Reversal of rocuronium induced neuromuscular block with sugammadex or neostigmine: a large observational study.

BACKGROUND: This 'real-life' study aimed to analyze the time from the start of neostigmine or sugammadex administration to recovery to a train of four ratio (TOFr) of 0.9 in a real-life in patients receiving rocuronium. The secondary aims were to assess the proportion of patients: presenting TOFr < 0.9 after 5, 10, and 20 min from reversal agent administration, receiving opioids for intraoperative analgesia and extubated in the post-anesthesia care unit (PACU). METHODS: This was a multisite, prospective, nonrandomized, observational real-life study. Reversal agent was administered at either T2 reappearance or at a post-tetanic count of 1 or 2. Drugs dosages were free according to each investigator's usual practice. RESULTS: Three hundred fifty-nine patients were enrolled onto the study. Time from reversal administration to TOFr to 0.9 is significantly faster in the sugammadex group than in the neostigmine group (shallow block: 2.2 vs. 6.9 min, respectively; P < 0.0001; deep block: 2.7 vs. 16.2 min, respectively; P < 0.0001). The number of patients with TOFr < 0.9 at 5, 10, and 20 min post-reversal agent administration was higher in the neostigmine than in the sugammadex group. Just five patients did not receive opioids. All patients were extubated in the operative room except for a single patient in the sugammadex group who was extubated following PACU admission. CONCLUSIONS: This real-life study confirms that reversal time is faster in patients receiving sugammadex than in those receiving neostigmine. TOFr < 0.9 20 min after reversal was only present in patients treated with neostigmine.

Hyperlipidemic acute pancreatitis: a possible role of antiretroviral therapy with entecavir.

In most cases clinical profile of acute hyperlipidemic pancreatitis is a preexisting lipoprotein abnormality associated to second risk factors such as alcohol abuse, diabetes mellitus or medications that can induce hypertrygliceridemia. We report a case of a young male affected by chronic hepatitis B virus infection admitted to Emergency Department due to acute abdominal pain, vomiting and fever. The patient was in antiretroviral treatment with entecavir; moreover he was affected by diabetes mellitus and he presented a past history of alcohol abuse. Laboratory tests demonstrated hyperglycemia, severe metabolic acidosis and hypertriglyceridemia, whereas abdominal computed tomography scan revealed peripancreatic edema: hyperlipidemic pancreatitits was supposed and the patient was admitted to the intensive care unit. Considering its possible role in the pathogenesis of pancreatitis, entecavir was interrupted and total of 3 sections of plasmapheresis were performed, allowing clinical resolution and prevention of pancreatic damage. The possible pathogenetic role of entecavir is discussed.

Propriospinal myoclonus following intrathecal bupivacaine in hip surgery: a case report.

Propriospinal myoclonus is a rare disorder characterized by sudden, shock-like, involuntary jerks that arise from the axial muscles and spread both rostrally and caudally to other myotomes through slow polysynaptic pathways. It can be idiopathic or secondary to intrinsic and extrinsic spinal cord lesions; additionally, it can develop as an adverse effect to the administration of several drugs, including neuraxial local anesthetics. This article describes a case of transient propriospinal myoclonus in a 77-year-old woman undergoing surgery for hip replacement who received 12 mg of 0.5% normobaric bupivacaine administered by a 25-G spinal needle. On postoperative day 1, the patient presented with spinal myoclonus, defined by clinical and electrophysiologic studies. Valproate and clonazepam controlled the symptoms, and on day 4 the myoclonus completely disappeared. Few cases of myoclonus induced by intrathecal bupivacaine administration have been reported in the literature, but systematic reviews written to clarify the global incidence and the physiopathology of this complication are still lacking.

Efficacy and safety of quinine-artesunate in an HIV-positive patient with severe falciparum malaria.

Severe falciparum malaria is a medical emergency that is associated with a high rate of mortality, even when treated in an Intensive Care Unit. Until recently, intravenous quinine was the standard treatment; however, artemisin derivatives are now regarded as the first-line treatment for multidrug-resistant falciparum malaria. Although several studies have demonstrated the superiority of Artesunate, this drug is not licensed in many countries. This article describes the case of an HIV-positive patient, who returned from Africa and presented with 10% parasitemia and clinical signs of severe falciparum malaria; this individual was successfully treated with a combination of artesunate and quinine. Artesunate was imported from the foreign market, and written consent for its administration was obtained in advance. Parasite clearance was rapidly achieved; however, on day IV, the patient developed acute respiratory distress syndrome that required mechanical ventilation. The patient was extubated on day XIV and discharged on day XXV. Due to its rapid action, artesunate was likely responsible for the good clinical outcome in this case; however, in order to clarify the role of this new combination therapy, further studies are required.