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Glycopyrrolate: Pharmacology and clinical use
CURRENT LITERATURE Abstracts Alterations in Nasal Airway Resistance Following Superior Repositioning of the Maxilla. ‘Ibrvey TA, Hall DJ, Warren DW. Am J Orthod 85:109, 1984
Parotid Benign Tumors: Comments on Surgical Treatment of 263 Cases. Martis C. Int J Oral Surg 12:211, 220, 1983
A traditional surgical procedure to correct vertical maxillary excess is superior repositioning of the maxilla. Superior repositioning procedures that appear to reduce the volume and possibly the airflow capacity of the nasal airway are of particular concern. The purpose of this study was to determine how superior repositioning of the maxilla affects the nasal airway. Specific objectives of the study were: 1) to evaluate presurgical nasal resistance in patients requiring superior repositioning of the maxilla to test the hypothesis that nasal airway resistance is a common feature in excessive vertical development of the lower third of the face; 2) to obtain measurements of nasal airway resistance following superior repositioning of the maxilla to establish whether consistent changes in nasal resistance follow such surgical procedures; and 3) to determine the relationship between the type of surgical procedure and changes in nasal resistance. Pre- and postoperative nasal-resistance values were obtained for 52 long-faced patients who underwent superior repositioning of the maxilla by the LeFort I downfracture technique. Of these 52 patients, 28 were superiorly repositioned with a one-piece osteotomy and 24 underwent segmental osteotomies. Results show that long-faced patients for whom superior repositioning of the maxilla is recommended generally have pretreatment nasal-resistance values within the previously reported range of normal. Superior repositioning of the maxilla, with or without involvement of the nasal floor, almost always results in decreased nasal airway resistance. Only one patient in this series showed a postsurgical increase in resistance to above normal values, while 17 of 19 who had high nasal resistance presurgically had normal values postsurgically. The authors conclude that superior repositioning of the maxilla does not increase resistance to nasal breathing, whether or not the surgical procedure elevates the floor of the nose.-B. D. TINER
Over a lo-year period 263 patients who had benign parotid tumors were treated. The predominant diagnosis was pleomorphic adenoma (185 cases). The author discusses the various modes of treatment: 1) extracapsular excision without superficial parotidectomy (52.6% of cases); 2) superficial parotidectomy (42.5% of cases); 3) total parotidectomy with preservation of the facial nerve (4.9% of cases). Indications for the different approaches to treatment are reviewed. There was no permanent facial palsy and no recurrence of the tumors in this series. Frey’s syndrome developed in three cases. No infections occurred.-ROBERT
CHUONG
Reprint requests to Dr. Martis: Department of Maxillofacial and Oral Surgery, Dental School, Thessaloniki University, Thessaloniki. Greece
Glycopyrrolate: Pharmacology and Clinical Use. Mirakhua RK, Dundee JW. Anaesthesia 38: 1195, 1983 This article reviewed compares use of glycopyrrolate with use of atropine in clinical anesthesia practice. Glycopyrrolate is a quaternary ammonium anticholinergic drug originally used as a premeditation to reduce the hazards of aspiration of gastric contents. Early reports indicated that it could be used with advantage in place of atropine as an adjunct to reversal of non-depolarizing neuromuscular blockage by anticholinesterases. Differences in pharmacologic action between glycopyrrolate and atropine noted in this study were numerous. Unlike atropine, glycopyrrolate does not penetrate the bloodbrain barrier to any significant extent. Also, the antisialagogue effect of glycopyrrolate is about five times as potent as that of a&opine. When administered by intramuscular injection, glycopyrrolate produced no increase in heart rate, whereas atropine elicited a highly significant and dose-related tachycardia. It was also noted that when used as a premeditation, glycopyrrolate was associated with a significantly lower incidence of dysrhythmia during induction of anesthesia than atropine following equipotent antisialogogue doses. Clinically, glycopyrrolate, when used in a mixture with neostigmine for antagonism of competitive neuromuscular block, is most advantageous. Unlike atropine, which exerts its effects before neostigmine and causes sharp increase in heart rate, glycopyrrolate has a similar onset of activity to neostigmine and also causes no reflex tachycardia. The authors leave little doubt that glycopyrrolate is an effective and potent anticholinergic and is a welcome addition to the drugs used for anesthesia. In clinical trials it has shown several advantages over atropine, use of which was the standard of practice in anesthesia for many years. Glycopyrrolate should be the drug of choice when used with anticholinesterases as the anticholinergic component of the reversal mixture of neuromuscular blockade. This may prove useful in general anesthesia for oral surgery cases that benefit from a nitrous-narcotic technique supplemented by nondepolarized neuromuscular block-
Reprint requests to Dr. Turvey: University of North Carolina, School of Dentistry, Chapel Hill. NC 27514
Antiemetic Efficacy of Droperidol and Metoclopramide Cohen SE, Woods CA, and Wyner J: Anesthesiology 60:67, 1984 The antiemetic effects of droperidol (1.25 mg) and metociopramide (IO mg) were compared in a study consisting of 87 healthy female outpatients undergoing general anesthesia with fentanyl, therapeutic nitrous oxide, IV succinylcholine, and controlled mask ventilation for therapeutic abortion. There was a lower incidence of nausea and vomiting in the group receiving metoclopramide but it was not of statistical significance. The patients in the group receiving metoclopramide were able to ambulate sooner than those in the droperidol group and had an earlier discharge. The overall results of the study showed that neither droperidol or metoclopramide proved effective as an antiemetic in the dose employed.DANIEL QU~N
ade.-CHARLES
Reprint Requests to: Dr. Cohen: Department of Anesthesiology, Stanford University Medical Center. Stanford, CA 93405
RINGGOLD
Reprint requests to Dr. Mirakhur: Royal Victoria Hospital, Grosvenor Road. Belfast BT126BA Ireland
753
Parotid Benign Tumors: Comments on Surgical Treatment of 263 Cases. Martis C. Int J Oral Surg 12:211, 220, 1983
A traditional surgical procedure to correct vertical maxillary excess is superior repositioning of the maxilla. Superior repositioning procedures that appear to reduce the volume and possibly the airflow capacity of the nasal airway are of particular concern. The purpose of this study was to determine how superior repositioning of the maxilla affects the nasal airway. Specific objectives of the study were: 1) to evaluate presurgical nasal resistance in patients requiring superior repositioning of the maxilla to test the hypothesis that nasal airway resistance is a common feature in excessive vertical development of the lower third of the face; 2) to obtain measurements of nasal airway resistance following superior repositioning of the maxilla to establish whether consistent changes in nasal resistance follow such surgical procedures; and 3) to determine the relationship between the type of surgical procedure and changes in nasal resistance. Pre- and postoperative nasal-resistance values were obtained for 52 long-faced patients who underwent superior repositioning of the maxilla by the LeFort I downfracture technique. Of these 52 patients, 28 were superiorly repositioned with a one-piece osteotomy and 24 underwent segmental osteotomies. Results show that long-faced patients for whom superior repositioning of the maxilla is recommended generally have pretreatment nasal-resistance values within the previously reported range of normal. Superior repositioning of the maxilla, with or without involvement of the nasal floor, almost always results in decreased nasal airway resistance. Only one patient in this series showed a postsurgical increase in resistance to above normal values, while 17 of 19 who had high nasal resistance presurgically had normal values postsurgically. The authors conclude that superior repositioning of the maxilla does not increase resistance to nasal breathing, whether or not the surgical procedure elevates the floor of the nose.-B. D. TINER
Over a lo-year period 263 patients who had benign parotid tumors were treated. The predominant diagnosis was pleomorphic adenoma (185 cases). The author discusses the various modes of treatment: 1) extracapsular excision without superficial parotidectomy (52.6% of cases); 2) superficial parotidectomy (42.5% of cases); 3) total parotidectomy with preservation of the facial nerve (4.9% of cases). Indications for the different approaches to treatment are reviewed. There was no permanent facial palsy and no recurrence of the tumors in this series. Frey’s syndrome developed in three cases. No infections occurred.-ROBERT
CHUONG
Reprint requests to Dr. Martis: Department of Maxillofacial and Oral Surgery, Dental School, Thessaloniki University, Thessaloniki. Greece
Glycopyrrolate: Pharmacology and Clinical Use. Mirakhua RK, Dundee JW. Anaesthesia 38: 1195, 1983 This article reviewed compares use of glycopyrrolate with use of atropine in clinical anesthesia practice. Glycopyrrolate is a quaternary ammonium anticholinergic drug originally used as a premeditation to reduce the hazards of aspiration of gastric contents. Early reports indicated that it could be used with advantage in place of atropine as an adjunct to reversal of non-depolarizing neuromuscular blockage by anticholinesterases. Differences in pharmacologic action between glycopyrrolate and atropine noted in this study were numerous. Unlike atropine, glycopyrrolate does not penetrate the bloodbrain barrier to any significant extent. Also, the antisialagogue effect of glycopyrrolate is about five times as potent as that of a&opine. When administered by intramuscular injection, glycopyrrolate produced no increase in heart rate, whereas atropine elicited a highly significant and dose-related tachycardia. It was also noted that when used as a premeditation, glycopyrrolate was associated with a significantly lower incidence of dysrhythmia during induction of anesthesia than atropine following equipotent antisialogogue doses. Clinically, glycopyrrolate, when used in a mixture with neostigmine for antagonism of competitive neuromuscular block, is most advantageous. Unlike atropine, which exerts its effects before neostigmine and causes sharp increase in heart rate, glycopyrrolate has a similar onset of activity to neostigmine and also causes no reflex tachycardia. The authors leave little doubt that glycopyrrolate is an effective and potent anticholinergic and is a welcome addition to the drugs used for anesthesia. In clinical trials it has shown several advantages over atropine, use of which was the standard of practice in anesthesia for many years. Glycopyrrolate should be the drug of choice when used with anticholinesterases as the anticholinergic component of the reversal mixture of neuromuscular blockade. This may prove useful in general anesthesia for oral surgery cases that benefit from a nitrous-narcotic technique supplemented by nondepolarized neuromuscular block-
Reprint requests to Dr. Turvey: University of North Carolina, School of Dentistry, Chapel Hill. NC 27514
Antiemetic Efficacy of Droperidol and Metoclopramide Cohen SE, Woods CA, and Wyner J: Anesthesiology 60:67, 1984 The antiemetic effects of droperidol (1.25 mg) and metociopramide (IO mg) were compared in a study consisting of 87 healthy female outpatients undergoing general anesthesia with fentanyl, therapeutic nitrous oxide, IV succinylcholine, and controlled mask ventilation for therapeutic abortion. There was a lower incidence of nausea and vomiting in the group receiving metoclopramide but it was not of statistical significance. The patients in the group receiving metoclopramide were able to ambulate sooner than those in the droperidol group and had an earlier discharge. The overall results of the study showed that neither droperidol or metoclopramide proved effective as an antiemetic in the dose employed.DANIEL QU~N
ade.-CHARLES
Reprint Requests to: Dr. Cohen: Department of Anesthesiology, Stanford University Medical Center. Stanford, CA 93405
RINGGOLD
Reprint requests to Dr. Mirakhur: Royal Victoria Hospital, Grosvenor Road. Belfast BT126BA Ireland
753