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An Emerging Role for Epigenetics in Cerebral Palsy. J Pers Med 2021; 11:jpm11111187. [PMID: 34834539 PMCID: PMC8625874 DOI: 10.3390/jpm11111187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
Cerebral palsy is a set of common, severe, motor disabilities categorized by a static, nondegenerative encephalopathy arising in the developing brain and associated with deficits in movement, posture, and activity. Spastic CP, which is the most common type, involves high muscle tone and is associated with altered muscle function including poor muscle growth and contracture, increased extracellular matrix deposition, microanatomic disruption, musculoskeletal deformities, weakness, and difficult movement control. These muscle-related manifestations of CP are major causes of progressive debilitation and frequently require intensive surgical and therapeutic intervention to control. Current clinical approaches involve sophisticated consideration of biomechanics, radiologic assessments, and movement analyses, but outcomes remain difficult to predict. There is a need for more precise and personalized approaches involving omics technologies, data science, and advanced analytics. An improved understanding of muscle involvement in spastic CP is needed. Unfortunately, the fundamental mechanisms and molecular pathways contributing to altered muscle function in spastic CP are only partially understood. In this review, we outline evidence supporting the emerging hypothesis that epigenetic phenomena play significant roles in musculoskeletal manifestations of CP.
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Lee S, Robinson K, Lodge M, Theroux M, Miller F, Akins R. Resistance to Neuromuscular Blockade by Rocuronium in Surgical Patients with Spastic Cerebral Palsy. J Pers Med 2021; 11:jpm11080765. [PMID: 34442409 PMCID: PMC8400439 DOI: 10.3390/jpm11080765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022] Open
Abstract
Individuals with spastic cerebral palsy (CP) often exhibit altered sensitivities to neuromuscular blocking agents (NMBAs) used for surgical intubation. We assessed usage of the NMBA rocuronium in patients with spastic CP and evaluated potential modifiers of dosing including gross motor function classification system (GMFCS) level, birthweight, gestational age, and the use of anticonvulsant therapy. In a case-control study, surgical patients with spastic CP (n = 64) or with idiopathic or non-neuromuscular conditions (n = 73) were enrolled after informed consent/assent. Patient data, GMFCS level, anticonvulsant use, and rocuronium dosing for intubation and post-intubation neuromuscular blockade were obtained from medical records. Findings reveal participants with CP required more rocuronium per body weight for intubation than controls (1.00 ± 0.08 versus 0.64 ± 0.03 mg/kg; p < 0.0001). Dosing increased with GMFCS level (Spearman's rho = 0.323; p = 0.005), and participants with moderate to severe disability (GMFCS III-V) had elevated rocuronium with (1.21 ± 0.13 mg/kg) or without (0.86 ± 0.09 mg/kg) concurrent anticonvulsant therapy. Children born full-term or with birthweight >2.5 kg in the CP cohort required more rocuronium than preterm and low birthweight counterparts. Individuals with CP exhibited highly varied and significant resistance to neuromuscular blockade with rocuronium that was related to GMFCS and gestational age and weight at birth.
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Affiliation(s)
- Stephanie Lee
- Nemours Biomedical Research, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (S.L.); (K.R.); (M.L.)
| | - Karyn Robinson
- Nemours Biomedical Research, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (S.L.); (K.R.); (M.L.)
| | - Madison Lodge
- Nemours Biomedical Research, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (S.L.); (K.R.); (M.L.)
| | - Mary Theroux
- Department of Anesthesiology, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA;
| | - Freeman Miller
- Department of Orthopedics, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA;
| | - Robert Akins
- Nemours Biomedical Research, Nemours-Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (S.L.); (K.R.); (M.L.)
- Correspondence: ; Tel.: +1-302-651-6779
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Jang EA, Kim TY, Jung EG, Jeong S, Bae HB, Lee S. Donepezil-related inadequate neuromuscular blockade during laparoscopic surgery: A case report. World J Clin Cases 2020; 8:5341-5346. [PMID: 33269268 PMCID: PMC7674726 DOI: 10.12998/wjcc.v8.i21.5341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels. This drug may potentially interact with neuromuscular blocking agents (NMBAs) that act on muscular acetylcholine receptors during general anesthesia. Herein, we present a case of inadequate neuromuscular blockade with rocuronium, a nondepolarizing NMBA, in a dementia patient who had taken donepezil.
CASE SUMMARY A 71-year-old man was scheduled for laparoscopic gastrectomy. He had been taking donepezil 5 mg for dementia. General anesthesia was induced with propofol and remifentanil. The depth of neuromuscular blockade was monitored by train-of-four (TOF) stimulation. After the administration of rocuronium, the TOF ratio decreased at an unusually slow rate, and a TOF count of 0 was detected 7 min later. After intubation, a TOF count of 1 was detected within 1 min, and a TOF ratio of 12% was detected within 2 min. The TOF count remained at 4 even with an additional bolus and continuous infusion of rocuronium, suggesting resistance to this NMBA. Instead of propofol, an inhalation anesthetic was administered alongside another NMBA (cisatracurium). Then, the quality of neuromuscular blockade improved, and the TOF count remained at 0-1 for the next 70 min. No further problems were encountered with respect to surgery or anesthesia.
CONCLUSION Donepezil may be responsible for inadequate neuromuscular blockade during anesthesia, especially when total intravenous anesthesia is used.
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Affiliation(s)
- Eun-A Jang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Tae-Young Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Eu-Gene Jung
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Seongtae Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Seongheon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju 61469, South Korea
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Review of Continuous Infusion Neuromuscular Blocking Agents in the Adult Intensive Care Unit. Crit Care Nurs Q 2017; 40:323-343. [PMID: 28834856 DOI: 10.1097/cnq.0000000000000171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of continuous infusion neuromuscular blocking agents remains controversial. The clinical benefit of these medications may be overshadowed by concerns of propagating intensive care unit-acquired weakness, which may prolong mechanical ventilation and impair the inability to assess neurologic function or pain. Despite these risks, the use of neuromuscular blocking agents in the intensive care unit is indicated in numerous clinical situations. Understanding pharmacologic nuances and clinical roles of these agents will aid in facilitating safe use in a variety of acute disease processes. This article provides clinicians with information regarding pharmacologic differences, indication for use, adverse effects, recommended doses, ancillary care, and monitoring among agents used for continuous neuromuscular blockade.
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Shaikh SI, Hegade G. Role of Anesthesiologist in the Management of a Child with Cerebral Palsy. Anesth Essays Res 2017; 11:544-549. [PMID: 28928544 PMCID: PMC5594763 DOI: 10.4103/0259-1162.194569] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.
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Affiliation(s)
- Safiya Imtiaz Shaikh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Ganapati Hegade
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
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Abstract
There are 3 surgical procedures that patients with cerebral palsy (CP) undergo that may be considered major procedures: femoral osteotomies combined with pelvic osteotomies, spine fusion, and intrathecal baclofen pump implant for the treatment of spasticity. Many complications are known to occur at a higher rate in this population, and some may be avoided with prior awareness of the preoperative pathophysiology of the patient with CP.
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Affiliation(s)
- Mary C Theroux
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Post Office Box 269, Wilmington, DE 19899, USA; Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, 111 S 11th Street, PA 19107, USA.
| | - Sabina DiCindio
- Department of Anesthesiology and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children, Post Office Box 269, Wilmington, DE 19899, USA; Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, 111 S 11th Street, PA 19107, USA
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Do SH. Magnesium: a versatile drug for anesthesiologists. Korean J Anesthesiol 2013; 65:4-8. [PMID: 23904932 PMCID: PMC3726845 DOI: 10.4097/kjae.2013.65.1.4] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/15/2013] [Indexed: 11/26/2022] Open
Abstract
Magnesium sulfate has been used in preeclampsia patients in order to prevent seizure. It is also used for the treatment of arrhythmia and asthma and as an anesthetic adjunct in patients undergoing surgery for pheochromocytoma. However, its potentiating effects on perioperative analgesia and muscle relaxation have drawn attention recently. These characteristics of magnesium (anesthetic- and analgesic-sparing effect) enable anesthesiologists to reduce the use of anesthetics during surgery and the use of analgesics after surgery. Magnesium sulfate has a high therapeutic index and cost-effectiveness. Considering these diverse characteristics useful for anesthesia, appropriate use of magnesium sulfate would improve surgical outcome and patients' satisfaction.
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Affiliation(s)
- Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Lerman J. Perioperative management of the paediatric patient with coexisting neuromuscular disease. Br J Anaesth 2012; 107 Suppl 1:i79-89. [PMID: 22156273 DOI: 10.1093/bja/aer335] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Children with neuromuscular diseases present a wide range of clinical manifestations and clinical implications for the anaesthesiologist. Neuromuscular diseases in children affect muscle strength by either directly weakening the muscle fibrils or indirectly by a degenerative nerve supply and weak neuromuscular junction. Of the more than 200 neuromuscular disorders known, the vast majority are genetic in origin. This review focuses on four of the more common neuromuscular disorders with emphasis on their pathophysiology and clinical implications for anaesthesiologists: malignant hyperthermia, the muscular dystrophies (Duchenne's, Becker's, and Emery-Dreifuss), mitochondrial disorders, and cerebral palsy.
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Affiliation(s)
- J Lerman
- Department of Anaesthesia, Women and Children's Hospital of Buffalo, State University of New York at Buffalo, 219 Bryant St, Buffalo, NY 14222, USA.
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Na HS, Lee JH, Hwang JY, Ryu JH, Han SH, Jeon YT, Do SH. Effects of magnesium sulphate on intraoperative neuromuscular blocking agent requirements and postoperative analgesia in children with cerebral palsy. Br J Anaesth 2009; 104:344-50. [PMID: 20042475 DOI: 10.1093/bja/aep379] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In this double-blind, randomized, placebo-controlled study, we evaluated the effects of magnesium sulphate on neuromuscular blocking agent requirements and analgesia in children with cerebral palsy (CP). METHODS We randomly divided 61 children with CP undergoing orthopaedic surgery into two groups. The magnesium group (Group M) received magnesium sulphate 50 mg kg(-1) i.v. as a bolus and 15 mg kg(-1) h(-1) by continuous infusion during the operation. The control group (Group S) received the same amount of isotonic saline. Rocuronium was administered 0.6 mg kg(-1) before intubation and 0.1 mg kg(-1) additionally when train-of-four counts were 2 or more. I.V. fentanyl and ketorolac were used to control postoperative pain. Total infused analgesic volumes and pain scores were evaluated at postoperative 30 min, and at 6, 24, and 48 h. RESULTS The rocuronium requirement of Group M was significantly less than that of Group S [0.29 (0.12) vs 0.42 (0.16) mg kg(-1) h(-1), P<0.05]. Cumulative analgesic consumption in Group M was significantly less after operation at 24 and 48 h (P<0.05), and pain scores in Group M were lower than in Group S during the entire postoperative period (P<0.05). Serum magnesium concentrations in Group M were higher until 24 h after operation (P<0.05). The incidence of postoperative nausea and vomiting and rescue drug injections was similar in the two groups. No shivering or adverse effects related to hypermagnesaemia were encountered. CONCLUSIONS I.V. magnesium sulphate reduces rocuronium requirements and postoperative analgesic consumption in children with CP.
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Affiliation(s)
- H-S Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
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Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs. J Clin Anesth 2009; 21:165-72. [PMID: 19464608 DOI: 10.1016/j.jclinane.2008.06.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 06/26/2008] [Accepted: 06/26/2008] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To determine the utilization of anesthesia resources by children with complex special health care needs. DESIGN Observational, inception cohort study of medical records. SETTING Urban, pediatric, tertiary-care hospital. MEASUREMENTS All general anesthetic cases were screened for preexisting complex special health care needs. Medical records were reviewed for demographic, clinical, and outcome data. MAIN RESULTS 435 children with complex special health care needs accounted for 479 delivered general anesthetic cases. This figure represented 14% of the total 3,437 cases presenting during the study period. It also represented 22% (49 of 224) of all cancellations. Down syndrome was the most identifiable developmental disorder (n = 43, 9%). Another 143 (30%) cases showed preexisting technology dependence. Scheduled surgical procedures (n = 425, 89%) comprised the majority of cases. Intraoperative and recovery room complications occurred in 6 (1%) and 133 (28%) cases, respectively. Eleven (2.3%) cases required unplanned post-anesthetic hospital ward or pediatric intensive care unit admission. Documentation of health care proxy or resuscitation status was not identified in any child under 18 years, and in only 4 of 33 children older than 18 years. CONCLUSIONS Children with complex special health care needs represented one out of 7 of all pediatric general anesthetic cases at a tertiary-care, academic center.
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Del Castillo AS, Jirón J, Jaramillo E, Sardi N. Utililzación de anestesia general en cesáreas de mujeres con parálisis cerebral:. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)61009-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Prolonged administration of antiepileptic drugs is associated with several drug interactions. In the field of anaesthesia and critical care, patients exhibit both sensitivity and resistance to non-depolarising neuromuscular blockers (NDNMBs) after acute and long-term administration of antiepileptic drugs, respectively. Although antiepileptic therapy alone has only mild neuromuscular effects, acutely administered antiepileptic drugs can potentiate the neuromuscular effects of NDNMBs as a result of direct pre- and post-junctional effects. Resistance to NDNMBs during long-term antiepileptic therapy is due to multiple factors operating alone or in combination, including induction of hepatic drug metabolism, increased protein binding of the NDNMBs and/or upregulation of acetylcholine receptors.
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Affiliation(s)
- Sulpicio G Soriano
- Harvard Medical School and Children's Hospital, Boston, Massachusetts 02115, USA.
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Abstract
We report a case of resistance to curarization in a term neonate undergoing surgery. The dosage of vecuronium required to obtain satisfactory muscular blockade and cessation of spontaneous breathing efforts was more than 10-fold the normal one. The operation was delayed for 90 min The mechanism of this marked resistance is unknown, but some possible hypotheses are presented, focusing on the neonate's poor intrauterine growth and an abnormality in pharmacodynamics.
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Affiliation(s)
- A Sarti
- Department of Anaesthesia and Intensive Care, Research and Care Children Hospital IRCCS Burlo Garofolo, Trieste, Italy.
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Abstract
Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri-operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri-operative seizure control, respiratory function and gastro-oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.
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Affiliation(s)
- J Nolan
- Department of Anaesthesia, Royal Children's Hospital, Victoria, Australia
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Boorin MR. Perioperative Management of the Mentally and Physically Impaired Patient. Oral Maxillofac Surg Clin North Am 1999. [DOI: 10.1016/s1042-3699(20)30243-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hepaguşlar H, Ozzeybek D, Elar Z. The effect of cerebral palsy on the action of vecuronium with or without anticonvulsants. Anaesthesia 1999; 54:593-6. [PMID: 10403876 DOI: 10.1046/j.1365-2044.1999.00799.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with cerebral palsy who are treated with anticonvulsant medication are resistant to vecuronium. We examined the contributions to vecuronium resistance made by cerebral palsy and anticonvulsants in a study of children with cerebral palsy and a control group. The acceleromyographic responses of the following three groups of children were studied: children with cerebral palsy not taking anticonvulsant medication (n = 11); children with cerebral palsy taking anticonvulsant medication (n = 8); and a control group of children who did not have cerebral palsy and were not taking anticonvulsant treatment (n = 10). Using a standardised technique, general anaesthesia was induced and maintained with 0.5-1. 5% isoflurane in a 60/40 nitrous oxide in oxygen mixture. After a stabilisation period which was performed with supramaximal train-of-four stimuli (2 Hz every 15 s) an intubating dose of vecuronium 0.1 mgkg-1 was administered. The first twitch of the train-of-four response (T1), the onset time, the times to 25, 50, 75 and 90% recovery of T1, recovery index, and the time to 70% recovery of train-of-four ratio were recorded. Recovery times to T1 and train-of-four responses were reduced significantly in both groups of children with cerebral palsy compared with the control group. These results suggest that children with cerebral palsy display resistance to vecuronium whether or not they are taking anticonvulsant drugs.
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Affiliation(s)
- H Hepaguşlar
- Department of Anaesthesiology, Ege University Hospital, Izmir, Turkey
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Abstract
Chronic phenytoin therapy causes resistance to some nondepolarising muscle relaxants. We have confirmed that this resistance is seen with vecuronium and suggest that at least a week of phenytoin therapy is required for a significant effect to develop. The mechanism of this resistance is not known. We have shown that an exaggerated rise in serum potassium after succinylcholine does not occur in patients with demonstrated resistance to vecuronium from chronic phenytoin therapy. This would suggest that significant extrajunctional acetylcholine receptor proliferation is an unlikely mechanism.
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Affiliation(s)
- P R Platt
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
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