Evaluation of prolonged magnesium infusion after allogeneic hematopoietic cell transplant.

PURPOSE: Calcineurin inhibitor use after allogeneic hematopoietic cell transplantation (allo-HCT) is associated with significant magnesium wasting. Utilization of a prolonged magnesium infusion is thought to lead to a lower serum peak concentration and therefore, decreased renal wasting of magnesium. In November 2017, our institution implemented a modification to our inpatient electrolyte replacement protocol for allo-HCT recipients that extended the magnesium infusion rate from 4 g/2 h to 4 g/4 h based on this theoretical advantage. The primary objective of this study was to compare the median magnesium requirements per day of admission between patients who received magnesium 4 g/2 h to patients who received magnesium 4 g/4 h. Secondary objectives included a comparison of the per-patient median serum magnesium concentration during admission, as well as the median incremental difference in serum magnesium concentration after intravenous replacement per patient per admission. METHODS: Allo-HCT recipients who received prolonged infusion magnesium infusions were compared to a historical cohort of allo-HCT patients who received shorter IV magnesium infusions. Admissions were included if the patient had received an allo-HCT within 100 days prior, was admitted to the Transplant and Cellular Therapy Unit at WVU Medicine J.W. Ruby Memorial Hospital, and received at least one magnesium infusion and one dose of cyclosporine or tacrolimus. Admissions were excluded if the patient received oral magnesium, total parenteral nutrition, aminoglycosides, amphotericin, carboplatin, cisplatin, or foscarnet. RESULTS: The pre-implementation group consisted of 81 admissions (n = 64 patients), while the post-implementation group consisted of 90 admissions (n = 60 patients). Median magnesium requirements per day of admission were not different between groups at 1.4 g of magnesium in the pre-implementation group and 1.9 g of magnesium in the post-implementation group (P = 0.25). Median serum magnesium concentrations and median incremental difference in serum magnesium concentration after intravenous replacement were also not different between groups: 1.65 mg/dL vs 1.60 mg/dL (P = 0.65) and 0.30 mg/dL vs 0.28 mg/dL (P = 0.67), respectively. CONCLUSIONS: Prolonged infusion of magnesium in allo-HCT recipients receiving CNI therapy does not result in improvement in magnesium retention.

Clinical Impact of Sugammadex in the Reversal of Neuromuscular Blockade.

Background A neuromuscular blockade (NMB) is used in general anesthesia to facilitate endotracheal intubation and muscle relaxation during procedural and surgical interventions. Rapid and complete reversal of the NMB allows for patient recovery to the preoperative baseline with ventilation and motor function, along with the complete return of gastroesophageal motility, thereby expediting recovery and preventing microaspiration in the postoperative period. Sugammadex is a modified gamma cyclodextrin that complexes with steroidal neuromuscular blocking agents (specifically, rocuronium and vecuronium), leading to a molecular gradient and removal of the agents from the neuromuscular junction. Sugammadex has been shown to have a more rapid reversal of neuromuscular blockade compared to neostigmine. The purpose of this study was to evaluate if perioperative efficiency was increased when sugammadex was used for paralytic reversal compared to the traditional regimen of neostigmine and glycopyrrolate. Methods A retrospective cohort study of patients admitted for surgical intervention in June 2019 was conducted. Two groups were compared: those who received sugammadex for reversal and those who received neostigmine, plus glycopyrrolate. The primary outcome was time to extubation from the administration of the reversal agent. Results Two hundred seventy-one surgical cases were evaluated. Average doses of sugammadex for those with profound neuromuscular blockade as indicated by a train of four (TOF) of 0 - 2 was 2.47 (0.9) mg/kg for sugammadex and 0.042 (0.01) mg/kg for neostigmine, plus glycopyrrolate. Seventeen patients in the sugammadex group experienced bradycardia after reversal compared to 22 in the neostigmine, plus glycopyrrolate, group (p = 0.73). Reintubation was required for three patients in the neostigmine, plus glycopyrrolate, group and no patients in the sugammadex group. The mean time to extubation from the procedure end comparing reversal with sugammadex and neostigmine, plus glycopyrrolate, was 12.5 (7.6) minutes versus 13.7 (8.8) minutes (p = 0.44), respectively. Comparison of reversal with sugammadex versus neostigmine, plus glycopyrrolate, and time spent in the post-anesthesia care unit was 83.6 (48.6) minutes versus 81.7 (46.6) (p = 0.73), respectively. Conclusions In this retrospective cohort study, we observed a deviation in the recommended sugammadex dosage and increased reintubation rates but no difference in time to extubation or Post-Anesthesia Care Unit (PACU) length of stay times when patients received sugammadex compared to neostigmine, plus glycopyrrolate, for neuromuscular blockade reversal. Understanding the PACU flow and culture, education of providers about dosages, along with completion of prospective studies, to correlate acceleromyograph values to reversal and postoperative ventilatory and deglutary function can help assess the true clinical value of sugammadex.

Crystal structure of di-µ-hydroxido-bis{[N,N'-bis-(2,6-di-methyl-phen-yl)pentane-2,4-diiminato(1-)]zinc}.

The title compound, [Zn2(C21H25N2)2(OH)2], is a binuclear zinc complex formed by two bidentate ß-diketiminate (nacnac) ligands and two µ-hydroxide O atoms, bridging two mononuclear units into a centrosymmetric dimeric unit. Each Zn(2+) cation is coordinated by two N-donor atoms from the nacnac ligand and two O-donor atoms of hydroxide anions to give a distorted tetra-hedral coordination environment. The Zn-O bond lengths are 1.9643 (13) and 2.0022 (14) Å, and the two Zn-N bond lengths are 1.9696 (14) and 1.9823 (14) Å. The distance between the two Zn(2+) cations in the dimer is 2.9420 (4) Å. Although hydroxide groups are present in the complex, no classical hydrogen-bonding inter-ations are observed because of the bulky ß-diketiminate ligands.