductions, bearing in mind that the use of newer, shorter-acting drugs has led to improved perioperative efficiency in clinical practice.

EFFECTS OF PRETREATMENT WITH CISATRACURIUM ON SUCCINYLCHOLINE-INDUCED FASCICULATIONS AND MYALGIA

S157 INTRODUCTION: Pretreatment with small doses of nondepolarizing muscle relaxants, particularly tubocurarine, is commonly used to prevent succinylcholine-induced side effects such as fasciculations and postoperative myalgia. The purpose of this placebo-controlled study was to compare the efficacy of cisatracurium (0.01 mg/kg) and tubocurarine (0.05 mg/kg) in prevention of succinylcholine-induced fasciculations and myalgia. METHODS: Following IRB approval and informed consent, 42 healthy outpatients undergoing peripheral surgery were randomized to receive saline (n=18), tubocurarine (n=12), or cisatracurium (n=12) two minutes prior to induction of anesthesia. Occurrence of diplopia, difficulty in swallowing, and signs of muscle weakness were noted. Anesthesia was induced with propofol (2.5 mg/kg iv) and succinylcholine (1.5 mg/kg iv) and maintained with fentanyl, isoflurane and N2 O 60% in O2. Muscle relaxation was maintained with cisatracurium 2-4 mg iv. At the end of the operation, residual neuromuscular block was antagonized with combination of neostigmine and glycopyrrolate. Fasciculations were recorded on a 4-point scale: 1=nil; 2=mild fine fasciculations of the eyes, face, neck or fingers without limb movement; 3=moderate fasciculations of greater intensity than mild that occurred at more than two sites or that produced limb movement; 4=severe vigorous, sustained, and widespread fasciculations possibly requiring forceful retention. Myalgia was scored preoperatively, in the PACU, and 24 h postoperatively using a 4-point scale: 1=absence of muscle pain; 2=mild muscle stiffness or pain, when specifically asked about in the nape of the neck, or in the shoulders and lower chest on deep breathing; 3=moderate muscle stiffness and pain spontaneously complained of by the patient that requires analgesics; 4=severe, incapacitating generalized muscle stiffness or pain. Data were analyzed using ANOVA or Kruskuall Wallis test (as appropriate), with p <0.05 considered statistically significant. RESULTS: The three groups were similar with respect to demographic and clinical data. No patient complained of diplopia or difficulty in swallowing. Significantly higher number of patients in the placebo and cisatracurium groups demonstrated moderate-to-severe fasciculations, as compared with the tubocurarine group. There was no difference in the incidence of myalgia between the groups. (Table 1)Table 1DISCUSSION: These data suggest that tubocurarine 0.05 mg/kg is more effective than cisatracurium 0.01 mg/kg in preventing succinylcholine-induced fasciculations. However, pretreatment with nondepolarizing muscle relaxants does not decrease the incidence of postoperative myalgia.

A Randomized, Double-Blind Comparison of Rocuronium, d-Tubocurarine, and "Mini-Dose" Succinylcholine for Preventing Succinylcholine-Induced Muscle Fasciculations

A Randomized, Double-Blind Comparison of Rocuronium, d-Tubocurarine, and "Mini-Dose" Succinylcholine for Preventing Succinylcholine-Induced Muscle Fasciculations

The Evaluation of Postoperative Myalgia after Administration of Succinylcholine and the Effect of Pancuronium Pretreatment

The Evaluation of Postoperative Myalgia after Administration of Succinylcholine and the Effect of Pancuronium Pretreatment

Propofol permits tracheal intubation but does not affect postoperative myalgias

Study Objective: To determine the effect of propofol without succinylcholine on intubating conditions and postoperative myalgias in ambulatory surgical patients undergoing general anesthesia. Design: Prospective, double-blind, randomized study. Setting: Ambulatory surgery adult patients. Patients: 56 ASA physical status I and II adult patients undergoing general endotracheal anesthesia. Interventions: Group 1 patients received thiamylal plus sucdnylcholine, Group 2 patients recdved propofol plus sucdnylcholine; and Group 3 patients received propofol plus saline. All patients received fentanyl, lidocaine, and nitrous oxide plus isoflurane in oxygen. Measurements and Main Results: Incidence and severity of fasciculations, tracheal intubating conditions, and myalgias on the first and third postoperative days were measured. Propofol did not affect the incidence or severity of fasciculations following sucdnylcholine, or the incidence of myalgias. Of patients who received propofol without succinylcholine, intubation was successful in 85%. Conclusions: Propofol did not affect the incidence or severity of postoperative myalgias following succinylcholine.

Comparison of Rocuronium and Mivacurium to Succinylcholine During Outpatient Laparoscopic Surgery

Tracheal intubating conditions and neuromuscular effects of succinylcholine, rocuronium, and mivacurium were studied in 100 healthy women undergoing outpatient laparoscopic surgery. After a standardized fentanyl-thiopental induction, tracheal intubation was facilitated with succinylcholine 1 mg/kg in Groups I (n = 23) and II (n = 25), rocuronium 0.6 mg/kg in Group III (n = 27), or mivacurium 0.2 mg/kg in Group IV (n = 25). If clinically indicated, bolus doses of rocuronium 5-10 mg (Groups I and III) or mivacurium 2-4 mg (Groups II and IV) were administered during the maintenance period. Anesthesia was maintained with desflurane and nitrous oxide 60% in oxygen. At the end of the surgery, residual neuromuscular block was reversed with edrophonium 0.5 mg/kg and atropine 10 micrograms/kg, if needed. The neuromuscular function was assessed using electromyography with a train-of-four mode of stimulation every 10 s at the wrist. Intubating conditions 90 s after succinylcholine and rocuronium were significantly better than after mivacurium. The onset time (from the end of injection until 95% suppression of the first twitch [T1]) for succinylcholine (63 +/- 21 s and 62 +/- 17 s in Groups I and II, respectively) were significantly shorter than for rocuronium (158 +/- 76 s) or mivacurium (210 +/- 93 s). Moreover, the onset times for rocuronium were significantly shorter than mivacurium. The recovery times (of T1 to 25% of the control value) were significantly shorter with succinylcholine and mivacurium than rocuronium. Significantly fewer patients needed reversal of residual neuromuscular blockade after mivacurium compared to rocuronium. One patient in Group I and six patients in Group IV displayed erythema on the upper body. Postoperative myalgia were experienced by 16% of the patients in Groups I and II compared to none in Groups III and IV. There was on difference in the incidence of postoperative nausea and vomiting among the four groups. In conclusion, rocuronium appears to be an acceptable alternative to succinylcholine for tracheal intubation. However, rocuronium's longer duration of action increases the need for reversal drugs. When rapid tracheal intubation is unnecessary, mivacurium is also an acceptable alternative to succinylcholine and is associated with a more rapid spontaneous recovery than rocuronium.

Rocuronium pretreatment reduces suxamethonium-induced myalgia: comparison with vecuronium

We have studied, in 150 patients undergoing elective oral surgery, the effectiveness and sequelae of pretreatment with rocuronium for reducing myalgia after suxamethonium. Patients were allocated randomly to one of three groups: anaesthesia was induced with propofol and fentanyl, and group V received vecuronium 1 mg, group R rocuronium 6 mg and group P placebo pretreatment. Suxamethonium 1.5 mg kg-1 was given 60 s after the pretreatment agent. All patients received ketorolac 10 mg i.v. and morphine 10 mg i.m. for analgesia. The incidence of postoperative myalgia on day 1 after rocuronium (20%) was significantly less than after vecuronium (42%) (P < 0.05) or placebo (70%) (P < 0.01). By day 4 the incidence of myalgia was 28.6% in the rocuronium group, 46.3% in the vecuronium group and 95% in the placebo group. Intubating conditions were not affected adversely by any pretreatment regimen.

Effectiveness and sequelae of very low-dose suxamethonium for nasal intubation

We have studied the effectiveness and sequelae of low-dose suxamethonium in 60 day-case oral surgery patients requiring nasal intubation. Anaesthesia was induced with propofol and alfentanil; 60 patients were allocated randomly to three groups of 20 patients and received no suxamethonium, suxamethonium 0.25 mg kg-1 or 0.5 mg kg-1. All patients received i.v. fentanyl and diclofenac 100 mg rectally for analgesia. Good intubating conditions were produced in all 20 patients receiving suxamethonium 0.25 mg kg-1, in 19 patients receiving suxamethonium 0.5 mg kg-1 and in 11 patients not receiving a neuromuscular blocker. The incidence of postoperative myalgia after suxamethonium 0.25 mg kg-1 (20%) did not differ significantly from the incidence after propofol and alfentanil alone (28%).

Postoperative Myalgia after Succinylcholine or Vecuronium for Outpatient Knee Arthroscopy

Postoperative Myalgia after Succinylcholine or Vecuronium for Outpatient Knee Arthroscopy

A Prospective, Randomized, Controlled Study of Intraoperative Efficacy and Postoperative Myalgia of Mivacurium with or without Reversal Agents in Comparisons to Succinylcholine in Ambulatory Surgical Patients

A Prospective, Randomized, Controlled Study of Intraoperative Efficacy and Postoperative Myalgia of Mivacurium with or without Reversal Agents in Comparisons to Succinylcholine in Ambulatory Surgical Patients

Influence of dose on suxamethonium-induced muscle damage

We have examined postoperative muscle pain and early increases in serum concentrations of myoglobin after administration of suxamethonium to see if these changes were dependent on the dose of drug. Thirty ASA I and II adult patients undergoing day-case surgery received a standard anaesthetic technique, including one of three doses of suxamethonium: 0.5, 1.5 or 3.0 mg kg-1. The incidence of postoperative myalgia and the severity of fasciculations were greater after suxamethonium 1.5 mg kg-1 than after a dose of 0.5 or 3.0 mg kg-1. Serum concentrations of myoglobin increased in a dose-dependent manner. Intubating conditions were significantly better with suxamethonium 1.5 or 3.0 mg kg-1 than with 0.5 mg kg-1. Changes in serum concentrations of calcium and potassium were small and similar in the three groups. We conclude that a dose of 3.0 mg kg-1 of suxamethonium provided a better combination of intubating conditions and minimal postoperative myalgia than the two lower doses.

EFFECT OF PREOPERATIVE I. M. ADMINISTRATION OF DICLOFENAC ON SUXAMETHONIUM-INDUCED MYALGIA

We have studied the effects of preoperative administration of diclofenac on suxamethonium-induced myalgia, plasma met-enkephalin-like activity (E-LA), prostaglandin E2-like activity (PGE2-LA), leukotriene C4-like activity (LTC4-LA) and histamine-like activity (H-LA). Thirty-four ASA I patients undergoing elective ophthalmic surgery were allocated randomly to two groups to receive either saline placebo or diclofenac 75 mg i.m. 20 min before operation, in a double-blind design. Anaesthesia was induced with thiopentone 5-7 mg kg-1 followed by suxamethonium 1.5 mg kg-1 and maintained with 67% nitrous oxide and halothane in oxygen. Plasma PGE2-LA, LTC4-LA, H-LA and E-LA were measured before premedication, 1 min after the administration of suxamethonium and 24 h after operation. Muscle fasciculations, intubation conditions and postoperative myalgia were graded numerically. Postoperative myalgia in the diclofenac group was significantly (P < 0.05) less (47.1%) than in the control group (76.5%). Post-suxamethonium and 24-h concentrations of plasma PGE2-LA and LTC4-LA were also significantly (P < 0.05) greater than baseline in the control group. Plasma H-LA was increased in both groups after suxamethonium and this increase was significant (P < 0.05) in the control group. We conclude that diclofenac reduces significantly the incidence and intensity of suxamethonium-induced myalgia.

THE IMPORTANCE OF ACTIVITY AND PRETREATMENT IN THE PREVENTION OF SEXUAMETHONIUM MYALGIAS

We have studied the effectiveness of pretreatment with atracurium 0.05 mg kg-1 and placebo before administration of suxamethonium, in the prevention of postoperative myalgia in inpatients having surgery in which rapid postoperative mobilization was possible (vaginal hysterectomy). On the second day after operation, the patients pretreated with atracurium had significantly fewer postoperative myalgias than those receiving placebo (P < 0.025). All patients were significantly more active on the second day compared with the first day after operation (P < 0.025). Possible causal relationships are discussed.

Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium

We studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone, N2O, isoflurane anaesthesia. Four groups of 20 patients each were pretreated with saline (group 1), tubocurarine 0.05 mg/kg (group 2), vecuronium 0.006 mg/kg (group 3), or midazolam 0.025 mg/kg (group 4), followed by suxamethonium 1.5 mg/kg. Group 5 received only vecuronium 0.1 mg/kg as relaxant (no suxamethonium). Fasciculations were graded, and postoperative myalgias rated on the first and third postoperative days. In groups 1-5 the incidence of fasciculations was 95, 15, 25, 95 and 0%; the incidence of myalgias on the first day after operation was 70, 45, 65, 75 and 60%, and on the third day after operation 20, 5, 20, 20, and 5%, respectively. We conclude that pretreatment with vecuronium, but not midazolam, decreases the incidence of fasciculations after suxamethonium (p less than 0.05) and that in this patient population, postoperative myalgias appear to be unrelated to the use of suxamethonium.

Effects of Precurarization Suxamethonium-Induced Postoperative Myalgia During the First Trimester of Pregnancy

Effects of Precurarization Suxamethonium-Induced Postoperative Myalgia During the First Trimester of Pregnancy