Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Resistance towards nondepolarising muscle relaxants

prolonged onset time

A systematic review

Mørk, Emilie L.; Kristensen, Mette L.; Stokholm, Janne B.; Söderström, Carl M.; Madsen, Matias V.; Gätke, Mona R.

European Journal of Anaesthesiology (EJA): July 2019 - Volume 36 - Issue 7 - p 477–485
doi: 10.1097/EJA.0000000000000991
Neuromuscular blocking agents

BACKGROUND Nondepolarising muscle relaxants (NDMRs) provide optimal conditions for tracheal intubation and improve surgical conditions. Several clinical conditions, diseases and pharmacological interactions have been suggested to cause resistance towards NDMRs that may translate into difficult intubation or inadequate operating conditions during surgery.

OBJECTIVE The aim of this study was to evaluate the current evidence of patient groups with resistance towards NDMRs. A prolonged onset time was defined as a difference that exceeded 25% compared with controls.

DESIGN A systematic review of randomised controlled trials and cohort studies.

DATA SOURCES A comprehensive search was performed in 2016 in PubMed and EMBASE.

ELIGIBILITY CRITERIA Patients with conditions or diseases, or patients taking medication, which lead to resistance towards current NDMRs (rocuronium, vecuronium, cisatracurium, atracurium, mivacurium and pancuronium). Included outcomes were onset time defined as the time between administration of NDMR to maximal (90, 95 or 100%) depression of baseline twitch height of the first twitch in a train-of-four.

RESULTS Twenty-five studies were included. Strong evidence supports a prolonged onset time of rocuronium in patients with thermal injury and Duchenne muscular dystrophy. Moderate evidence supports a prolonged onset time of NDMRs during hypothermia and in patients with infection, oculopharyngeal muscular dystrophy, liver cirrhosis treated with ulinastatin, when remifentanil is administered prior to administration of an NDMR, in fasting patients being rehydrated intravenously prior to administration of NDMR, in children with end-stage renal failure and in patients with atrial or ventricular septal defects.

CONCLUSION A prolonged onset time should be suspected in patients with thermal injury and Duchenne's muscular dystrophy. Further, evidence supports a prolonged onset time in patients with infection, oculopharyngeal muscular dystrophy, congenital heart defects, kidney failure, liver cirrhosis treated with ulinastatin along with remifentanil or intravenous fluids administered prior to NDMR.

From the Department of Anaesthesiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark (EL-M, ML-K, JB-S, CM-S, MV-M, MR-G)

Correspondence to Emilie L. Mørk, MD, Herlev Hospital, Herlev DK 2730, Region Hovedstaden, Denmark E-mail:

Published online 3 April 2019

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

© 2019 European Society of Anaesthesiology