Effect of deImedetomidine on muscle relaIant effect of cisatracurium in patients with epilepsy / 中国临床药理学与治疗学

AIM: To determine the effect of dexmedetomidine on muscle relaxant effect of cisatracurium in patients with epilepsy. METHODS: Sixty patients undergoing elective neurosurgery, aged from 18 to 59 years old, were divided into three groups (n = 20) according to the maximum onset time of dexmedetomidine: immediate induction group after dexmedetomidine infusion (Group A), induction group 15 minutes after dexmedetomidine infusion (Group B) and normal saline infusion (Group C). The neuromuscular conduction function was monitored by muscle relaxation monitor, and the ulnar nerve was stimulated in TOF mode (frequency 2 Hz, wave width 0.2 ms, stimulation current 70 mA, string interval 12 s). Patients in group A were given dexmedetomidine 1 μg/kg after entering the room, and anesthesia induction was started immediately after 10 min pumping; Group B patients were given dexmedetomidine 1 μg/kg after entering the room, and anesthesia induction was started 15 minutes after 10 minutes of pump injection; Patients in group C began induction immediately after pumping the same milliliter of normal saline within 10 min. During anesthesia induction, 0.15 mg/kg cisatracurium was injected intravenously, and endotracheal intubation was performed when T

Prevalencia de bloqueo residual en la Unidad de Cuidados Postanestésicos del Hospital Metropolitano / Prevalence of residual blockade in the Postanesthetic Care Unit of the Hospital Metropolitano

RESUMEN El bloqueo residual se define como la debilidad muscular postoperatoria producida por un antagonismo incompleto de los relajantes neu-romusculares, siendo sus principales complicaciones las respiratorias. Actualmente, el mejor método de evaluación objetiva del bloqueo neuromuscular es el Tren de Cuatro (TOF). El objetivo de este estudio fue describir la prevalencia de bloqueo residual en la Unidad de Cuidados Postanestésicos (UCPA) en pacientes ASA I y ASA II sometidos a cirugía electiva y de emergencia bajo anestesia general en el Hospital Metropolitano. Se realizó un estudio observacional, descriptivo y prospectivo en 211 sujetos, donde mediante el TOF se deter-minó que la prevalencia de bloqueo residual en la UCPA fue del 8,5%, valor que se relacionó con la falta de monitorización de la función neuromuscular, determinando además que el empleo de fármacos que revierten el bloqueo neuromuscular no excluye la presencia de bloqueo residual. Se recomienda el uso rutinario de monitorización de la relajación neuromuscular para prevenir y diagnosticar el bloqueo residual, además de la administración de reversión farmacológica independientemente del tiempo quirúrgico.

ABSTRACT Residual blockade is defined as postoperative muscle weakness caused by incomplete antagonism of neuromuscular relaxants, its main complications being respiratory, currently the best method of objective evaluation of neuromuscular blockade is the Train of Four (TOF). The objective of this study was to describe the prevalence of residual block in the Post Anesthesia Care Unit (UCPA) in patients with ASA I and ASA II undergoing elective and emergency surgery under general anesthesia at the Metropolitan Hospital. An observational, descrip-tive and prospective study was conducted in 211 subjects, where it was determined that the prevalence of residual block in UCPA was 8.5% with TOF, a value that was related to the lack of monitoring of neuromuscular function, also determining that the use of drugs that reverse neuromuscular blockade does not exclude the presence of residual blockade. Routine use of neuromuscular relaxation monitoring is recommended to prevent and diagnose residual block, in addition to drug reversal administration regardless of surgical time.

Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit

INTRODUCTION@#The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU).@*METHODS@#An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed.@*RESULTS@#A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB.@*CONCLUSION@#PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.

Comparison of the effects of deep and moderate neuromuscular block on respiratory system compliance and surgical space conditions during robot-assisted laparoscopic radical prostatectomy: a randomized clinical study / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

OBJECTIVE@#Robot-assisted radical prostatectomy (RARP) requires pneumoperitoneum (Pnp) and a steep head-down position that may disturb respiratory system compliance (Crs) during surgery. Our aim was to compare the effects of different degrees of neuromuscular block (NMB) on Crs with the same Pnp pressure during RARP.@*METHODS@#One hundred patients who underwent RARP were enrolled and randomly allocated to a deep or moderate NMB group with 50 patients in each group. Rocuronium was administered to both groups: in the moderate NMB group to maintain 1-2 responses to train-of-four (TOF) stimulation; and in the deep NMB group to maintain no response to TOF stimulation and 1-2 responses in the post-tetanic count. Pnp pressure in both groups was 10 mmHg (1 mmHg=133.3 Pa). Peak inspiratory pressure (Ppeak), mean pressure (Pmean), Crs, and airway resistance (Raw) were recorded after anesthesia induction and at 0, 30, 60, and 90 min of Pnp and post-Pnp. Surgical space conditions were evaluated after the procedure on a 4-point scale.@*RESULTS@#Immediately after the Pnp, Ppeak, Pmean, and Raw significantly increased, while Crs decreased and persisted during Pnp in both groups. The results did not significantly differ between the two groups at any of the time points. There was no difference in surgical space conditions between groups. Body movements occurred in 14 cases in the moderate NMB group and in one case in the deep NMB group, and all occurred during obturator lymphadenectomy. A significant difference between the two groups was observed.@*CONCLUSIONS@#Under the same Pnp pressure in RARP, deep and moderate NMBs resulted in similar changes in Crs, and in other respiratory mechanics and surgical space conditions. However, deep NMB significantly reduced body movements during surgery.

Comparison of the effects of deep and moderate neuromuscular block on respiratory system compliance and surgical space conditions during robot-assisted laparoscopic radical prostatectomy: a randomized clinical study / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Objective: Robot-assisted radical prostatectomy (RARP) requires pneumoperitoneum (Pnp) and a steep head-down position that may disturb respiratory system compliance (Crs) during surgery. Our aim was to compare the effects of different degrees of neuromuscular block (NMB) on Crs with the same Pnp pressure during RARP. Methods: One hundred patients who underwent RARP were enrolled and randomly allocated to a deep or moderate NMB group with 50 patients in each group. Rocuronium was administered to both groups: in the moderate NMB group to maintain 1–2 responses to train-of-four (TOF) stimulation; and in the deep NMB group to maintain no response to TOF stimulation and 1–2 responses in the post-tetanic count. Pnp pressure in both groups was 10 mmHg (1 mmHg=133.3 Pa). Peak inspiratory pressure (Ppeak), mean pressure (Pmean), Crs, and airway resistance (Raw) were recorded after anesthesia induction and at 0, 30, 60, and 90 min of Pnp and post-Pnp. Surgical space conditions were evaluated after the procedure on a 4-point scale. Results: Immediately after the Pnp, Ppeak, Pmean, and Raw significantly increased, while Crs decreased and persisted during Pnp in both groups. The results did not significantly differ between the two groups at any of the time points. There was no difference in surgical space conditions between groups. Body movements occurred in 14 cases in the moderate NMB group and in one case in the deep NMB group, and all occurred during obturator lymphadenectomy. A significant difference between the two groups was observed. Conclusions: Under the same Pnp pressure in RARP, deep and moderate NMBs resulted in similar changes in Crs, and in other respiratory mechanics and surgical space conditions. However, deep NMB significantly reduced body movements during surgery.

Is 1 mg/kg of sugammadex sufficient to reverse moderate neuromuscular block? A randomized clinical trial / ¿Es suficiente 1mg/kg de sugammadex para revertir el bloqueo neuromuscular moderado? Ensayo clínico aleatorizado

Abstract Background: Sugammadex has made it possible to reverse any type of rocuronium-induced block quickly and safely. The most frequent neuromuscular blockade is the moderate one where doses smaller than those recommended by the industry could get a full reversal. Objective: We aimed to evaluate the effectiveness of half the industry recommended dose of sugammadex to reverse a moderate neuromuscular block. Methods: Unicenter phase IV clinical trial that included 34 patients undergoing laparoscopic cholecystectomy. Intravenous general anesthesia was induced, with acceleromyographic monitoring of the neuromuscular block. After the intervention, the block was reversed with all or half the dose of sugammadex recommended for moderate blocks, using a blinded syringe. Results: Patient characteristics of the 2 groups were similar. Mean time to recovery was 3.6± 1.7minutes for the study group and 3.1 ± 1.7minutes for the control group (P=0.42). Reversal of the block was complete with a single dose of sugammadex in all patients. There was an important linear correlation between depth of block and time to recovery. Conclusion: Intraoperative monitoring is essential to allow us to individualize the dose of the neuromuscular blocking agent. To reverse a moderate block under neuromuscular monitoring, a dose of 1 mg/kg is sufficient in most cases and is equally safe and effective.

Resumen Introducción: El sugammadex permite revertir cualquier tipo de bloqueo inducido por rocuronio de forma rápida y segura. El bloqueo neuromuscular más frecuente es el moderado, en el cual dosis inferiores a las recomendadas por la industria podrían revertirlo completamente. Objetivo: Evaluar la efectividad de la mitad de la dosis de sugammadex recomendada por la industria para revertir un bloqueo neuromuscular moderado. Métodos: Ensayo clínico de fase IV en un unico centro que incluyó a 34 pacientes intervenidos de colecistectomía laparoscópica. Se realizó anestesia general intravenosa con monitoreo aceleromiográfico del bloqueo neuromuscular. Tras la intervención, el bloqueo se revirtió con la totalidad o con la mitad de la dosis de sugammadex recomendada para bloqueos moderados, utilizando una jeringa ciega. Resultados: Las características de los pacientes de los dos grupos fueron similares. La media de tiempo de recuperación fue de 3,6 ± 1,7 minutos para el grupo de estudio y de 3,1 ± 1,7 minutos para el grupo de control (p = 0,42). La reversión del bloqueo se completó con una dosis única de sugammadex en todos los pacientes. Hubo una correlación lineal importante entre la profundidad del bloqueo y el tiempo de recuperación. Conclusión: El monitoreo transquirúrgico es esencial para individualizar la dosis del agente de bloqueo neuromuscular. Para revertir un bloqueo moderado bajo monitoreo neuromuscular, una dosis de 1mg/kg es suficiente e igualmente segura y efectiva.

Reversal of neuromuscular block with sugammadex in five heart transplant pediatric recipients / Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco

Abstract Heart transplantation is a frequent procedure in the treatment of end-stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose-dependent life-threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequale and discuss the reversal of neuromuscular block in this patient population.

Resumo O transplante cardíaco é um procedimento frequente no tratamento da disfunção cardíaca em estágio final. Portanto, essa população de pacientes também será exposta com mais frequência a outros procedimentos cirúrgicos mais comuns após o transplante. Em sua avaliação, o anestesiologista deve ter em mente algumas questões específicas relacionadas à história de transplante cardíaco desses pacientes, tais como a reversão do bloqueio neuromuscular. Vários estudos relataram que os inibidores da colinesterase, como a neostigmina, podem produzir uma bradicardia dose-dependente que ameaça a vida em receptores de transplante cardíaco, enquanto um estudo relatou o uso seguro de neostigmina. A reversão do bloqueio neuromuscular com sugamadex é outra possibilidade, mas os dados na literatura são escassos. Descrevemos cinco casos nos quais a reversão bem-sucedida do bloqueio neuromuscular foi realizada com sugamadex em receptores pediátricos de transplante cardíaco sem deixar sequelas e discutimos a reversão do bloqueio neuromuscular nessa população de pacientes.

Sugammadex by ideal body weight versus 20% and 40% corrected weight in bariatric surgery - double-blind randomized clinical trial / Uso de sugamadex pelo peso corporal ideal versus corrigido em 20% e 40% em cirurgia bariátrica - ensaio clínico randômico e duplo-cego

Abstract Background and objectives: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. Methods: A prospective clinical trial was conducted with sixty participants with body mass index ≥ 40 kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6 mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6 mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2 mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF ≥ 0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. Results: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean ± standard deviation) 225.2 ± 81.2, 173.9 ± 86.8 and 174.1 ± 74.9 respectively, in the IW, CW20 and CW40 groups (p = 0.087). Conclusions: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

Resumo Justificativa e objetivos: Os parâmetros de peso para o uso de sugamadex em pacientes com obesidade mórbida ainda precisam ser definidos. Métodos: Um ensaio clínico prospectivo foi feito com 60 participantes com índice de massa corporal ≥ 40 kg.m-2, submetidos a cirurgia bariátrica, randomizados em três grupos: peso ideal (PI), peso corrigido em 20% (PC20) e peso corrigido em 40% (PC40). Todos os pacientes receberam anestesia intravenosa total. Rocurônio foi administrado em dose de 0,6 mg.kg-1 para intubação traqueal pelo peso ideal, seguido de infusão (0,3 a 0,6 mg.kg-1.h-1). A sequência de quatro estímulos (TOF) foi usada para monitorar a profundidade do bloqueio. Após recuperação espontânea da segunda resposta do TOF no fim da cirurgia, 2 mg.kg-1 de sugamadex foi administrado. O desfecho primário foi o tempo de reversão do bloqueio neuromuscular até obter TOF ≥ 0,9. O desfecho secundário foi a ocorrência de curarização residual pós-operatória na sala de recuperação pós-anestésica, avaliaram-se a capacidade do paciente de passar do leito cirúrgico para o de transporte, a adequação da oxigenação, o padrão respiratório, a habilidade para deglutir saliva e a clareza de visão. Resultados: Os grupos foram homogêneos quanto a gênero, idade, peso corporal total, peso corporal ideal, índice de massa corporal, tipo e tempo de cirurgia. Os tempos de reversão (segundos) foram (média ± desvio-padrão) 225,2 ± 81,2, 173,9 ± 86,8 e 174,1 ± 74,9, respectivamente, nos grupos PI, PC20 e PC40 (p = 0,087). Conclusões: Não foram observadas diferenças entre os grupos quanto ao tempo de reversão do bloqueio neuromuscular e frequência de curarização residual pós-operatória. Concluímos que o peso corporal ideal pode ser usado para calcular a dose de sugamadex para reverter o bloqueio neuromuscular moderado em pacientes com obesidade mórbida.

Deep versus moderate neuromuscular block during one-lung ventilation in lung resection surgery / Bloqueio neuromuscular profundo versus moderado durante a ventilação monopulmonar em cirurgia de ressecção pulmonar

Abstract Background and objectives: Neuromuscular relaxants are essential during general anesthesia for several procedures. Classical anesthesiology literature indicates that the use of neuromuscular blockade in thoracic surgery may be deleterious in patients in lateral decubitus position in one-lung ventilation. The primary objective of our study was to compare respiratory function according to the degree of patient neuromuscular relaxation. Secondary, we wanted to check that neuromuscular blockade during one-lung ventilation is not deleterious. Methods: A prospective, longitudinal observational study was made in which each patient served as both treated subject and control. 76 consecutive patients programmed for lung resection surgery in Gregorio Marañon Hospital along 2013 who required one-lung ventilation in lateral decubitus were included. Ventilator data, hemodynamic parameters were registered in different moments according to train-of-four response (intense, deep and moderate blockade) during one-lung ventilation. Results: Peak, plateau and mean pressures were significantly lower during the intense and deep blockade. Besides compliance and peripheral oxygen saturation were significantly higher in that moments. Heart rate was significantly higher during deep blockade. No mechanical ventilation parameters were modified during measurements. Conclusions: Deep neuromuscular blockade attenuates the poor lung mechanics observed during one-lung ventilation.

Resumo Justificativa e objetivos: Os relaxantes neuromusculares são essenciais durante a anestesia geral para vários procedimentos. A literatura clássica de anestesiologia indica que o uso de bloqueio neuromuscular em cirurgia torácica pode ser prejudicial em pacientes posicionados em decúbito lateral com ventilação seletiva. O objetivo primário deste estudo foi comparar a função respiratória de acordo com o grau de relaxamento neuromuscular do paciente. O objetivo secundário foi verificar que o bloqueio neuromuscular durante a ventilação seletiva não é prejudicial. Métodos: Estudo observacional, prospectivo e longitudinal no qual cada paciente serviu como próprio controle. Foram incluídos 76 pacientes consecutivos, agendados para cirurgia de ressecção do pulmão no Hospital Gregorio Marañon ao longo de 2013, submetidos à ventilação seletiva em decúbito lateral. Os dados do ventilador e os parâmetros hemodinâmicos foram registrados em diferentes momentos de acordo com a resposta por sequência de quatro estímulos (bloqueio intenso, profundo e moderado) durante a ventilação seletiva. Resultados: As pressões de pico, platô e média foram significativamente menores durante os bloqueios intenso e profundo. Além disso, complacência e saturação periférica de oxigênio foram significativamente maiores nesses momentos. A frequência cardíaca foi significativamente maior durante o bloqueio profundo. Não houve alteração dos parâmetros da ventilação mecânica durante as mensurações. Conclusões: O bloqueio neuromuscular profundo atenua a mecânica pulmonar deficiente observada durante a ventilação seletiva.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists / Pesquisa de curarização residual no pós-operatório, eventos respiratórios agudos e abordagem de anestesiologistas

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate >20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR <0.9, and 15% (n = 61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

JUSTIFICATIVA E OBJETIVOS: A paralisia residual após o uso de bloqueadores neuromusculares (BNMs) sem monitoração neuromuscular continua sendo um problema clínico, mesmo quando BNMs são usados. Este estudo pesquisou a curarização residual pós-operatória e os eventos respiratórios críticos em sala de recuperação, bem como a abordagem clínica da CRPO feita pelos anestesiologistas em nossa instituição. MÉTODOS: Este estudo observacional incluiu 415 pacientes que receberam anestesia geral com BNMs de ação intermediária. A manutenção da anestesia foi feita por anestesiologistas não participantes, "cegos" para o estudo. A monitoração neuromuscular foi realizada no momento da chegada à sala de recuperação. Um ERC foi definido como necessidade de suporte ventilatório; saturação periférica de oxigênio <90% e 90-93%, a despeito de receber 3 L/min de O2 via cânula nasal; frequência respiratória >20 bpm; uso de musculatura acessória; dificuldade de engolir ou falar e necessidade de reintubação. A abordagem clínica de nossos anestesiologistas, em relação aos agentes de reversão, foi avaliada usando um miniquestionário de oito perguntas logo após o estudo. RESULTADOS: A incidência de CRPO foi de 43% (n = 179) para a SQE <0 e 15% (n = 61) para a SQE <0,7. A incidência de SQE <0,9 foi significativamente maior em mulheres, pacientes com estado físico ASA III e com anestesia de curta duração (p < 0,05). Além disso, 66% (n = 272) dos 415 pacientes que chegam à sala de recuperação haviam recebido neostigmina. Uma SQE <0,9 foi encontrada em 46% (n = 126) dos pacientes que receberam neostigmina. CONCLUSÃO: Quando a monitoração neuromuscular objetiva de rotina não está disponível, a CRPO continua sendo um problema clínico, a despeito do uso de BNMs. O momento e o antagonismo ideais do bloqueio neuromuscular e a monitoração neuromuscular objetiva de rotina são recomendados para aumentar a segurança do paciente.

Effects of long-term glucocorticoid administration on neuromuscular block of cisatracurium in elderly pa-tients undergoing general anesthesia / 临床麻醉学杂志

Objective To investigate the effects of long-term glucocorticoid administration on neuromuscular block of cisatracurium in elderly patients undergoing general anesthesia. Methods Forty ASA Ⅱ or Ⅲ patients,aged≥65 yr,with BMI of 18-24 kg/m2 ,scheduled for elec-tive operation were studied.According to the history of using or not long-term glucocorticoid,patients were assigned into two groups (n = 20 each):control group(group C),glucocorticoid group(group J).Midazolam 0.03 mg/kg was injected,mask inhalation of 8% sevoflurane and flow rate of oxygen 8L,every 30 s decline 2%,until the 4%.After the disappearance of eyelash reflex,cisatracurium 0.1 5 mg/kg was injected intravenously.After 1 min intravenous injection of remifentanil 2 g/kg and 30 s after stop of sevoflurane inhalation anesthesia, endotracheal intubation for mechanical ventilation,target controlled infusion of propofol and remifentanil anesthesia,using TOF-Watch SX acceleromyography monitoring of muscle relaxation,and onset time,clinical duration and recovery in-dex(for T1 to return from 25% to 75% of the control twitch)were recorded.Results Compared with group C,the onset time was significantly prolonged,clinical duration and recovery index were short-ened in group J (P <0.05 ).Conclusion Long-term glucocorticoid admininstration could reduce the neuromuscular blocking effect of cisatracurium in elderly patients.

Use of sugammadex on burn patients: descriptive study / Uso de sugamadex no paciente queimado: estudo descritivo / Utilización del sugammadex en el paciente quemado: estudio descriptivo

A burn patient is a challenge for any anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. The victim may have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population.

O paciente queimado representa um desafio para o anestesiologista, pois se submete a várias intervenções cirúrgicas durante sua hospitalização e necessita de anestesia geral e relaxamento muscular na maior parte delas. Apresenta sistema respiratório comprometido e uma resposta aos relaxantes musculares que difere do paciente sadio; portanto, um monitoramento correto e reversão tornam-se imprescindíveis. Avaliamos a eficácia e segurança do sugamadex nessa população.

El paciente quemado supone un reto para el anestesista, pues se somete a varias intervenciones quirúrgicas durante su ingreso, requiriendo anestesia general y relajación muscular en la mayor parte de ellas. Presentan un sistema respiratorio comprometido y una respuesta a los relajantes musculares que difiere de la del paciente sano, por lo que se hace imprescindible una correcta monitorización y reversión. Valoramos la efectividad y seguridad del sugammadex en esta población.

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.

Hourglass Pattern:a Safe and Effective Method of Ultrasound-guided Fascia Iliaca Compartment Block / 中国微创外科杂志

Objective To confirm the efficacy of the “Hourglass Pattern”of ultrasound-guided fascia iliaca compartment block (FICB). Methods Approved by the medical ethics committee,we selected 30 patients undergoing selective total hip arthroplasty (THA ) in our hospital between January and May 2014.Before neuraxial anesthesia,ultrasound-guided FICB was performed.After identification of the “Hourglass Pattern”(internal oblique muscle and the sartorius muscle),a catheter was inserted. The sheath between the fascia iliaca and the iliacus muscle was distended with 40 ml of 0.2% ropivacaine,and then a continuous infusion of ropivacaine at a rate of 10 ml /h was administered for 48 h.Loss of sensation in the distribution areas of the femoral nerve and lateral femoral cutaneous nerve within 30 min was recorded.Patients were interviewed at 4 h,8 h,12 h,24 h,36 h and 48 h after block for pain intensity.Patients’ satisfaction scores at 48 h after block and the occurrence of adverse events (infection,local anesthetic toxicity,hemorrhage and hematoma)was recorded. Results The successful rate of the block was 100% without any adverse events.The median of numerical rating pain scale (NRPS)was below 4 points at 4 h,8 h,12 h,24 h,36 h and 48 h after block,and the patients’satisfaction score was (8.0 ±0.9 )points at 48 h after block.No adverse events occurred. Conclusions Ultrasound-guided FICB by using the “Hourglass Pattern”technique can offer effective analgesia after THA.It’s a safe method and can be easily performed.

Cardiac arrest following reversal of muscle relaxation by pyridostigmine: A case report

The anticholinesterase pyridostigmine is usually used as a reversal agent of non-depolarizing muscle relaxants in general anesthesia. Most adverse muscarinic effects of anticholinesterases are controlled by anticholinergics; however, there is still a potential for fatal cardiac complications. We report a case of cardiac arrest associated with coronary vasospasm that developed during emergence from general anesthesia in a 61-year-old male patient undergoing uvulopalatopharyngoplasty with preoperatively undiagnosed coronary vasospastic angina. Anticholinesterases should be administered with caution for neuromuscular blockade reversal, especially in patients with coronary vasospastic angina.

Sugammadex: clinical development and practical use / 대한마취과학회지

Sugammadex is belonging to a new class of drugs: the selective relaxant binding agents. Sugammadex can reverse residual paralysis by encapsulating free circulating non depolarizing muscle relaxants. The mains advantages of sugammadex when compared with conventional anticholinesterase agents are a much faster recovery time and the unique ability, for the first time, to reverse rapidly and efficiently deep levels of neuromuscular blockade. However it only works for reversal of rocuronium or vecuronium-induced neuromuscular blockade. When administered 3 min after rocuronium the use of a large dose (16 mg/kg) can even reverse rocuronium significantly faster than the spontaneous recovery after succinylcholine.

Do bupivacaine, clindamycin, and gentamicin at their clinical concentrations enhance rocuronium-induced neuromuscular block? / 대한마취과학회지

BACKGROUND: Bupivacaine, clindamycin, and gentamicin inhibit neuromuscular (NM) conduction. When they are combined, they may synergistically reduce the effective concentration of each to the therapeutic concentration in augmenting rocuronium-induced NM block. Thus, the aim of this study was to investigate whether combinations of the three drugs, at around their therapeutic concentrations, potentiate rocuronium-induced NM block. METHODS: Fifty-seven left-phrenic nerve hemidiaphragms (Male S-D rats, 150-250 g) were hung in a 20-ml organ bath filled with Krebs solution. Three consecutive single-twitch tensions (0.1 Hz) and one tetanic tension (50 Hz for 1.9 s) were obtained. A Krebs solution was premixed with concentration sets of bupivacaine and clindamycin, bupivacaine and gentamicin, or bupivacaine, clindamycin and gentamicin. Then, the concentration of rocuronium was cumulatively increased in the Krebs solution (1, 3, 5, 7, 9, 12, 14, 16, 18, and 20 microM) until an 80% to 90% reduction in single twitch was attained. The effective concentrations for each experiment were determined with the probit model. RESULTS: The combinations of bupivacaine, clindamycin, and gentamicin enhanced rocuronium-induced NM block. When the three drugs were applied simultaneously, their concentrations were reduced to near-therapeutic levels in potentiating the action of rocuronium. CONCLUSIONS: Bupivacaine, clindamycin, and gentamicin blocked NM conduction, and when all three drugs were applied together, they augmented rocuronium-induced NM block at their near-therapeutic concentrations. Clinicians should be aware of the cooperability in NM block between drugs that interrupt NM conduction.

The antagonistic effect of neostigmine on rocuronium-, clindamycin-, or both-induced neuromuscular blocking in the rat phrenic nerve-hemidiaphragm / 대한마취과학회지

BACKGROUND: Neostigmine augments clindamycin-induced neuromuscular block and antagonizes rocuronium-induced neuromuscular block; however, it remains unclear whether neostigmine enhances the neuromuscular blocking (NMB) that is caused by combinations of rocuronium and clindamycin. The intent of this study was to determine whether neostigmine potentiates the muscle relaxation that is induced by combinations of rocuronium and clindamycin and to estimate whether both clindamycin and rocuronium have synergistic actions on NMB. METHODS: Forty-one left phrenic nerve-hemidiaphragms (from male Sprague-Dawley rats, 150-250 g) were mounted in Krebs solution. Three consecutive single twitches (ST, 0.1 Hz) and one tetanic tension (50 Hz for 1.9 s) were obtained for each increase in concentration of rocuronium or clindamycin. The concentrations of rocuronium were cumulatively increased until an 80% to 90% reduction in ST was attained in the Krebs solutions pre-treated with 0 (n = 5), 0.1 (n = 1), 0.25 (n = 1), 0.5 (n = 4), or 1.0 (n = 1) mM clindamycin or with 0 (n = 4), 0.1 (n = 1), 0.5 (n = 5), 1.0 (n = 5), or 2.0 (n = 4) mM clindamycin in combination with 250 nM neostigmine, and so were the concentrations of clindamycin in the Krebs solutions pre-treated with 0 (n = 6) or 250 nM (n = 6) neostigmine. RESULTS: Clindamycin increased the potency of rocuronium for ST and tetanic fade, irrespective of the presence of neostigmine. Neostigmine shifted the concentration-response curve of rocuronium to the right in the presence or absence of clindamycin. The interaction between rocuronium and clindamycin was synergistic when clindamycin concentrations were in excess of 0.5 mM, irrespective of the presence of neostigmine. CONCLUSIONS: Neostigmine may partially antagonize the neuromuscular block that is induced by a combination of clindamycin and rocuronium. Clinicians are advised to be aware that clindamycin synergistically increases the degree of rocuronium-induced neuromuscular block, even when neostigmine is present.

Estimation and simulation of kinetic-pharmacodynamic parameters of rocuronium by Bragg's dose-response-time model

BACKGROUND: The effect-time data involves some pharmacokinetic (PK) information. Bragg model could derive the information from pharmacodynamic (PD) data alone. After administering rocuronium, we collected tension data without these plasma concentration values. We determined kinetic-pharmacodynamic (K-PD) parameters, simulated the predictions of effect-time relation at different amount of dose, and validated the calculated infusion rates (IR) by comparing with IR directly measured. METHODS: Thirteen dexterous male patients were given rocuronium 300microg/kg during propofol-fentanyl anesthesia. Twitch tensions of the right adductor pollicis in response to supramaximal single twitch stimulation every 10 seconds were measured until muscle paralysis recovered by 70 +/- 10% of control. The above data were fitted to Bragg equation, using Tablecurve3D(R). The parameters, k1, k2, IR50, and gamma, were derived with either individual regression or population regression. The correlations between individual parameter and time, the simulation, and validation by infusing rocuronium 3.66microg/kg/min were examined. RESULTS: Based on population regression, IR50 was 3.70microg/kg/min, gamma was 4.51, k1 (keo) was 0.71/min, and k2 (k10) was 0.022/min. The longer the duration of rocuronium action was, the smaller the values of IR50 and k2 were (correlation coefficient: -0.92, -0.61, respectively). ED50 calculated (= IR50/k2) was 168microg/kg. The effects of rocuronium 3.66microg/kg/min were estimated (45% by direct measurement, 49% by population parameters, and 21% by individual parameters). CONCLUSIONS: The results of infusion rate validation suggests that population parameters may better be applicable than individual post hoc parameters to predicting the clinically relevant effect-time relations.

Clinical use of sugammadex

An ideal reversal agent could be given at any time after the administration of a neuromuscular blocking agent, and should have no muscarinic side-effects. Sugammadex is a modified gamma-cyclodextrin designed to encapsulate rocuronium bromide, providing a rapid reversal of neuromuscular blockade. Sugammadex is a revolutionary investigational reversal drug currently undergoing Phase III testing whose introduction into clinical practice in Korea may change the face of clinical neuromuscular pharmacology. The dose of sugammadex for reversal of moderate block (when T2 is detectable) is approximately 2 mg/kg, the dose is 4-8 mg/kg for profound block (post-tetanic count 1-2) and a larger dose of 16 mg/kg for immediate reversal. The use of sugammadex has not been reported to be associated with recurrence of block provided a dose that is adequate for reversal has been used. Sugammadex appears to have an acceptable safety profile. Volatile agent such as sevoflurane seems not to influence the sugammadex ability to reverse the rocuronium neuromuscular blockade.