ABSTRACT
In the management of complex medical cases such as a multifetal pregnancy, knowledge of the ethical and legal implications is important, alongside having competent medical skills. This article reviews these principles and applies them to scenarios of multifetal pregnancy and fetal reduction. Such a discussion is not solely theoretical, but is also relevant to clinical practice. The importance of topics such as bioethical principles and informed consent are also herein addressed.
Subject(s)
Ethics, Medical , Legislation, Medical , Pregnancy Reduction, Multifetal/ethics , Pregnancy Reduction, Multifetal/legislation & jurisprudence , Pregnancy, Multiple , Female , Humans , Informed Consent , Pregnancy , SingaporeABSTRACT
BACKGROUND: The purpose of this study was to verify which muscle among the adductor pollicis (AP), orbicularis oculi (OO), and corrugator supercilii (CS) is a better predictor of optimal intubating conditions after administration of rocuronium. METHODS: In this prospective trial, 201 patients were randomized into six groups to receive rocuronium at a dose of 0.6 or 1.0 mg kg(-1) during propofol-remifentanil-nitrous oxide anaesthesia. The tracheal intubation was performed after maximal neuromuscular block by acceleromyography at the thumb (AP), the eyelid (OO), and the superciliary arch (CS). The onset time, intubating conditions, peak vital signs, and bispectral index were assessed. RESULTS: The onset time of rocuronium in the OO and CS muscle was significantly shorter than in the AP muscle (P<0.001), but excellent intubating conditions were significantly increased in the AP (87%) and the CS (77%) compared with the OO (32%) after a dose of 0.6 mg kg(-1) of rocuronium (P<0.05). CONCLUSIONS: After administration of rocuronium, twitch monitoring at the OO allows a faster intubation but is associated with an unacceptable incidence of inadequate intubating conditions. Excellent intubating conditions are observed most frequently with AP monitoring but with the longest delay before intubation is attempted. Monitoring of the CS allows intubation earlier than that of AP with fewer patients having excellent but no patients having inadequate intubating conditions.
Subject(s)
Androstanols/pharmacology , Intubation, Intratracheal/methods , Muscle Relaxation/drug effects , Muscle, Skeletal/drug effects , Neuromuscular Nondepolarizing Agents/pharmacology , Adult , Androstanols/administration & dosage , Anesthesia, General/methods , Dose-Response Relationship, Drug , Electroencephalography/drug effects , Eyelids , Facial Muscles/drug effects , Facial Muscles/physiology , Facial Nerve/physiology , Female , Hemodynamics/drug effects , Humans , Laryngoscopy , Male , Middle Aged , Monitoring, Intraoperative/methods , Muscle Relaxation/physiology , Muscle, Skeletal/physiology , Neuromuscular Blockade/methods , Neuromuscular Nondepolarizing Agents/administration & dosage , Prospective Studies , Rocuronium , Thumb , Young AdultABSTRACT
BACKGROUND AND OBJECTIVE: Neuromuscular blocking effects according to the severity of liver dysfunction have not been evaluated. We assessed the neuromuscular effects of mivacurium in carbon tetrachloride (CCl4)-treated rabbits with toxic hepatitis in vivo. METHODS: We compared the dose-response relationships and the neuromuscular blocking effects of mivacurium in 66 rabbits randomly treated with 0.3 mL kg(-1) of corn oil, 0.3 mL kg(-1) of CCl4 or 0.6 mL kg(-1) of CCl4 for 11 weeks, respectively. Train-of-four stimuli were applied every 10 s to the common peroneal nerve and the force of contraction of the tibialis anterior muscle was measured. RESULTS: Severe hepatitis was associated with a rightward shift of the mivacurium dose-response curves, but mild hepatitis had no effect. The calculated ED50 values for the control, mild and severe hepatitis were 17.1+/-2.6, 18.2+/-2.7 and 31.8+/-3.2 microg kg(-1), respectively. Rabbits with severe hepatitis had a significantly prolonged recovery time from neuromuscular blockade compared with other rabbits. Cholinesterase activity had a negative correlation with recovery indices of mivacurium even in severe hepatic injury. Severe hepatitis induced a prolongation of action duration of repeated doses, but maintained the constant intervals. CONCLUSIONS: The dose-response and the time course of neuromuscular blockade of mivacurium differ in mild hepatitis compared with severe hepatitis, but required no adjustments of different doses for repeated injection after the desired depth of neuromuscular block, and had a negative correlation with the activity of plasma cholinesterase in both hepatic injuries.
Subject(s)
Chemical and Drug Induced Liver Injury/physiopathology , Isoquinolines/pharmacology , Muscle Relaxation/drug effects , Neuromuscular Nondepolarizing Agents/pharmacology , Animals , Biomarkers/blood , Carbon Tetrachloride , Chemical and Drug Induced Liver Injury/blood , Cholinesterases/blood , Disease Models, Animal , Dose-Response Relationship, Drug , Liver Function Tests , Male , Mivacurium , Muscle Relaxation/physiology , Rabbits , Random Allocation , Time FactorsABSTRACT
We present two cases of sudden unanticipated cardiovascular complications in patients with noncatecholamine-secreting adrenocortical adenomas during laparoscopic adrenalectomy. In the first case, the patient developed paroxysmal tachycardia and hypertension followed by ventricular fibrillation shortly after clipping of the adrenal vein. In the second case, the patient suffered hypertension and bigeminy during manipulation of the adrenal gland just around the adrenal vein. Awareness of such complications during either conventional or laparoscopic adrenalectomy is important even if the operation is performed in a patient with an apparently noncatecholamine-secreting adrenocortical adenoma.
