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JBI Database of Systematic Reviews and... Oct 2018The objective of this systematic review is to identify the effectiveness of sugammadex versus neostigmine on the reversal of rocuronium-induced neuromuscular blockade in... (Comparative Study)
Comparative Study
Effectiveness of sugammadex versus neostigmine on restoration of neuromuscular function in surgical patients with myasthenia gravis undergoing rocuronium-induced neuromuscular blockade: a systematic review protocol.
The objective of this systematic review is to identify the effectiveness of sugammadex versus neostigmine on the reversal of rocuronium-induced neuromuscular blockade in surgical patients with myasthenia gravis undergoing general anesthesia.
Topics: Anesthesia, General; Cholinesterase Inhibitors; Delayed Emergence from Anesthesia; Humans; Incidence; Myasthenia Gravis; Neostigmine; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Rocuronium; Sugammadex; Time Factors; Vecuronium Bromide; Systematic Reviews as Topic
PubMed: 30335038
DOI: 10.11124/JBISRIR-2017-003624 -
Journal of Clinical Monitoring and... Jun 2019There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four... (Observational Study)
Observational Study
There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four assessment, which can be less reliable in retrospective studies. The goal of our study was to investigate the real-world practice pattern of dosing of neuromuscular blocking agents (NMBA), utilizing the amount of NMBA used during the course of a case, adjusted for patient weight and case duration, as a surrogate measure of depth of NMB. We also aimed to identify case factors associated with larger NMBA doses. In this retrospective observational analysis of our anesthesia information management system, we analyzed all general endotracheal anesthesia cases from 2012 to 2015 in which an intermediate-acting NMBA was used. Cases using a long-acting NMBA or only succinylcholine were excluded. The expected duration of the case was calculated based on the cumulative dose of NMB used, normalized to the patient's ideal body weight and the ED95 of the drug. If the expected duration of the case was greater than the actual case duration documented in the case record, it was classified as higher dosing (HD). If the expected duration was equal to or less than the actual duration, it was considered predicted dosing (PD). Categorical comparisons between HD and PD groups were made for various patient, procedural, and provider factors. 72,684 cases were included in the final analysis, of which 46,358, or 64% of cases, used HD. Cases with patients who were morbidly obese, younger than 65 years, and who were lower ASA Physical Status classification (I or II) used more HD as opposed to PD. Cases that were non-open, used total intravenous anesthesia, emergent cases, or used non-rapid sequence anesthesia induction had higher rates of HD than their matched counterparts. All results were statistically significant. HD was more common in cases that documented train-of-four and used the reversal agent neostigmine. Approximately two-thirds of general endotracheal anesthesia cases using an intermediate-acting NMBA used HD. Cases with higher rates of HD may be those that are traditionally technically complex or emergent, would benefit from greater paralysis, or do not use adjunctive medications for muscle relaxation. Age greater than 65 years was shown to have lower rates of HD, likely due to provider awareness of age-related changes in pharmacokinetics and pharmacodynamics. Intraoperative monitoring and NMB antagonism with neostigmine were used more frequently with HD.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Androstanols; Anesthesia, General; Atracurium; Body Mass Index; Electronic Health Records; Female; Humans; Male; Middle Aged; Monitoring, Intraoperative; Muscle Relaxation; Neostigmine; Neuromuscular Blockade; Neuromuscular Blocking Agents; Neuromuscular Nondepolarizing Agents; Prevalence; Retrospective Studies; Rocuronium; Sugammadex; Vecuronium Bromide; Young Adult
PubMed: 30094585
DOI: 10.1007/s10877-018-0186-4 -
Acta Parasitologica Jun 2018The neuroimmunoregulation of inflammation has been well characterized. Entamoeba histolytica provokes an inflammatory response in the host in which macrophages and...
The neuroimmunoregulation of inflammation has been well characterized. Entamoeba histolytica provokes an inflammatory response in the host in which macrophages and neutrophils are the first line of defense. The aim of this study was to analyze the effect of the 220 kDa lectin of Entamoeba histolytica on stimulation of human macrophages and neutrophils, especially the secretion of cytokines and the relation of these to neurotransmitters. Human cells were interacted with L220, epinephrine, nicotine, esmolol and vecuronium bromide. The concentrations of IL-1β, IFN-γ, TNF-α and IL-10 were determined by ELISA at, 4 h of interaction. L220 has a cytokine stimulating function of macrophages and neutrophils for secretion of IL-1β, and IL-10 only by macrophages, which was modulated by the effect of vecuronium on cholinergic receptors in this immune cells.
Topics: Adolescent; Cytokines; Entamoeba histolytica; Epinephrine; Humans; Lectins; Macrophage Activation; Macrophages; Neurotransmitter Agents; Neutrophil Activation; Neutrophils; Nicotine; Protozoan Proteins; Vecuronium Bromide; Young Adult
PubMed: 29654688
DOI: 10.1515/ap-2018-0031 -
Pediatric Critical Care Medicine : a... Jun 2018To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries,...
OBJECTIVES
To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost.
DESIGN
This is a pre- and postimplementation quality improvement study.
SETTING
An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital.
PATIENTS
Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion.
INTERVENTIONS
Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs.
MEASUREMENTS AND MAIN RESULTS
Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160.
CONCLUSIONS
Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.
Topics: Atracurium; Child; Child, Preschool; Critical Care; Dexmedetomidine; Female; Fentanyl; Humans; Infant; Infusions, Intravenous; Injections, Intravenous; Intensive Care Units, Pediatric; Male; Midazolam; Morphine; Practice Patterns, Physicians'; Quality Improvement; Vecuronium Bromide
PubMed: 29652752
DOI: 10.1097/PCC.0000000000001549 -
American Journal of Respiratory and... Apr 2018
Topics: Atracurium; Humans; Neuromuscular Blocking Agents; Respiratory Distress Syndrome; Vecuronium Bromide
PubMed: 29324189
DOI: 10.1164/rccm.201712-2610ED -
Child's Nervous System : ChNS :... Feb 2018
Topics: Adjuvants, Anesthesia; Adrenergic alpha-1 Receptor Agonists; Analgesics, Opioid; Anesthesia, General; Anesthetics, Inhalation; Atropine; Female; Fentanyl; Fetal Therapies; Humans; Injections, Intramuscular; Medication Errors; Meningomyelocele; Neuromuscular Nondepolarizing Agents; Neurosurgical Procedures; Pain, Procedural; Phenylephrine; Pregnancy; Pregnancy Trimester, Second; Remifentanil; Sevoflurane; Stress, Physiological; Vecuronium Bromide
PubMed: 29249071
DOI: 10.1007/s00381-017-3677-6 -
Indian Journal of Anaesthesia Oct 2017Previous studies suggest that administration of vecuronium based on total body weight rather than ideal body weight (IBW) in obesity results in overdosing with prolonged...
BACKGROUND AND AIMS
Previous studies suggest that administration of vecuronium based on total body weight rather than ideal body weight (IBW) in obesity results in overdosing with prolonged recovery times. We hypothesised that larger doses of neostigmine could result in faster recovery in obese patients administered vecuronium based on total body weight.
METHODS
Forty-five obese American Society of Anesthesiologists' II patients undergoing elective surgery under general anaesthesia were randomised into 3 groups to receive neostigmine 30, 40 and 50 μg/kg. Following induction, patients were paralysed with vecuronium 0.1 mg/kg based on total body weight. Reversal was achieved with neostigmine based on the patient's group, and time to train-of-four (TOF) ratios of 0.5, 0.7 and 0.9 measured. The primary outcome variable was time to achieve TOF ratio >0.9.
RESULTS
Neostigmine 50 μg/kg achieved faster recovery to TOF 0.7 than neostigmine 30 and 40 μg/kg. There was no significant difference in recovery times to TOF 0.7 in patients receiving either 30 or 40 μg/kg of neostigmine. However, neostigmine 40 μg/kg attained TOF ratio 0.9 faster than 30 μg/kg. We did not note a significant difference between the 40 and 50 μg/kg dose with regard to recovery of TOF to 0.9.
CONCLUSION
Facilitated recovery from neuromuscular blockade to TOF of 0.7 was faster with neostigmine 50 μg/kg compared to 40 or 30 μg/kg. Recovery to TOF ratio of 0.9 was not significantly different with 40 or 50 μg/kg doses although such time was faster as compared to 30 μg/kg dose.
PubMed: 29242649
DOI: 10.4103/ija.IJA_297_17 -
American Journal of Respiratory and... Apr 2018The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular... (Comparative Study)
Comparative Study Observational Study
RATIONALE
The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages.
OBJECTIVES
To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS.
METHODS
Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location.
MEASUREMENTS AND MAIN RESULTS
Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056).
CONCLUSIONS
When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.
Topics: Atracurium; Cohort Studies; Female; Humans; Male; Middle Aged; Neuromuscular Blocking Agents; Respiratory Distress Syndrome; Risk; Treatment Outcome; Vecuronium Bromide
PubMed: 29241014
DOI: 10.1164/rccm.201706-1132OC -
Turkish Journal of Medical Sciences Nov 2017Background/aim: Myocardial protection is an important factor of open heart surgery and biological biomarkers (lactate, CKMB, cardiac troponin I, and pyruvate) are used...
Background/aim: Myocardial protection is an important factor of open heart surgery and biological biomarkers (lactate, CKMB, cardiac troponin I, and pyruvate) are used to assess myocardial damage. This study compares the effects of dexmedetomidine and remifentanil on myocardial protection during coronary artery bypass grafting (CABG) surgery. Materials and methods: Patients scheduled for elective CABG surgery (n = 60) were included in this study. Anesthesia induction was introduced with propofol, fentanyl, and vecuronium bromide. Anesthesia was maintained with remifentanil infusion and sevoflurane in the remifentanil group (Group R) and with dexmedetomidine infusion and sevoflurane in the dexmedetomidine group (Group D). Blood samples for biochemical markers were taken from the coronary sinus catheter before cardiopulmonary bypass (T1), 20 min after aortic cross-clamping (T2), 20 min after removal of the aortic cross-clamping (T3), and 10 min after separation from cardiopulmonary bypass (T4).Results: Demographic data were similar between the groups. Lactate level at the T2 period and CKMB levels during the study period were lower in Group D than in Group R. In both groups, all values except pyruvate significantly increased over time. Conclusion: The dexmedetomidine-sevoflurane combination may improve the cardioprotective effect in comparison with remifentanil-sevoflurane in CABG surgery.
PubMed: 29151310
DOI: 10.3906/sag-1612-130 -
Canadian Journal of Anaesthesia =... Feb 2018Nitrous oxide (NO) has been reported to increase the risk of postoperative nausea and vomiting (PONV) in a dose-dependent manner. We investigated the effect of adding NO... (Comparative Study)
Comparative Study Randomized Controlled Trial
Nitrous oxide added at the end of isoflurane anesthesia hastens early recovery without increasing the risk for postoperative nausea and vomiting: a randomized clinical trial.
BACKGROUND
Nitrous oxide (NO) has been reported to increase the risk of postoperative nausea and vomiting (PONV) in a dose-dependent manner. We investigated the effect of adding NO at the end of isoflurane inhalational anesthesia on the recovery and incidence of PONV. Our hypothesis was that NO would reduce the time to early recovery without increasing the incidence of PONV.
METHODS
After obtaining ethics committee approval and written informed consent, 100 women at American Society of Anesthesiologists physical status I-III and scheduled for laparoscopic-assisted vaginal hysterectomy were randomized into two groups (G) according to the carrier gas: GO (air in 30% oxygen) and GNO (the same mixture until the last 30 min of surgery, when 70% NO in 30% oxygen was used). No PONV prophylaxis was given. Anesthesia was induced with thiopental 5 mg·kg, vecuronium 0.1 mg·kg, and fentanyl 1-2 μg·kg iv and maintained with isoflurane. Indicators of early recovery (time to extubation, eye opening, following commands, orientation) were assessed by an anesthesiologist unaware of the group assignment. The incidence and severity of PONV was measured at two and 24 hr postoperatively.
RESULTS
Altogether, 82 participants completed the study (42 in GO, 40 in GNO) and were analyzed. The mean (SD) time of NO administration in GNO patients was 27.1 (10.1) min. The mean (SD) time to extubation was faster in GNO patients [5.4 (2.9) min] than in GO patients [7.5 (3.7) min] (mean difference, 2.0 min; 95% confidence interval [CI], 0.6 to 3.4, P = 0.009). The ability to open eyes, follow commands, and being oriented were all faster in GNO patients than in GO patients (differences of 3.9 min, 95% CI, 1.6 to 6.1, P = 0.001; 3.4 min, 95% CI, 1.0 to 5.7, P = 0.006; 3.8 min, 95% CI, 0.9 to 6.7, P = 0.010, respectively). The incidence of PONV was not different between the groups, but the rescue antiemetic was required less often in the GNO patients (mean difference in metoclopramide dose between the GNO and GO groups, 5.1 mg; 95% CI, 0.8 to 9.4, P = 0.019).
CONCLUSIONS
Adding NO during the last 30 min of an isoflurane-based inhalational anesthetic reduced the time to extubation, eye opening, and orientation.
Topics: Adult; Anesthesia Recovery Period; Anesthetics, Inhalation; Antiemetics; Dose-Response Relationship, Drug; Female; Fentanyl; Humans; Hysterectomy, Vaginal; Incidence; Isoflurane; Laparoscopy; Middle Aged; Nitrous Oxide; Postoperative Nausea and Vomiting; Thiopental; Vecuronium Bromide
PubMed: 29150782
DOI: 10.1007/s12630-017-1013-y