1
|
Schutzer-Weissmann J, Wojcikiewicz T, Karmali A, Lukosiute A, Sun R, Kanji R, Ahmed AR, Purkayastha S, Brett SJ, Cousins J. Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery. Br J Anaesth 2023; 130:103-110. [PMID: 35027169 PMCID: PMC9875910 DOI: 10.1016/j.bja.2021.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/26/2021] [Accepted: 12/08/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Obesity is a risk factor for airway-related incidents during anaesthesia. High-flow nasal oxygen has been advocated to improve safety in high-risk groups, but its effectiveness in the obese population is uncertain. This study compared the effect of high-flow nasal oxygen and low-flow facemask oxygen delivery on duration of apnoea in morbidly obese patients. METHODS Morbidly obese patients undergoing bariatric surgery were randomly allocated to receive either high-flow nasal (70 L min-1) or facemask (15 L min-1) oxygen. After induction of anaesthesia, the patients were apnoeic for 18 min or until peripheral oxygen saturation decreased to 92%. RESULTS Eighty patients were studied (41 High-Flow Nasal Oxygen, 39 Facemask). The median apnoea time was 18 min in both the High-Flow Nasal Oxygen (IQR 18-18 min) and the Facemask (inter-quartile range [IQR], 4.1-18 min) groups. Five patients in the High-Flow Nasal Oxygen group and 14 patients in the Facemask group desaturated to 92% within 18 min. The risk of desaturation was significantly lower in the High-Flow Nasal Oxygen group (hazard ratio=0.27; 95% confidence interval [CI], 0.11-0.65; P=0.007). CONCLUSIONS In experienced hands, apnoeic oxygenation is possible in morbidly obese patients, and oxygen desaturation did not occur for 18 min in the majority of patients, whether oxygen delivery was high-flow nasal or low-flow facemask. High-flow nasal oxygen may reduce desaturation risk compared with facemask oxygen. Desaturation risk is a more clinically relevant outcome than duration of apnoea. Individual physiological factors are likely to be the primary determinant of risk rather than method of oxygen delivery. CLINICAL TRIAL REGISTRATION NCT03428256.
Collapse
Affiliation(s)
- John Schutzer-Weissmann
- Imperial College Healthcare NHS Trust, London, UK,The Royal Marsden Hospital NHS Foundation Trust, London, UK,Corresponding author.
| | - Thomas Wojcikiewicz
- Imperial College Healthcare NHS Trust, London, UK,Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Anil Karmali
- Imperial College Healthcare NHS Trust, London, UK,London North West University Healthcare NHS Trust, Harrow, UK
| | - Asta Lukosiute
- Imperial College Healthcare NHS Trust, London, UK,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ruoyi Sun
- Imperial College Healthcare NHS Trust, London, UK
| | - Rafiq Kanji
- Imperial College Healthcare NHS Trust, London, UK,Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ahmed R. Ahmed
- Imperial College Healthcare NHS Trust, London, UK,Department of Surgery and Cancer, Imperial College London, UK
| | - Sanjay Purkayastha
- Imperial College Healthcare NHS Trust, London, UK,Department of Surgery and Cancer, Imperial College London, UK
| | - Stephen J. Brett
- Imperial College Healthcare NHS Trust, London, UK,Department of Surgery and Cancer, Imperial College London, UK
| | | |
Collapse
|
2
|
Yamadori Y, Yamagami Y, Matsumoto Y, Koizumi M, Nakamura A, Mizuta D, Yasuda K, Shirakami G. General anesthesia with remimazolam for a pediatric patient with MELAS and recurrent epilepsy: a case report. JA Clin Rep 2022; 8:75. [PMID: 36112237 PMCID: PMC9481841 DOI: 10.1186/s40981-022-00564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a mitochondrial disease. We report here the safe use of remimazolam in a pediatric MELAS patient. Case presentation A 10-year-old girl (118 cm, 16 kg) was scheduled for an open gastrostomy to improve nutrition and epileptic seizure control. We induced and maintained general anesthesia with remimazolam, remifentanil, fentanyl, and rocuronium. We also performed a bilateral subcostal transversus abdominis plane block before the surgery. The surgery finished uneventfully. After we discontinued remimazolam administration, the patient woke up immediately but calmly without flumazenil. Epileptic seizures did not occur during intra- and early post-operative periods. Conclusion Remimazolam enabled us to provide a pediatric MELAS patient with general anesthesia without causing delayed emergence or epileptic seizures.
Collapse
|
3
|
Vested M, Pape P, Kristensen CM, Dinesen F, Vang M, Christensen RE, Bjerring Lindahl C, Albrechtsen C, Rasmussen LS. Rocuronium 0.3 mg/kg or 0.9 mg/kg comparing onset time, duration of action and intubating conditions in patients 80 years and older. A randomized study. Acta Anaesthesiol Scand 2022; 66:811-817. [PMID: 35675032 PMCID: PMC9544287 DOI: 10.1111/aas.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/11/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited data exist about the optimal dose of rocuronium for intubation in elderly patients. We hypothesized that rocuronium 0.9 mg kg-1 would lead to a shorter onset time than 0.3 mg kg-1 in patients above 80 years. METHODS Thirty-four patients were randomized to either rocuronium 0.3 mg kg-1 or 0.9 mg kg-1 . The primary outcome was onset time defined as time to train-of-four (TOF) count of 0. Other outcomes included duration of action (time to TOF ratio > 0.9), proportion of excellent intubating conditions using the Fuchs-Buder scale and tracheal intubating conditions using the Intubating Difficulty Scale (IDS). RESULTS Rocuronium 0.9 mg kg-1 resulted in shorter onset time compared to rocuronium 0.3 mg kg-1 ; 108 sec (SD 40) vs. 228 sec (SD 140) (difference: 119 seconds (95% CI: 41-196), P=0.005)), respectively. However, in 66% of the patients receiving rocuronium 0.3 mg kg-1 a TOF count of 0 was not obtained. Duration of action was longer after rocuronium 0.9 mg kg-1 : 118 minutes (SD 43) vs. 46 minutes (SD 13) (difference: 72 minutes (95% CI: 49-95) P<0.0001)), and a greater proportion of excellent intubating conditions (Fuchs-Buder) was obtained; 11/16 (69%) vs 4/18 (22%) (P=0.006). No difference was found regarding IDS score. CONCLUSION Rocuronium 0.9 mg kg-1 resulted in a shorter onset time compared to rocuronium 0.3 mg kg-1 in patients above 80 years of age. In 66% of the patients receiving rocuronium 0.3 mg kg-1 a TOF count of 0 was not obtained.
Collapse
Affiliation(s)
- Matias Vested
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Pernille Pape
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Camilla Meno Kristensen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Felicia Dinesen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Malene Vang
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | | | - Cecilie Bjerring Lindahl
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Charlotte Albrechtsen
- Department of Anaesthesia, Juliane Marie Centret, Rigshospitalet, University of Copenhagen
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen.,Department of Clinical Medicine, University of Copenhagen
| |
Collapse
|
4
|
Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study. J Clin Anesth 2022; 78:110673. [DOI: 10.1016/j.jclinane.2022.110673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
|
5
|
Comparison between the trapezius and adductor pollicis muscles as an acceleromyography monitoring site for moderate neuromuscular blockade during lumbar surgery. Sci Rep 2021; 11:14568. [PMID: 34267301 PMCID: PMC8282790 DOI: 10.1038/s41598-021-94062-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/06/2021] [Indexed: 11/08/2022] Open
Abstract
Acceleromyography at the adductor pollicis located in a distal part of the body may not reflect the degree of neuromuscular blockade (NMB) at the proximally located muscles manipulated during lumbar surgery. We investigated the usefulness and characteristics of acceleromyographic monitoring at the trapezius for providing moderate NMB during lumbar surgery. Fifty patients were randomized to maintain a train-of-four count 1–3 using acceleromyography at the adductor pollicis (group A; n = 25) or the trapezius (group T; n = 25). Total rocuronium dose administered intraoperatively [mean ± SD, 106.4 ± 31.3 vs. 74.1 ± 17.6 mg; P < 0.001] and surgical satisfaction (median [IQR], 7 [5–8] vs. 5 [4–5]; P < 0.001) were significantly higher in group T than group A. Lumbar retractor pressure (88.9 ± 12.0 vs. 98.0 ± 7.8 mmHg; P = 0.003) and lumbar muscle tone in group T were significantly lower than group A. Time to maximum block with an intubating dose was significantly shorter in group T than group A (44 [37–54] vs. 60 [55–65] sec; P < 0.001). Other outcomes were comparable. Acceleromyography at the trapezius muscle during lumbar surgery required a higher rocuronium dose for moderate NMB than the adductor pollicis muscle, thereby the consequent deeper NMB provided better surgical conditions. Trapezius as proximal muscle may better reflect surgical conditions of spine muscle.
Collapse
|
6
|
High-dose rocuronium-induced paralysis of the adductor pollicis muscle facilitates detection of the timing for tracheal intubation in elderly patients: a randomized double-blind study. J Anesth 2020; 34:876-880. [PMID: 32705417 PMCID: PMC7377532 DOI: 10.1007/s00540-020-02831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/18/2020] [Indexed: 10/31/2022]
Abstract
Purpose Methods Results Conclusions
Collapse
|
7
|
Meijer FS, Niesters M, van Velzen M, Martini CH, Olofsen E, Edry R, Sessler DI, van Dorp ELA, Dahan A, Boon M. Does nociception monitor-guided anesthesia affect opioid consumption? A systematic review of randomized controlled trials. J Clin Monit Comput 2020; 34:629-641. [PMID: 31327102 PMCID: PMC7367908 DOI: 10.1007/s10877-019-00362-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/16/2019] [Indexed: 12/23/2022]
Abstract
Monitors that estimate nociception during anesthesia may be used to guide opioid and other analgesics administration to optimize anesthesia care and possibly outcome. We reviewed the literature to evaluate current evidence of the effect of nociception-guided management over standard anesthesia practice during surgery. A systematic review of the literature on the effect of nociception monitoring on anesthesia practice was conducted. Reports were eligible if they compared nociception-guided anesthesia to standard practice during surgery. Primary endpoint of this review is intraoperative opioid consumption. Secondary endpoints included hemodynamic control, postoperative pain and pain treatment. We identified 12 randomized controlled trials that compared one of five different nociception monitoring techniques to standard anesthesia care. Most studies were single center studies of small sample size. Six studies reported intraoperative opioid consumption as primary outcome. There was considerable variability with respect to surgical procedure and anesthesia technique. For nociception monitors that were investigated by more than one study, analysis of the pooled data was performed. The surgical plethysmographic index was the only monitor for which an intra operative opioid sparing effect was found. For the other monitors, either no effect was detected, or pooled analysis could not be performed due to paucity of study data. On secondary outcomes, no consistent effect of nociception-guided anesthesia could be established. Although some nociception monitors show promising results, no definitive conclusions regarding the effect of nociception monitoring on intraoperative opioid consumption or other anesthesia related outcome can be drawn.Clinical trial number PROSPERO ID 102913.
Collapse
Affiliation(s)
- Fleur S. Meijer
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Chris H. Martini
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Ruth Edry
- Department of Anesthesiology, Rambam Medical Centre, The Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH USA
| | - Eveline L. A. van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| | - Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2 (Postal Zone H5-Q), 2333 ZA Leiden, The Netherlands
| |
Collapse
|
8
|
Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair. Eur J Anaesthesiol 2018; 35:876-882. [DOI: 10.1097/eja.0000000000000833] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
9
|
Fujimoto M, Kawano K, Yamamoto T. The adequate rocuronium dose required for complete block of the adductor muscles of the thigh. Acta Anaesthesiol Scand 2018; 62:304-311. [PMID: 29178460 DOI: 10.1111/aas.13045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/13/2017] [Accepted: 11/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rocuronium can prevent the obturator jerk during transurethral resection of bladder tumors. We investigated the adequate rocuronium dose required for complete block of the thigh adductor muscles, and its correlation with individual responses of the adductor pollicis muscle to rocuronium. METHODS Eleven patients scheduled for transurethral resection of bladder tumors under general anesthesia were investigated. After general anesthesia induction, neuromuscular monitoring of the adductor pollicis muscle and ultrasonography-guided stimulation of the obturator nerve was commenced. Rocuronium, 0.15 mg/kg, was repeatedly administered intravenously. The adequate rocuronium dose required for complete block of the thigh muscles, defined as the cumulative dose of rocuronium administered until that time, and its correlation with the first twitch response of the adductor pollicis muscle on train-of-four stimulation after initial rocuronium administration was analyzed. RESULTS The rocuronium dose found adequate for complete block of the thigh muscles was 0.30 mg/kg in seven patients and 0.45 mg/kg in the remaining four patients, which did not correlate with the first twitch response. At the time of complete block of the thigh muscles, the neuromuscular blockade level of the adductor pollicis muscle varied greatly, although the level was never more profound than a post-tetanic count of 1. CONCLUSION Although the response of the adductor pollicis muscle to rocuronium cannot be used to determine the adequate rocuronium dose required for complete block of the thigh muscles, intense blockade, with maintenance of post-tetanic count at ≤ 1 in the adductor pollicis muscle is essential to prevent the obturator jerk.
Collapse
Affiliation(s)
- M. Fujimoto
- Department of Anesthesiology; Graduate School of Medical Sciences; Kumamoto University; Kumamoto Japan
| | - K. Kawano
- Department of Anesthesiology; Graduate School of Medical Sciences; Kumamoto University; Kumamoto Japan
| | - T. Yamamoto
- Department of Anesthesiology; Graduate School of Medical Sciences; Kumamoto University; Kumamoto Japan
| |
Collapse
|
10
|
Kim YB, Sung TY, Yang HS. Factors that affect the onset of action of non-depolarizing neuromuscular blocking agents. Korean J Anesthesiol 2017; 70:500-510. [PMID: 29046769 PMCID: PMC5645582 DOI: 10.4097/kjae.2017.70.5.500] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/02/2017] [Indexed: 12/14/2022] Open
Abstract
Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.
Collapse
Affiliation(s)
- Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
11
|
Madsen M, Scheppan S, Mørk E, Kissmeyer P, Rosenberg J, Gätke M. Influence of deep neuromuscular block on the surgeonś assessment of surgical conditions during laparotomy: a randomized controlled double blinded trial with rocuronium and sugammadex. Br J Anaesth 2017; 119:435-442. [DOI: 10.1093/bja/aex241] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 01/31/2023] Open
|
12
|
Soltesz S, Stark C, Noé KG, Anapolski M, Mencke T. Comparison of the trapezius and the adductor pollicis muscle as predictor of good intubating conditions: a randomized controlled trial. BMC Anesthesiol 2017; 17:106. [PMID: 28818054 PMCID: PMC5561588 DOI: 10.1186/s12871-017-0401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 08/14/2017] [Indexed: 11/11/2022] Open
Abstract
Background Adequate muscle relaxation is important for ensuring optimal conditions for intubation. Although acceleromyography of the adductor pollicis muscle is commonly used to assess conditions for intubation, we hypothesized that acceleromyography of the trapezius is more indicative of optimal intubating conditions. The primary outcome was the difference between both measurement sites with regard to prediction of good or acceptable intubating conditions. Methods Neuromuscular blockade after injection of rocuronium 0.3 mg/kg IV was measured simultaneously with acceleromyography of the adductor pollicis muscle and the trapezius muscle in sixty female patients, American Society of Anesthesiologists physical status I to III, undergoing general anesthesia for gynecologic surgery. Exclusion criteria were: expected difficult tracheal intubation (e.g. history of difficult intubation, reduced mouth opening (< 2 cm) and/or Mallampati Score 4), increased risk of pulmonary aspiration (e.g. gastroesophageal reflux or delayed gastric emptying) allergies to drugs used during the study, pregnancy, neuromuscular diseases, medication with potential to influence neuromuscular function (e.g. furosemide, magnesium, cephalosporins) and hepatic or renal insufficiency (serum bilirubin >26 μmol/L, serum creatinine >90 μmol/l). Patients were randomized to 2 groups: group A (n = 30): endotracheal intubation after onset of the neuromuscular block at the adductor pollicis muscle. Group B (n = 30): endotracheal intubation after onset at the trapezius muscle. Intubating conditions were compared between both groups by means of a standardised score (the Copenhagen score) with Fisher’s exact test. Results Onset of the block after rocuronium injection was observed at the adductor pollicis muscle compared to the trapezius with 2.8 (1.1) versus 2.5 (1.1) min (mean ± SD; P = 0.006). Intubating conditions were poor in 2 patients (7%) of group A, and in 1 patient (3%) of group T. They were acceptable (either excellent or good) in 28 patients (93%) in group A, and in 1 patient (97%) in group T (P = 0.82). Conclusions Performing acceleromyography at the trapezius muscle reduced the time between injection of neuromuscular blocking agents and intubation by 18 s (11%). Thus, trapezius muscle acceleromyography is an acceptable alternative to adductor pollicis muscle acceleromyography in predicting acceptable intubating conditions, which allows for earlier indication of adequate intubating conditions. Trial registration ClinicalTrial.gov Identifier: NCT01849198. Registered April 29, 2013.
Collapse
Affiliation(s)
- Stefan Soltesz
- Department of Anesthesia and Intensive Care Medicine, KKH Dormagen, Dormagen, Germany. .,Klinik für Anästhesie, Intensiv- und Notfallmedizin, Kreiskrankenhaus Dormagen, D-41540, Dormagen, Germany.
| | - Christian Stark
- Department of Anesthesia and Intensive Care Medicine, KKH Dormagen, Dormagen, Germany
| | - Karl G Noé
- Department Ob/Gyn, University of Witten-Herdecke, KKH Dormagen, Dormagen, Germany
| | - Michael Anapolski
- Department Ob/Gyn, University of Witten-Herdecke, KKH Dormagen, Dormagen, Germany
| | - Thomas Mencke
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Rostock, Germany
| |
Collapse
|
13
|
Anandan K, Suseela I, Purayil HV. Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium. Anesth Essays Res 2017; 11:421-425. [PMID: 28663634 PMCID: PMC5490136 DOI: 10.4103/0259-1162.194582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO4 pretreatment is good options. Aims: To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. Settings and Design: A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. Materials and Methods: After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18–60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40–70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Statistical Analysis Used: Chi-square test and independent t-test were done with PASW statistics 18 to analyze data. Results: The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s (P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups (P = 0.791). Hemodynamic parameters were comparable between groups at all time frames (P > 0.05). Conclusion: Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation.
Collapse
Affiliation(s)
- Krishnadas Anandan
- Department of Anesthesia, Government Medical College, Kozhikode, Kerala, India
| | - Indu Suseela
- Department of Anesthesia, Government Medical College, Kozhikode, Kerala, India
| | - Harish Valiya Purayil
- Department of Anesthesia, Vythiri Thaluk Headquarters Hospital, Wayanad, Kerala, India
| |
Collapse
|
14
|
Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: A randomised controlled trial. Eur J Anaesthesiol 2017; 33:341-7. [PMID: 26479510 DOI: 10.1097/eja.0000000000000360] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg). OBJECTIVE The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy. DESIGN A randomised, controlled, double-blinded study. SETTING Private hospital in Denmark. PARTICIPANTS Ninety-nine patients. INTERVENTIONS Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days. MAIN OUTCOME MEASURES The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery. RESULTS Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores. CONCLUSION Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg). TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01722097.
Collapse
|
15
|
Do we really need sugammadex as an antagonist of muscle relaxants in anesthesia? Curr Opin Anaesthesiol 2016; 29:462-7. [DOI: 10.1097/aco.0000000000000359] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
16
|
Vega EA, Ibacache ME, Anderson BJ, Holford NHG, Nazar CE, Solari S, Allende FA, Cortínez LI. Rocuronium pharmacokinetics and pharmacodynamics in the adductor pollicis and masseter muscles. Acta Anaesthesiol Scand 2016; 60:734-46. [PMID: 26899676 DOI: 10.1111/aas.12703] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to characterize the dose-effect relationship of rocuronium at the adductor pollicis and masseter muscles. METHODS Ten, ASA I, adult patients, received a bolus dose of rocuronium 0.3 mg/kg during propofol based anesthesia. Train-of-four (TOF) was simultaneously monitored at the masseter and the adductor pollicis muscles until recovery. Rocuronium arterial serum concentrations were measured during 120 min. The first twitch of the TOF response was used to characterize the time-effect profile of both muscles using pharmacokinetic-pharmacodynamic analysis in NONMEM. A decrease in NONMEM objective function (∆OFV) of 3.84 points for an added parameter was considered significant at the 0.05 level. RESULTS Onset time at the masseter (mean ± SD, 1.5 ± 0.9 min) was faster than at the adductor pollicis (2.7 ± 1.4 min, P < 0.05). Recovery, measured as the time to TOF ratio = 0.9 was similar between muscles 29.9 ± 6.7 (adductor pollicis) vs. 29.3 ± 8.1 (masseter). (P = 0.77). The estimated pharmacodynamic parameters [mean (95% CI)] of the adductor pollicis muscle and the masseter muscle were; plasma effect-site equilibration half-time (teq) 3.25 (2.34, 3.69) min vs. 2.86 (1.83, 3.29) min, (∆OFV 383.665); Ce50 of 1.24 (1.13, 1.56) mg/l vs. 1.19 (1.00, 1.21) mg/l, (∆OFV 184.284); Hill coefficient of 3.97 (3.82, 5.62) vs. 4.68 (3.83, 5.71), (∆OFV 78.906). CONCLUSIONS We found that the masseter muscle has faster onset of blockade and similar recovery profile than adductor pollicis muscle. These findings were best, explained by a faster plasma effect-site equilibration of the masseter muscle to rocuronium.
Collapse
Affiliation(s)
- E. A. Vega
- Departamento de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Marcoleta 367, PO Box: 114-D, Santiago Chile
| | - M. E. Ibacache
- Departamento de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Marcoleta 367, PO Box: 114-D, Santiago Chile
| | - B. J. Anderson
- Department of Anaesthesiology; University of Auckland; Auckland New Zealand
| | - N. H. G. Holford
- Department of Pharmacology & Clinical Pharmacology; University of Auckland; Auckland New Zealand
| | - C. E. Nazar
- Departamento de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Marcoleta 367, PO Box: 114-D, Santiago Chile
| | - S. Solari
- Laboratorio Clínico; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - F. A. Allende
- Laboratorio Clínico; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - L. I. Cortínez
- Departamento de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Marcoleta 367, PO Box: 114-D, Santiago Chile
| |
Collapse
|
17
|
Rosenberg J, Fuchs-Buder T. Why surgeons need to know about anaesthesia. Surg Endosc 2016; 30:3661-4. [DOI: 10.1007/s00464-016-5075-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 06/22/2016] [Indexed: 12/31/2022]
|
18
|
Soltesz S, Stark C, Noé KG, Anapolski M, Mencke T. Monitoring recovery from rocuronium-induced neuromuscular block using acceleromyography at the trapezius versus the adductor pollicis muscle: an observational trial. Can J Anaesth 2016; 63:709-17. [PMID: 26864194 DOI: 10.1007/s12630-016-0609-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 01/14/2016] [Accepted: 02/02/2016] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Positioning for surgery can restrict access to the patient's hand, thereby limiting assessment of the response at the adductor pollicis muscle to ulnar nerve stimulation. We evaluated a novel site to assess neuromuscular block by stimulating the accessory nerve and measuring the acceleromyographic response at the trapezius muscle. METHODS In this prospective non-blinded observational study, we assessed neuromuscular transmission in anesthetized adult female patients undergoing elective laparoscopic gynecological surgery. We performed the assessment by simultaneous recording acceleromyographic responses with the TOF-Watch(®) SX monitor at both the right adductor pollicis and left trapezius muscles. The neuromuscular block was achieved using rocuronium 0.3 mg·kg(-1), and the repeatability, time course, and limits of agreement (Bland-Altman) of responses were compared at the two recording sites. The primary endpoint was the 90% train-of-four (TOF) recovery time with other endpoints included the onset time of the block, maximum T1 depression, time to 25% T1 recovery, and recovery time course of the T1 response and TOF ratio. RESULTS Thirty-six patients were enrolled with responses obtained from 27 subjects. The variability of baseline responses recorded at the trapezius muscle was larger than that recorded at the adductor pollicis muscle, as determined by their mean (SD) repeatability coefficients [twitch height T1, 6.1 (1.9)% and 4.2 (1.6)%, respectively; P = 0.001; TOF ratio, 6.2 (2.1)% and 4.3 (1.7)%, respectively; P = 0.001]. The recorded responses showed relatively narrow limits of agreement. The onset time of the block was 0.3 min earlier at the trapezius muscle than at the adductor pollicis muscle [2.3 (0.8) min and 2.6 (0.7) min, respectively; P = 0.007], with limits of agreement ranging from 1.6 min earlier to 1.0 min later. The time to 25% T1 recovery was 1.8 min earlier at the trapezius muscle than at the adductor pollicis muscle [18.2 (5.7) min and 20.0 (5.2) min, respectively; P = 0.039], with limits of agreement ranging from 11.1 min earlier to 7.5 min later. Additionally, the time to achieve 90% TOF ratio was 4.4 min earlier at the trapezius muscle than at the adductor pollicis muscle [32.6 (7.9) min and 37 (9.1) min, respectively; P = 0.004], with limits of agreement ranging from 18.4 min earlier to 9.7 min later. CONCLUSIONS We conclude that recording evoked acceleromyographic responses at the trapezius muscle is an acceptable alternative when monitoring from the adductor pollicis muscle is compromised. Nevertheless, we caution that recording a 90% TOF response at the trapezius muscle may overestimate functional recovery from the neuromuscular blockade. This trial was registered at ClinicalTrials.gov identifier, NCT01849198.
Collapse
Affiliation(s)
- Stefan Soltesz
- Department of Anesthesia and Intensive Care Medicine, KKH Dormagen, 41540, Dormagen, Germany.
| | - Christian Stark
- Department of Anesthesia and Intensive Care Medicine, KKH Dormagen, 41540, Dormagen, Germany
| | - Karl G Noé
- Department of Obstetrics and Gynecology, University of Witten-Herdecke, KKH Dormagen, Dormagen, Germany
| | | | - Thomas Mencke
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Rostock, Germany
| |
Collapse
|
19
|
|
20
|
Baumüller E, Schaller S, Chiquito Lama Y, Frick C, Bauhofer T, Eikermann M, Fink H, Blobner M. Postoperative impairment of motor function at train-of-four ratio ≥0.9 cannot be improved by sugammadex (1 mg kg −1 ). Br J Anaesth 2015; 114:785-93. [DOI: 10.1093/bja/aeu453] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 12/17/2022] Open
|
21
|
MADSEN MV, GÄTKE MR, SPRINGBORG HH, ROSENBERG J, LUND J, ISTRE O. Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy--a randomised, blinded crossover study. Acta Anaesthesiol Scand 2015; 59:441-7. [PMID: 25789421 DOI: 10.1111/aas.12493] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/14/2015] [Accepted: 01/17/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy. METHODS Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex. RESULTS At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07-0.59) (P=0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06-0.54) (P=0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P=0.03, Mann-Whitney U-test). CONCLUSION Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.
Collapse
Affiliation(s)
- M. V. MADSEN
- Department of Anaesthesiology; Herlev Hospital; University of Copenhagen; Herlev Denmark
| | - M. R. GÄTKE
- Department of Anaesthesiology; Herlev Hospital; University of Copenhagen; Herlev Denmark
| | - H. H. SPRINGBORG
- Department of Anaesthesiology and Center for Minimal Invasive Gynaecology; Aleris-Hamlet Hospital Copenhagen; Søborg Denmark
| | - J. ROSENBERG
- Department of Surgery; Herlev Hospital; University of Copenhagen; Herlev Denmark
| | - J. LUND
- Department of Anaesthesiology and Center for Minimal Invasive Gynaecology; Aleris-Hamlet Hospital Copenhagen; Søborg Denmark
| | - O. ISTRE
- Department of Anaesthesiology and Center for Minimal Invasive Gynaecology; Aleris-Hamlet Hospital Copenhagen; Søborg Denmark
| |
Collapse
|
22
|
Farhan H, Moreno-Duarte I, McLean D, Eikermann M. Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery? CURRENT ANESTHESIOLOGY REPORTS 2014; 4:290-302. [PMID: 25530723 PMCID: PMC4267566 DOI: 10.1007/s40140-014-0073-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neuromuscular blocking agents are used to facilitate tracheal intubation in patients undergoing ambulatory surgery. The use of high-dose neuromuscular blocking agents to achieve muscle paralysis throughout the case carries an increased risk of residual post-operative neuromuscular blockade, which is associated with increased respiratory morbidity. Visually monitoring the train-of-four (TOF) fade is not sensitive enough to detect a TOF fade between 0.4 and 0.9. A ratio <0.9 indicates inadequate recovery. Quantitative neuromuscular transmission monitoring (e.g., acceleromyography) should be used to exclude residual neuromuscular blockade at the end of the case. Residual neuromuscular blockade needs to be reversed with neostigmine, but it's use must be guided by TOF monitoring results since deep block cannot be reversed, and neostigmine administration after complete recovery of the TOF-ratio can induce muscle weakness. The development and use of new selectively binding reversal agents (sugammadex and calabadion) warrants reevaluation of this area of clinical practice.
Collapse
Affiliation(s)
- Hassan Farhan
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Ingrid Moreno-Duarte
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Duncan McLean
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55, Fruit Street, Boston, MA 02115, USA
- Universitaet Duisburg-Essen, Essen, Germany
| |
Collapse
|
23
|
Huang L, Yang M, Chen L, Li S. Resistance to rocuronium of rat diaphragm as compared with limb muscles. J Surg Res 2014; 192:471-9. [DOI: 10.1016/j.jss.2014.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 06/03/2014] [Accepted: 07/09/2014] [Indexed: 10/25/2022]
|
24
|
Chen D, Yang MR, Huang LN, Qiu YW, Li ST. Dexamethasone‑induced hyposensitivity to rocuronium in rat diaphragm associated with muscle‑fiber transformation. Mol Med Rep 2013; 9:527-34. [PMID: 24271055 DOI: 10.3892/mmr.2013.1819] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 11/13/2013] [Indexed: 11/06/2022] Open
Abstract
The aim of the current study was to investigate the effect of chronic dexamethasone (Dex) administration on rat diaphragm function and sensitivity to rocuronium and muscle‑fiber transformation. Adult male Sprague‑Dawley rats were randomized to receive a daily intraperitoneal injection of Dex to evaluate whether alterations in diaphragm function and susceptibility to rocuronium would be induced. In addition, diaphragm contractile properties, histopathology and isometric twitch tensions of nerve‑hemidiaphragm preparations were evaluated. Dex administration led to impaired diaphragm force generation, increased fatigue resistance and a prolonged half‑relaxation time, as well as time‑to‑peak tension. Dex treatment led to desensitization of the rat diaphragm to rocuronium, as demonstrated by a shift of the rocuronium concentration‑twitch tension curves to the right. Histochemical analysis of adenosine triphosphatase revealed that the distribution and cross‑sectional area of type II fibers were decreased in rats exposed to Dex. The present study indicates that chronic Dex treatment induced alterations in muscle function and that susceptibility to rocuronium is associated with muscle fiber‑type transformation, which may aid in directing future administration of muscle relaxants.
Collapse
Affiliation(s)
- Dan Chen
- Department of Anesthesiology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200030, P.R. China
| | - Mei-Rong Yang
- Department of Anesthesiology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200030, P.R. China
| | - Li-Na Huang
- Department of Anesthesiology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200030, P.R. China
| | - Yu-Wei Qiu
- Department of Anesthesiology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200030, P.R. China
| | - Shi-Tong Li
- Department of Anesthesiology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200030, P.R. China
| |
Collapse
|
25
|
Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2013; 112:498-505. [PMID: 24240315 DOI: 10.1093/bja/aet377] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The routine use of neuromuscular blocking agents reduces the occurrence of unacceptable surgical conditions. In some surgeries, such as retroperitoneal laparoscopies, deep neuromuscular block (NMB) may further improve surgical conditions compared with moderate NMB. In this study, the effect of deep NMB on surgical conditions was assessed. METHODS Twenty-four patients undergoing elective laparoscopic surgery for prostatectomy or nephrectomy were randomized to receive moderate NMB (train-of-four 1-2) using the combination of atracurium/mivacurium, or deep NMB (post-tetanic count 1-2) using high-dose rocuronium. After surgery, NMB was antagonized with neostigmine (moderate NMB), or sugammadex (deep NMB). During all surgeries, one surgeon scored the quality of surgical conditions using a five-point surgical rating scale (SRS) ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Video images were obtained and 12 anaesthetists rated a random selection of images. RESULTS Mean (standard deviation) SRS was 4.0 (0.4) during moderate and 4.7 (0.4) during deep NMB (P<0.001). Moderate block resulted in 18% of scores at the low end of the scale (Scores 1-3); deep block resulted in 99% of scores at the high end of the scale (Scores 4 and 5). Cardiorespiratory conditions were similar during and after surgery in both groups. Between anaesthetists and surgeon, there was poor agreement between scores of individual images (average κ statistic 0.05). CONCLUSIONS Application of the five-point SRS showed that deep NMB results in an improved quality of surgical conditions compared with moderate block in retroperitoneal laparoscopies, without compromise to the patients' peri- and postoperative cardiorespiratory conditions. Trial registration The study was registered at clinicaltrials.gov under number NCT01361149.
Collapse
|
26
|
Brull SJ, Kopman AF, Naguib M. Management Principles to Reduce the Risk of Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0014-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
27
|
Warr J, Thiboutot Z, Rose L, Mehta S, Burry LD. Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults. Ann Pharmacother 2011; 45:1116-26. [PMID: 21828347 DOI: 10.1345/aph.1q004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To summarize literature describing use of neuromuscular blocking agents (NMBAs) for common critical care indications and provide a review of NMBA pharmacology, pharmacokinetics, dosing, drug interactions, monitoring, complications, and reversal. DATA SOURCES Searches of MEDLINE (1975-May 2011), EMBASE (1980-May 2011), and Cumulative Index to Nursing and Allied Health Literature (1981-May 2011) were conducted to identify observational and interventional studies evaluating the efficacy or safety of NMBAs for management of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), status asthmaticus, elevated intracranial pressure (ICP), and therapeutic hypothermia. STUDY SELECTION AND DATA EXTRACTION We excluded case reports, animal- or laboratory-based studies, trials describing NMBA use during rapid sequence intubation or in the operating room, and studies published in languages other than English or French. DATA SYNTHESIS Clinical applications of NMBAs in intensive care include, but are not limited to, immobilizing patients for procedural interventions, decreasing oxygen consumption, facilitating mechanical ventilation, reducing intracranial pressure, preventing shivering, and management of tetanus. Recent data on ARDS demonstrated that early application of NMBAs improved adjusted 90-day survival for patients with severe lung injury. These results may lead to increased use of these drugs. While emerging data support the use of cisatracurium in select patients with ALI/ARDS, current literature does not support the use of one NMBA over another for other critical care indications. Cisatracurium may be kinetically preferred for patients with organ dysfunction. Close monitoring with peripheral nerve stimulation is recommended with sustained use of NMBAs to avoid drug accumulation and minimize the risk for adverse drug events. Reversal of paralysis is achieved by discontinuing therapy or, rarely, the use of anticholinesterases. CONCLUSIONS NMBAs are high-alert medications used to manage critically ill patients. New data are available regarding the use of these agents for treatment of ALI/ARDS and status asthmaticus, management of elevated ICP, and provision of therapeutic hypothermia after cardiac arrest. To improve outcomes and promote patient safety, intensive care unit team members should have a thorough knowledge of this class of medications.
Collapse
Affiliation(s)
- Julia Warr
- University of Waterloo, Waterloo, Ontario, Canada
| | | | | | | | | |
Collapse
|
28
|
Vivancos GG, Klamt JG, Garcia LV. Effects of 2 mg.kg⁻¹ of intravenous lidocaine on the latency of two different doses of rocuronium and on the hemodynamic response to orotracheal intubation. Rev Bras Anestesiol 2011; 61:1-12. [PMID: 21334502 DOI: 10.1016/s0034-7094(11)70001-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 07/27/2010] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Lidocaine potentiates the effects of neuromuscular blockers and attenuates the hemodynamic response to orotracheal intubation. The objective of the present study was to test the effects of lidocaine on the latency of two different doses of rocuronium and on the hemodynamic response to intubation. METHODS Eighty patients were distributed in 4 groups: Groups 1 and 2 received 0.6 mg.kg(-1) of rocuronium; patients in Group 2 also received 2 mg.kg(-1) of lidocaine before intubation. Patients in Groups 3 and 4 received 1.2 mg.kg(-1) of rocuronium; patients in Group 4 received additional 2 mg.kg(-1) of lidocaine. The latency of the neuromuscular blockade was measured by acceleromyography. Hemodynamic evaluation was performed at baseline, immediately before, and 1 minute after orotracheal intubation (OI). RESULTS Statistically significant differences were not observed between the latency from 0.6 mg.kg(-1) and 1.2 mg.kg(-1) of rocuronium in patients who received lidocaine before induction and those who did not. The latency in patients who received 0.6 mg.kg(-1) of rocuronium with lidocaine was statistically similar to that of those who received 1.2 mg.kg(-1) rocuronium independently of whether lidocaine was administered or not. Patients who did not receive lidocaine before induction showed the same increases in systolic, diastolic, and mean arterial pressure and heart rate after OI, which was not observed in those patients who received lidocaine. CONCLUSIONS Intravenous lidocaine before anesthetic induction was capable of attenuating the hemodynamic response associated to OI maneuvers, but it did not reduce the latency of the neuromuscular blockade produced by two different doses of rocuronium.
Collapse
Affiliation(s)
- Gustavo Gameiro Vivancos
- Hospital das Clínicas de Ribeirão Preto da Faculdade de Medicina de Ribeirão Preto - FMRP, Brazil
| | | | | |
Collapse
|
29
|
Onset of rocuronium-induced neuromuscular block evaluated subjectively and accerelomyographically at the masseter muscle. J Anesth 2011; 25:376-9. [DOI: 10.1007/s00540-011-1129-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 03/08/2011] [Indexed: 10/18/2022]
|
30
|
Monitoring masseter muscle evoked responses enables faster tracheal intubation. J Anesth 2010; 24:173-6. [DOI: 10.1007/s00540-009-0848-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/22/2009] [Indexed: 10/19/2022]
|
31
|
Suzuki T, Mizutani H, Miyake E, Fukano N, Saeki S, Ogawa S. Infusion requirements and reversibility of rocuronium at the corrugator supercilii and adductor pollicis muscles. Acta Anaesthesiol Scand 2009; 53:1336-40. [PMID: 19650798 DOI: 10.1111/j.1399-6576.2009.02073.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study is to compare the infusion rates required to maintain a constant neuromuscular block and the reversibility of rocuronium at the corrugator supercilii muscle (CSM) and the adductor pollicis muscle (APM). METHODS We randomly allocated 30 female patients into two groups of 15 patients each to monitor neuromuscular block at either the CSM or the APM. After induction of anaesthesia and laryngeal mask insertion, contraction of the CSM to the facial nerve stimulation or that of the APM to the ulnar nerve stimulation was quantified using an acceleromyograph during 1.0-1.5% end-tidal sevoflurane anaesthesia. All the patients received a bolus of 1 mg/kg rocuronium. When the first twitch (T1) of train-of-four (TOF) recovered to 10% of the control, rocuronium infusion was commenced and maintained at T1 of 10% of the control at the CSM or APM for 120 min. Immediately after rocuronium infusion was discontinued, the time required for 0.04 mg/kg neostigmine-facilitated recovery to a TOF ratio of 0.9 was recorded. RESULTS Rocuronium infusion dose after a lapse of 120 min was significantly larger in the CSM than in the APM [7.1 (2.3) vs. 4.7 (2.6) microg/kg/min; P=0.001]. The time for facilitated recovery was shorter in the CSM than in the APM [11.4 (3.8) vs. 16.2 (6.0) min; P=0.016]. CONCLUSION A larger rocuronium infusion dose was required to maintain a constant neuromuscular block at the CSM. Neostigmine-mediated reversal was faster at the CSM.
Collapse
Affiliation(s)
- T Suzuki
- Department of Anesthesiology, Surugadai Nihon University Hospital, 1-8-13, Kanda-Surugadai, Chiyoda-Ku, Tokyo, Japan.
| | | | | | | | | | | |
Collapse
|
32
|
d'Hollander AA, Bourgain JL. [Residual curarization and pharyngeal muscles: remain vigilant!]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:868-877. [PMID: 19854607 DOI: 10.1016/j.annfar.2009.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 07/08/2009] [Indexed: 05/28/2023]
Abstract
The different concepts treating of "residual curarization" were presented according to two directions: the analysis of their contents--epidemiologic, clinical, instrumental--and the description of the pharyngeal striated muscles functions in these contexts. It appears that certain, too marked, "residual curarization" levels remain a well-evidenced factor increasing some morbidities in numerous clinical situations. All the methods of instrumental monitoring of the level of curarization--mecanography, electromyography, accelerometry--appeared useful to document the levels of "residual curarization" before patient's extubation or awakening. Today, for our speciality, it became particularly clear that: neither the selected muscle-- adductor pollicis--, neither the test currently privileged--train-of-four 2Hz--, nor the thresholds currently selected--0.90 or 1.00--did not constitute the unavoidable proof of a "residual curarization" complete absence. For the healthy volunteer receiving a curare, a train of four of the adductor pollicis greater than 0.90 can exist in presence of spirometric alterations evidencing the lack of adequate pharyngeal dilatation. In daily routine, the pharyngeal control is already disturbed by numerous molecules including: benzodiazepines, halogenated vapours, propofol, i.e. even under non-hypnotic concentrations. Faced to such evidences, our medical speciality will, undoubtedly, have to acquire new knowledge to develop muscle relaxant management control processes eliminating the surmorbidities related to "residual curarization". These tests must be validated also to exclude morbidity-prone dysfunctions of the pharyngeal striated muscles. Considering this new paradigm would be a major safety evolution for our speciality.
Collapse
|
33
|
Abstract
Sugammadex is a cyclodextrin molecule that encapsulates and inactivates rocuronium and vecuronium. As a result, any degree of neuromuscular block produced by rocuronium or vecuronium can be rapidly and completely reversed without autonomic effects. Because sugammadex is optimised for reversing rocuronium it is most likely to be used in conjunction with this drug. Sugammadex will allow deep levels of block to be maintained until the very end of surgery, and will allow block to be reversed at any time after rocuronium administration, even just a few minutes. The recommended dose-range is 2-16 mg.kg-1 (ascender), depending on the level of block. The availability of sugammadex reversal may increase the use of rocuronium, and decrease the use of suxamethonium and benzylisoquinoline neuromuscular blocking drugs. In addition, it will certainly increase pharmacy costs, which may be offset by faster recovery and discharge from the post-anesthesia recovery unit. Sugammadex may also change monitoring practices in that post-tetanic count will be required to quantify deep block, and quantitative monitoring of recovery may be driven by cost concerns in order to allow the use of the smallest dose of sugammadex that gives a satisfactory train-of-four ratio. Alternatively, monitoring may essentially be abandoned since a large dose of sugammadex will reliably reverse any degree of rocuronium-induced block. The ultimate clinical utility of sugammadex will be clear only after large-scale clinical use.
Collapse
Affiliation(s)
- J E Caldwell
- Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, CA, USA.
| | | |
Collapse
|
34
|
Jeung HJ, Kwak SH, Ri M, Jeong CW, Kim SJ, Bae HB. Effect of mixed administration of propofol and rocuronium on intubating conditions. Korean J Anesthesiol 2009; 56:140-145. [PMID: 30625712 DOI: 10.4097/kjae.2009.56.2.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We investigated whether the intubating condition change acoording to the methods of administration of propofol and rocuronium. METHODS Ninety adult patients (ASA physical status I or II) undergoing elective surgery were randomly assigned to one of three groups; Group I (n = 30) received rocuronium (0.6 mg/kg) after administration of propofol (2 mg/kg), Group II (n = 30) received propofol and rocuronium simultaneously via different intravenous routes, and Group III (n = 30) received a mixture of propofol and rocuronium via same intravenous route. Intubation was attempted at 60 seconds after administration of rocuronium. Hemodynamic parameters (mean blood pressure, heart rate) were measured before and after propofol administration with 20 seconds interval. Intubating conditions (jaw relaxation, vocal cord movement, and response to tracheal intubation) were evaluated as excellent, good, fair and poor. Train of four counts were recorded at 60 seconds after administration of rocuronium. RESULTS Excellent intubating conditions were obtained in 13% in group I, 60% in group II, 77% in group III. Mean train of four counts were 3.7 in group I, 3.4 in group II, and 3.5 in group III. Mean blood pressures were decreased gradually after propofol administration in all groups. However, heart rates were not changed in all groups. CONCLUSIONS At induction of anesthesia, simultaneous or mixed administration of propofol and rocuronium provides excellent or good intubating conditions 60 seconds after rocuronium administration. It could be an effective alternative to succinylcholine for rapid sequence induction of anesthesia.
Collapse
Affiliation(s)
- Hye Jin Jeung
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Mai Ri
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Cheol Won Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Seok Jai Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Hong Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.
| |
Collapse
|
35
|
Osawa T. Different recovery of the train-of-four ratio from rocuronium-induced neuromuscular blockade in the diaphragm and the tibialis anterior muscle in rat. J Anesth 2008; 22:236-41. [PMID: 18685929 DOI: 10.1007/s00540-008-0613-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 02/03/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE To clarify differences between the diaphragm and the limb muscles in terms of the effects of neuromuscular blockers concerning train-of-four (TOF) ratios, we compared the recovery of twitch tensions and TOF ratios in the diaphragm and in the tibialis anterior muscle in rats in vivo. METHODS We conducted a dose-response study in 16 rats and a recovery study in 8 rats. In the recovery study, we made phrenic nerve-diaphragm and sciatic nerve-tibialis anterior preparations simultaneously in each of 8 rats that were anesthetized intraperitoneally with pentobarbitone (30 mg x kg(-1)) and urethane (500 mg x kg(-1)). After supramaximal stimuli were applied simultaneously in a TOF pattern to both the phrenic and sciatic nerves, rocuronium was injected intravenously, at 10 mg x kg(-1). In the diaphragm and the tibialis anterior muscle, we monitored the first-twitch response to TOF stimuli (T1) and also the TOF ratios. The following variables were determined for each muscle: (1) the times at which T1 recovered to 25%, 50%, and 75% of control T1, and the times at which the TOF ratio recovered to 25%, 50%, and 75%; and (2) the values of the TOF ratio at 25%, 50%, and 75% recovery of T1. RESULTS At 25%, 50%, and 75% recovery of T1 in the diaphragm, TOF ratios were 8.9 +/- 5.0 %, 26.7 +/- 7.7 %, and 55.9 +/- 5.4%, respectively, while in the tibialis anterior, the TOF ratios were 18.0 +/- 5.9%, 32.5 +/- 7.4%, and 54.4 +/- 7.5%, respectively (diaphragm vs tibialis anterior; P < 0.01 for comparisons at both 25% and 50% recovery of T1). CONCLUSION Our method of simultaneous in vivo evaluation of TOF ratios in both the diaphragm and the tibialis anterior confirmed significant differences between the two muscles in relationships between first-twitch tension and the TOF ratio.
Collapse
Affiliation(s)
- Takeshi Osawa
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan
| |
Collapse
|
36
|
Gopalakrishna MD, Krishna HM, Shenoy UK. The effect of ephedrine on intubating conditions and haemodynamics during rapid tracheal intubation using propofol and rocuronium. Br J Anaesth 2007; 99:191-4. [PMID: 17510045 DOI: 10.1093/bja/aem125] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We compared the effect of pre-treatment with ephedrine 75, 100, 150 microg kg(-1) and saline on intubating conditions and haemodynamics during rapid tracheal intubation using propofol and rocuronium. METHODS One hundred adult patients randomized into one of the four groups-PE 75, PE 100, PE 150, and saline (control) groups-were pre-treated with i.v. ephedrine 75, 100, 150 microg kg(-1) or saline, respectively, 1 min before rapid tracheal intubation using propofol 2.5 mg kg(-1) and rocuronium 0.6 mg kg(-1). A blinded anaesthesiologist assessed the intubating conditions. Heart rate and mean arterial pressure were recorded before anaesthesia induction (baseline), post-induction, and every minute after intubation for 5 min. A 20% change in haemodynamic variables from baseline was regarded as clinically significant. Data were analysed using anova test with post hoc Tukey's test and chi2 or Fisher's exact test. P < 0.05 was regarded as significant. RESULTS Patient characteristics, baseline heart rate, and mean arterial pressure were comparable between the groups. Intubating conditions were significantly better in the PE 75 (P = 0.003) and PE 100 (P = 0.001) groups. A significant increase in heart rate was observed in the PE 75 and PE 150 groups when compared with the saline group. A statistically significant difference in mean arterial pressure was noted between PE 75 and PE 150 groups and between PE 150 and saline groups at most of the time intervals. However, when considering the clinical significance of these, all groups were comparable (P > 0.05). CONCLUSIONS Ephedrine either 75 or 100 microg kg(-1) given before rapid tracheal intubation using propofol and rocuronium bromide improves the intubation conditions. It is not effective in preventing the hypotension which follows ensuing induction of anaesthesia.
Collapse
Affiliation(s)
- M D Gopalakrishna
- Department of Anaesthesiology, Kasturba Medical College, Manipal 576104, India
| | | | | |
Collapse
|
37
|
Hemmerling TM, Le N. Brief review: Neuromuscular monitoring: an update for the clinician. Can J Anaesth 2007; 54:58-72. [PMID: 17197470 DOI: 10.1007/bf03021901] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To review established techniques and to provide an update on new methods for clinical monitoring of neuromuscular function relevant to anesthesia. SOURCE A PubMed search of relevant article for the period 1985-2005 was undertaken, and bibliographies were scanned for additional sources. PRINCIPAL FINDINGS There is no substitute for objective neuromuscular monitoring; for research purposes, mechanomyography (MMG) is the gold standard; however, the most versatile method in the clinical setting is acceleromyography since it can be applied at various muscles and has a long track record of clinical utility. Kinemyography is valid to monitor recovery of neuromuscular transmission at the adductor pollicis muscle (AP), whereas phonomyography is easy to apply to various muscles and shows promising agreement with MMG. Monitoring of the corrugator supercilii muscle (CS) may be used to determine the earliest time for tracheal intubation as it reflects laryngeal relaxation better than monitoring at the AP. Recovery of neuromuscular transmission is best monitored at the AP, since it is the last muscle to recover from neuromuscular blockade (NMB). If train-of-four (TOF) stimulation is used, a TOF-ratio > 0.9 should be the target before awakening the patient. If surgery or the type of anesthesia necessitates NMB of a certain degree, e.g., TOF-ratio = 0.25, monitoring of muscles which best reflect the degree of NMB at the surgical site is preferable. CONCLUSION Objective methods should be used to monitor neuromuscular function in clinical anesthesia. Acceleromyography offers the best compromise with respect to ease of use, practicality, versatility, precision and applicability at various muscles. The CS is the optimal muscle to determine the earliest time for intubation, e.g., for rapid sequence induction.
Collapse
Affiliation(s)
- Thomas M Hemmerling
- Anaesthesia Department, McGill University Health Centre (MUHC), Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
| | | |
Collapse
|
38
|
Kim YB, Kwak HJ, Kim DH, Lee KC, Lee W, Chang YJ. Effect of Storage Temperature of Rocuronium on Intubating Condition and Clinical Duration after Low-dose Technique. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.4.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Yong Beom Kim
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Hyun Jung Kwak
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Dae Hee Kim
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Kyoung Cheon Lee
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Wonsang Lee
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Young-Jin Chang
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| |
Collapse
|
39
|
Kim JH, Ok SJ, Lee HW, Lim HJ, Chang SH, Yoon SM. The Effect of Combined Ephedrine and Lidocaine Pretreatment on Tracheal Intubation Condition and Maximum Neuromuscular Block after Rocuronium Administration. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.3.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jong Hyuk Kim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Se Jin Ok
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hye Won Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hae Ja Lim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seong Ho Chang
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Suk Min Yoon
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
40
|
Yu G, Yang K, Baker AB, Young I. The effect of bi-level positive airway pressure mechanical ventilation on gas exchange during general anaesthesia. Br J Anaesth 2006; 96:522-32. [PMID: 16500951 DOI: 10.1093/bja/ael033] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Atelectasis may occur and ventilation-perfusion mismatch may increase during general anaesthesia with neuromuscular paralysis and mechanical ventilation, though preservation of some intermittent muscle contraction might mitigate this process. There is still no ideal manoeuvre to minimize such mismatch or atelectasis. Bi-level positive airway pressure (BiPAP) ventilation adjusts to extra breaths and improves gas exchange during recovery of diaphragm function after neuromuscular paralysis. We hypothesize that BiPAP ventilation may limit the development of pulmonary shunt and may improve ventilation-perfusion mismatch when compared with standard IPPV, with or without PEEP when neuromuscular paralysis has been used during surgery. METHODS Twenty ventilated patients either on BiPAP or IPPV with or without PEEP were studied randomly using the multiple inert gas elimination technique (MIGET) at 60 and 120 min after rocuronium at induction and after 60 min. Non-invasive cardiac output (NICO) monitoring and plasma concentrations of rocuronium were measured. We compared the data of MIGET, gas exchange, haemodynamic variables and pulmonary mechanics measurements between the different ventilatory modes. RESULTS Intrapulmonary shunt (blood flow to V(A)/Q < 0.005) did not increase at 60 min of anaesthesia in any of the different ventilation modes compared with the shunt value before anaesthesia. Log standard deviation of perfusion increased in IPPV, with and without PEEP groups, compared with the baseline (P< 0.05) but did not increase in the BiPAP group. BiPAP ventilation generated a higher level of Pa(O2)than IPPV with or without PEEP (P<0.05). CONCLUSION BiPAP ventilation was beneficial in decreasing ventilation-perfusion mismatch and improving oxygenation when compared with conventional IPPV (with or without PEEP).
Collapse
Affiliation(s)
- G Yu
- Department of Anaesthetics, University of Sydney and Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
| | | | | | | |
Collapse
|
41
|
Thangathurai D, Roffey P, Mogos M, Riad M, Bohorguez A. Mediastinal haemorrhage mimicking tamponade during en-bloc oesophagectomy. Eur J Anaesthesiol 2005; 22:555-6. [PMID: 16045149 DOI: 10.1017/s0265021505240942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
42
|
Hinz J, Auer P, Moerer O, Neumann P, Crozier TA. Effects of mivacurium on the diaphragm evaluated by cervical magnetic stimulation of the phrenic nerves. Eur J Anaesthesiol 2005; 22:530-5. [PMID: 16045143 DOI: 10.1017/s0265021505000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Non-depolarizing neuromuscular blocking agents have differential effects on the diaphragm and skeletal muscles. We employed a new method to study the effects of mivacurium on the diaphragm and compared the results obtained with this method with published data. METHODS Anaesthesia was induced and maintained with propofol and alfentanil and the trachea was intubated after topical anaesthesia. Contractions of the diaphragm were induced by cervical magnetic stimulation of the phrenic nerves and quantified by measuring airway pressure responses. The neuromuscular effects on skeletal muscles were measured by acceleromyography of the adductor pollicis muscle. Mivacurium (0.15 mg kg(-1)) was injected and neuromuscular responses were recorded until the effects had waned. RESULTS Eleven male and 10 female patients (ASA I-II; 57 +/- 16 yr; 78 +/- 13 kg; mean +/- standard deviation) participated. Median maximal reduction of twitch response was less (P < 0.05) for the diaphragm (89%) than for the adductor pollicis (100%). Time to 25% recovery was shorter for the diaphragm than for the adductor pollicis (8.8 +/- 2.2 min vs. 22.6 +/- 5.0 min, P < 0.05). The difference between the recovery index of the diaphragm (7.3 min (3.6-18.4)) and the adductor pollicis (8.2 min (4.4-20.9) (median (range)) just missed our chosen level of statistical significance (P = 0.06). The recovery time to train-of-four 0.8 was shorter for the diaphragm (median and 95% confidence interval 25.1 +/- 10.2 min) than for the adductor pollicis (median and 95% confidence interval 37.5 +/- 9.4 min, P < 0.05). CONCLUSIONS The duration of the clinical effect of mivacurium on the diaphragm is markedly shorter than on the adductor pollicis muscles but there was only a small difference in the recovery index of the two muscles. These effects and the time courses determined with the new method closely resemble the results obtained with different methods in other studies.
Collapse
Affiliation(s)
- J Hinz
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany.
| | | | | | | | | |
Collapse
|
43
|
Itoh H, Shibata K, Matsumoto T, Nitta S, Nishi M, Kobayashi T, Yamamoto K. Effects of neuromuscular-blocking drugs in rats in vivo: direct measurements in the diaphragm and tibialis anterior muscle. Acta Anaesthesiol Scand 2004; 48:903-8. [PMID: 15242438 DOI: 10.1111/j.0001-5172.2004.00439.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Effects of neuromuscular-blocking drugs are often investigated in rodents using both the diaphragm in vitro and the tibialis anterior muscle in vivo. Differences in the properties of these muscles cannot be neglected. We evaluated the neuromuscular effects of drugs on the rat diaphragm in vivo in comparison with the tibialis anterior muscle, directly measuring twitch tension with a force transducer. METHODS Respectively using sternotomy and an approach via the gluteal space, transducers were attached to the diaphragm and the tibialis anterior muscle. Phrenic and sciatic nerves were stimulated supramaximally by single square pulses to record isometric contraction of muscles. Pancuronium, vecuronium, or rocuronium was infused continuously at a rate adjusted repeatedly until stable tension was obtained. Effective doses for 50% (ED 50) and 90% (ED 90) depression of tension were calculated, using a cumulative infusion dosing method. RESULTS Isometric contraction of the diaphragm could be recorded despite movements of the heart and lungs. For all three drugs, both mean ED 50 and ED 90 were more than twice as large for the diaphragm as for the tibialis anterior (P<0.05). In addition, slopes of dose-response curves for the diaphragm were significantly less steep than those of the tibialis anterior for the three drugs. CONCLUSION Neuromuscular-blocking effects on the diaphragm can be recorded in vivo. According to direct contractile force measurement, the diaphragm is more resistant to non-depolarizing neuromuscular-blocking drugs than the tibialis anterior muscle.
Collapse
Affiliation(s)
- H Itoh
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
| | | | | | | | | | | | | |
Collapse
|
44
|
Meistelman C. Effect sites of neuromuscular blocking agents and the monitoring of clinical muscle relaxation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 523:227-38. [PMID: 15088854 DOI: 10.1007/978-1-4419-9192-8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Claude Meistelman
- Department of Anaesthesiology, University Hospital Nancy, Nancy, France
| |
Collapse
|
45
|
Hemmerling TM, Donati F. Neuromuscular blockade at the larynx, the diaphragm and the corrugator supercilii muscle: a review. Can J Anaesth 2003; 50:779-94. [PMID: 14525816 DOI: 10.1007/bf03019373] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To review recent findings concerning neuromuscular blockade and monitoring at the larynx, the diaphragm, and the corrugator supercilii muscle. SOURCE This narrative review is based on recent publications. PRINCIPAL FINDINGS Neuromuscular blockade at the larynx and the diaphragm is less intense than at the adductor pollicis muscle; the onset and offset of neuromuscular blockade is more rapid. The corrugator supercilii muscle reflects better the time course of neuromuscular blockade of the larynx than the adductor pollicis muscle, is better suited to monitor the onset of neuromuscular blockade for intubation, and should give a better reflection of the time course and degree of neuromuscular blockade of the larynx or the diaphragm. Recovery of neuromuscular function at the end of any procedure is best reflected at the adductor pollicis muscle where neuromuscular transmission is last restored. Clinical monitoring of the larynx or the diaphragm is still limited by the absence of a simple method. Acceleromyography of the corrugator supercilii muscle is prone to artifacts that do not occur during monitoring of the adductor pollicis muscle. Phonomyography, a new method of monitoring that is currently being tested, is based on the phenomenon that muscle contraction creates low-frequency sound waves, which can be detected using special microphones to quantify neuromuscular blockade. This method seems promising because it can be easily used on all muscles of interest. CONCLUSION Research during the last 15 years has greatly enhanced our knowledge about how muscles react differently to muscle relaxants and has enabled us to achieve better surgical conditions with safer use of muscle relaxants. Interesting technologies have been developed to reliably monitor neuromuscular blockade at the larynx and the diaphragm, but are currently restricted to research settings. Our increased understanding should help us in ongoing efforts to develop the "ideal" muscle relaxant and the "ideal" method of neuromuscular monitoring.
Collapse
Affiliation(s)
- Thomas M Hemmerling
- Department of Anesthesiology, Hôtel-Dieu, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | | |
Collapse
|
46
|
Neuromuscular effects of rapacuronium on the diaphragm and skeletal muscles in anaesthetized patients using cervical magnetic stimulation for stimulating the phrenic nerves. Eur J Anaesthesiol 2002. [DOI: 10.1097/00003643-200212000-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
47
|
Hemmerling TM, Schmidt J, Schurr C, Breuer G, Jacobi KE. A comparison between anterior and posterior monitoring of neuromuscular blockade at the diaphragm: both sites can be used interchangeably. Anesth Analg 2002; 95:940-3, table of contents. [PMID: 12351272 DOI: 10.1097/00000539-200210000-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We present a novel site of monitoring neuromuscular blockade of the diaphragm at the patient's back. After the induction of anesthesia, 12 patients were orotracheally intubated. Two Ag/AgCl-electrodes were attached at the right seventh or eighth intercostal space between the midclavicular and anterior axillary line; two Ag/AgCl-electrodes were paravertebrally attached on the right side lateral to vertebrae T12-L1 or L1-2. Two Ag/AgCl-skin-electrodes were placed over the right thenar area for an electromyography recording of the adductor pollicis (AP) muscle, and two Ag/AgCl-skin-electrodes were used to stimulate the ulnar nerve. Onset and offset of neuromuscular blockade after rocuronium 0.6 mg/kg were determined, and significant differences between diaphragm and AP muscle and agreement between the two methods were determined. Mean maximum block was more than 96% at all sites. Lag time, onset 50, and onset time were not significantly different between the diaphragm and the AP. However, time to reach 25% of control twitch was significantly longer at the AP muscle than at the diaphragm (P < 0.001). The difference of the means and limits of agreement between the anterior and the posterior site of diaphragmatic monitoring were 0 +/- 11 s, 3 +/- 9 s, 0 +/- 19 s, and -2% +/- 5% for lag, onset 50, onset time, and peak effect, respectively, and -2 +/- 2 min for the time to reach 25% of control twitch of neuromuscular blockade. We conclude that anterior and posterior diaphragmatic monitoring can be used interchangeably to determine neuromuscular blockade after rocuronium. IMPLICATIONS We present a novel site of monitoring neuromuscular blockade of the diaphragm at the patient's back, which shows good agreement with the conventional anterior site at the seventh or eighth intercostal space.
Collapse
|
48
|
Hemmerling TM, Schmidt J, Schurr C, Breuer G, Jacobi KE. A Comparison Between Anterior and Posterior Monitoring of Neuromuscular Blockade at the Diaphragm: Both Sites Can Be Used Interchangeably. Anesth Analg 2002. [DOI: 10.1213/00000539-200210000-00027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
49
|
Smith CE, Kovach B, Polk JD, Hagen JF, Fallon WF. Prehospital tracheal intubating conditions during rapid sequence intubation: rocuronium versus vecuronium. Air Med J 2002; 21:26-32. [PMID: 11805764 DOI: 10.1067/mmj.2002.121713] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The study purpose was to evaluate tracheal intubating conditions and cardiovascular effects of rocuronium (roc) and vecuronium (vec) in the transport setting. METHODS A prospective blinded study of adult patients requiring emergency rapid sequence oral tracheal intubation using direct laryngoscopy. Patients received equipotent doses of roc 1.0 mg/kg (n = 44) or vec 0.15 mg/kg (n = 56) on an alternate day basis. RESULTS Intubation was successful in 95% of patients in the vec group and 100% in the roc group. The percentage of patients having good or excellent jaw relaxation and vocal cord exposure was similar between groups (vec/79%, roc/77%). Eleven patients (vec/7, roc/4) had difficult intubation as evidenced by Grade III or IV view and more than three attempts. Five patients in the vec group had inadequate neuromuscular blockade versus 1 patient in the roc group (P = 0.17). No cardiovascular differences occurred between groups after intubation. CONCLUSION Tracheal intubating conditions and clinical evidence of complete neuromuscular blockade tended to be better after roc than after vec.
Collapse
Affiliation(s)
- Charles E Smith
- MetroHealth Medical Center, Department of Anesthesiology, Cleveland, OH 44109, USA.
| | | | | | | | | |
Collapse
|
50
|
|