PENGARUH PRETREATMENT MIDAZOLAM ATAU ATRAKURIUM TERHADAP FASIKULASI, MIALGIA DAN KENAIKAN KADAR KREATIN FOSFOKINASE DARAH AKIBAT SUKSINILKOLYN EFFECT OF PRETREATMENT WITH MIDAZOLAM OR ATRACURIUM ON FASCICULATION, MYALGIA AND ELEVATION OF BLOOD CPK LEVEL FOLLOWING SUCCINYLCHOLINE ADMINISTRATION

Abstract

Background : Succinylcholine is commonly used for intubating fascilitation in emergency and day-case anaesthesia. Most occured side effects of succinylcholine is fasciculation, myalgia and elevation of blood creatine phosphokinase level. Atracurium, like other non depolarizing muscle relaxants, had been proved as a gold standard for pretreatment against these side effects. Midazolam, that has been known as popular premedication drug, has not been studied most for these utilities yet. Objective : The aim of this study was to prove that pretreatment with midazolam 0,03 mg ke or atracurium 0,05 mg ke could reduce fasciculation; myalgia and elevation of CPK level following succinylcholine administration. Method : This study was designed as double blind randomly clinical trial on 54 patients underwent elective surgery, 16-40 year age, ASA I-II and fullfill the inclusion criterias. Before pretreatment drug had been given, a blood sample for preinduction creatine phosphokinase level measurement were taken. Patients was divided into three groups of pretreatment drugs, receiving midazolam 0,03 mg kg4 , atracurium 0,05 mg kgl and NaC1 0,9% (control group). Three minutes later, anaesthesia was induced with thiopentone 4-5 mg ke and succinylcholine 1,5 mg kg-1. Fasciculations were scored followed by intubation. Twenty four hours after operation, myalgias were scored and a blood sample for post operation CPK level measurement were taken. Statistical analysis were performed by Anova — post hoc Bonferroni test, chi square — Wilcoxon Signed Ranks test and Spearman correlation test. Results : The characteristic features of the three groups are similar. There are significantly reduction of fasciculation incidence (p<0.01), myalgia incidence (p<0.01) and CPK level elevation in atracurium group (p<0.05). In midazolam group, myalgia insidence is .significantly reduced (p<0.01) but CPK level elevation is only slight reduced (p=0.086) and there is no reduction of fasciculation incidence (p=0.1.25). The only significant correlation proved is between myalgia and CPK level elevation (corr.coef=0,334; p=0,013). Conclusions : Atracurium is proved to be effective for pretreatment against fasciculation, inyalgia and elevation of C'PK level. Midazolam is as effective as atracurium to reduce myalgia, less effective to reduce CPK level elevation and not effective to reduce fasciculation. Latar belakang : Pernakaian suksinilkolin sebagai fasilitas intubasi masib merupakan pilihan dalam anestesia, terutama untuk kasus emergensi dan rawat jalan. Efek samping yang sering timbul adalah fasikulasi, mialgia dan kenaikan kadar kreatin. fosfokinase (CPK) darah. Atrakurium, seperti pelumpuh otot non depolarisasi lain, telah teruji sebagai baku emas pretreatment terhadap efek samping iM. Midazolam yang populer sebagai obat premedikasi belum banyak diteliti sebagai pretreatment. Tujuan : Membuktikan bahwa pretreatment midazolain 0,03 mg/kgBB atau atrakuri.um 0,05 mg/kgBB dapat mengurangi fasikulasi, mialgia dan kenaikan kadar kreatin fosfokinase darah akibat pemberian Metode : Penelitian ini dirancang sebagai uji Minis acak tersamar ganda terhadap 54 penderita yang akan menjalani operasi elektif, usia 16 — 40 tahun, status fisik ASA I-II dan memenuhi kriteria inklusi. Sebelum mendapat obat pretreatment, dilakukan pengambilan darah untuk penieriksaan kadar kreatin fosfokinase pra perlalcuan. Penderita dibagi menjadi tiga kelompok sesuai pretreatment yang diberilcan, yaitu midazolam 0,03 mg/kgBB iv, atrakurium 0,05 mg/kgBB iv dan kontrol mendapat NaCI 0,9%. Tiga menit kemudian semua penderita diinduksi dengan tiopental 4-5 mg/kgBB iv dan suksinilkolin 1,5 mg/kgBB iv. Fasikulasi yang timbul dinilai dilanjutkan dengan intubasi. Duapuluh empat jam pasca operasi dilakukan penilaian mialgia dan pengambilan darah untulc pemeriksaan kadar kreatin fosfokinase pasca perlalcuan. Penderita mendapat tramadol iv sebagai analgetik pasca operasi. Uji statistik menggunakan uji Anova — Post hoc Bonferroni dan uji Kai kuadrat — Wilcoxon Signed Rank serta uji korelasi dui Spearman. Hasil : Data karakteristik penderita berbeda tidak bermakna pada ketiga kelompok. Pada kelompok atralcurium terjadi penurunan kejadian fasikulasi (p<0,01), mialgia (pc0,01) dan kenaikan Icadar kreatin fosfokinase yang bermakna (p<0,05). Pada kelompok midazolam teijadi penurunan kejadian mialgia yang bermakna (p<0,01), sedikit kenaikan Icadar kreatin fosfokinase (p=0,086) dan tidak teijadi penurunan kejadian fasikulasi (p-0,125). Pada uji korelasi terhadap tiga variabel terikat hanya tampak korelasi bermakna antara mialgia clan kenaikan kadar kreatin fosfokinase (koef kor=0,334;p=0,013). Kesimpulan : Atralcurium sebagai pret•eatment terbukti efektif mengurangi fasikulasi, mialgia maupun kenaikan kadar kreatin fosfokinase darah. Midazolam sama efektif dengan atrakurium dalam hal mengurangi mialgia, namun kurang efektif untuk mengurangi kenailcan kadar kreatin fosfokinase dan tidak efektif untuik mencegah fasikulasi