Dose Requirements of Vecuronium, Pancuronium, and Atracurium During Orthotopic Liver Transplantation

To further elucidate the role of the liver in the clearance of vecuronium, atracurium, and pancuronium, 30 patients undergoing orthotopic liver transplantation were randomly assigned to three comparable groups to receive a continuous infusion of vecuronium, atracurium, or pancuronium. The evoked integrated compound action potential of the hypothenar eminence in response to train-of-four ulnar nerve stimulation was measured and recorded. Anesthesia was induced with 3–5 mg/kg of thiopental, 50 μg/kg of midazolam, and 1–5 μg/kg of fentanyl IV and was maintained with continuous infusions of midazolam and fentanyl while the lungs were ventilated with an air-oxygen mixture. The infusion rates of vecuronium, atracurium, and pancuronium were adjusted to achieve a Tl/Tc ratio of between 0.02 and 0.10 (T1 = height of first twitch, Tc = height of control twitch). Vecuronium and pancuronium requirements, which were 0.072 ± 0.022 and 0.042 ± 0.015 mg·kg−1·h−1 (mean ± standard deviation) respectively during the dissection phase, decreased significantly during the anhepatic phase to 0.036 ± 0.021 and 0.018 ± 0.012 mg·kg−1·h−1 and returned toward the initial values in the postreperfusion phase (0.055 ± 0.018 and 0.032 ± 0.012 mg·kg·−1·h−1); whereas atracurium requirements remained unchanged during the three phases (0.667 ± 0.199, 0.567 ± 0.142, and 0.692 ± 0.254 mg·kg−1·h−1). These data suggest that the liver has an important role in the elimination of vecuronium and pancuronium, whereas the elimination of atracurium is unaltered during exclusion of the liver from the circulation.