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Radkowski P, Krupiniewicz KJ, Suchcicki M, Machoń NJ, Cappello S, Szewczyk M, Wolska JM, Stompór T. Navigating Anesthesia: Muscle Relaxants and Reversal Agents in Patients with Renal Impairment. Med Sci Monit 2024; 30:e945141. [PMID: 39188037 PMCID: PMC11365435 DOI: 10.12659/msm.945141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 06/14/2024] [Indexed: 08/28/2024] Open
Abstract
This comprehensive review explores the interaction between neuromuscular blocking agents, reversal agents, and renal function, focusing on various drugs commonly used in anesthesia and their effects on kidney health. Succinylcholine, commonly used for anesthesia induction, can trigger elevated potassium levels in patients with specific medical conditions, leading to serious cardiac complications. While studies suggest the use of succinylcholine in patients with renal failure is safe, cases of postoperative hyperkalemia warrant further investigation. Some agents, such as atracurium and mivacurium, are minimally affected by impaired kidney function, whereas others, such as cisatracurium and rocuronium, can have altered clearance, necessitating dose adjustments in patients with renal failure. The reversal agents neostigmine and sugammadex affect renal markers, while cystatin C levels remain relatively stable with sugammadex use, indicating its milder impact on glomerular function, compared with neostigmine. Notably, the combination of rocuronium and sugammadex in rat studies shows potential nephrotoxic effects, cautioning against the simultaneous use of these agents. In conclusion, understanding the interplay between neuromuscular blocking agents and renal function is crucial for optimizing patient care during anesthesia. While some agents can be used safely in patients with renal failure, others can require careful dosing and monitoring. Further research is needed to comprehensively assess the long-term impact of these agents on kidney health, especially in high-risk patient populations. This article aims to review the use of muscle relaxants and reversal for anesthesia in patients with impaired renal function.
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Affiliation(s)
- Paweł Radkowski
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
- Department of Anesthesiology and Intensive Care, Regional Specialist Hospital, Olsztyn, Poland
- Department of Anesthesiology and Intensive Care, Hospital zum Heiligen Geist in Fritzlar, Fritzlar, Germany
| | | | - Mariusz Suchcicki
- Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Natalia Joanna Machoń
- Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Sara Cappello
- Faculty of Medicine and Surgery, University of Cagliari, Cagliari, Italy
| | - Maciej Szewczyk
- Residency in Rheumatology, University Clinical Hospital No. 1 in Szczecin, Szczecin, Poland
| | - Joanna Maria Wolska
- Department of Anesthesiology and Intensive Care, Regional Specialist Hospital, Olsztyn, Poland
| | - Tomasz Stompór
- Department of Nephrology, Transplantology and Internal Diseases, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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3
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Yamamoto M, Takagi S, Kijima M, Sato H, Doshu-Kajiura A, Kitajima O, Suzuki T. Influence of the Pringle maneuver during partial hepatectomy on the neuromuscular block induced by intermittent and continuous dosing of rocuronium. J Anesth 2023; 37:828-834. [PMID: 37548656 DOI: 10.1007/s00540-023-03239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE The Pringle maneuver (PM) is a common procedure in hepatectomy that is known to interrupt drug elimination. The purpose of this study was to examine the influence of PM on the duration of action of rocuronium administered by intermittent bolus dosing, the continuous rocuronium infusion dose required for maintenance of a moderate neuromuscular block, and changes in plasma concentrations of rocuronium. METHODS Twenty-seven adult patients undergoing partial hepatectomy with PM were enrolled in this study. The duration of action of 0.2 mg/kg rocuronium boluses (DUR), and the continuous rocuronium infusion dose required for maintenance of the height of the first twitch of the train-of-four (T1) at 10-20% of the control value (%T1), respectively, were electromyographically monitored on the adductor digiti minimi muscle. The effects of PM on DUR, %T1, and the plasma concentration of rocuronium were measured. RESULTS The DUR was significantly prolonged during PM [mean: 42.2 (SD: 8.0) min, P < 0.001] compared to baseline [29.7 (6.3) min]. It was prolonged even after completion of the PM [46.2 (10.5) min, P < 0.001]. The plasma concentration of rocuronium measured at every reappearance of T1 was comparable between before and during PM. %T1 [15.5 (5.6)%] was significantly depressed after the start of PM [6.5 (3.9)%, P < 0.001], with persistence of the depression even after completion of PM. However, there were no significant changes in the plasma concentration of rocuronium. CONCLUSIONS Rocuronium-induced neuromuscular block is significantly augmented during PM. However, the augmentation is not associated with an increase in plasma rocuronium concentration.
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Affiliation(s)
- Mai Yamamoto
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shunichi Takagi
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Miho Kijima
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hanae Sato
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Akira Doshu-Kajiura
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Osamu Kitajima
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Takahiro Suzuki
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
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Carvalho H, Verdonck M, Eleveld DJ, Ramirez D, D'Haese J, Flamée P, Geerts L, Wylleman J, Cools W, Barbe K, Struys MMRF, Poelaert J. Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial. J Clin Anesth 2023; 90:111225. [PMID: 37542918 DOI: 10.1016/j.jclinane.2023.111225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Objective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s STUDY OBJECTIVE: The present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements. DESIGN Observational trial. SETTING Tertiary Belgian hospital, from August 2020 up to September 2021. PATIENTS AND INTERVENTIONS Seventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria). MAIN RESULTS Published rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance. CONCLUSIONS Simulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
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Affiliation(s)
- Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium; Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Belgium.
| | - Michaël Verdonck
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Douglas J Eleveld
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - David Ramirez
- Servicio Anestesiología y Reanimación, Fundación Valle de Lili, Cali, Colombia
| | - Jan D'Haese
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Panagiotis Flamée
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Lieselot Geerts
- Department of Anaesthesia, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jasper Wylleman
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Wilfried Cools
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kurt Barbe
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel M R F Struys
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
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Shannon ML, Muhammad A, James NT, Williams ML, Breeyear J, Edwards T, Mosley JD, Choi L, Kannankeril P, Van Driest S. Variant-based heritability assessment of dexmedetomidine and fentanyl clearance in pediatric patients. Clin Transl Sci 2023; 16:1628-1638. [PMID: 37353859 PMCID: PMC10499425 DOI: 10.1111/cts.13574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
Despite complex pathways of drug disposition, clinical pharmacogenetic predictors currently rely on only a few high effect variants. Quantification of the polygenic contribution to variability in drug disposition is necessary to prioritize target drugs for pharmacogenomic approaches and guide analytic methods. Dexmedetomidine and fentanyl, often used in postoperative care of pediatric patients, have high rates of inter-individual variability in dosing requirements. Analyzing previously generated population pharmacokinetic parameters, we used Bayesian hierarchical mixed modeling to measure narrow-sense (additive) heritability (h SNP 2 ) of dexmedetomidine and fentanyl clearance in children and identify relative contributions of small, moderate, and large effect-size variants toh SNP 2 . We used genome-wide association studies (GWAS) to identify variants contributing to variation in dexmedetomidine and fentanyl clearance, followed by functional analyses to identify associated pathways. For dexmedetomidine, median clearance was 33.0 L/h (interquartile range [IQR] 23.8-47.9 L/h) andh SNP 2 was estimated to be 0.35 (90% credible interval 0.00-0.90), with 45% ofh SNP 2 attributed to large-, 32% to moderate-, and 23% to small-effect variants. The fentanyl cohort had median clearance of 8.2 L/h (IQR 4.7-16.7 L/h), with estimatedh SNP 2 of 0.30 (90% credible interval 0.00-0.84). Large-effect variants accounted for 30% ofh SNP 2 , whereas moderate- and small-effect variants accounted for 37% and 33%, respectively. As expected, given small sample sizes, no individual variants or pathways were significantly associated with dexmedetomidine or fentanyl clearance by GWAS. We conclude that clearance of both drugs is highly polygenic, motivating the future use of polygenic risk scores to guide appropriate dosing of dexmedetomidine and fentanyl.
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Affiliation(s)
| | - Ayesha Muhammad
- School of MedicineVanderbilt UniversityNashvilleTennesseeUSA
| | - Nathan T. James
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Berry Consultants, LLCAustinTexasUSA
| | - Michael L. Williams
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Department of Clinical Pharmacology and Quantitative PharmacologyAstraZenecaGothenburgSweden
| | - Joseph Breeyear
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Todd Edwards
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jonathan D. Mosley
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical InformaticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Leena Choi
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Prince Kannankeril
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sara Van Driest
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
All of Us Research ProgramNational Institutes of HealthWashingtonDCUSA
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Ahlström SE, Bergman PH, Jokela RM, Olkkola KT, Kaunisto MA, Kalso EA. Clinical and genetic factors associated with post-operative nausea and vomiting after propofol anaesthesia. Acta Anaesthesiol Scand 2023; 67:1018-1027. [PMID: 37156489 DOI: 10.1111/aas.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The incidence of post-operative nausea and vomiting (PONV) remains at about 30% despite all therapeutic efforts to reduce it. The clinical risk factors guiding the prophylactic treatment are well established, but genetic factors associated with PONV remain poorly known. The aim of this study was to explore clinical and genetic factors impacting PONV by performing a genome-wide association study (GWAS) together with relevant clinical factors as covariates, and systematically attempt to replicate previously reported PONV associations. Relevant clinical factors are explored with logistic regression model. METHODS This was an observational case control study in Helsinki University Hospital between 1 August 2006 and 31 December 2010. One thousand consenting women with elevated risk for PONV, undergoing breast cancer surgery with standardised propofol anaesthesia and antiemetics. After exclusions for clinical reasons and failed genotyping, 815 patients were included with 187 PONV cases and 628 controls. Emergence of PONV up to 7th post-operative day was recorded. PONV at 2-24 h after surgery was selected to be the primary outcome. The GWAS explored associations between PONV and 653 034 genetic variants. Replication attempts included 31 variants in 16 genes. RESULTS The overall incidence of PONV up to 7th post-operative day was 35%, where 3% had PONV at 0-2 h and 23% at 2-24 h after surgery. Age, American Society of Anaesthesiologists status, the amount of oxycodone used in the post-anaesthesia care unit, smoking status, previous PONV, and history of motion sickness were statistically significant predictive factors in the logistic model. The receiver operating characteristic-area under the curve of 0.75 (95% CI 0.71-0.79) was calculated for the model. The GWAS identified six variants with suggestive association to PONV (p < 1 × 10-5 ). Of the previously reported variants, association with the DRD2 variant rs18004972 (TaqIA) was replicated (p = .028). CONCLUSIONS Our GWAS approach did not identify any high-impact PONV susceptibility variants. The results provide some support for a role of dopamine D2 receptors in PONV.
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Affiliation(s)
- Sirkku E Ahlström
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Paula H Bergman
- Biostatistics Consulting, Department of Public Health, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Ritva M Jokela
- HUS Joint Resources, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- INDIVIDRUG Research Programme, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mari A Kaunisto
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Eija A Kalso
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- SleepWell Research Programme, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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7
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Gu QL, Xue FL, Zheng ZL, Wang HN, Guan YP, Wen YZ, Ye F, Huang M, Huang WQ, Wang ZX, Li JL. Nongenetic and genetic predictors of haemodynamic instability induced by propofol and opioids: A retrospective clinical study. Br J Clin Pharmacol 2023; 89:209-221. [PMID: 35939394 DOI: 10.1111/bcp.15480] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Propofol and opioids are commonly used in anaesthesia, but are highly susceptible to haemodynamic instability, thereby threatening the patient's surgical safety and prognosis. The purpose of this study was to investigate the predictors of haemodynamic instability and establish its predictive model. METHODS A total of 150 Chinese patients undergoing thyroid or breast surgery participated in the study, with target-controlled infusion concentrations of propofol, opioids dosage, heart rate (HR), mean arterial pressure (MAP) and Narcotrend Index recorded at key points throughout the procedure. The Agena MassARRAY system was used to genotype candidate single nucleotide polymorphisms related to pharmacodynamics and pharmacokinetics of propofol and opioids. RESULTS Among nongenetic factors, baseline HR (R = -.579, P < .001) and baseline MAP (R = -.725, P < .001) had a significant effect on the haemodynamic instability. Among genetic factors, the CT/CC genotype of GABRB1 rs4694846 (95% confidence interval [CI]: -11.309 to -3.155), AA/AG of OPRM1 rs1799971 (95%CI: 0.773 to 10.290), AA of CES2 rs8192925 (95%CI: 1.842 to 9.090) were associated with higher HR instability; the AA/GG genotype of NR1I2 rs6438550 (95%CI: 0.351 to 7.761), AA of BDNF rs2049046 (95%CI: -9.039 to -0.640) and GG of GABBR2 rs1167768 (95%CI: -10.146 to -1.740) were associated with higher MAP instability. The predictive models of HR and MAP fluctuations were developed, accounting for 45.0 and 59.2% of variations, respectively. CONCLUSION We found that cardiovascular fundamentals and genetic variants of GABRB1, GABBR2, OPRM1, BDNF, CES2 and NR1I2 are associated with cardiovascular susceptibility, which can provide a reference for haemodynamic management in clinical anaesthesia.
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Affiliation(s)
- Qing-Ling Gu
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Fa-Ling Xue
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhuo-Ling Zheng
- Department of Pharmacy, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hai-Ni Wang
- Department of Pharmacy, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
| | - Yan-Ping Guan
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yong-Zi Wen
- Junzhi Biomedical Research Laboratory (Foshan) Co., Ltd., Foshan, Guangdong, China
| | - Fang Ye
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wen-Qi Huang
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhong-Xing Wang
- Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia-Li Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, Guangdong, China
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8
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Vishneski SR, Saha AK, Fram MR, Templeton LB, Lee LK, Ririe DG, Goenaga‐Diaz EJ, Smith LD, Templeton TW. Risk factors for administration of additional reversal following neuromuscular blockade with rocuronium in children: A retrospective case-control study. Paediatr Anaesth 2022; 32:916-925. [PMID: 35438816 PMCID: PMC9544061 DOI: 10.1111/pan.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prevalence and risk factors for residual neuromuscular blockade in children remain poorly characterized. We hypothesize that specific patient and anesthetic risk factors may be associated with the administration of additional reversal in children following initial reversal of rocuronium with neostigmine. METHODS Our electronic health record was queried for patients <18 years of age who received rocuronium and reversal with neostigmine from 2017 through 2020. Patients receiving other nondepolarizing neuromuscular blocking drugs were excluded. The outcome of interest was defined as the administration of additional neostigmine or sugammadex following primary reversal with neostigmine. Time between the last dose of rocuronium and initial dose of neostigmine, and the cumulative dose of rocuronium were dichotomized. These were combined with other covariates including age, weight, sex, racial group, procedure type, ASA physical status, >1 rocuronium dose administered during the procedure, initial neostigmine dose <0.05 mg kg-1 , use of train-of-four monitoring, duration of anesthesia, inpatient or outpatient, emergency case, neuromuscular disease, and extremes of weight, to assess possible associations with the primary outcome. RESULTS During the study period, 101/6373 (1.58%) patients received rocuronium and additional reversal. Dichotomization of time between last dose of rocuronium and neostigmine yielded <28 min since the last dose of rocuronium and cumulative dose of rocuronium >0.45 mg kg-1 hr-1 . These were associated with the administration of additional reversal with an OR 1.52 (95% CI, 1.08-2.35) and OR 1.71 (95% CI, 1.10-2.67), respectively. Other risk factors included an initial neostigmine dose <0.05 mg kg-1 , OR 4.98 (95% CI, 2.84-6.49), and African American race, OR 1.78 (95% CI, 1.07-2.87). CONCLUSION Risk factors associated with the administration of additional reversal included time <28 min from the last dose of rocuronium to initial dose of neostigmine, cumulative dose of rocuronium >0.45 mg kg-1 hr-1 , initial neostigmine dose <0.05 mg kg-1 , and African American race.
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Affiliation(s)
- Susan R. Vishneski
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Amit K. Saha
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | - Leah B. Templeton
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Lisa K. Lee
- Department of AnesthesiologyUCLALos AngelesCaliforniaUSA
| | - Douglas G. Ririe
- Department of AnesthesiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Zhu H, Wang Y, Wang Q, Zhao S, Xu F, Hu Z, Zhou R, Huang S, Han L, Chen X. Polymorphisms contribute to differences in the effect of rocuronium in Chinese patients. Basic Clin Pharmacol Toxicol 2021; 130:141-150. [PMID: 34734679 DOI: 10.1111/bcpt.13682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/17/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
Rocuronium is widely utilized in clinical general anaesthesia, and individual differences in pharmacology and clearance have been observed. Two hundred thirty-six Chinese patients undergoing selective thyroid/breast mass resection were studied. Total intravenous anaesthesia was induced with a single dose of propofol (2 mg·kg-1 ), sufentanil (0.5 μg·kg-1 ), and rocuronium (0.6 mg·kg-1 ) and maintained with propofol (3-5 mg·kg-1 ·h-1 ) and remifentanil (0.2-0.4 μg·kg-1 ·min-1 ). Intubation conditions and a train-of-four index of patients were utilized to assess the effects and duration of rocuronium. The data from 228 patients were analysed and reported. Genotypes NR1I2 rs2472677 C > T, NR1I2 rs6785049 G > A, SLCO1B1 rs4363657 T > C, SLCO1A2 rs4762699 T > C, and UGT1A1 rs4148323 G > A contributed to individual variation in rocuronium. Of the clinical variables tested, age, BMI, total dose of propofol, NR1I2 rs2472677, and SLCO1A2 rs4762699 correlated significantly (P < 0.05 for all) with the clinical duration or total clinical action time of rocuronium in a multiple linear regression model. No significant interactions were observed in intubation conditions. Genetic variations in NR1I2 rs2472677, NR1I2 rs6785049, SLCO1B1 rs4363657, SLCO1A2 rs4762699, and UGT1A1 rs4148323 were related to extensive interindividual variability in the clinical duration and total clinical action time of rocuronium.
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Affiliation(s)
- Hongyu Zhu
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yafeng Wang
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Wang
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Zhao
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Xu
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Hu
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruihui Zhou
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiqian Huang
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linlin Han
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangdong Chen
- Department of Anaesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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