Guidelines on muscle relaxants and reversal in anaesthesia / 中华麻醉学杂志

Objectives:To provide an update to the 1999 French guidelines on " Muscle relaxants and reversal in anaesthesia" , a consensus committee of sixteen experts was convened.A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout.The entire guidelines process was conducted independently of any industrial funding (i.e.pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE ?) system to assess the quality of the evidence on which the recommendations were based.The potential drawbacks of making strong recommendations based on low-quality evidence were stressed.Few of the recommendations remained ungraded. Methods:The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g.electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated.The results of the literature analysis and the recommendations were then assessed using the GRADE ? system. Results:The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia.Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE ? system for five of the questions, and for two of these questions expert opinions were given.After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. Conclusion:Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia.In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

Caso de hipertermia maligna en paciente intervenida de apendicectomía laparoscópica / Malignant Hyperthermia after a laparoscopic appendicectomy: Case report

Malignant hyperthermia is an hypermetabolic syndrome in which the intracellular calcium receptors are altered. Patients who present compatible symptoms with this symdrome are genetically predisposed. Many of the cases have been described in the surgical area, due to the use of anesthesic drugs and neuromuscular blockers. However, there are some cases with an unknown trigger. The prevalence of the syndrome is very difficult to estimate. The diagnosis and early treatment are pronostic factors predicting the evolution of the syndrome.

La hipertermia maligna es conocida como un síndrome de estimulación masiva del metabolismo, debido a la alteración en la liberación de calcio intracelular. Muchos pacientes que presentan clínica compatible con este síndrome están genéticamente predispuestos. La mayoría de los casos se describen en el ámbito quirúrgico, con el empleo de fármacos anestésicos y determinados relajantes neuromusculares, aunque también existen casos en los que no se halla desencadenante. De prevalencia difícil de estimar, la sospecha diagnóstica y el tratamiento precoz marcan el pronóstico evolutivo de estos pacientes.

Intubating Conditions Under Non-Depolarizing Muscle Relaxants – A Comparative Study

Introduction: In conditions like significant burns,traumatic injuries or an abdominal infection succinylcholineadministration could be hazardous as it is associatedwith dangerous hyperkalemia. Vecuronium, atracuriumand Pancuronium not only are the alternatives but alsooffer skeletal muscle relaxation at shortest intervals postintubation. We assessed the intubating conditions achievedand the hemodynamic effects of pancuronium, vecuronium,and atracurium among patients undergoing routine surgicalprocedures requiring general anaesthesia.Material and methods: A prospective randomized trial wascarried out among 60 participants aged 15-56, who were inthe good physical condition and belonged to ASA I or ASAII categories.study was conducted at Civil Hospital, AizawlMizoram. The patients were randomly allocated to 3 groups oftwenty each viz, Group A, Group B and Group C. Followinginduction of anaesthesia Inj. Pancuronium bromide 0.1 mg/kg.was given to Group A; Inj. Vecuronium 0.1 mg/kg to GroupB. and Inj. Atracurium 0.6 mg/kg to Group C. Pulse rate andblood pressure were recorded immediately and time intervalafter intubation.Results: The apnoea time was longest in group A (57±7seconds) followed by group C (50±14 seconds) and groupB (49±8 seconds). The mean pulse rate, however, variedsignificantly post-intubation across the three groups. Theintergroup comparison showed a significantly higher rise ofthe mean arterial pressure in group A compared with group Bat all corresponding tie intervals in the post intubation period.Conclusion: Though all the three skeletal muscle relaxantsprovided adequate intubating conditions, Vecuronium offeredthe shortest intubation time while the Pancuronium took thelongest time.

Comparison of different brands of centrally acting skeletal muscle relaxants: a cost analysis study

Background: Skeletal muscle relaxants are structurally distinct drugs prescribed for reducing muscle spasms, pain, and hyperreflexia. Centrally acting skeletal muscle relaxants are manufactured by various pharmaceutical companies with variable price. The present study, aimed to analyze the cost variation of various brands of centrally acting skeletal muscle relaxants, so as to help the physician to choose the cost effective treatment.Methods: Current index of medical stores (CIMS) April 2018 and online literature were used as information guide to review the prices of drugs used in the treatment of musculo skeletal pain and spastic neurological disorders.Results: Among anti spasmodic group, thiocolchicoside 4 mg shows maximum price variation of 337.5%, whereas carisoprodol 350 mg shows the least variation of 0.1%. It is evident from antispastic group that baclofen 10 mg shows maximum price variation of 93.91% and 5 mg of Baclofen shows the least variation of 11.22%. It is observed that, among anti spastic group, a percentage prize variation of 93.91 for 10 mg and 11.22 for 5 mg baclofen. Largest % prize variation is seen in metaxalone + diclofenac sodium (400+50) mg as 525% and the least variation is observed in tolperisone+ paracetamol (150+325) mg as 3.88%.Conclusions: Centrally acting orally effective skeletal muscle relaxants are commonly prescribed for painful musculoskeletal and spastic neurological disorders. Physicians should give due importance for the cost of the drugs while selecting appropriate drug for musculo skeletal disorders.

​Compare Onset Time Of Cisatracurium For Tracheal Intubation With And Without Priming Dose Of Rocuronium

Background: Priming is one of those techniques in which a small dose of non-depolarizing muscle relaxants is administeredfollowed by a large intubating dose. Cisatracurium is the newly introduced drug with Hoffman elimination. The problem with itsuse is delayed onset of action. The present study was conducted to compare the onset of cisatracurium for tracheal intubationwith and without priming dose of rocuronium.Materials and Methods: A total of 60 American Society of Anesthesiologist physical Status Ι and ΙΙ patients undergoing surgeryunder general anesthesia were included in the study. Patients were divided into two groups of 30 each. Patients in Group Rreceived priming dose of rocuronium 0.06 mg/kg before intubating dose of cisatracurium (0.14 mg/kg). Group C patients didnot get any priming, only normal saline was given before intubating dose of cisatracurium (0.15 mg/kg).Results: Time gap between administration of the cisatracurium and complete loss of T1 was recorded as intubation time.The intubation time was significantly less in Group R, i.e., 130 ± 11.02 s as compared to Group C, i.e., 230.33 ± 12.82 s. Theintubating conditions were similar in both the groups. The hemodynamic changes were statistically insignificant. The time to25% recovery of the T1 response is defined as the clinically effective duration of neuromuscular block. The rate of recovery isdescribed by the recovery index, which is defined as the time from 25% to 75% T1 recovery.Conclusion: Priming with rocuronium decreased the onset time without increasing the clinical duration of action or recovery index.

Effects of general anesthesia maintenance without muscle relaxants for double-balloon enteroscopy:a randomized controlled trial / 中华消化内镜杂志

Objective To evaluate the feasibility and safety of maintaining general anesthesia without neuromuscular blockade in oral double-balloon enteroscopy. Methods Totally 120 patients undergoing oral double-balloon enteroscopy under general anesthesia were randomly assigned into two groups:the observation group and the control group. The observation group was not given muscle relaxants for anesthesia maintenance,while the control group was given muscle relaxants punctually. Observation indexes were monitored,including the mean arterial pressure (MAP),heart rate (HR),peak airway pressure (Ppeak)and end-tidal CO2 partial pressure (PETCO2 )before anesthesia (T0),immediately after intubation (T1),at the time of endoscopy placement (T2),at the end of endoscopy withdrawal (T3),and at the time of waking-up (T4). The cases of spontaneous breathing recovery before the end of endoscopy,postoperative recovery time,extubation time,length of PACU stay,postoperative adverse reactions and satisfactory rates were recorded. Results Twelve cases were removed by the exclusion criteria,and the remaining 108 cases completed the study,including 56 cases in the observation group and 52 cases in the control group. The one-time success rate of induction was both 100％ in the two groups. There were no significant differences in MAP,HR,Ppeak,and PETCO2 between the two groups at each observation point (all P>0. 05),and the same is true for within group comparison with T0 (all P>0. 05). The recovery rate of spontaneous respiration in the observation group was significantly higher than that in the control group [100％ (56/ 56)VS 42％(22/ 52),χ2 = 44. 73,P = 0. 000]. The awaken time,extubation time and length of PACU stay were 6±2 min,10±3 min,and 11± 4 min,respectively,in the observation group,compared with 15± 5 min (t= -12. 64,P= 0. 000),17±5 min (t = -8. 90,P = 0. 000),and 17±7 min (t = -5. 73,P = 0. 000)in the control group. None of the patients required assisted ventilation. Hypoxemia occurred in 2 cases and nausea in 3 cases in the control group,while only nausea occurred in 1 patient in the observation group. The overall incidence of adverse reactions was not statisticaly different between the two groups (P > 0. 05). Anesthesia satisfaction rate of two groups was 100％. Conclusion It is feasible and safe to perform oral double-balloon enteroscopy without muscle relaxants during maintaining under general anesthesia,with quick recovery of spontaneous breathing and awakening,early extubation and less cost.

Effects of general anesthesia maintenance without muscle relaxants for double-balloon enteroscopy: a randomized controlled trial / 中华消化内镜杂志

Objective@#To evaluate the feasibility and safety of maintaining general anesthesia without neuromuscular blockade in oral double-balloon enteroscopy.@*Methods@#Totally 120 patients undergoing oral double-balloon enteroscopy under general anesthesia were randomly assigned into two groups: the observation group and the control group. The observation group was not given muscle relaxants for anesthesia maintenance, while the control group was given muscle relaxants punctually. Observation indexes were monitored, including the mean arterial pressure (MAP), heart rate (HR), peak airway pressure (Ppeak) and end-tidal CO2 partial pressure (PETCO2) before anesthesia (T0), immediately after intubation (T1), at the time of endoscopy placement (T2), at the end of endoscopy withdrawal (T3), and at the time of waking-up (T4). The cases of spontaneous breathing recovery before the end of endoscopy, postoperative recovery time, extubation time, length of PACU stay, postoperative adverse reactions and satisfactory rates were recorded.@*Results@#Twelve cases were removed by the exclusion criteria, and the remaining 108 cases completed the study, including 56 cases in the observation group and 52 cases in the control group. The one-time success rate of induction was both 100% in the two groups. There were no significant differences in MAP, HR, Ppeak, and PETCO2 between the two groups at each observation point (all P>0.05), and the same is true for within group comparison with T0 (all P>0.05). The recovery rate of spontaneous respiration in the observation group was significantly higher than that in the control group [100% (56/56) VS 42% (22/52), χ2=44.73, P=0.000]. The awaken time, extubation time and length of PACU stay were 6±2 min, 10±3 min, and 11±4 min, respectively, in the observation group, compared with 15±5 min (t=-12.64, P=0.000), 17±5 min (t=-8.90, P=0.000), and 17±7 min (t=-5.73, P=0.000) in the control group. None of the patients required assisted ventilation. Hypoxemia occurred in 2 cases and nausea in 3 cases in the control group, while only nausea occurred in 1 patient in the observation group. The overall incidence of adverse reactions was not statisticaly different between the two groups (P>0.05). Anesthesia satisfaction rate of two groups was 100%.@*Conclusion@#It is feasible and safe to perform oral double-balloon enteroscopy without muscle relaxants during maintaining under general anesthesia, with quick recovery of spontaneous breathing and awakening, early extubation and less cost.

Advances in chemical constituents of isoquinoline alkaloids from Nelumbo nucifera and their smooth muscle relaxation effect / 中国中药杂志

Lotus( Nelumbo nucifera) is a traditional medicinal plant,and nowadays it is regarded both as medicine and food. It is widespread across China and rich in natural resources. Almost every part of N. nucifera could be used for medical or edible purpose,including seeds( Lianzi),black ripe fruits( Shilianzi),seed coats( Lianyi),green embryos of mature seed( Lianzixin),flowers( Lianhua),stamens( Lianxu),receptacles( Lianfang),leaves( Heye),leaf or flower stalks( Hegeng),leaf bases( Heyedi),rhizomes( Ou) and rhizome nodes( Oujie). Therefore,this plant is praised as a commercial crop with great economic values. Isoquinoline type alkaloids are the main chemical components of lotus. Smooth muscles usually exist in the digestive tract,respiratory tract and vascular,urinary,reproductive and other human systems. Dysfunction of smooth muscle contraction will induce many diseases including hypertension,asthma and gastrointestinal disorder,etc.,and most of current therapeutic strategies rely on relaxation of smooth muscle by drugs.Previous studies have shown that alkaloids of lotus have strong relaxation activity on smooth muscle. The present paper reviews phytochemistry and smooth muscle relaxation activity of 59 isoquinoline alkaloids from N. nucifera through accessing CNKI,PubMed and multiple databases for biomedical sciences.

Caso clínico: Diagnóstico de alergia a relajantes musculares y opiáceos / Case report: Diagnosis of allergy to muscle relaxants and opiates

The anesthesiologist is the specialist who most often faces allergic reactions due to the number of drugs and substances that are exposed to the patient during the course of an intervention. Although they are rare, they have a mortality rate between 3% and 10%. We present a clinical case of a 42-year-old woman with a history of anaphylactic reaction grade 2 that is coordinated for a Werthein-Meigs surgery, for which it is decided to test her with skin tests. The results were positive for morphine, fentanil, remifentanil and atracurium, which directly affected the perioperative management.

El anestesiólogo es el especialista que con mayor frecuencia se enfrenta a reacciones alérgicas por el número de fármacos y sustancias a las que se expone al paciente en el transcurso de una intervención. Si bien son poco frecuentes presentan una mortalidad entre 3 a 10%. Presentamos un caso clínico de una mujer de 42 años con un antecedente de reaccion anafiláctica grado 2 que se coordina para una cirugía de Werthein- Meigs, por lo cual se decide testearla con pruebas cutáneas. Los rsultados fueron positivos para morfina, fentani, remifentanil y atracurio, lo cual incidió directamente en el manejo perioperatorio.

Pain medication and long QT syndrome

Long QT syndrome is a cardiac repolarization disorder and is associated with an increased risk of torsades de pointes. The acquired form is most often attributable to administration of specific medications and/or electrolyte imbalance. This review provides insights into the risk for QT prolongation associated with drugs frequently used in the treatment of chronic pain. In the field of pain medicine all the major drug classes (i.e. NSAIDs, opioids, anticonvulsive and antidepressant drugs, cannabinoids, muscle relaxants) contain agents that increase the risk of QT prolongation. Other substances, not used in the treatment of pain, such as proton pump inhibitors, antiemetics, and diuretics are also associated with long QT syndrome. When the possible benefits of therapy outweigh the associated risks, slow dose titration and electrocardiography monitoring are recommended.

Comparison of Sugammadex and Neostigmine on First Spontaneous Breathing and Adverse Effects for Laparoscopic Cholecystectomy

OBJECTIVE: The purpose of the study was to investigate the time from the injection of muscle relaxants to the first spontaneous respiration between sugammadex and conventional reversal for patients undergoing laparoscopic cholecystectomy. METHODS: This study was retrospectively conducted on patients who were diagnosed with gallbladder stone (N802) between January 2014 and April 2017. The data were collected from the electronic medical records of a total of 186 patients (84 patients in the neostigmine group and 102 patients in the sugammadex group). RESULTS: The time required for the first spontaneous respiration in the sugammadex group was shorter than that in the neostigmine group (3.6 min vs 4.9 min; p < 0.05). After the injection of intermediate muscle relaxants, the comparison of heart rate and mean arterial pressure in the sugammadex and neostigmine groups revealed that the heart rate in the neostigmine group was higher than in the sugammadex group after 5 min (p < 0.05). The mean arterial pressure in the neostigmine group was higher than in the sugammadex group after 10 min (p < 0.05). A significant adverse effect of tachycardia was observed in the neostigmine group (p < 0.05), but the frequency of rescue antiemetic in the sugammadex group was significantly higher than in the neostigmine group (p < 0.05). CONCLUSION: In this study, the unwanted effect of neostigmine group was tachycardia; therefore, in the case of patients with hemodynamic instability, sugammadex is recommended. At 12 hours after the injection of sugammadex to patients, more antiemetics were required than in the neostigmine group; therefore, more research should be conducted on postoperative nausea and vomiting.

Importance of cervicogenic general dizziness / Journal of Rural Medicine

A 15-month retrospective study of 1,000 outpatients was conducted to determine the exact cause of general dizziness. The most common diagnosis in all analyzed cases was cervicogenic general dizziness (89%). The majority of the patients who underwent magnetic resonance imaging of the cervical spine had narrow spinal canals. Measuring the anteroposterior diameter of the spinal canal in each case was critical to obtain an accurate diagnosis in line with the diagnostic criteria used. General dizziness may develop because of inappropriate neck posture over long periods of time in individuals with some form of underlying cervical disease. The causes of general dizziness were different between male and female patients and between patients of different age groups. Triggers leading to general dizziness included engaging in farming, gardening, or weeding activities for long periods of time, particularly in elderly women. Selection of the appropriate muscle relaxant type and dosage is important in the treatment of patients with cervicogenic general dizziness who also experience a stiff neck and shoulders. Following treatment, 90% of patients no longer experienced general dizziness or exhibited clear improvements in their symptoms within 1 week. The results of this study emphasize the importance of cervicogenic general dizziness, which is due to cervical vertebral lesions and is exacerbated by excessive stress on the cervical spine.

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation / Relaxantes musculares não despolarizantes melhoram a visibilidade em laringoscopia direta sem efeito sobre a ventilação via máscara facial

Abstract Background: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. Methods: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Results: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p = 0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. Conclusion: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Resumo Justificativa: A ventilação difícil ou impossível via máscara facial complicada pela intubação traqueal difícil durante a indução da anestesia ocorre em 0,4% dos casos de anestesia em adultos, possivelmente leva a complicações fatais. Devido a tais catástrofes, recomendou-se que a administração de relaxantes musculares seja feita após a confirmação de ventilação adequada via máscara facial, sem uma validação científica sólida dessa conduta. Métodos: Neste estudo observacional, a facilidade de ventilação e os escores de visibilidade em laringoscopia direta antes e após a administração de cisatracúrio foram avaliados em 90 adultos jovens e saudáveis, sem riscos anestésicos e sem intubação difícil prevista, agendados para cirurgias eletivas gerais. Resultados: Antes do relaxamento muscular, 43 pacientes (48%) eram Cormack Grau I, enquanto os 47 (52%) restantes eram ou Cormack Grau II (28, 31%) ou Cormack Grade III (19, 21%). Após o relaxamento muscular com cisatracúrio, o número de pacientes com Cormack Grau I aumentou significativamente de 43 (48%) para 65 (72%) (p = 0,0013). Apenas um paciente (5%) dos 19 melhorou sua classificação de Cormack do Grau III para o Grau I, enquanto 16 dos 19 (84%) melhoraram suas classificações de Cormack do Grau III para o grau II após o uso de cisatracúrio. A qualidade da ventilação via máscara facial não diferiu com ou sem relaxantes musculares em todos os pacientes. Conclusão: O uso de cisatracúrio em adultos jovens saudáveis submetidos a cirurgias eletivas gerais sem intubação traqueal difícil prevista não teve efeito sobre a qualidade da ventilação via máscara facial, mesmo resultando em melhora quantificável da visibilidade da laringe.

Análise dos medicamentos relaxantes musculares de ação central comercializados no Brasil na perspectiva do Cuidado ao Idoso / Analysis of centrally acting muscle relaxants marketed in Brazil from the perspective of Elderly Care

Objetivo: Analisar na perspectiva do idoso as evidências científicas relativas ao emprego terapêutico e a segurança de relaxantes musculares registrados no Brasil. Método: estudo de análise da oferta de medicamentos contendo fármacos do grupo M03B - Relaxantes musculares de ação central da classificação Anatômica Terapêutica Química. Verificaram-se os fármacos do grupo M03B registrados no Brasil. Pesquisaram-se as evidências científicas relativas à segurança e eficácia. Analisou-se a disponibilidade de informações sobre segurança na bula. Resultados: Identificou-se 18 fármacos do grupo M03B, dos quais 7 (38,9%) estão registrados no Brasil. Das 67 especialidades registradas, 35 (52,2%) são associações farmacológicas. Conclusão: As evidências para uso de relaxantes musculares em idosos são limitadas. As bulas desses medicamentos não apresentam informações relevantes sobre eventos adversos (AU).

OBJECTIVE: To analyze the scientific evidence regarding the therapeutic use and safety of muscle relaxant medicines registered in Brazil from the perspective of the health of the elderly. METHODS: This is a study of the analysis of the supply of medicines containing group M03B drugs ­ Centrally acting muscle relaxants of the Anatomical Therapeutic Chemical classification. The M03B group drugs registered in Brazil were observed. The scientific evidence on safety and efficacy has been investigated. The availability of safety information in the package leaflet was analyzed. RESULTS: We identified 18 drugs from group M03B, of which 7 (38.9%) are registered in Brazil. Of the 67 specialties registered, 35 (52.2%) are pharmacological associations. CONCLUSION: Evidence for the use of muscle relaxants in the elderly is limited. The package leaflets do not contain relevant information on adverse events (AU).

In vivo sedative and muscle relaxants activity of Diospyros lotus L

OBJECTIVE: To evaluate the sedative effect of Diospyros lotus L (D. lotus) extract in mice using the open field and Rota rod tests. METHODS: For the sedative and muscle relaxants activities of extract/fractions of the plant, in-vivo open field and phenobarbitone-induced sleeping time were used, while the Roda rod test was employed in animals for the assessment of muscle relaxant activity. RESULTS: Results from this investigation revealed that the extracts of D. lotus have exhibited significant sedative effect in mice (45.98%) at 100 mg/kg i.p. When the extract was partitioned with different solvents, the n-hexane fraction was inactive whereas the chloroform fraction was the most active with 82.67% sedative effect at 50 and 100 mg/kg i.p. On the other hand, the ethyl acetate and n-butanol fractions displayed significant sedative effects (55.65% and 40.87%, respectively) at 100 mg/kg i.p. Among the tested extract/fractions, only chloroform and ethyl acetate fractions showed significant (P < 0.05) muscle relaxant activity in the Rota rod test. CONCLUSIONS: In short, our study provided scientific background to the traditional uses of D. lotus as sedative.

Postoperative residual neuromuscular blockade

Postoperative residual neuromuscular blockade or residual paralysis in the postanesthesia care unit is associated with postoperative complications such as muscle weakness, difficulty in breathing, airway obstruction, and hypoxemia. Residual paralysis can be defined by inadequate neuromuscular recovery as measured by objective neuromuscular monitoring. The train-of-four ratio threshold less than or equal to 0.9 is considered to indicate inadequate neuromuscular recovery. Careful management of residual paralysis may decrease the occurrence of adverse events associated with residual neuromuscular blockade. In this review, the clinical implications of residual neuromuscular blockade are summarized.

Comparison of pharmacodynamics of rocuronium administered by intermittent bolus injection according to body surface area and real body weight / 实用医学杂志

Objective To compare the pharmacodynamics of rocuronium intermittently administered according to body surface area and real body weight and individual differences. Method Forty-two patients undergoing elective surgery under general anesthesia were enrolled into the body surface area group (BSA group) and the real body weight group (RBW group), with 21 patients in each group. The patients in the two groups were induced with 2ED95 of rocuronium according to body surface area and real body weight (16.64 mg/m2 in BSA group; 0.6 mg/kg in RBW group). Whenever T1 recovered to 10%, a dosage of 0.5ED95 was administred repeatedly for 30 min before the end of the operation. The time of neuromuscular blockade and recovery of muscle relaxation were recorded, and the dosage of rocuronium was also recorded. Results No significant difference in each index of neuromuscular block time-effect was found between the two groups (P > 0.05). The single dosage and maintainance amount of muscle relaxation were less in the BSA group than that in RBW group (P < 0.05). Compared with the RBW group, the single dosage, dosing intervals, pharmacological duration and the time TOFr recovered to 0.7 between the different individuals were less in the BSA group (P < 0.05). Conclusion The intermittent administration of rocuronium can maintain the same clinical efficacy according to body surface area as that according to real body weight , with significantly less dosageand reducing the differences of individuals in blockade time-effect of muscle relaxation.

Streptozotocin Diabetes Attenuates the Effects of Nondepolarizing Neuromuscular Relaxants on Rat Muscles

The hypothesis of this study was that diabetes-induced desensitization of rat soleus (SOL) and extensor digitorum longus (EDL) to non-depolarizing muscle relaxants (NDMRs) depends on the stage of diabetes and on the kind of NDMRs. We tested the different magnitude of resistance to vecuronium, cisatracurium, and rocuronium at different stages of streptozotocin (STZ)-induced diabetes by the EDL sciatic nerve-muscle preparations, and the SOL sciatic nerve-muscle preparations from rats after 4 and 16 weeks of STZ treatment. The concentration-twitch tension curves were significantly shifted from those of the control group to the right in the diabetic groups. Concentration giving 50% of maximal inhibition (IC50) was larger in the diabetic groups for all the NDMRs. For rocuronium and cisatracurium in both SOL and EDL, IC50 was significantly larger in diabetic 16 weeks group than those in the diabetic 4 weeks group. For SOL/EDL, the IC50 ratios were significantly largest in the diabetic 16 weeks group, second largest in the diabetic 4 weeks group, and smallest for the control group. Diabetes-induced desensitization to NDMRs depended on the stage of diabetes and on the different kind of muscles observed while was independent on different kind of NDMRs. The resistance to NDMRs was stronger in the later stage of diabetes (16 versus 4 weeks after STZ treatment). Additionally, when monitoring in SOL, diabetes attenuated the actions of neuromuscular blockade more intensely than that in EDL. Nonetheless, the hyposensitivity to NDMRs in diabetes was not relevant for the kind of NDMRs.

Anaphylaxis caused by muscle relaxant (eperisone hydrochloride)

Eperisone hydrochloride is an antispasmodic drug, decreasing spasticity of skeletal muscle and alleviating stiffness, and as a consequence, controlling pain. It is preferably prescribed with other analgesics, beneficially less decreasing alertness compared with other antispasmodics. Its fatal drug adverse reactions were rarely reported. A 70 year-old female with hives, swollen face, hoarse voice, and near fainting admitted via emergency department. She suffered from the series of the fatal symptoms after administration of the pills, prescribed for her neck pain. Two months before, she had experienced hives on similar medications. At presentation, she revealed hypoxemia and hypotension, and treated with epinephrine, glucocorticoids and antihistamines. Among the medicines she took, eperisone hydrochloride was proven as the causative medicine and others were excluded in oral provocation tests. The positive result in intradermal test with eperisone hydrochloride suggested immediate-type hypersensitivity reaction. We report a case of anaphylaxis to eperisone hydrochloride, one of the widely prescribed medicines in clinical practice, previously without awareness of drug adverse reaction.