Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial

Abstract Background Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. Methods One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg−1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. Results Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. Conclusions The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. Clinical trial number and registry URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.

Comparison of analgesic efficacy and postoperative recovery between multi-point and single-point fascia iliaca compartment block in patients with hip fracture: a randomized controlled trial / 中华全科医师杂志

Objective:To compare the analgesic effect and postoperative recovery between multi-point and single-point ultrasound-guided fascia iliaca compartment block (FCIB) in elderly patients with hip fracture.Methods:From June 2019 to April 2020, 96 patients aged (71.1±5.4) years undergoing elective surgery for hip fracture in Renji Hospital were randomly assigned in multi-point block group or single-point block group, and the multi-point or single-point ultrasound-guided FCIB was performed for the two groups, respectively. The primary outcomes were the success rate for block of femoral nerve, lateral femoral cutaneous nerve and obturator nerve, and the 24 hours postoperative pain visual analog scale (VAS) score at rest and passive movement. The secondary outcomes were the onset time of sensory blocks of the above three nerves, complications of FICB, the satisfaction score of pain control during 48 hours after surgery and postoperative recovery of patients.Results:The success rate for block of lateral femoral cutaneous nerve in multi-point block group was 97.9% (47/48), which was significantly higher than that in single-point block group (83.3%(40/48)) ( P=0.031). The success rate for block of obturator nerve in multi-point block group was 95.8% (46/48), which was significantly higher than that in single-point block group which was 81.3% (39/48) ( P=0.025). The success rate of femoral nerve block in both groups was 97.9% (47/48) ( P=1.000). The 24 hours postoperative VAS scores at rest and passive movement in the multi-point block group were significantly lower than those in the single-point block group ( P<0.05). The onset time for block of lateral femoral cutaneous nerve and obturator nerve in multi-point block group was shorter than that in single-point block group ( P=0.025 and P<0.01). There was no significant difference in the onset time for block of femoral nerve between the two groups ( P=0.343). The satisfaction score of patients at 48 hours after surgery in multipoint block group was higher than that in single point block group ( P=0.024). The length of hospital stay in the multi-point block group was shorter than that in the single-point block group ( P=0.042), the proportion of intravenous analgesic drugs used after surgery was lower than that in the single-point block group ( P=0.041), and the complication rate within 30 days after surgery was also lower than that in the single point block group ( P=0.026). Conclusion:Compared with single-point block, ultrasound-guided multi-point block in iliac fascia space has advantages of increasing analgesic efficacy and promoting postoperative recovery in elderly patients with hip fracture.

Efficacy of ultrasound guided intercostal nerve pulse radiofrequency combined with nerve block in the treatment of post-herpetic neuralgia / 中国基层医药

Objective:To analyze the efficacy and safety of ultrasound-guided intercostal nerve pulse radiofrequency combined with nerve block in the treatment of post-herpetic neuralgia.Methods:The clinical data of 62 patients with post-herpetic neuralgia who received treatment in The Affiliated Hospital of Southwest Medical University from May 2017 to May 2021 were retrospectively analyzed. These patients underwent nerve block (NB group, n = 30) or pulsed radiofrequency plus nerve block (PRF + NB group, n = 32). Before and after treatment, The Numerical Rating Scale (NRS) score and Pittsburgh Sleep Quality Index (PSQI) score were compared between the two groups. After treatment, the occurrence of complications including pneumothorax, infection, and skin numbness was evaluated in each group. Results:Before treatment, there were no significant differences in NRS and PSQI scores between the two groups (all P > 0.05). Immediately, 1 week and 1 month after treatment, there was no significant difference in PSQI score between the two groups (all P > 0.05). At 3 and 6 months after treatment, the NRS score in the NB +PRF group was (1.71 ± 0.35) points and (1.68 ± 0.36) points, which were significantly lower than (2.72 ± 0.68) points and (3.26 ± 0.76) points in the NB group ( t = 54.40, 78.18, both P < 0.05). There were no treatment-related complications such as pneumothorax, infection, nerve numbness, or muscle weakness in the two groups. Conclusion:Ultrasound-guided pulsed radiofrequency combined with nerve block has a definite curative effect on post-herpetic neuralgia and is highly safe. The medium- and long-term efficacy of the combined therapy is superior to that of nerve block alone.

Efecto del óxido nítrico inhalado en la mecánica ventilatoria y oxigenación de pacientes con hipoxemia grave refractaria a prono prolongado y bloqueo neuromuscular secundario a infección por SARS-CoV-2 / Effect of inhaled nitric oxide on ventilatory mechanics and oxygenation of patients with severe hypoxemia refractory to prolonged prone and neuromuscular blockade secondary to SARS-CoV-2 / Efeito do óxido nítrico inalado na mecânica ventilatória e oxigenação de pacientes com hipoxemia grave refratária a pronação prolongada e bloqueio neuromuscular secundário à infecção por SARS-CoV-2

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Abstract: Introduction: Among the patients infected with SARS-CoV-2, 14.6% were admitted to intensive care unit. this 29 to 75% required invasive mechanical ventilation with an associated mortality of 12 to 81%. Acute respiratory distress syndrome (ARDS) is the most serious form of presentation. The pathophysiology of ARDS secondary to SARS-CoV-2 differs from conventional causes. It presents dysregulation in hypoxic pulmonary vasoconstriction, secondary acute pulmonary hypertension and microthrombotic phenomena. The development of refractory severe hypoxemia (PaO2 < 60 mmHg or PaO2/FiO2 < 100 mmHg, with FiO2 80 to 100%, with PEEP > 10 to 20 cmH2O for at least 10 to 12 hours) constitutes the scenario of maximum severity with an associated mortality of 71 to 94%. The use of rescue strategies that impact on the specific pathophysiology of this entity such as the use of inhaled nitric oxide, neuromuscular blockade and prone ventilation have emerged as therapeutic targets of interest. Protective mechanical ventilation (plateau pressure [Pplat] < 27 cmH2O and driving pressure [DP] < 15 cmH2O) continues to be the cornerstone of the management. Objectives: To determine whether there is an association between the use of inhaled nitric oxide and prone ventilation with ventilatory mechanics in patients with severe refractory hypoxemia secondary to SARS-CoV-2 infection. Material and methods: A historical, retrospective, descriptive, comparative and retrolective cohort study was carried out. Data from the records of patients admitted to the Respiratory ICU of the ABC Medical Center with a diagnosis of ARDS secondary to SARS-CoV-2 infection who required iNO and mechanical ventilation in prone from April 1 to December 31, 2020 were analyzed. A univariate analysis was performed, the statistical analysis was performed in SPSS v 21, measures of trend, dispersion were analyzed as well as the analysis of risk factors with Student's t test and χ2. Results: A total of 108 patients were analyzed, of which 54 received iNO, neuromuscular blockade and prone and 54 only neuromuscular blockade and prone ventilation. 81.5% (n = 88) were men. The most common comorbidity was diabetes mellitus in 51.9% (n = 56). The increase in oxygenation (delta PaO2/FiO2) was with a median of 31.9 ± 15.2 mmHg in the iNO group and 52.9 ± 16.74 mmHg in the control group (p = 0.001). The postintervention Pplat in the iNO group was 26.3 ± 3 and 34.5 ± 1.9 cmH2O in the control group (p = 0.792). The preintervention DP in the iNO group was 17.2 ± 3.9 and 13.4 ± 2.8 cmH2O in control group vs 13.1 ± 1.29 and 12 ± 1.92 cmH2O after the intervention (p = 0.001). Conclusions: The use of iNO in patients with severe hypoxemia refractory to prone ventilation and neuromuscular blockade did not produce a statistically significant improvement in oxygenation, however it allowed to reprogram the ventilatory support to keep the patient in goals of alveolar protection.

Resumo: Introdução: 14.6% dos pacientes infectados com SARS-CoV-2 são internados em terapia intensiva. Destes, 29 a 75% necessitam de ventilação mecânica invasiva com mortalidade associada de 12 a 81%. A síndrome do desconforto respiratório agudo (SDRA) é a forma mais grave de apresentação. A fisiopatologia da SDRA secundária ao SARS-CoV-2 difere das causas convencionais. Apresenta desregulação na vasoconstrição pulmonar hipóxica, hipertensão pulmonar aguda secundária e fenômenos microtrombóticos. O desenvolvimento de hipoxemia grave refratária (PaO2 < 60 mmHg ou PaO2/FiO2 < 100 mmHg, com FiO2 de 80 a 100%, PEEP > 10 a 20 cmH2O por pelo menos 10 a 12 horas) constitui o cenário mais grave com mortalidade associada de 71 a 94%. O uso de estratégias de resgate que impactam na fisiopatologia específica dessa entidade, como o uso de óxido nítrico inalatório (NOi), bloqueio neuromuscular e ventilação prona, surgiram como alvos terapêuticos de interesse. A ventilação mecânica protetora (Pressão de Platô [PPLAT] < 27 cmH2O e Pressão de Condução [CP] < 15 cmH2O) continua sendo a base de seu manejo. Objetivo: Determinar se existe associação entre o uso de óxido nítrico inalatório e ventilação prona prolongada com mecânica ventilatória em pacientes com hipoxemia refratária grave secundária à infecção por SARS-CoV-2. Material e métodos: Realizou-se um estudo de coorte histórico, retrospectivo, descritivo, comparativo e retroletivo. Analisaram-se dados dos prontuários de pacientes internados na UTI Respiratória do Centro Médico ABC com diagnóstico de SDRA secundária à infecção por SARS-CoV-2 que necessitaram de óxido nítrico inalatório e ventilação mecânica prona no período de 1o de abril a 31 de dezembro de 2020. Realizou-se uma análise univariada , a análise estatística foi realizada no SPSS v 21, foram analisadas as medidas de tendência e dispersão, assim como a análise dos fatores de risco com teste t de Student e χ2. Resultados: Analisaram-se 108 pacientes, dos quais 54 receberam NOi, bloqueio neuromuscular e prono e 54 apenas bloqueio neuromuscular e ventilação prona. 81.5% (n = 88) eram homens. A comorbidade mais comum foi diabetes mellitus em 51.9% (n = 56). O aumento da oxigenação (Delta PaO2/FiO2) foi com mediana de 31.9 ± 15.2 mmHg no grupo NOi e 52.9 ± 16.74 mmHg no grupo controle (p = 0.001). A PPLAT após a intervenção no grupo NOi foi de 26.3 ± 3 e 34.5 ± 1.9 cmH2O no grupo controle (p = 0.792). A PC antes da intervenção no grupo NOi foi de 17.2 ± 3.9 e 13.4 ± 2.8 cmH2O no grupo controle vs 13.1 ± 1.29 e 12 ± 1.92 cmH2O após a intervenção (p = 0.001). Conclusões: O uso de NOi em pacientes com hipoxemia grave refratária à ventilação em pronação e bloqueio neuromuscular não produziu melhora estatisticamente significativa na oxigenação, porém permitiu que o suporte ventilatório fosse reprogramado para manter as metas de proteção alveolar do paciente.

Effects of ultrasound-guided erector spinae plane block on analgesic dosage, lumbar function and pain in patients undergoing percutaneous kyphoplasty / 中国基层医药

Objective:To investigate the effects of ultrasound-guided erector spinae plane block on analgesic dosage, lumbar function and pain in patients undergoing percutaneous kyphoplasty.Methods:A total of 100 patients who underwent percutaneous kyphoplasty in Hangzhou Cancer Hospital from November 2018 to October 2021 were included in this study. They were randomly assigned to undergo either local infiltration anesthesia (control group, n = 50) or ultrasound-guided erector spinae plane block (observation group, n = 50). Analgesic dosages, pain status at different phases (Visual Analogue Scale score) and lumbar function (Oswestry Disability Index score), intraoperative and postoperative conditions (operative time, time to get out of bed, time to first exhaust), and the incidence of adverse reactions were compared between the two groups. Results:At 24 and 48 hours after surgery, the amount of analgesics infused in the observation group was (24.54 ± 2.52) mL and (55.68 ± 5.61) mL, respectively, and the number of analgesic pump pressings was (1.01 ± 0.26) times and (3.15 ± 1.02) times, which were significantly lower than those in the control group [amount of analgesics infused at 24 and 48 hours after surgery: (32.78 ± 3.31) mL, (62.57 ± 6.42) mL; the number of analgesic pump pressings at 24 and 48 hours after surgery: (6.42 ± 1.53) times, (10.78 ± 2.45) times, t = 14.00, 5.71, 24.65, 20.33, all P < 0.001]. Visual Analogue Scale score at the time at which the balloon was pressurized and expanded in the observation group was significantly lower than that in the control group [(4.10 ± 0.87) points vs. (4.65 ± 1.01) points, t = 2.92, P < 0.05]. At 1 day and 1 month after surgery, Oswestry Disability Index score in the observation group was (18.37 ± 2.78) points and (12.15 ± 2.02) points, respectively, which were lower than (23.56 ± 3.42) points and (17.53 ± 2.34) points in the control group ( t = 8.33, 12.31, both P < 0.05). The time to get out of bed and the time to first exhaust in the observation group were (9.12 ± 2.54) days and (23.56 ± 4.56) hours, respectively, which were significantly shorter than those in the control group [(11.64 ± 3.12) days, (28.14 ± 5.12) hours, t = 4.43, 4.72, both P < 0.001). There was no significant difference in the incidence of adverse reactions between the two groups ( P > 0.05). Conclusion:Ultrasound-guided erector spinae plane block for percutaneous kyphoplasty can effectively ameliorate lumbar spine function, reduce postoperative pain, and facilitate postoperative recovery, without affecting the dosage of narcotics and analgesics. The method is safe and effective.

Analgesic effects of ultrasound-guided rectus sheath block in open gastrectomy / 中国基层医药

Objective:To investigate the analgesic effects of ultrasound-guided rectus abdominis sheath block (RSB) in open gastrectomy.Methods:Forty-one patients with gastric cancer who underwent open gastrectomy in Binzhou Hospital of Traditional Chinese Medicine from December 2019 to December 2020 were included in this study. They were randomly assigned to undergo either RSB with 40 mL of 0.375% ropivacaine (group A, n = 21) or RSB with 40 mL of 0.9% sodium chloride injection (group B, n = 20) based on total intravenous anesthesia. After skin sutures, patient-controlled analgesia (PCA) was performed. Intraoperative dose of remifentanil and postoperative dose of PCA drug were compared between the two groups. Results:Intraoperative dose of remifentanil was significantly lower in the group A than that in the group B [(1 021.4 ± 172.0) μg vs. (1 415.0 ± 330.6) μg, t = -4.04, P = 0.001]. Postoperative doses of PCA drug used by 1 and 2 hours after surgery were (1.14 ± 0.90) mL and (0.85 ± 0.70) mL respectively in group A, which were significantly lower than (1.85 ± 0.70) mL and (1.45 ± 1.00) mL in the group B ( t = -5.96, -2.75, P < 0.001, P = 0.009). There were no significant differences in postoperative doses of PCA drug used by 3, 6, 12, 24, 48 and 72 hours after surgery between the two groups (both P > 0.05). Conclusion:RSB with 40 mL of ropivacaine applied to both sides of the incision before open gastrectomy can reduce the dose of remifentanil used during surgery and the dose of PCA drug used within 2 hours after surgery.

Appropriate degree of neuromuscular block for monitoring abnormal muscle response during microvascular decompression / 中华麻醉学杂志

Objective:To determine the appropriate degree of neuromuscular block (NMB) for abnormal muscle response (AMR) monitoring during microvascular decompression.Methods:Fifty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 20-64 yr, with body mass index≤30 kg/m 2, who were diagnosed with facial spasm before surgery, scheduled for elective microvascular decompression, were selected.Anesthesia was induced with midazolam 0.05-0.10 mg/kg, sufentanil 0.3-0.5 μg/kg and propofol 1.5-2.5 mg/kg. After patients lost consciousness, electrophysiological monitoring was performed, the zygomatic branch of the facial nerve was stimulated, and the baseline of AMR was recorded in the mental muscle.NMB was monitored with TOF-Watch SX monitor.After rocuronium 0.6 mg/kg was intravenously injected, the amplitude and latency of AMR were measured at different degrees of NMB (100%, 75%, 50% and 25%). The amplitude reservation ratio (the ratio of the amplitude of AMR monitored to the baseline value) was calculated.Linear correlation of the amplitude reservation ratio or latency of AMR with the degree of NMB was analyzed.The criteria for determining the appropriate degree of NMB in AMR monitoring were: 1.amplitude reservation ratio of AMR≥50%; 2.no body movement during electrical stimulatation of facial nerve. Results:No patients had any body movement during electrical stimulation performed at different degrees of NMB.The amplitude reservation ratio ( Y) was negatively correlated with the degree of NMB ( X) ( r=-0.943, t=-42.73, P<0.001), the linear regression equation of the interaction between the degree of NMB ( X) and the amplitude reservation ratio (Y) was Y=90.36-0.894 7 X, and the coefficient of determination R2 was 0.8804 ( F=1825.41, P<0.001). The amplitude reservation ratio ( Y) was positively correlated with the degree of NMB ( X) ( r=0.879, t=28.67, P<0.001) in the latency period, the linear regression equation of the interaction between the degree of NMB ( X) and the latency ( Y) was Y=10.77+ 0.074 3 X, and the coefficient of determination R2 was 0.7681 ( F=821.30, P<0.001). The estimated appropriate degree of NMB for AMR monitoring during microvascular decompression was 25%-45%. Conclusions:The appropriate degree of NMB for AMR monitoring during microvascular decompression was 25%-45%.

Clinical efficacy of ultrasound-guided adductor block with chloroprocaine combined with fentanyl for early rehabilitation training after total knee arthroplasty / 中国基层医药

Objective:To investigate the effects of ultrasound-guided adductor block with chloroprocaine combined with fentanyl on analgesia and early rehabilitation after total knee arthroplasty.Methods:Eighty-eight patients who underwent total knee arthroplasty in Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine between June 2018 and June 2020 were included in this study. They were randomly divided into control and study groups, with 44 patients per group. The control group was subjected to distal adductor block with ropivacaine. The study group received distal adductor block with ropivacaine combined with fentanyl. Before and after distal adductor block, resting pain response was evaluated using the Visual Analogue Scale. The success rate, onset time of block, and duration of block effect were recorded. The quadriceps femoris muscle strength, knee joint range of motion, and Hospital for Special Surgery knee score before and after block were measured. The time spent in stand-to-walk test and 10-meter walking test, and incidence of falls during rehabilitation training as well as drug-related adverse reactions were recorded.Results:There were no significant differences in resting-state and task-state Visual Analogue Scale scores post-block between the two groups ( t = 0.43, 0.46, P = 0.689, 0.644). The onset time of block and duration of block effect in the study group were (5.02 ± 0.94) minutes and (2.64 ± 0.39) minutes, respectively, which were significantly shorter than those in the control group [(7.49 ± 1.12) minutes, (7.08 ± 0.92) minutes, t = 5.73, 13.02, both P < 0.001]. There was no significant difference in block success rate between study and control groups (100.0% vs. 100.0%, χ 2 = 0.00, P = 1.000). The quadriceps femoris muscle strength, knee range of motion, and Hospital for Special Surgery knee score in the study group were (4.68 ± 0.44), (112.57 ± 9.96) o and (70.56 ± 6.84) points, which were superior to those in the control group [(4.19 ± 0.42), (101.30 ± 9.67) o,(62.47 ± 6.16) points, t = 3.42, 4.64, 6.58, all P < 0.001). The time spent in stand-to-walk test and 10-meter walking test were (7.95 ± 1.48) minutes and (4.67 ± 0.63) minutes, respectively, which were significantly shorter than those in the control group [(13.41 ± 2.05) minutes, (6.24 ± 0.77) minutes, t = 8.23, 6.74, both P < 0.001). The incidence of falls in the study group was significantly lower than that in the control group (11.3% vs. 29.5%, χ 2 = 4.47, P = 0.034). There was no significant difference in total incidence of drug-related adverse reactions between the two groups (9.1% vs. 13.6%, χ 2 = 0.45, P = 0.502). Conclusion:Distal adductor block with cloprocaine combined with fentanyl meets the requirement of short-term intensive analgesia after total knee arthroplasty, and achieves sufficient analgesia, maximum retention of motor function, rapid onset, and repaid recovery.

Action of heparin and acetylcholine modulators on the neurotoxicity of the toad Rhinella schneideri (Anura: Bufonidae) in Brazil / Acción de la heparina y moduladores de acetilcolina en la neurotoxicidad del sapo Rhinella schneideri (Anura: Bufonidae) en Brasil

Abstract Introduction: Rhinella schneideri is a toad widely distributed in South America and its poison is characterized by inducing cardiotoxicity and neurotoxicity. Objective: In this work, we investigated pharmacological strategies to attenuate the peripheral neurotoxicity induced by R. schneideri poison in avian neuromuscular preparation. Methods: The experiments were carried out using isolated chick biventer cervicis preparation subjected to field stimulation for muscle twitches recordings or exposed to acetylcholine and potassium chloride for contracture responses. Results: Poison (10 μg/ml) produced complete neuromuscular blockade in chick biventer cervicis preparation within approximately 70 min incubation (times for 50 and 90 % blockade: 15 ± 3 min and 40 ± 2 min, respectively; P < 0.05, N= 5); contracture responses to exogenous acetylcholine and KCl were unaffected by poison indicating no specificity with postsynaptic receptors or myotoxicity, respectively. Poison (10 μg/ml)-induced neuromuscular blockade was not prevented by heparin (5 and 150 IU/ml) under pre- or post-treatment conditions. Incubation at low temperature (23-25 °C) abolished the neuromuscular blockade; after raising the temperature to 37 °C, the complete neuromuscular blockade was slightly slower than that seen in preparations directly incubated at 37 °C (times for 50 and 90 % blockade: 23 ± 2 min and 60 ± 2.5 min, respectively; P < 0.05, N= 4). Neostigmine (3.3 μM) did not reverse the neuromuscular blockade in BC preparation whereas 3,4-diaminopyridine (91.6 μM) produced a partial and sustained reversal of the twitch responses (29 ± 7.8 % of maximal reversal reached in approximately 40 min incubation; P < 0.05, N= 4). Conclusions: R. schneideri poison induces potent peripheral neurotoxicity in vitro which can be partially reversible by 3,4-diaminopyridine.

Resumen Introducción: Rhinella schneideri está ampliamente distribuida en Suramérica y su veneno es caracterizado por inducir cardiotoxicidad y neurotoxicidad. Objetivo: En este trabajo, investigamos estrategias farmacológicas para atenuar la neurotoxicidad periférica inducida por el veneno de R. schneideri en preparaciones neuromusculares de aves. Métodos: Los experimentos fueron realizados usando preparaciones de biventer cervicis de pollos sometidas a estimulación de campo para el registro de las contracciones musculares o expuestas a la acetilcolina y al cloruro de potasio para la respuesta contractural. Resultados: El veneno (10 µg/ml) provocó un bloqueo neuromuscular completo en las preparaciones después de aproximadamente 70 min de incubación (tiempos para 50 y 90 % de bloqueo: 15 ± 3 min y 40 ± 2 min, respectivamente; P < 0.05, N = 5); las contracturas en respuesta a la acetilcolina y el KCl exógenos no fueron afectadas por el veneno, indicando que no hay una interacción especifica con receptores postsinápticos o miotoxicidad respectivamente. El bloqueo neuromuscular causado por el veneno (10 µg/ml) no fue prevenido por la heparina (5 y 150 UI/ml) bajo condiciones pre y post-tratamiento. La incubación a bajas temperaturas (23-25 ºC) abolió el bloqueo neuromuscular; después de aumentar la temperatura a 37 ºC, el bloqueo neuromuscular total fue levemente más lento que el visto en preparaciones directamente incubadas a 37 ºC (tiempos para 50 y 90 % de bloqueo: 23 ± 2 min y 60 ± 2.5 min, respectivamente; P < 0.05, N= 4). Neostigmina (3.3 µM) no revirtió el bloqueo neuromuscular, mientras que 3.4-diaminopiridina (91.6 µM) produjo una reversión parcial y sostenida de las respuestas neuromusculares (29 ± 7.8 % de la reversión máxima alcanzada en aproximadamente 40 min de incubación; P < 0.05, N = 4). Conclusiones: El veneno de R. schneideri indujo neurotoxicidad periférica potente in vitro, el cual puede ser revertido por 3.4-diaminopiridina.

Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile / Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units

Background: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). Aim: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. Material and Methods: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. Results: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. Conclusions: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Desafíos en el manejo de la sedación, analgesia y bloqueo neuromuscular en el paciente crítico COVID-19 en Chile / Challenges in the management of analgesia and sedation in critically ill patients with COVID-19 in Chile

Approximately 5% of COVID-19 patients will have a severe disease requiring invasive or non-invasive mechanical ventilation. In this conditions, sedatives and analgesics are fundamental to promote tolerance, comfort and synchrony with the mechanical ventilator. High and unusual requirements for sedation, analgesics and neuromuscular blockers have been reported in these patients, contributing to prolonged exposure, a high rate of delirium and prolongation of mechanical ventilation. These factors, added to the progressive shortage of these drugs, a high demand for care and less capacity for personalized attention, have created an adverse scenario for their proper and rational use. This paper proposes different pharmacotherapeutic optimization strategies for a rational management of sedation, analgesia and neuromuscular block in critically ill patients with COVID-19, with the therapeutic alternatives available in Chile.

Manejo anestésico en la enfermedad de Steinert. A propósito de un caso / Anesthetic management in Steinert's disease: case report

Resumen: Se presenta el caso de paciente masculino, de 60 años, programado para resección transuretral de próstata. Como antecedentes destacan enfermedad de Steinert e implantación de marcapasos. La enfermedad de Steinert es el antecedente principal que guiará nuestra práctica anestésica y, tras valorar el tipo de intervención prevista, se decide anestesia locorregional, dadas las potenciales complicaciones que pueden presentar estos pacientes con la anestesia general. La conducta anestésica de los pacientes con enfermedad de Steinert supone un reto para el anestesiólogo tanto por la gran cantidad de complicaciones que pueden aparecer en el intra- y en el postoperatorio, como por la baja frecuencia de esta enfermedad. Además, el estrés quirúrgico y las técnicas utilizadas pueden interferir en el curso de la enfermedad. Por todo ello, el abordaje y los cuidados intra- y postoperatorios se deben planificar y seleccionar con cuidado con el fin de obtener los mejores resultados y extremar la seguridad del paciente.

Abstract: A 60-year-old man with prostatic hypertrophy was scheduled for transurethral resection of the prostate. Steinert's disease and implantation of a pacemaker were his previous pathology. Being Steinert's disease the most relevant clinical characteristic and the type of intervention urologist has planned, we decide locoregional anesthesia technique, avoiding the potential complications that these patients may present with general anesthesia. The anesthetic management of Steinert's disease patients is a challenge for the anesthesiologist both due to the large number of complications that may appear during intra- and postoperative time as well as the low frequency of this pathology. In addition, surgical stress and the techniques we use can interfere with the course of the disease. Therefore, the approach and immediate intra-and postoperative care should be carefully planned and selected in order to obtain the best results and maximize patient safety.

Dose of intravenously infused cisatracurium for maintenance of deep neuromuscular blockade during thoracic surgery / 中华麻醉学杂志

Objective:To investigate the dose of intravenously infused cisatracurium for the maintenance of deep neuromuscular blockade during thoracic surgery.Methods:Patients of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 18-64 yr, scheduled for elective thoracic surgery under general anesthesia, were studied.The patients were connected to a muscle relaxation monitor after entering the operating room.After the completion of muscle relaxant calibration and anesthesia induction, cisatracurium was intravenously infused at a constant rate to maintain deep neuromuscular blockade (post-tetanic count [PTC]≤5 ). The infusion rate was calculated by modified Dixon up-and-down method.The first patient received cisatracurium at 0.12 mg·kg -1·h -1.If the PTC was 0 or was maintained≤5 continuously, the infusion rate was decreased 0.01 mg·kg -1·h -1 in the next patient, until PTC was >5 during operation.The mean dose for the patient was used as initial dose.Then the infusion rate was increased/decreased by 0.005 mg·kg -1·h -1.The 95% effective dose of cisatracurium (ED 95) was the median of 6 thresholds. Results:A total of 22 cases completed the study.The ED 95 of continuous intravenous infusion of cisatracurium for the maintenance of deep neuromuscular blockade was 0.108 mg·kg -1·h -1(95% confidence interval 0.105-0.125 mg·kg -1·h -1). Conclusion:The dose of intravenous infusion of cisatracurium for the maintenance of deep neuromuscular blockade during thoracic surgery is 0.108 mg·kg -1·h -1.

Sugammadex versus neostigmine for reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation: a large-scale, retrospective study / 中华麻醉学杂志

Objective:To compare the efficacy of sugammadex versus neostigmine on reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation. Methods:The clinical data of patients undergoing kidney transplantation from donation after cardiac death in our hospital from January 2018 to December 2020 were retrospectively analyzed.Patients were divided into sugammadex group (group S) and neostigmine group (group N) according to the use of muscle relaxant antagonists.The onset time of antagonism, time of tracheal extubation, and time of postanesthesia care unit stay were recorded.The creatinine clearance rate was recorded before operation and at 1, 3, 5 and 7 days after operation.The occurrence of postoperative complications was recorded.Results:A total of 603 patients were enrolled in this study, with 278 patients in group S and 325 patients in group N. Compared with group N, the onset time of antagonism, time of extubation , and time of postanesthesia care unit stay were significantly shortened, the incidence of hypoxemia within 24 h after surgery and pulmonary infection occurred within 7 days after surgery was decreased ( P<0.05), and no significant change was found in the creatinine clearance rate at each time point and incidence of postoperative cardiovascular complications and graft complications in group S ( P>0.05). Conclusion:Compared with neostigmine, sugammadex can reverse rocuronium-induced residual neuromuscular blockade more quickly, which is helpful for early recovery with a higher safety when applied in the patients undergoing renal transplantation.

Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis / Desafios perioperatórios e pontos de atenção no bloqueio neuromuscular durante timectomia robótica para miastenia gravis

Abstract Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Resumo Miastenia Gravis (MG) é uma doença autoimune que se caracteriza por fraqueza e fadiga da musculatura esquelética, com melhora após o repouso. É uma doença de grande interesse para o anestesiologista, pois compromete a junção neuromuscular. Recentemente, a timectomia robótica tem sido empregada por apresentar as vantagens da abordagem minimamente invasiva. O procedimento introduz uma série de novos desafios para a equipe de anestesia. Relatamos aqui as várias considerações anestésicas e o cuidado perioperatório em uma série de 20 pacientes submetidos a timectomia robótica. Sendo um procedimento recente, há limitada literatura discutindo esse tópico e, além disso, a maior parte da literatura disponível concentra a atenção na Ventilação Monopulmonar (VMP) e na peridural torácica. A nosso ver, este é a primeiro relato na literatura sem o emprego de VMP e peridural torácica para o manejo da timectomia robótica.

Bloqueio neuromuscular e manuseio das vias aéreas na intubação endotraqueal em unidades de terapia intensiva brasileiras: um levantamento nacional / Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey

RESUMO Objetivo: Descrever o uso do bloqueio neuromuscular e de outras práticas entre os médicos brasileiros atuantes em unidades de terapia intensiva para pacientes adultos. Métodos: Um levantamento nacional on-line foi aplicado a intensivistas brasileiros. As questões foram selecionadas utilizando o método Delphi e avaliavam os dados demográficos dos médicos, as características da unidade de terapia intensiva, as práticas relativas ao manuseio das vias aéreas e o uso de bloqueio neuromuscular e sedação durante a intubação endotraqueal na unidade de terapia intensiva. Como desfecho secundário, aplicamos uma análise multivariada para avaliar fatores associados com o uso do bloqueio neuromuscular. Resultados: Responderam ao questionário 565 intensivistas de todas as regiões do país. A maioria dos que responderam era homens (65%), com média de idade de 38 ± 8,4 anos, e 58,5% dos participantes tinham título de especialista em terapia intensiva. Apenas 40,7% dos intensivistas relataram o uso de bloqueio neuromuscular durante todas ou em mais de 75% das intubações endotraqueais. Na análise multivariada, o número de intubações realizadas por mês e a especialização do médico em anestesiologia se associaram diretamente com o uso frequente de bloqueio neuromuscular. Etomidato e cetamina foram utilizados mais comumente na situação clínica de hipotensão e choque, enquanto propofol e midazolam foram mais comumente prescritos em situações de estabilidade hemodinâmica. Conclusão: O relato de uso de bloqueio neuromuscular foi baixo entre intensivistas, e os fármacos sedativos foram escolhidos segundo a estabilidade hemodinâmica do paciente. Estes resultados podem ajudar no delineamento de futuros estudos relativos ao manuseio das vias aéreas no Brasil.

Abstract Objective: To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. Methods: An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. Results: Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. Conclusion: The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

Pupillary Response to Light is Preserved in Patients without Brain Insult Undergoing Rapid Sequence Intubation

Objective of the Study: This paper has been aimed to determine whether the pharmacological neuromuscular blockade with rocuroniumduring emergency Rapid Sequence Intubation (RSI) affected pupillary response to light (PLR) in patients with brain insult as compared to patients who had non-neurological illness. Previous studies elucidated that RSI with pharmacological neuromuscular blockade does not affect PLR, except in patients with significant neurological lesion. Our objective is to examine the validity of existing but scarce literature on this subject, with further stratification of patients involved in this study into neurological and non-neurological disease groups.Methods:This was a prospective case-reference study of case group with brain insult patients compared with reference group of patients without neurological diseases undergoing RSI in emergency settings. It is single centered study, conducted from October 2019 till May 2020. A pair of a neurosurgeon and a medical officer assessed pupillary light response after administration of neuromuscular blockade and intubation, each blinded to other’s assessment of PLR. Cases without pupillary response before RSI intubation were excluded. The primary outcome measure was clinically observable Pupillary Light Response (PLR) following neuromuscular blockade with Rocuronium in each group.Results:We examined 50 patients undergoing RSIwith Rocuronium, either in emergency department or Intensive Care Unit (ICU), 25 each in index and reference group respectively. All patients in the reference group showed PLR after RSI. Of case group patients receiving RSI, only15 of 25 (60%) demonstrated PLR after RSI. This was statistically significant (p value<0.05) when compared to number of patients with intact PLR after RSI in reference group. Cohen’s Kappa Coefficient (k) for inter-observer agreement was 0.70.Conclusion: Rocuronium does not appearto affect PLR after emergent RSI in patients without brain injury. Only in patients with known brain insult showed impaired PLR, suggesting impaired pupillary light reflex mechanism may be the culprit for this aberration, rather than pharmacological neuromuscular blockade

Parálisis residual posoperatoria tras anestesia general sin monitorización neuromuscular objetiva: un estudio observacional en el Hospital Regional Docente de Cajamarca, Perú / Postoperative residual paralysis after general anesthesia without objective neuromuscular monitoring: An observational study at the Regional Cajamarca Hospital, Perú

Objetivo: Determinar la incidencia y severidad de la parálisis residual en pacientes sin monitorización neuromuscular intraoperatoria. Materiales y métodos: Se realizó un estudio prospectivo y observacional en 236 pacientes adultos ASA I-III intervenidos bajo anestesia general sin monitorización neuromuscular intraoperatoria. A su llegada a la Unidad de Cuidados Post-Anestesia (UCPA) se realizó la monitorización neuromuscular mediante aceleromiografía del músculo aductor del pulgar. La incidencia de parálisis residual con TOF ratio (TOFr) < 0,9 y TOFr < 0,7 fueron valorados. Resultados: La incidencia de parálisis residual en la UCPA con TOFr < 0,9 fue de 81,36% (IC 95%: 76,39-86,33) y con TOFr < 0,7 fue de 33,9% (IC 95%: 27,86-39,94). La neostigmina fue utilizada para revertir el bloqueo neuromuscular solamente en el 48,3% de los casos. La incidencia de parálisis residual con TOFr < 0,7 fue significativamente mayor entre los que no recibieron antagonistas del bloqueo neuromuscular y los que sí lo recibieron (42,62% vs. 24,56%, p=0.003). Conclusiones: La incidencia y severidad de la parálisis residual posoperatoria en pacientes sin monitorización neuromuscular fue elevada en nuestra institución, probablemente favorecida por una dosificación no guiada de los relajantes musculares, la escasa utilidad de los criterios subjetivos para valorar la recuperación de la función neuromuscular y la falta de reversión rutinaria del bloqueo neuromuscular.

Objective: To determine both the incidence and severity of residual paralysis in patients not undergoing intraoperative neuromuscular monitoring. Material and Methods: A prospective observational study was performed in 236 ASA I-III adult subjects who underwent surgery under general anesthesia without intraoperative neuromuscular monitoring. When patients were brought to the Post-Anesthesia Care Unit (PACU), neuromuscular monitoring was performed using acceleromiography of the adductor muscle of the thumb. The incidence of residual paralysis with TOF ratio (TOFr) values <0.9 and <0.7 was assessed. Results: The incidence of residual paralysis in the PACU with TOFr <0.9 was 81.36% (95% CI: 76.39%-86.33%) and with TOFr <0.7 was 33.9% (95% CI: 27.86%-39.94%). Neostigmine was used to revert neuromuscular blockade only in 48.3% of all cases. The incidence of residual paralysis with TOFr<0.7 was significantly higher in those subjects who did not receive neuromuscular blockade antagonists compared with those who did (42.62% vs. 24.56%, p= 0.03). Conclusions: Both the incidence and severity of residual postoperative paralysis in patients without neuromuscular monitoring was notoriously high in our institution, likely favored by a non-guided dosing of muscle relaxant agents, as well as due to low usefulness of subjective criteria for assessing recovery of neuromuscular function and the lack of routine reversion of neuromuscular blockade.

Immediate rescue reversal of rocuronium-induced intense neuromuscular blockade using sugammadex in pediatric surgical patients

BACKGROUND@#The dose of Sugammadex for rescue reversal of intense neuromuscular block has not been studied in children. The only recommended dose of Sugammadex in children is 2mg/kg to reverse a shallow block. @*OBJECTIVES@#To assess the efficacy and safety of Sugammadex 2mg/kg and 4mg/kg as immediate rescue reversal of intense rocuronium-induced neuromuscular block in pediatric patients@*METHODS@#80 children, aged 2 to 11 years old, requiring general anesthesia were enrolled in this randomized prospective study. Group 1 given Sugammadex 2mg/kg (40 subjects) while Group 2 received Sugammadex 4mg/kg (40 subjects), at the end of the procedure if PTC=0. The Recovery Time was recorded (TOF ratio ≥0.9) (Primary Outcome). Discharge readiness in the PACU was assessed using Modified Aldrete Scale (Secondary Outcome). Monitoring of adverse effects in the ward continued until 24 hours postoperatively.@*RESULTS@#There were significantly more patients in the Sugammadex 4mg/kg that had a recovery time of ≤2min as compared to those given Sugammadex 2mg/kg (p=0.012). There was no significant difference in the Aldrete score between the two groups (p=0.2776). All patients achieved a very satisfactory discharge score in the PACU. The adverse effects experienced by the patients in the two doses of Sugammadex in the PACU and up to 24 hours postoperatively were not significantly different.@*CONCLUSION@#Sugammadex 4mg/kg can be considered safe and effective as an immediate reversal agent for rocuronium-induced intense neuromuscular blockade in children.@*RECOMMENDATIONS@#Clinicians should identify if Sugammadex 6mg/kg, compared with 4mg/kg, would translate to a shorter Recovery time to a TOF ratio of 0.9. The time from TOF ratio of 0.9 to the time of extubation should be measured to increase the efficacy and safety assessment of Sugammadex in this age group.

Clinical application of ultrasound-guided fascia iliaca compartment block and proximal popliteal sciatic nerve block on patients undergoing total knee arthroplasty / 中国基层医药

Objective@#To observe the application of ultrasound-guided fascia iliaca compartment block(FICB) and proximal popliteal sciatic nerve block(PPSNB) on patients undergoing total knee arthroplasty.@*Methods@#From January 2015 to January 2018, 60 patients scheduled for total knee arthroplasty undergoing laryngeal mask airway(LMA) general anesthesia in the People′s Hospital of Langfang were divided into three groups by the random number table, with 20 cases in each group.Before general anesthesia, every patient received dezocine 5mg iv, group A received FICB, group B received FICB combined with PPSNB(extraparaneural), group C received FICB combined with PPSNB(subparaneural).40mL of 0.375% ropivacaine was injected guiding by ultrasound.The dosage of propofol and remifentanil, time of awake, awake visual analogue scale(VAS), mean arterial blood pressure(MAP) and heart rate(HR) at pre-block(T1), LMA insert(T2), skin incision(T3), femoral bone cutting(T4), LMA remove(T5), and awake stage(T6) were recorded.The incidence of using vasoactive drugs and adverse reaction were also recorded.@*Results@#The dosage of propofol and remifentanil, the time of awake and awake VAS in group A, group B and group C were: group A (768.0±8.5)mg, (977±21)μg, (18.4±2.1)min, (4.2±0.7)points; group B (554.0±7.1)mg, (775±12)μg, (12.3±1.6)min, (2.4±0.6)points; group C (530±8.2)mg, (738±15)μg, (11.8±1.7)min, (1.3±0.5)points.The dosage of propofol and remifentanil, time of awake, awake VAS in group B and group C were significantly lower than those in group A (F=29.23, 42.56, 32.42, 19.31, all P<0.05). The awake VAS in group C was lower than that in group B (q=8.12, P<0.05). MAP and HR at T2, T3, T4, T5 and T6 in group B or group C were significantly lower than those in group A (MAP: F=85.66, 78.46, 86.04, 62.75, 61.31; HR: F=26.03, 42.75, 38.04, 29.31, 31.50, all P<0.05). The number of patients who required vasoactive drugs and adverse reaction in group B or group C were significantly lower than those in group A (χ2=11.32, 12.81, 15.24, 15.24, 10.15, all P<0.05). The incidence rates of incision pain at awake stage in group A, group B and group C were: group A(30%), group B(20%), group C(0%), that in group C was lower than group B (χ2=9.87, P<0.05).@*Conclusion@#The ultrasound-guided FICB and PPSNB(subparaneural) can obviously reduce the dosage of general anaesthetic and maintain the stability of hemodynamics in patients undergoing total knee arthroplasty.It has effective analgesia and less adverse reactions during sober.