Download the Free Unbound MEDLINE PubMed App to your smartphone or tablet.
Available for iPhone, iPad, iPod touch, and Android.
- Holy Moly! Severe Serotonin Syndrome Associated With a Recreational Agent. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):248A.
Critical Care Case Report Posters ISESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Serotonin syndrome is a potentially life-threatening drug reaction that may occur following therapeutic drug use, inadvertent interactions between drugs, overdose of particular drugs, or the recreational use of certain drugs . It is caused by drug induced excess of intrasynaptic 5-hydroxytryptamine (5-HT) . We report a case of severe serotonin syndrome caused by interaction between a serotonin-norepinephrine reuptake inhibitor (SNRI) and street drug- `Molly'.CASE PRESENTATION: A 41-year-old male with history of bipolar disorder was brought to ED for evaluation of extreme combativeness for one day. He was on risperidone and desvenlafaxine (an SNRI) and admitted to taking a "street drug -Molly". Vitals revealed temperature of 40⁰C, pulse of 108bpm and blood pressure of 155/122mmhg. The patient was extremely agitated, diaphoretic and tremulous. Despite multiple intravenous lorazepam boluses, he remained combative. He was subsequently intubated and placed on a mechanical ventilator. Laboratory workup was significant for sodium of 118 meq/L, creatinine kinase (CK) of 3543U/L and myoglobin of 16,261ng/ml. Based on his clinical presentation, severe serotonin syndrome was diagnosed and managed with aggressive fluid hydration, cessation of serotonergic agent, sedation and neuromuscular blockade with cisatracurium. He subsequently developed massive rhabdomyolysis followed by acute renal failure requiring initiation of hemodialysis. With supportive care, his renal and neurological function improved and he was successfully extubated on day 19. He was discharged to a subacute facility on day 35.DISCUSSION: "Molly" colloquially refers to MDMA(3,4-methylenedioxy-N-methylamphetamine) that is relatively free of adulterants. MDMA is a ring-substituted amphetamine derivative which indirectly stimulates the release and inhibits the reuptake of 5-HT . Its use especially in association with SSRIs or SNRIs has been associated with severe serotonin syndrome [1,3] requiring immediate and aggressive medical intervention.CONCLUSIONS: Clinicians should be aware about the dangerous interaction between serotonergic agents and recreational drugs which could result in potentially lethal serotonin syndrome.Reference #1: Boyer EW, Shannon M.The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20.Reference #2: Gillman PK. The serotonin syndrome and its treatment. J Psychopharmacol 1999;13:100 - 9.Reference #3: Parrott AC. Recreational Ecstasy/MDMA, the serotonin syndrome, and serotonergic neurotoxicity. Pharmacol Biochem Behav. 2002 Apr;71(4):837-44.DISCLOSURE: The following authors have nothing to disclose: Srijana Rai, Pranabh Shrestha, Ram Katpally, Marc AdelmanNo Product/Research Disclosure Information.
- 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]
- Allergy 2014 Jun 24.
Allergy to atracurium is a rare condition with serious consequences of diagnostic error. However, correct diagnosis is not always straightforward.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 8 patients with perioperative anaphylaxis to atracurium and 7 individuals experiencing perioperative anaphylaxis but not exposed to neuromuscular blocking agents (NMBA) were included. Furthermore, 5 other patient groups were included in the study, all individuals exposed to different NMBA, either sensitized or not to the drug. Basophil activation with atracurium was analysed flow cytometrically.ROC analyses between 8 atracurium sensitized patients and 7 non-exposed controls allowed identification of 5% as the decision threshold for BAT positivity. For this cut off 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, 2 individuals had a clear positive BAT. BAT atracurium was positive in one cisatracurium sensitised patient and negative in all cisatracurium exposed patients with a negative skin test 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 skin tests. The technique enables quick and simultaneous testing of potentially cross-reactive NMBA and the identification of safe alternatives for future surgery. This article is protected by copyright. All rights reserved.
- Effect of dexmedetomidine-etomidate-fentanyl combined anesthesia on somatosensory- and motor-evoked potentials in patients undergoing spinal surgery. [JOURNAL ARTICLE]
- Exp Ther Med 2014 May; 7(5):1383-1387.
This aim of the present study was to evaluate the effects of dexmedetomidine (DEX) on the intraoperative monitoring of somatosensory-evoked potentials (SEPs) and motor-evoked potentials (MEPs) in patients undergoing spinal surgery. A total of 36 patients who received spinal surgery under general anesthesia were randomly divided into two groups (n=18 per group), group C, the test group and group D, the control group, and these groups were subjected to a matching anesthesia induction. In brief, the anesthesia was administered via injection of etomidate and fentanyl; once the patients were unconscious, a laryngeal mask airway (LMA) was inserted, SEPs and MEPs were monitored and the collected data were considered to be basic data. Cisatracurium was subsequently injected and an endotracheal tube (7#) was inserted to replace the LMA. The following procedures were conducted for anesthesia maintenance: Group C, the anesthesia was maintained via target-controlled infusion of etomidate and intermittent injection of fentanyl; and group D, DEX (0.5 μg/kg) was injected over a duration of 10 min and then pumped at a rate of 0.5 μg/kg/h. In the two groups, all of the other drugs used were the same and a muscle relaxant was not administered. The bispectral index was maintained between 45 and 55 during surgery, and the SEPs and MEPs were monitored continuously until the surgery was completed. No significant difference in duration and amplitude of the SEPs (P15-N20) was identified between group C and D (P>0.05). Furthermore, the MEPs were monitored in the two groups at specific durations and no significant difference was observed between the two groups (P>0.05). The SEPs and MEPs were maintained in the patients who were administered with the DEX-etomidate-fentanyl combined anesthesia during spinal surgery.
- Pharmacological treatments for acute respiratory distress syndrome: systematic review. [JOURNAL ARTICLE]
- Minerva Anestesiol 2014 Jun 17.
Our objective was to systematically review the effect of pharmacological therapies on mortality in patients with acute respiratory distress syndrome (ARDS), focusing on randomized controlled trials (RCTs) published since a previous review in 2004.We updated previous searches and searched OVID versions of MEDLINE, EMBASE and CENTRAL (to January 2013) and proceedings from conferences and bibliographies of included studies. We included RCTs of pharmacologic therapies compared with placebo or no therapy for adult patients with ARDS, using authors' definitions, which reported on mortality (≤3 months after randomization). We excluded subgroups of patients with ARDS reported in RCTs enrolling other populations and RCTs of therapies to prevent ARDS, nutritional or fluid interventions, inhaled nitric oxide, therapies coupled to a mechanical ventilation strategy, or oxygen. Two reviewers independently screened citations, selected articles for inclusion, and abstracted clinical and methodological data from included studies with disagreements resolved by a third reviewer. Mortality data were pooled using randomeffects models.From 13461 citations, 58 trials (6635 patients) of 21 classes of medications met selection criteria; 26 trials (3880 patients) were published after 2003. Meta-analyses reduced 28-day mortality with a 48-hour infusion of cisatracurium in early ARDS (relative risk 0.66, 95% confidence interval 0.50 to 0.87; 431 patients, 138 deaths). There was no effect on mortality with granulocyte-macrophage colony stimulating factor, late low-dose methylprednisolone, neutrophil elastase inhibitors, intravenous salbutamol, surfactant, or N-acetylcysteine; each metaanalysis included ≥1 trial published after 2003. Seven single trials of other treatments published after 2003 showed no effect. Metaanalysis of older trials of prostaglandin E1 also showed no effect.Effective pharmacotherapy for ARDS remains extremely limited. Cisatracurium is a promising treatment for early moderate-severe ARDS (using Berlin definition nomenclature) and merits further investigation in a large RCT.