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- Balancing neuromuscular blockade versus preserved muscle activity. [JOURNAL ARTICLE]
- Curr Opin Crit Care 2014 Dec 17.
Acute respiratory distress syndrome (ARDS) is still associated with a high mortality. The best way to ensure mechanical ventilation in ARDS patients is still debated, recent data arguing for a muscle paralysis and a controlled ventilation whereas other elements being in favor of a preserved spontaneous breathing. The purpose of this review is to discuss the benefits and the disadvantages of both strategies.Randomized controlled trials have brought the evidence that at the acute phase of ARDS, a 48-h administration of cisatracurium is associated with a decrease in mortality for the most severe hypoxemic patients. Other studies suggest that spontaneous breathing could be deleterious at this period. In the less severe patients (mild ARDS), however, a few studies have demonstrated the benefits of preserving spontaneous breathing with an improvement in oxygenation and a decrease in the length of mechanical ventilation.In ARDS patients, the ventilator strategy should be a balance between muscle paralysis in the most hypoxemic patients and preserved spontaneous breathing after improvement or from the acute phase in less severe forms. However, monitoring plateau pressure, tidal volume and perhaps also transpulmonary pressure seems crucial to limit the occurrence of ventilator-induced lung injury.
- Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery†. [Journal Article]
- J Surg Case Rep 2014; 2014(12)
Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovah's Witness patient following emergent colectomy. The patient's hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patient's lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patient's course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.
- Comparing the effects of morphine sulfate and diclofenac suppositories on postoperative pain in coronary artery bypass graft patients. [Journal Article]
- Anesth Pain Med 2014 Oct; 4(4):e19423.
Simple and efficient way of pain management after Coronary Artery Bypass Graft (CABG) surgery is an important aspect of patients' care.This study aimed to compare the effects of morphine and diclofenac suppositories on postoperative pain management.In this double-blinded clinical trial study, 120 patients aged 30-65 years old, undergone CABG, were equally divided into two groups of A (morphine) and B (diclofenac). All patients were anesthetized with intravenous fentanyl 10 μg/kg, etomidate 0.2 mg/kg and cisatracurium 0.2 mg/kg. Anesthesia was maintained with oxygen 50% and air 50%, propofol 50 μg/kg/min, fentanyl 1-2 μg/kg/h and atracurium 0.6 mg/kg/h. Analgesics were administered after the operation at intensive care unit (ICU) and Visual Analogue Score (VAS) was evaluated in both groups in 4-hour intervals after extubation for 24 hours. After extubation in case of VAS > 3, morphine suppository 10 mg (group A) or diclofenac suppository 50 mg (group B) was administered for patients.No significant statistical relationship was found between the two groups regarding gender, age, BMI, paracetamol consumption, length of operation time, cardiopulmonary bypass pump (CPB) time, and stay time at ICU (P Value ≥ 0.05). Total dosage of used morphine was 22 ± 8.3 mg in each patient and total dosage of used diclofenac was 94 ± 32.01 mg. Average variation of VAS at measured intervals was significant (P Value ≤ 0.0001), but these variations were not significantly different when comparing the two groups (P Value = 0.023).Both morphine and diclofenac suppositories reduced pain significantly and similarly after CABG surgery.
- Comparison of the incidence of sore throat after rapid sequence intubation with succinylcholine and cisatracurium. [Journal Article]
- Anesth Pain Med 2014 Aug; 4(3):e20030.
Postoperative sore throat is a common complication of endotracheal intubation and can lead to dissatisfaction after surgery. Airway management has the strongest influence on the incidence of sore throat and improving endotracheal intubating conditions can reduce this complaint. Type of induction agent used during anesthesia can contribute to variances in the degree of post-operative sore throat.We aimed to compare the incidence of postoperative sore throat after rapid sequence induction with Succinylcholine and high dose Cisatracurium.The study was carried out on patients admitted to Shohada-e-Tajrish hospital for emergent abdominal surgery. Of the 80 patients who were enrolled in the study, 40 were randomly assigned to receive Succinylcholine while the remaining patients received Cistracurium during induction. Sore throat, muscle ache, hoarseness, dry throat and pain were assessed in each patient at baseline in recovery and at 2, 4, 12 and 24 hours post-operation.Number of patients who developed sore throat was significantly higher in the Succinylcholine group (75%) compared to Cisatracurium group (27.5%) at the time of entrance to the recovery room (P = 0.001). These numbers decreased at 2 hours post-operation (42% versus 17.5%) but the difference was still statistically significant (P < 0.05). At 12 (P = 0.062) and 24 (P = 0.14) hours post operation, the difference was no longer significant.Use of high dose Cisatracurium for induction during rapid sequence intubation carries a lower chance of developing sore throat compared to Succinylcholine. Studies comparing other adverse effects of these two agents are required to guide physician's choice of induction agent.
- Early Administration of Cisatracurium Attenuates Sepsis-Induced Diaphragm Dysfunction in Rats. [JOURNAL ARTICLE]
- Inflammation 2014 Sep 30.
Sepsis can often induce diaphragm dysfunction, which is associated with localized elaboration of cytokines within the diaphragm. The administration of cisatracurium has been shown to decrease the inflammatory response and to facilitate mechanical ventilation. In this study, we explored whether cisatracurium could attenuate sepsis-induced diaphragm dysfunction in rats. Animals were divided into three groups: (1) the control group: rats underwent a sham surgical procedure with cecal exposure, but the cecum was neither ligated nor punctured; (2) the CLP group: rats underwent cecal ligation and puncture (CLP) and received a continuous infusion of NaCl 0.9 %; and (3) the Cis + CLP group: rats underwent CLP and received a continuous infusion of cisatracurium. After the surgical procedure, all animals underwent controlled mechanical ventilation for 18 h. Plasma concentrations of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-mobility group box 1 (HMGB1) were measured using an enzyme-linked immunosorbent assay. Upon completion of the experimental protocol, diaphragm contractility and HMGB1 protein expression were analyzed. Impaired diaphragm contractile function, including both force-related properties and force-frequency responses, was pronounced after CLP in comparison with that observed in the control rats. Furthermore, CLP elevated serum levels of IL-6, TNF-α, and HMGB1, and induced HMGB1 protein expression in the diaphragm. In contrast, cisatracurium counteracted the sepsis-induced inflammation reaction in the diaphragm and serum and maintained diaphragm function. These data suggest that early infusion of cisatracurium attenuates sepsis-induced diaphragm dysfunction; this may be attributable to its anti-inflammatory action.
- A study of stress response to endotracheal intubation comparing glidescope and flexible fiberoptic bronchoscope. [Journal Article]
- Pak J Med Sci 2014 Sep; 30(5):1001-6.
To compare hemodynamic stress response (HDSR) to ET intubation using Glidescope (GLS) and Flexible fiberoptic laryngoscope (FFB).This prospective randomized comparative study was conducted at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia from June 2011 - November 2013. Eighty ASA 1 & 2 patients with normal airway undergoing elective surgical procedure requiring ET intubation were included in the study. Patients were randomly assigned in two groups GLS or FFB. General anesthesia was induced with propofol and fentanyl. Muscle relaxation was achieved with cisatracurium and ET intubation was performed using either GLS or FFB. Noninvasive hemodynamic data was recorded (HR, systolic, diastolic and mean blood pressure) as pre-induction, baseline and after ET intubation at one minute intervals for successive five minutes. End tidal Sevoflurane and CO2 at the time of intubation, need of external neck pressure, time to successful intubation and number of attempts were recorded; and rate pressure product was calculated.Induction of anesthesia resulted in significant fall in blood pressure in both the groups. ET intubation resulted in similar rise of BP in both groups (for 3-4 minutes) from their baseline values; however the rise was not significantly different from their respective pre-induction values. Time to intubation was longer with FFB compared to GLS however, need for external neck manipulation was more with GLS.There was no difference in HDSR due to ET intubation using either GLS or FFB in healthy adult patients with normal airway. Rate pressure product remained within the acceptable range.
- Effects on somatosensory and motor evoked potentials of senile patients using different doses of dexmedetomidine during spine surgery. [JOURNAL ARTICLE]
- Ir J Med Sci 2014 Sep 3.
The aim of this study was to evaluate the effects of different doses of dexmedetomidine (Dex) compounded propofol and fentanyl on intraoperative somatosensory evoked potential (SEP) and motor evoked potential (MEP) monitoring on senile patients.Forty-five patients undergoing elective spinal surgery were randomly divided into three groups: group C, group D1 (Dex, 0.3 μg kg(-1) h(-1)), and group D2 (Dex, 0.8 μg kg(-1) h(-1)). Anesthesia administration: midazolam, propofol, fentanyl, and cisatracurium. Anesthesia maintenance: propofol and fentanyl. No muscle relaxant was used throughout the operation. When muscle relaxation was T 4/T 1 > 75 %, SEPs and MEPs were monitored for the baseline. In group D1, Dex (0.3 μg/kg, loading dose) was administered, followed by a 0.3 μg kg(-1) h(-1) infusion of said drug until the end of surgery. In group D2, Dex (0.8 μg/kg, loading dose) was injected, followed by a 0.8 μg kg(-1) h(-1) infusion of said drug.Compared with group C, no significant difference was observed in the amplitude and latency of SEP (P15-N20) waves in groups D1 and D2 (P > 0.05). In groups C and D1, the MEP waveform did not disappear at every stage. In group D2, three patients lost the MEP waveform after the Dex loading dose, while four patients lost it during the Dex infusion stage. A significant difference was observed between groups C and D1. The median time to recover the MEP waveform was 47 min.Dex did not affect SEPs of senile patients, but inhibited MEPs when larger doses were administered.
- The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration. [Journal Article]
- Korean J Anesthesiol 2014 Jul; 67(1):26-31.
The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration.A total of 140 adult patients were randomized into 4 groups to receive either 30 µg/kg ephedrine (Group 30, n = 35), 70 µg/kg ephedrine (Group 70, n = 35), 110 µg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration.An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 ± 44.7 s, Group 70: 152.6 ± 40.3 s, Group 110: 151.2 ± 51.6 s) compared to Group C (224.6 ± 56.9 s) after 0.15 mg/kg of cisatracurium (P < 0.001). Ephedrine doses of either 70 or 110 µg/kg for pretreatment significantly improved intubating conditions (P < 0.05). Systolic and diastolic blood pressure and heart rate at 1 min after tracheal intubation were significantly increased than other times in all groups (P < 0.001), with no differences among the groups. However, 5 patients in Group 110 experienced marked hypertension (systolic/diastolic blood pressure: > 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups.We conclude that pre-treatment with ephedrine 70 µg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects.
- Differences between acceleromyography and electromyography during neuromuscular function monitoring in anesthetized Beagle dogs. [JOURNAL ARTICLE]
- Vet Anaesth Analg 2014 Jul 2.
Quantitative neuromuscular monitoring is essential for studies of potency and duration of neuromuscular blocking agents, and for detecting residual paralysis in anesthetized patients. This investigation evaluates whether there are systematic differences between acceleromyography (AMG) and electromyography (EMG); two quantitative methods for monitoring neuromuscular block.Prospective.Ten healthy Beagle dogs.Dogs were anesthetized with isoflurane and dexmedetomidine. Both ulnar nerves were stimulated with a train-of-four (TOF) pattern every 15 seconds. The magnitude of the first twitch (T1) and the TOF ratio (magnitude of T4/T1; TOFR) were quantified simultaneously with AMG and EMG, applied randomly to each extremity. The extent of maximal block (T1 depression) and onset time were measured by AMG and EMG during TOF monitoring after the administration of cisatracurium (0.05 mg kg(-1) ). In addition, recovery of T1 to 25% and 75%, the recovery index (time between T1 of 25% and 75%), and recovery of the TOFR to 0.9 were used to characterize recovery from cisatracurium and were compared between monitors. Regression and Bland-Altman plots for T1 and TOFR were also created.Maximal block and onset time were not different between monitors. Time to recovery of T1 to 25% and 75%, and time to TOF ratio 0.9 was significantly shorter with AMG. The recovery index was not different between monitors. When the TOFR returned to 0.9 with AMG, EMG still measured considerable residual block (TOFR 0.47).Electromyography consistently detected residual NMB when recovery from NMB was complete as assessed by AMG.
- Flowcytometric diagnosis of atracurium-induced anaphylaxis. [Journal Article, Research Support, Non-U.S. Gov't]
- Allergy 2014 Oct; 69(10):1324-32.
Allergy to atracurium is a rare condition with serious consequences of diagnostic error. However, correct diagnosis is not always straightforward. The aim of this study is to assess the utility of the basophil activation test (BAT) in atracurium sensitization and to investigate its role in identifying cross-reactivity between muscle relaxants.For validation, eight patients with perioperative anaphylaxis to atracurium and seven individuals experiencing perioperative anaphylaxis but not exposed to neuromuscular blocking agents (NMBA) were included. Furthermore, five other patient groups were included in the study, and all individuals exposed to different NMBA, either sensitized or not to the drug. Basophil activation with atracurium was analysed flow cytometrically.ROC analyses between eight atracurium-sensitized patients and seven nonexposed controls allowed identification of 5% as the decision threshold for BAT positivity. For this cutoff, the BAT attained a sensitivity of 63%, specificity of 100%, positive predictive value of 100% and negative predictive value of 70%. Of the atracurium-exposed individuals with a negative atracurium skin test (ST), two individuals had a clear positive BAT. BAT atracurium was positive in one cisatracurium-sensitized patient and negative in all cisatracurium-exposed patients with a negative ST to cisatracurium. All rocuronium- and suxamethonium-sensitized patients displayed a negative BAT with atracurium.The BAT proves to be a useful diagnostic for atracurium-induced anaphylaxis and may be complementary to STs. The technique enables quick and simultaneous testing of potentially crossreactive NMBA and the identification of safe alternatives for future surgery.