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Xu S, Zhang Q, Li Y, Luo C, Lai R, Guo L, Hai L, Lv G, Wu Y. Pathway to Construct α-Acyloxy Esters by B(C 6F 5) 3-Catalyzed O-H Insertion of Carboxylic Acids with Sulfoxonium Ylides. J Org Chem 2023; 88:15335-15349. [PMID: 37875403 DOI: 10.1021/acs.joc.3c01830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
We report the first example of B(C6F5)3-catalyzed O-H insertion reaction of sulfoxonium ylides and carboxylic acids, achieving efficient construction of diester moieties under metal-free condition. This protocol is characterized by broad substrate tolerance, particularly for various phenylacetic acids, and good compatibility with water/air condition, which is superior to most other methods.
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Affiliation(s)
- Shuran Xu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Qingyao Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Yuanyuan Li
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Cankun Luo
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Ruizhi Lai
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Li Guo
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Li Hai
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
| | - Guanghui Lv
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
- Department of Pharmacy, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, Hubei, China
| | - Yong Wu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Department of Medicinal Chemistry, West China School of Pharmacy, Sichuan University, No. 17, third Section, South Renmin Road, Chengdu 610041, Sichuan, P. R. China
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Lang B, Han L, Zeng L, Zhang Q, Chen S, Huang L, Jia Z, Yu Q, Zhang L. Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis. BMC Pediatr 2022; 22:295. [PMID: 35590273 PMCID: PMC9118813 DOI: 10.1186/s12887-022-03288-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 04/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent survey revealed that extensive off-label use of sugammadex in pediatric anesthesia deserved particular attention. The present study with trial sequential analysis (TSA) aimed to evaluate the effects of sugammadex for antagonizing neuromuscular blockade (NMB) in pediatric patients, and to investigate whether the findings achieved the required information size to draw conclusions. METHODS PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to April 2021. All randomized controlled trials used sugammadex as reversal agent in pediatric patients were enrolled. Time from NMB reversal to recovery of the train-of-four ratio (TOFr) to 0.9 and extubation time were considered as co-primary outcomes, and incidences of adverse events were considered as secondary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of evidences. RESULTS Data from 18 studies involving 1,065 pediatric patients were acquired. The results revealed that use of sugammadex was associated with shorter duration from administration of reversal agents to TOFr > 0.9 (MD = -14.42, with 95% CI [-17.08, -11.75]) and shorter interval from reversal from NMB to extubation (MD = -13.98, with 95% CI [-16.70, -11.26]) compared to control groups. TSA also indicated that the current sample sizes were sufficient with unnecessary further trials. Analysis of secondary outcomes indicated that administration of sugammadex was associated with less incidence of postoperative nausea and vomiting (PONV), bradycardia, and dry mouth compared to control groups. CONCLUSION Considering of satisfactory and rapid neuromuscular blockade reversal with low incidences of adverse events, sugammadex might be considered as the preferred option for children in clinical anesthesia practice compared to acetylcholinesterase inhibitors. However, overall low-quality evidences in present study rated by GRADE system indicated that superiority of sugammadex employed in pediatric patients needs to be confirmed by more studies with high quality and large sample size in future.
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Affiliation(s)
- Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Lu Han
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Qianqian Zhang
- Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Zhijun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Biopharmaceutics, West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
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Righetti RF, Grams ST, Costa WNDS, Saraiva LT, de Salles ICD, Yamaguti WP. Neuromuscular Electrical Stimulation in Patients With Severe COVID-19 Associated With Sepsis and Septic Shock. Front Med (Lausanne) 2022; 9:751636. [PMID: 35252228 PMCID: PMC8888402 DOI: 10.3389/fmed.2022.751636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/11/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Neuromuscular electrical stimulation (NMES) can be applied to critically ill patients. However, its results on muscle strength and functionality in patients with COVID-19 are unknown. OBJECTIVE Evaluate the effects of intervention with NMES on muscle mass and functionality of patients with severe COVID-19 associated with sepsis and septic shock. METHODS Seven patients with COVID-19 associated with sepsis or septic shock were selected, but only 5 patients completed all days of the intervention with NMES. The intervention was performed by a single physiotherapist on 7 consecutive days in a daily session of 40 min. The outcome measures were the femoris cross-sectional area; thickness of the anterior compartment of the quadriceps muscle; rectus femoris echogenicity; International Classification of Functioning, Disability, and Health (ICF)-muscle strength; PFIT-s, DEMMI, and the SOMS; feasibility, and safety. The patients were evaluated on days 1, 5, and 8. RESULTS The rectus femoris cross-sectional area decreased significantly from days 1 to 8, but showed maintenance of the thickness of the anterior compartment of the quadriceps muscle from days 1 to 8. The MRC score increased significantly from days 1 to 5 and kept this improvement until day 8. All patients showed an increase in the MRC score and reduction of the ICF-muscle strength, meaning improved muscle strength from days 1 to 8. The PFIT-s increased significantly from days 1 to 5 and improved until day 8 compared to day 5. DEMMI and SOMS score increased significantly on day 8 compared to days 1 and 5. CONCLUSION Rehabilitation with NMES showed improvement in muscle strength and functionality of patients in this study with a potential protective effect on muscle mass loss in patients with critical COVID-19 associated with sepsis and septic shock. This study is the first report of the potential effects of neuromuscular electrical stimulation in patients with severe COVID-19 associated with sepsis and septic shock.
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Shelukhina IV, Zhmak MN, Lobanov AV, Ivanov IA, Garifulina AI, Kravchenko IN, Rasskazova EA, Salmova MA, Tukhovskaya EA, Rykov VA, Slashcheva GA, Egorova NS, Muzyka IS, Tsetlin VI, Utkin YN. Azemiopsin, a Selective Peptide Antagonist of Muscle Nicotinic Acetylcholine Receptor: Preclinical Evaluation as a Local Muscle Relaxant. Toxins (Basel) 2018; 10:E34. [PMID: 29316656 PMCID: PMC5793121 DOI: 10.3390/toxins10010034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/31/2017] [Accepted: 01/02/2018] [Indexed: 12/19/2022] Open
Abstract
Azemiopsin (Az), a linear peptide from the Azemiops feae viper venom, contains no disulfide bonds, is a high-affinity and selective inhibitor of nicotinic acetylcholine receptor (nAChR) of muscle type and may be considered as potentially applicable nondepolarizing muscle relaxant. In this study, we investigated its preclinical profile in regard to in vitro and in vivo efficacy, acute and chronic toxicity, pharmacokinetics, allergenic capacity, immunotoxicity and mutagenic potency. The peptide effectively inhibited (IC50 ~ 19 nM) calcium response of muscle nAChR evoked by 30 μM (EC100) acetylcholine but was less potent (IC50 ~ 3 μM) at α7 nAChR activated by 10 μM (EC50) acetylcholine and had a low affinity to α4β2 and α3-containing nAChR, as well as to GABAA or 5HT₃ receptors. Its muscle relaxant effect was demonstrated at intramuscular injection to mice at doses of 30-300 µg/kg, 30 µg/kg being the initial effective dose and 90 µg/kg-the average effective dose. The maximal muscle relaxant effect of Az was achieved in 10 min after the administration and elimination half-life of Az in mice was calculated as 20-40 min. The longest period of Az action observed at a dose of 300 µg/kg was 55 min. The highest acute toxicity (LD50 510 μg/kg) was observed at intravenous injection of Az, at intramuscular or intraperitoneal administration it was less toxic. The peptide showed practically no immunotoxic, allergenic or mutagenic capacity. Overall, the results demonstrate that Az has good drug-like properties for the application as local muscle relaxant and in its parameters, is not inferior to the relaxants currently used. However, some Az modification might be effective to extend its narrow therapeutic window, a typical characteristic and a weak point of all nondepolarizing myorelaxants.
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Affiliation(s)
- Irina V. Shelukhina
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Maxim N. Zhmak
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Alexander V. Lobanov
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Igor A. Ivanov
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Alexandra I. Garifulina
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Irina N. Kravchenko
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Ekaterina A. Rasskazova
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Margarita A. Salmova
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Elena A. Tukhovskaya
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Vladimir A. Rykov
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Gulsara A. Slashcheva
- Branch of the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino 142290, Moscow Region, Russia; (A.V.L); (I.N.K.); (E.A.R.); (M.A.S.); (E.A.T.); (V.A.R.); (G.A.S.)
| | - Natalya S. Egorova
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Inessa S. Muzyka
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Victor I. Tsetlin
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
| | - Yuri N. Utkin
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, ul. Miklukho-Maklaya 16/10, Moscow 117997, Russia; (I.V.S.); (M.N.Z.); (I.A.I.); (A.I.G.); (N.S.E.); (I.S.M.); (V.I.T.)
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Kim YB, Sung TY, Yang HS. Factors that affect the onset of action of non-depolarizing neuromuscular blocking agents. Korean J Anesthesiol 2017; 70:500-510. [PMID: 29046769 PMCID: PMC5645582 DOI: 10.4097/kjae.2017.70.5.500] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/02/2017] [Indexed: 12/14/2022] Open
Abstract
Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.
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Affiliation(s)
- Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kandukuri DS, Phillips JK, Tahmindjis M, Hildreth CM. Effect of anaesthetic and choice of neuromuscular blocker on vagal control of heart rate under laboratory animal experimental conditions. Lab Anim 2017; 52:280-291. [PMID: 28862524 DOI: 10.1177/0023677217725365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuromuscular-blocking agents are commonly used in laboratory animal research settings. Due to actions of cholinergic receptors at locations other than the motor end-plate, these agents have a strong propensity to modulate autonomic outflow and may therefore not be desirable in studies examining autonomic function. This study aimed to compare the effect of two non-depolarizing neuromuscular-blocking agents, pancuronium and cisatracurium, on blood pressure, heart rate and non-invasive indices of autonomic function (heart rate variability, systolic blood pressure variability and baroreflex sensitivity) under two different types of anaesthesia in Lewis rats. Pancuronium produced a profound vagolytic response characterized by tachycardia, reduction in heart rate variability and baroreflex sensitivity under urethane anaesthesia, and with minimal effect under isoflurane anaesthesia. Conversely, cisatracurium produced no evidence of vagolytic action under either urethane or isoflurane anaesthesia. Therefore, for studies interested in examining autonomic function, particularly baroreflex or vagal function, neuromuscular blockade would be best achieved using cisatracurium.
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Affiliation(s)
- Divya Sarma Kandukuri
- 1 Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Jacqueline K Phillips
- 1 Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Mark Tahmindjis
- 2 Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Cara M Hildreth
- 1 Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Farooq K, Hunter JM. Neuromuscular blocking agents and reversal agents. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2017. [DOI: 10.1016/j.mpaic.2017.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Wu XY, Wang YL, Hai L, Gong P, Wu Y. A new and efficient method for the synthesis of rocuronium bromide. CHINESE CHEM LETT 2017. [DOI: 10.1016/j.cclet.2016.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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The Benefit of Neuromuscular Blockade in Patients with Postanoxic Myoclonus Otherwise Obscuring Continuous Electroencephalography (CEEG). Crit Care Res Pract 2017; 2017:2504058. [PMID: 28265468 PMCID: PMC5317108 DOI: 10.1155/2017/2504058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/08/2017] [Accepted: 01/18/2017] [Indexed: 12/04/2022] Open
Abstract
Introduction. Myoclonus status epilepticus is independently associated with poor outcome in coma patients after cardiac arrest. Determining if myoclonus is of cortical origin on continuous electroencephalography (CEEG) can be difficult secondary to the muscle artifact obscuring the underlying CEEG. The use of a neuromuscular blocker can be useful in these cases. Methods. Retrospective review of CEEG in patients with postanoxic myoclonus who received cisatracurium while being monitored. Results. Twelve patients (mean age: 53.3 years; 58.3% male) met inclusion criteria of clinical postanoxic myoclonus. The initial CEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with continuous slowing (50%), burst suppression with myoclonic artifact (41.7%), and continuous myogenic artifact obscuring CEEG (8.3%). After intravenous administration of cisatracurium (0.1 mg–2 mg), reduction in artifact improved quality of CEEG recordings in 9/12 (75%), revealing previously unrecognized patterns: continuous EEG seizures (33.3%), lateralizing slowing (16.7%), burst suppression (16.7%), generalized periodic discharges (8.3%), and, in the patient who had an initially uninterpretable CEEG from myogenic artifact, continuous slowing. Conclusion. Short-acting neuromuscular blockade is useful in determining background cerebral activity on CEEG otherwise partially or completely obscured by muscle artifact in patients with postanoxic myoclonus. Fully understanding background cerebral activity is important in prognostication and treatment, particularly when there are underlying EEG seizures.
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Lobaz S, Clymer M, Sammut M. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. ACTA ACUST UNITED AC 2014. [DOI: 10.4137/cmt.s10241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.
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Affiliation(s)
- Steven Lobaz
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mark Clymer
- Department of Anaesthetics and Intensive Care Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - Mario Sammut
- Department of Anaesthetics and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
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Roberts DJ, Hall RI. Drug absorption, distribution, metabolism and excretion considerations in critically ill adults. Expert Opin Drug Metab Toxicol 2013; 9:1067-84. [PMID: 23682923 DOI: 10.1517/17425255.2013.799137] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION All critically ill patients require medication to treat organ dysfunction. However, the pharmacokinetics of drugs used to treat these patients is complex due to frequent alterations in drug absorption, distribution, metabolism, and excretion (ADME). AREAS COVERED This review examines pharmacokinetic aspects of drug administration for adult intensive care unit (ICU) patients. Specifically, the authors examine the ADME changes that occur and which should be considered by clinicians when delivering drug therapy to critically ill patients. EXPERT OPINION Dosage pharmacokinetics determined from single-dose or limited-duration administration studies in healthy volunteers may not apply to critically ill patients. Organ dysfunction among these patients may be due to pre-existing disease or the effects of a systemic or locoregional inflammatory response precipitated by their illness. Alterations in pharmacokinetics observed among the critically ill include altered bioavailability after enteral administration, increased volume of distribution and blood-brain barrier permeability and changes in P-glycoprotein and cytochrome P450 enzyme function. However, the effect of these changes on clinically important outcomes remains uncertain and poorly studied. Future investigations should examine not only pharmacokinetic changes among the critically ill, but also whether recognition of these changes and alterations in drug therapy directed as a consequence of their observation alters patient outcomes.
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Affiliation(s)
- Derek J Roberts
- University of Calgary, Departments of Surgery and Community Health Sciences, Calgary, Alberta T2N 5A1, Canada
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Kruijt Spanjer MR, Bakker NA, Absalom AR. Pharmacology in the elderly and newer anaesthesia drugs. Best Pract Res Clin Anaesthesiol 2011; 25:355-65. [PMID: 21925401 DOI: 10.1016/j.bpa.2011.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/06/2011] [Indexed: 12/17/2022]
Abstract
In developed countries, a growing proportion of patients presenting for anesthesia and surgery are elderly. Despite this, and the fact that aging is known to be associated with alterations in drug pharmacokinetics and dynamics, there is little detailed information about the impact of aging on the pharmacology of commonly used anesthetic agents. In this review, we discuss existing current knowledge on the physiological changes that occur with age and the way these changes affect the pharmacokinetics and dynamics of anesthetic agents. Also, an overview of up-to-date PK-PD modeling concepts and their usefulness and limitations in modern anesthesiologic practice with respect to the elderly population is given. Finally, newer agents such as sugammadex, remifentanyl, ropivacaine and desflurane are discussed in detail with emphasis on current evidence concerning dosing, safety and efficacy of their use in the elderly.
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Affiliation(s)
- Martijn R Kruijt Spanjer
- Department of Anesthesiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Neuromuscular blocking agents and reversal agents. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2011. [DOI: 10.1016/j.mpaic.2011.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Koo MS, Kim NY, Lee HJ, Yoon SW, Kim KS. Rocuronium-induced neuromuscular block after long pretreatment of clonidine in rabbits. Korean J Anesthesiol 2010; 59:190-5. [PMID: 20877704 PMCID: PMC2946037 DOI: 10.4097/kjae.2010.59.3.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 06/01/2010] [Indexed: 11/24/2022] Open
Abstract
Background Clonidine, an α-2 adrenergic agonist, is used in the perioperative period and in intensive care for the management of hypertension. The in vivo and in vitro effects of clonidine on the actions of nondepolarizing neuromuscular blocking drugs are conflicting. We evaluated the potency and time course of rocuronium-induced neuromuscular block after prolonged pretreatment with clonidine in rabbits. Methods Sixty rabbits were randomly assigned to three groups; control (C) group: normal saline 0.1 ml/kg daily subcutaneous for 6 weeks; S3 group: clonidine 4 µg/kg daily subcutaneous for 3 weeks; S6 group: clonidine 4 µg/kg daily subcutaneous for 6 weeks. The dose-response relations of rocuronium were tested in 30 rabbits (10 from each of the three groups) during ketamine-thiopental anesthesia, while the time course of rocuronium 0.6 mg/kg was examined in 10 rabbits each from the three groups. Results There was no difference in mean arterial pressure and pulse rate among the experimental groups. The calculated ED50 for rocuronium decreased significantly from 64.1 µg/kg (C group) to 50.3 µg/kg (S3 group) and 47.8µg/kg (S6 group) (P < 0.001). There was no difference in the onset and the recovery times after rocuronium. Conclusions Rocuronium after pretreatment with clonidine for three or six weeks may have an increased effect, but no difference in the duration of action compared with control group.
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Affiliation(s)
- Min Seok Koo
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
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Kim YB, Jung WS, Bang MS, Lee KC. Effect of Different Doses of Rocuronium on Intubation and the Incidence of Acute Laryngeal Sequelae. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.4.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gachon University Medicine and Science, Seoul, Korea
| | - Wol Seon Jung
- Department of Anesthesiology and Pain Medicine, Gachon University Medicine and Science, Seoul, Korea
| | - Min-suk Bang
- Department of Anesthesiology and Pain Medicine, Gachon University Medicine and Science, Seoul, Korea
| | - Kyung-Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University Medicine and Science, Seoul, Korea
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Testelmans D, Maes K, Wouters P, Powers SK, Decramer M, Gayan-Ramirez G. Infusions of rocuronium and cisatracurium exert different effects on rat diaphragm function. Intensive Care Med 2007; 33:872-879. [PMID: 17361387 DOI: 10.1007/s00134-007-0584-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 02/12/2007] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aminosteroidal and benzylisoquinoline neuromuscular blocking agents are used in the intensive care unit to facilitate mechanical ventilation. The use of these agents has been associated with development of critical illness myopathy; however, the relative frequency of myopathy development among agents is not known. The aim of our study was to compare the effects of 24 h infusion of rocuronium or cisatracurium on the diaphragm in mechanically ventilated rats. DESIGN Randomized, controlled experiment. SETTING Basic animal science laboratory. SUBJECTS Male Wistar rats, 14 weeks old. INTERVENTIONS Rats were divided into four groups to receive either saline, rocuronium (low dose) or cisatracurium (low or high dose). MEASUREMENTS AND RESULTS After 24 h, in vitro diaphragm tetanic force was decreased after rocuronium (-33% vs. saline), while the force was more preserved after cisatracurium, even in the high-dose group. Cross-sectional areas of the different diaphragm and gastrocnemius fibers were unaltered. Diaphragmatic MURF-1 mRNA was increased after rocuronium (+44% vs. saline), while unchanged in both cisatracurium groups. Calpain activity was increased after rocuronium (+75% vs. saline) and unchanged in the cisatracurium groups. MURF-1 mRNA expression and calpain activity were negatively correlated with diaphragm force. CONCLUSIONS Cisatracurium infusion during controlled mechanical ventilation exerted less detrimental effects on diaphragm function and proteolytic activity than infusion of rocuronium, even with the higher effective dose. These data suggest that increased calpain activity and increased activation of the ubiquitin proteasome system play a role in the different effects of these agents.
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Affiliation(s)
- Dries Testelmans
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, O&N 1, bus 706, Herestraat 49, 3000, Leuven, Belgium
| | - Karen Maes
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, O&N 1, bus 706, Herestraat 49, 3000, Leuven, Belgium
| | - Patrick Wouters
- Department of Anesthesiology, Katholieke Universiteit Leuven, UZ Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Marc Decramer
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, O&N 1, bus 706, Herestraat 49, 3000, Leuven, Belgium
| | - Ghislaine Gayan-Ramirez
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, O&N 1, bus 706, Herestraat 49, 3000, Leuven, Belgium.
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Kim YB, Kwak HJ, Kim DH, Lee KC, Lee W, Chang YJ. Effect of Storage Temperature of Rocuronium on Intubating Condition and Clinical Duration after Low-dose Technique. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.4.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Yong Beom Kim
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Hyun Jung Kwak
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Dae Hee Kim
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Kyoung Cheon Lee
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
| | - Wonsang Lee
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Young-Jin Chang
- Department of Anesthesology and Pain Medicine, Gil Medical Center, Gachon University of Medicine and Science, Inchoen, Korea
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Abstract
OBJECTIVE To describe the current evidence-based knowledge of the causes, diagnostic evaluation, and treatment of patients with anaphylaxis associated with surgical and interventional procedures. DATA SOURCES Articles published between 1966 and 2003 were identified in MEDLINE using the keywords anaphylactoid, anaphylaxis, anesthetics, antibiotics, cephalosporins, contrast media, colloids, flow cytometry, hypersensitivity, latex, neuromuscular depolarizing agents, neuromuscular nondepolarizing agents, penicillins, radioallergosorbent test, skin test, and vancomycin. Additional studies were identified from article reference lists. STUDY SELECTION Relevant, peer-reviewed original research articles and reviews. RESULTS Neuromuscular blocking agents, natural rubber latex, antibiotics, and induction agents are the most common causes of anaphylaxis during surgical and interventional procedures. Colloids, opioids, and radiocontrast media probably account for less than 10% of all reactions. Newer agents implicated in anaphylaxis include isosulphan blue and chlorhexidine. Skin tests are useful for evaluating allergic reactions to anesthetic agents and penicillins and for selecting alternative agents. Skin testing and specific IgE measurements for latex vary in allergen standardization and sensitivity and specificity, respectively. Flow cytometric allergen stimulation tests show promise in differentiating allergic from idiosyncratic ("pseudoallergic") reactions. Drug desensitization has been shown to be useful for penicillin anaphylaxis. Premedication with histamine receptor antagonists and corticosteroids helps prevent or attenuate radiocontrast media reactions. CONCLUSIONS Anaphylaxis during surgical and interventional procedures may be difficult to evaluate because of the rapid, successive use of multiple drugs or diagnostic agents. Careful analysis of anesthetic records and diagnostic tests for all the putative agents are necessary to ensure a complete evaluation.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy, and Immunology, Tan Tock Seng Hospital, Singapore.
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Carno MA, Hoffman LA, Henker R, Carcillo J, Sanders MH. Sleep monitoring in children during neuromuscular blockade in the pediatric intensive care unit: a pilot study. Pediatr Crit Care Med 2004; 5:224-9. [PMID: 15115558 DOI: 10.1097/01.pcc.0000124024.92280.f9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sleep is an important physiologic process that is known to be disrupted in the intensive care unit. Nevertheless, there is little information on how intensive care unit admission affects sleep in children. Because laryngotracheoplasty is elective but entails 5-7 days of neuromuscular blockade following surgery, children undergoing this procedure present a unique opportunity to analyze sleep during neuromuscular blockade apart from confounding variables resulting from critical illness. OBJECTIVE To determine the feasibility of using polysomnography to assess sleep patterns in children during neuromuscular blockade. METHODS Polysomnography recordings were obtained continuously for 4 days (96 hrs) in two children following laryngotracheoplasty. Medication administration (neuromuscular blockades, sedatives) and time of suctioning were also recorded. RESULTS Both subjects had documented sleep. However, the proportion of time in each stage was markedly different from developmental norms, and a greater proportion of sleep occurred during the day. Furthermore, there was substantial day-night and day-to-day variability. Some rebound of consolidated sleep appeared by day 4. Sedative use varied considerably. However, neither bolus sedation administration nor endotracheal suctioning appeared to affect sleep. Few monitoring difficulties were encountered. CONCLUSIONS Sleep can be monitored with minimal difficulty in children undergoing neuromuscular blockade in the pediatric intensive care unit. Sleep occurred throughout the day, and there was considerable fragmentation. To fully assess sleep in the intensive care unit, monitoring needs to be continuous over several days, rather than only at night or for < or =24 hrs. Further research is needed in the area to determine typical sleep patterns in children undergoing neuromuscular blockade.
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Boros EE, Samano V, Ray JA, Thompson JB, Jung DK, Kaldor I, Koble CS, Martin MT, Styles VL, Mook RA, Feldman PL, Savarese JJ, Belmont MR, Bigham EC, Boswell GE, Hashim MA, Patel SS, Wisowaty JC, Bowers GD, Moseley CL, Walsh JS, Reese MJ, Rutkowske RD, Sefler AM, Spitzer TD. Neuromuscular blocking activity and therapeutic potential of mixed-tetrahydroisoquinolinium halofumarates and halosuccinates in rhesus monkeys. J Med Chem 2003; 46:2502-15. [PMID: 12773054 DOI: 10.1021/jm020574+] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Structure-activity relationships in rhesus monkeys for a novel mixed-onium class of ultra-short-acting nondepolarizing tetrahydroisoquinolinium neuromuscular blockers (NMBs) are described. Bis-onium chlorofumarate 20a with (1R,2S)-benzyltetrahydroisoquinolinium groups was a potent lead compound (ED(95) = 0.079 mg/kg) with an ultra-short duration of NMB effect (7.1 min) and a selectivity index (SI: defined as a ratio of the cardiovascular threshold dose to the ED(95)) similar to that of mivacurium (3). The mean threshold dose for cardiovascular effects with 20a was ca. 20 times its ED(95) value (SI = 20). A novel mixed-onium analogue of 20a was prepared by replacing the benzyltetrahydroisoquinolinium group distal to the fumarate chlorine atom with a (1S,2R)-phenyltetrahydroisoquinolinium moiety. The resulting mixed-onium chlorofumarate 24a displayed good NMB potency (ED(95) = 0.063 mg/kg), ultra-short duration of action (5.6 min) and an improved selectivity index (SI = 57). Several other mixed-onium derivatives containing octanedioate (25a; ED(95) = 0.103 mg/kg), difluorosuccinate (27c; ED(95) = 0.056 mg/kg), and fluorofumarate (28a; ED(95) = 0.137 mg/kg) linkers were also potent, ultra-short-acting NMBs with good to excellent selectivity index values (SI = 37-96). Octanedioate 25a was longer acting at higher doses compared to difluorosuccinate 27c and chlorofumarate 24a. Durations of NMB effect following a 0.4 mg/kg bolus dose (100% block) of 25a, 27c, and 24a were 16.9, 13.0, and 10.0 min, respectively. Recovery time for mixed-onium chlorofumarate 24a following a 1 h continuous infusion at 10-20 microg/kg/min (95-100% block) was ca. 5 min which is similar to that observed following a 0.2 mg/kg bolus dose of this compound and indicates a lack of cummulative effects. Preliminary studies with chlorofumarate 24a in whole human blood revealed that mixed-onium thiazolidine 29 was the major metabolite and that plasma cholinesterases do not play the primary role in duration of NMB effect. The NMB properties of 24a in rhesus monkeys led to its clinical evaluation as a possible alternative to succinylcholine.
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Affiliation(s)
- Eric E Boros
- GlaxoSmithKline Research & Development, Five Moore Drive, Research Triangle Park, North Carolina 27709, USA.
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Abstract
Since curare was introduced into clinical anaesthesia in 1942, efforts to create better neuromuscular blocking (NMB) muscle relaxants have continued. Today, muscle relaxation remains a mainstay of modern anaesthesia and intensive care. Through manipulation of the traditional structure-action relationships, many new and improved muscle relaxants have been created, and several have been brought to clinical use. However, structure-action relationship is inconsistent and has its limits. Using computer-aided molecular conformational analyses, the conformation-action relationships of NMB agents of various chemical classes have been explored. Conformation, no less than structure, of the NMB agents has shed new light on their mechanisms of action. By reflection, the conformations also suggest new details of the topology of the receptive sites of the nicotinic acetylcholine receptor modeled for the motor endplate of the skeletal muscle.
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Affiliation(s)
- Chingmuh Lee
- Department of Anesthesiology, Harbor-UCLA Medical Center Campus of UCLA School of Medicine, 1000 West Carson Street, Torrance, CA 90274, USA.
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