A prospective study on the predictors of mechanical ventilation in organophosphate poisoning

Background: Organophosphorus poisoning is one of the most common poisonings often requiring ICU care and ventilatory support. The objective and aim of this study are to identify the factors which predict the need for ventilation in these patients.Methods: 50 patients who were diagnosed to have consumed organophosphorus compound poison admitted in Konaseema Institute of Medical Sciences and Research Foundation who presented within 24 hours of consumption are included in the study. Patients with double poisonings, concomitant illnesses, chronic lung diseases and those treated outside are excluded from the study.Results: A total number of 50 patients were studied. 18(36%) patients required ventilation. Generalized fasciculations was a discernible feature in 66% of cases in this study. 69.2% of patients with a fasciculation score of ≥4 required ventilation. Ventilation was needed by 55% of patients who had a Glasgow Coma Scale score of ≤10.Conclusions: Patients who presented with higher fasciculation scores and/or lower GCS scores were more likely to require ventilation. Using GCS scores as a predictor for the requirement of ventilatory support in organophosphate poisoning, a GCS score ten or less was significantly associated with an increased need for ventilatory support.

Inadvertent injection of succinylcholine as an epidural test dose / Injeção inadvertida de succinilcolina como uma dose teste epidural

Abstract Background and objectives: Epidural action of neuromuscular blocking agents could be explained under the light of their physicochemical characteristics and epidural space properties. In the literature there are few cases of accidental neuromuscular agent's epidural administration, manifesting mainly with neuromuscular blockade institution or fasciculations. Case report: We report a case of accidental succinylcholine administration as an epidural test dose, in a female patient undergoing scheduled laparotomy, under combined general and epidural anesthesia. Approximately 2 min after the succinylcholine injection the patient complained for shortness of breath, while mild fasciculations appeared in her trunk and face, managed by immediate general anesthesia institution. With the exception of a relatively longer duration of neuromuscular blockade compared with intravenous administration, no neurological or cardiovascular sequelae or other symptoms of local or systemic toxicity were observed. Conclusions: Oral administration of diazepam seems to lessen the adverse effects from accidental epidural administration of succinylcholine. The meticulous and discriminative labeling of syringes, as well as keeping persistent cautions during all anesthesia procedures remains of crucial importance.

Resumo Justificativa e objetivos: A ação epidural de agentes bloqueadores neuromusculares pode ser explicada à luz de suas características físico-químicas e propriedades do espaço epidural. Na literatura existem poucos casos sobre a administração acidental em espaço epidural de agente neuromuscular que se manifesta principalmente com a instituição de bloqueio neuromuscular ou fasciculações. Relato de caso: Relatamos um caso de administração acidental de succinilcolina como uma dose teste epidural em uma paciente submetida à laparotomia programada, sob anestesia combinada geral e peridural. Aproximadamente dois minutos após a injeção de succinilcolina, a paciente queixou-se de falta de ar, enquanto fasciculações leves apareceram em seu tronco e rosto, tratadas com a instituição imediata de anestesia geral. Exceto pela duração relativamente longa do bloqueio neuromuscular em comparação com a administração intravenosa, sequelas neurológicas ou cardiovasculares ou outros sintomas de toxicidade local ou sistêmica não foram observados. Conclusões: A administração oral de diazepam parece diminuir os efeitos adversos da administração epidural acidental de succinilcolina. A meticulosidade e discriminação dos rótulos das seringas, bem como os cuidados persistentes mantidos durante todos os procedimentos de anestesia, continuam a ser de importância crucial.

Usefulness of propofol to prevent succinylcholine induced fasciculations and myalgia, a comparison with thiopentone sodium as an induction agent.

Background: Succinylcholine induced fasciculations and myalgia may be a source of greater distress to the patient than the surgical pain. Aims & Objective: This study was designed to see if propofol offered any protection against succinylcholine induced fasciculations and myalgia compared with thiopentone sodium. Material and Methods: This prospective, randomized study was conducted in a teaching and tertiary care hospital. The study included 99 adult patients scheduled to undergo general anaesthesia for elective surgery. The patients were allocated randomly and equally into Group P1, P2 and T. Anaesthesia was induced in group P1 with propofol 2.5 mg/kg, group P2 with propofol 3.5 mg/kg and group T with thiopentone sodium 5 mg/kg. Tracheal intubation was facilitated by administration of intravenous succinylcholine 2 mg/kg. Incidence and severity of fasciculations were recorded. Anaesthesia was maintained with 50% Nitrous oxide in oxygen, Isoflurane and Vecuronium bromide. At the end of surgery, neuromuscular blockage is reversed and patients were extubated. All the patients were assessed at 6, 12 and 24 hours postoperatively to evaluate the incidence and severity of myalgia. Anova test was applied for quantitative data and Chi-square test for qualitative data. P value < 0.05 was taken as significant. Results: The demographic data of patients of the three groups were comparable. The total incidence of fasciculations were 25(75.76%), 16(48.48%) and 26(78.79%) in group P1, P2 and T respectively (p<0.001). Total score of fasciculations was 44(44.44%), 22(22.22%) and 53(53.54%) in group P1, P2 and T respectively. The severity of fasciculations was reduced more in group P2 than group P1 and T (p=0.0006). The total incidence of myalgia were 19(57.57%), 10(30.3%) and 23(69.7%) in group P1, P2 and T respectively (p<0.001). Total score of myalgia was 35(35.35), 18(18.18) and 45 (45.45) in group P1, P2 and T respectively. The severity of myalgia was reduced more in group P2 than group P1 and T (p<0.001). There was no correlation between fasciculations and myalgia in the present study (Pearson’s r correlation, r = - 0.139). Conclusion: Propofol 3.5 mg/kg in comparison with propofol 2.5 mg/kg and thiopentone sodium 5 mg/kg is effective in reducing the incidence and severity of succinylcholine induced fasciculations and myalgia.

Benign fasciculations responsive to gabapentin

Fasciculations are symptoms present in a broad spectrum of conditions, ranging from normal manifestations to motor neuron diseases. They also represent the main picture of benign fasciculation syndrome. We report a case of such syndrome: a 48-years-old woman complaining about fasciculations for three decades who remained with the symptoms even after the compensation of a disclosed hyperthyroidism. The introduction of gabapentin rendered control of her fasciculations. The available data in the literature about the therapeutic approaches for fasciculations are revised, as long as the rare reports of evolution from patients with "benign" fasciculations to cases of amyotrophic lateral sclerosis, underlining the importance of following the patients with fasciculations.

Fasciculações são sintomas presentes em um amplo espectro de condições, desde manifestações normais até doenças do neurônio motor. Elas representam também o principal aspecto da síndrome de fasciculações benignas. Relatamos um caso desta síndrome: uma paciente de 48 anos com queixas de fasciculações por três décadas que, mesmo após a compensação de um quadro de hipertireoidismo, permaneceu com os sintomas. A introdução de gabapentina levou a controle das fasciculações. Os dados disponíveis na literatura sobre as abordagens terapêuticas para fasciculações são revisados, assim como os raros relatos de evolução de pacientes com fasciculações "benignas" para casos de esclerose lateral amiotrófica, salientando a importância do seguimento dos pacientes com fasciculações.

Optimal Priming Dose of Rocuronium for Prevention of Succinylcholine Induced Fasciculations

BACKGROUND: Subparalyzing dose of nondepolarizing muscle relaxants is often given prior to succinylcholine to reduce its adverse effects. At the same time, priming dose may worsen the intubating condition due to its antagonizing effect at neuromuscular junction. Although optimal priming dose of rocuronium is known to 0.03-0.04 mg/kg but higher priming dose may reduce interval from priming drug to succinylcholine. This study was designed to determine the maximal priming dose of rocuronium. METHODS: Sixty ASA I or II adult patients were randomized into three groups: group R1 received 0.06 mg/kg of rocuronium, group R2, 0.09 mg/kg and group Scc, normal saline. About 3 minutes after priming dose, thiopental 4 mg/kg, fentanyl 1microg/kg and succinylcholine 2 mg/kg were administered for anesthesia induction. The presence and severity of fasciculations and intubating conditions were evaluated with the incidence of side effects. RESULTS: In preventing fasciculations, group R1 and R2 were significantly better than group Scc, without significant difference between group R1 and R2. Intubation conditions were significantly worse in group R2 than in group Scc. CONCLUSIONS: The maximal priming dose of rocuronium to prevent fasciculations and optimizing intubating condition was 0.06 mg/kg.

Precurarization Effects of the Interval between Pretreatment with Rocuronium or Vecuronium and Succinylcholine Administration / 대한마취과학회지

BACKGROUND: Subparalyzing doses of nondepolarizing muscle relaxants are often given prior to succinylcholine to reduce the adverse effects of succinylcholine. We designed this study to determine the optimal choice of nondepolarizing muscle relaxants and the optimal interval between pretreatment and succinylcholine administration. METHODS: 240 ASA I or II adult patients were randomized into six groups: groups V1.5 and V3 received 0.015 mg/kg of vecuronium 1.5 min and 3 min before succinylcholine; group R1, R1.5, and R3 received 0.09 mg/kg of rocuronium 1 min, 1.5 min and 3 min before succinylcholine; and group SCC received no pretreatment. In this study, 2 mg/kg of succinylcholine was used. The presence and severity of fasciculations and intubating conditions were evaluated. Myalgia was also recorded on postoperative days 1 and 2. RESULTS: Group R3 was significantly better than other groups in terms of preventing fasciculations, and was followed by groups R1.5, R1, V3, V1.5 and group SCC. Intubating conditions were significantly worse in all pretreated groups than in group SCC, but no significant differences were observed between the pretreated groups. CONCLUSIONS: Succinylcholine-induced fasciculations are effectively prevented by pretreating with rocuronium 3 min or 1.5 min prior to succinylcholine administration. However intubating conditions are worsened by pretreatments.

Rocuronium Pretreatment for Prevention of Myalgia Following Succinylcholine Administration / 대한마취과학회지

BACKGROUND: The purpose of this study was to assess the effect of rocuronium pretreatment on the succinylcholine induced biochemical changes and fasciculations, myalgia and to compare it with vecuronium pretreatment. METHODS: We have studied 60 patients undergoing minor elective surgery, in a prospective double blinded method. Three groups of 20 patients each were pretreated with saline 0.01 ml/kg (group C), rocuronium 0.05 mg/kg (group R), or vecuronium 0.007 mg/kg (group V). Three minutes after the pretreatment, 1.5 mg/kg succinylcholine was injected. Serum potassium five minutes after succinylcholine and creatine kinase 24 hr after operation were measured. Fasciculations and postoperative myalgia at 24 and 48 h were evaluated. RESULTS: The increase in creatine kinase and incidence of fasciculations were lowest in the rocuronium group (33 IU/L; 15%) and followed by vecuronium group (58 IU/L; 50%) and highest in the control group (101 IU/L; 100%). The increase in serum potassium concentration (0.3 mEq/L) was not attenuated by any regimen. The incidence of postoperative myalgia on day 1 and day 2 was lower in the rocuronium (40%, 30%) and the vecuronium (50%; 35%) group than control group (85%; 75%). CONCLUSIONS: Rocuronium pretreatment is more effective in reducing creatine kinase rise and fasciculations after succinylcholine than vecuronium. However rocuronium and vecuronium are also effective in preventing postoperative myalgia.