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To the Editor, In the retrospective study by Sidi et aL I we feel that the authors fail to support their conclusions adequately. They reported incidents of prolonged neuromuscular blockade and ventilatory failure after renal transplantation eight patients out of 65 over a one-year period. They conclude that the administration of 5 mg. kg -1 cyclosporine iv contributed to this complication, As support for their argument they state that three of the eight patients with respiratory failure received cyclosporine (P < 0.05 by Fisher's exact test). They quote the publications by Gramstad et al. and Fragen et al. work performed in an animal model (cats) and in vitro, but not yet confirmed in humans. In the other five they were unable to offer an explanation, disregarding the drugs used for premedication. Their routine premedication included ranitidine 150 mg and 20 patients received diazepam 5-10 mg. Was there any correlation between the patients with prolonged neuromuscular blockade and respiratory failure and premedication with diazepam? Diazepam has muscle relaxant properties 2 and an elimination half-life of 20--40 hr with active metabolites which have an even longer half-life. 2 It is also highly protein bound and patients with chronic renal failure have an increased unbound fraction, 2'3 Further, histamine H 2 receptor antagonists inhibit the oxidative metabolism of diazepam. 2 Despite the routine infusion of 5 mg 9 kg-I of cyclosporine commenced one hour prior to surgery and given over four hours, prolonged neuromuscular blockade and respiratory failure is an extremely uncommon complication in our renal transplant patients. We reviewed all our renal transplants performed in 1989 (104 patients) and 1990 (107 patients). In the 211 transplants, all hut six patients received cyclosporine. Our routine does not include premedicant drugs; induction is with thiopentone and succinylcholine and maintenance with oxygen, nitrous oxide, halothane and fentanyl 1-2 IJ, g" kgi. A peripheral nerve stimulator is used intraoperatively. Reversal is with neostigmine and atropine. When the patient is breathing spontaneously, is fully awake, and neuromusuclar function is adequate as shown by peripheral nerve stimulation, the trachea is extubated and he is returned to the renal unit.

Neuromuscular blockade and ventilatory failure after cyclosporine