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.

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

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 2min 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.

Sugammadex en paciente neonatal / Sugammadex in the neonatal patient

Introducción: La inclusión de drogas que revierten efectivamente el bloqueo de la placa neuromuscular mejora el perfil de uso de los medicamentos que la relajan, y más aún si estos carecen de efectos adversos de importancia clínica y se pueden emplear en neonatos. Objetivos: Este artículo describe el caso de 2 pacientes pediátricos en quienes se aplicó sugammadex para la reversión de la relajación neuromuscular. Metodología: Estudio observacional descriptivo retrospectivo con un diseño de reporte de casos. Resultados: Se describe el uso exitoso de sugammadex para la reversión del bloqueo neuromuscular inducido por rocuronio en 2 pacientes neonatos y la ausencia de eventos adversos. Discusión: La literatura para el uso de sugammadex en pacientes recién nacidos es poca y controvertida, lo cual no apoya su amplia prescripción en neonatología debido a la falta de estudios que aseguren su efectividad y la ausencia de efectos adversos. No existen dosis recomendadas por grupo etario y una lista de efectos adversos esperables que contraindiquen su administración. Aun así, es ideal poder disponer de medicamentos que reviertan la relajación derivada del uso de bloqueadores neuromusculares en cualquier edad, lo cual incluye a los pacientes neonatos. Conclusiones: Tras una dosis de sugammadex se describe la reversión del bloqueo neuromuscular en 2 pacientes neonatos, siendo esta efectiva para la restauración funcional de la placa neuromuscular. Para poder recomendar su amplio uso en recién nacidos es ideal la realización de estudios experimentales controlados.

Introduction: The inclusion of drugs that effectively reverse the neuromuscular junction blockade enhances the profile of drugs used for relaxation of the neuromuscular junction; better yet if these agents are free from any clinically important adverse effects and amenable to use in neonates. Objectives: This article describes a case of two pediatric patients who received Sugammadex to reverse neuromuscular relaxation. Methodology: Retrospective, descriptive, observational study designed as a case report. Results: This is a description of a Sugammadex successful reversal of Rocuronium-induced neuromuscular blockade in two neonates with no adverse events. Discussion: The literature on the use of Sugammadex in newborn patients is scarce and controversial which does not contribute to a broad prescription of the drug in neonatology settings due to the shortage of studies attesting to its effectiveness and absence of adverse effects. There are no recommended doses per age group and a list of expected adverse effects to contraindícate its administration. However, the idea is to have available drugs that reverse the relaxation resulting from the use of neuromuscular blockers at any age, including neonates. Conclusions: Following the administration of a dose of Sugammadex the reversal of neuromuscular blockade in neonate patients is described with effective functional recovery of the neuromuscular junction. Further experimental controlled trials are needed to recommend the use of Sugammadex in newborn babies.

Aproximación al conocimiento de los hábitos que tienen los anestesiólogos en el uso de relajantes neuromusculares no despolarizantes y sus reversores, Valle del Cauca, Colombia / The Use of Neuromuscular Non-depolarizing Blockers and their Reversal Agents by Anesthesiologists Valle del Cauca, Colombia

Objetivos: Describir los hábitos que, en torno al uso de relajantes neuromusculares no despolarizantes, tienen los anestesiólogos en nuestro medio. Aproximarnos al conocimiento de la prevalencia del uso de relajantes neuromusculares no despolarizantes y a la percepción que sobre su monitoría tienen los anestesiólogos en el departamento del Valle del Cauca. Metodología: Se realizó un estudio descriptivo de corte transversal con 258 anestesiólogos y se revisó la base de datos de la Clínica Visual y Auditiva del Instituto para Niños Ciegos y Sordos del Valle del Cauca, para obtener información sobre el consumo de neostigmina y el número de cirugías con anestesia general realizadas entre los años 2007 y 2010. Resultados: El 30% de los anestesiólogos encuestados refirieron utilizar los relajantes neuromusculares no despolarizantes en anestesia general a veces, mientras que el 61% dijeron hacerlo de manera frecuente, casi siempre o siempre. Sobre el empleo de la monitoría de la relajación neuromuscular (MRNM), el 68% de los encuestados respondieron no usarla casi nunca, y solo el 13% dijeron hacerlo frecuentemente, casi siempre o siempre. El 32% de los anestesiólogos perciben que casi nunca usan reversores de la relajación neuromuscular. El 25% dijo hacerlo a veces, mientras que el 24,7% y el 17,8% afirmaron, respectivamente, hacerlo frecuentemente, siempre o casi siempre. En el Instituto para Niños Ciegos y Sordos del Valle del Cauca (INCS), el consumo de neostigmina muestra una disminución, en contraste con un aumento del número de cirugías con anestesia general realizadas desde 2007 hasta 2010. Conclusiones: Los anestesiólogos del Valle del Cauca dicen hacer uso frecuente de relajantes neuromusculares en anestesia general. La monitoría de la relajación neuromuscular no es una práctica habitual entre ellos. Aun cuando el diseño del estudio no permite concluir sobre asociaciones en torno a los datos obtenidos, sí sugiere que el hábito de uso de los medicamentos relajantes neuromusculares, en nuestro medio, es riesgoso. La disminución en la reversión y un escaso hábito de monitorización pueden estar exponiendo a nuestros pacientes a una morbimortalidad prevenible, derivada del uso de estos medicamentos.

Objectives: To describe the prevalence of use of non-depolarizing neuromuscular blockers/ relaxants by anesthesiologists in our area, and the perception of anesthesiologists in the Valle del Cauca region with regards to monitoring. Methodology: A descriptive, cross-sectional study including 258 anesthesiologists, and a review of the data from the Eye and Hearing Clinic for Blind and Deaf Children in Valle del Cauca to collect information about the use of neostigmine and the number of surgeries performed under general anesthesia between 2007 and 2010. Results: Thirty per-cent of the anesthesiologists surveyed claimed to occasionally use nondepolarizing neuromuscular relaxants in general anesthesia, while 61% said that they used them often, usually or always. With regards to the use of neuromuscular relaxation monitoring (NMRM), 68% the doctors surveyed said they rarely used it, and only 13% claimed using it often, usually or always. Thirty two per-cent of the anesthesiologists are believe that they almost never use neuromuscular blockade reversing agents. Twenty five per-cent said they occasionally reversed their patients, while 24.7% and 17.8% said they used reversal often, always or usually, respectively. At the Institute for Blind and Deaf Children of Valle del Cauca (INCS), the use of neostigmine is declining in contrast to the rising numbers of surgeries performed under general anesthesia from 2007 until 2010. Conclusions: The Valle del Cauca anesthesiologist claims to frequently use neuromuscular blockers in general anesthesia. Monitoring of neuromuscular blockade is not a usual practice among them. Although the study is not conclusive with regards to the associations based on the data collected, it does suggest that the habit of using neuromuscular blockers in our environment is risky. The limited use of reversal agents and rare monitoring may be exposing our patients to a preventable morbidity-mortality resulting from the use of these drugs.

Anestesia general para cesárea. Papel del sugammadex en la calidad y la seguridad del acto anestésico. Reporte de caso / General Anesthesia for C-Section. The Role of Sugammadex in the quality and safety of anesthesia. Case Report

La cesárea es una de las intervenciones quirúrgicas más realizadas en el planeta. En el 5% de los casos se practica bajo anestesia general (7,5 millones de anestesias generales para cesárea cada año). Debido a sus requerimientos particulares (paciente con estómago lleno, necesidad de relajación neuromuscular, bienestar del binomio madre-hijo, expectativas de pronta atención del recién nacido por parte de la madre y relativa corta duración del procedimiento) la anestesia general representa un reto en cada intervención. En este artículo se presenta el caso de una mujer gestante que requirió anestesia general para una cesárea de urgencia. Se utilizó rocuronio como relajante neuromuscular y se obtuvo un acceso rápido a la vía aérea, así como condiciones quirúrgicas adecuadas. Al final se revirtió el procedimiento con sugammadex a dosis de 1 mg/kg. El surgimiento de nuevos agentes para la reversión de la relajación neuromuscular contribuye a un manejo seguro durante el acto anestésico; además, estos agentes disminuyen la probabilidad de relajación residual y permiten un mejor control del tiempo y de la profundidad de la relajación. Los estudios sugieren dosis de sugammadex que muy probablemente cambiarán con el advenimiento de nuevos estudios, haciéndolas ajustables al grado de relajación neuromuscular que se tenga, lo cual ayudará a disminuir los costos y, por lo tanto, a aumentar la disponibilidad del medicamento en nuestros quirófanos.

C-section is one of the most common surgical procedures in the world, with 5% of the cases being managed under general anesthesia (7.5 million C-sections performed under general anesthesia every year). Due to its special circumstances (i.e., the patient has a full stomach, need for neuromuscular relaxation, mother-child wellbeing, the mother is expected to immediately provide care to the baby, and the procedure takes a short time), general anesthesia is a challenge in every case. This article discusses the case of a pregnant woman who required general anesthesia for an emergency C-section. The neuromuscular relaxant used was Rocuronium. The airway was secured promptly and the surgical conditions were appropriate. The procedure was finally reversed with sugammadex at a dose of 1mg/kg. The availability of new neuromuscular relaxation reversal agents contributes to safe management during anesthesia; furthermore, these agents limit the chances of a residual relaxation and allow better time control and depth of relaxation. Studies suggest sugammadex doses that will probably change with the advent of new trials, adapting them to the degree of neuromuscular relaxation obtained, and this will help to reduce costs and hence improve the availability of the drug in our ORs.

Bloqueantes neuromusculares: en pro del uso adecuado / Neuromuscular blocking agents: an argument for their adequate use

Introducción. En el uso de bloqueantes musculares hay controversia: a favor está la necesidad de garantizar una adecuada intubación de manera rápida en los casos de urgencia y facilitar el campo quirúrgico al cirujano, además de otros beneficios reportados; en contra están los efectos adversos y los riesgos publicados. Objetivo. Promover la buena práctica médica en el uso de los bloqueantes musculares. Materiales y métodos. Revisión de la literatura científica disponible sobre el tema enfocada a indicaciones, riesgos, beneficios y monitoreo. Resultados. La indicación absoluta de bloqueante muscular es la intubación de secuencia rápida. Existen otros usos recomendados: intubación en cirugía electiva y ciertos tipos de cirugía y situaciones especiales (SDRA, TECAR, hipertensión intraabdominal, hipertensión intracraneana). Por otra parte, los bloqueantes pueden ser evitados en muchas anestesias generales. Lo más importante es conocer sus indicaciones y riesgos, y usarlos de manera adecuada. Conclusión. Hay situaciones en las que se puede evitar el uso de los bloqueantes, pero hay otras en las que son indispensables o están recomendados. Si van a ser usados, debe elegirse el bloqueanteideal para cada paciente, en el momento oportuno, con la dosis ajustada y siempre con el monitoreo apropiado.

Introduction. The debate regarding the use of muscle relaxants is still ongoing, with arguments against such as their adverse effects and published risks, and arguments in favor such as the need to ensure rapid and adequate intubation inemergency cases, the benefit of an easy surgical field for the surgeon, and other reported benefits. Objective. To review aspects associated with the adequate use of neuromuscular blocking agentsin anesthesia. Materials and methods. Narrative review of the scientific literature available on the subject thatfocused on indications, risks, benefits and monitoring. Results. The absolute indication of muscle relaxants is rapid-sequence intubation, but there areother situations where they are recommended: Intubation in elective surgery, certain types of specialsurgical procedures and situations (ARDS, electroconvulsive therapy, intra-abdominal hypertension, intracranial hypertension), and they may be avoided in many general anesthesia cases. Most important is to be aware of theirindications, risks and adequate use.

Sugammadex en un paciente con insuficiencia renal crónica / Sugammadex use in a patient with chronic renal failure

La introducción del sugammadex en la práctica clínica podría mejorar el perfil de seguridad de los relajantes neuromusculares; sin embargo, su uso en pacientes con nefropatía es cuestionable, pues, en razón del mecanismo de eliminación del fármaco, este podría ser problemático. Este artículo se basa en un caso en el cual se administró sugammadex a una paciente con nefropatía, quien presentó rápida reversión de la relajación neuromuscular sin que se observaran efectos adversos.

The introduction of sugammadex in clinical practice could improve the safety profile of muscle relaxants, however, its use in patients with renal diseases is questionable when considering its clearance mechanism, as this could generate some problems. This case report describes a patient with renal disease in whom sugammadex was administered with a quick neuromuscular block reversal without any adverse effects.

Reações de hipersensibilidade a medicamentos: parte II / Drug hypersensivity reactions: part II

As reações de hipersensibilidade a medicamentos são comuns na prática clínica. A maioria das reações ocorrem por mecanismos não-imunológicos e não existem provas diagnósticas aplicáveis a todas as situações. O diagnóstico é particularmente complexo em pacientes em uso de vários medicamentos. Na Parte II do artigo sobre Hipersensibilidade a Medicamentos os autores analisam especificamente as reações a determinados qrupos de medicamentos: analgésicos e AINE, antibióticos, anticonvulsivantes, anestésicos locais, látex no ambiente cirúrgico, relaxantes neuromusculares, contrastes radiológicos e a situação especial de pacientes sensíveis a vários grupos de fármacos. O conhecimento das características das reações e da conduta mais apropriada determinam o sucesso no diagnóstico e orientação do paciente.

Adverse drug reactions are common conditions in clinical practice. The majority of these reactions occurs through non-immunologic mechanisms and there are no available validated diagnostic methods for all the situations. Diagnosis is specially difficult in patients who are using many medications. In Part II of Drugs Hypersensitivity authors analyse reactions to specifics drugs groups, as analgesics and NSAID, antibiotics, anticonvulsivants, local anesthetics, latex on surgical environment, neuromuscular relaxants, radiologic contrasts, and the special condition of patients with multiple drugs sensitivities. The knowledge of charatcteristics of the reactions and more appropriate management determine success in diagnosis and patient's guidance.