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Couto M, Vide S, Marco-Ariño N, Troconiz IF, Esteves S, Nunes CS, Amorim P, Mendes J. Comparison of two pharmacokinetic-pharmacodynamic models of rocuronium bromide during profound neuromuscular block: analysis of estimated and measured post-tetanic count effect. Br J Anaesth 2022; 128:473-481. [PMID: 35120713 DOI: 10.1016/j.bja.2021.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/14/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Profound neuromuscular block (NMB) is important in surgeries where complete immobility is considered essential to improve tracheal intubation and surgical conditions. Rocuronium bromide is a commonly used NMB agent. This work describes a noninvasive approach for estimation of post-tetanic count (PTC) based on two pharmacokinetic (PK) models, the Saldien and the De Haes models. The aim was to investigate the rocuronium bromide PK-pharmacodynamic (PD) relationship in estimating the PTC effect during profound NMB. METHODS In this prospective, non-randomised, observational study, an induction bolus of rocuronium bromide was administered followed by continuous infusion for maintenance of a PTC of 1-2. measured every 3 min. Measurements were analysed as discrete categorical data and by applying the nonlinear mixed-effect modelling approach. Performance of the selected models was evaluated through simulation model-based diagnostics, further assessing the precision of the parameter estimates and the performance of the models at the individual level. RESULTS Data from 30 adult patients undergoing elective abdominal or neurosurgical procedures were included. Post-tetanic count response profiles during rocuronium bromide infusion were successfully characterised using the population PD analysis. The models showed a good performance for all PTC categories, albeit with a moderate over-prediction of PTC >6. CONCLUSIONS Our findings indicate that using plasma concentrations of rocuronium bromide estimated with either of the two models, combined with a PD model, provides equal model performance when predicting PTC. These promising results may provide an important advance in guiding rocuronium bromide administration when profound NMB in routine clinical practice is desired.
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Affiliation(s)
- Mafalda Couto
- Department of Mechanical Engineering, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal; Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Porto, Portugal.
| | - Sérgio Vide
- Centro de Investigação Clínica em Anestesiologia, Serviço de Anestesiologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal; Systems Pharmacology Effect Control & Modeling Research Group, Anesthesiology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Nicolás Marco-Ariño
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, Pamplona, Spain; Navarra Institute for Health Research (Instituto de Investigación Sanitaria de Navarra), University of Navarra, Pamplona, Spain
| | - Iñaki F Troconiz
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, Pamplona, Spain; Navarra Institute for Health Research (Instituto de Investigación Sanitaria de Navarra), University of Navarra, Pamplona, Spain
| | - Simão Esteves
- Centro de Investigação Clínica em Anestesiologia, Serviço de Anestesiologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Catarina S Nunes
- Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Porto, Portugal; Centro de Investigação Clínica em Anestesiologia, Serviço de Anestesiologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal; Department of Sciences and Technology, Delegation of Porto, Universidade Aberta, Porto, Portugal
| | - Pedro Amorim
- Centro de Investigação Clínica em Anestesiologia, Serviço de Anestesiologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Joaquim Mendes
- Department of Mechanical Engineering, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal; Instituto de Ciência e Inovação em Engenharia Mecânica e Engenharia Industrial, Porto, Portugal
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Cortés-Beringola A, Vicent L, Martín-Asenjo R, Puerto E, Domínguez-Pérez L, Maruri R, Moreno G, Vidán MT, Bueno H. Diagnosis, prevention, and management of delirium in the intensive cardiac care unit. Am Heart J 2021; 232:164-176. [PMID: 33253676 DOI: 10.1016/j.ahj.2020.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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Affiliation(s)
- Alejandro Cortés-Beringola
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Cardiology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lourdes Vicent
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Elena Puerto
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Laura Domínguez-Pérez
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Ramón Maruri
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María T Vidán
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Héctor Bueno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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Groetzinger LM, Hutchins AT, Rivosecchi RM. An Evaluation of Continuous Infusion Rocuronium for Sustained Neuromuscular Blockade in Critically Ill Adults. Ann Pharmacother 2020; 55:732-737. [PMID: 33043678 DOI: 10.1177/1060028020966731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recent medication shortages of the neuromuscular blocking agent (NMBA) cisatracurium have forced the prescribing of aminosteroidal agents such as rocuronium. There are limited data on the use and dosing of continuous infusion (CI) rocuronium in critically ill patients outside of the operating room. OBJECTIVE We sought to describe the use of CI rocuronium for sustained neuromuscular blockade in intensive care unit (ICU) patients by characterizing the dosing, utilization, and safety profile in patients with multiple organ failure (MOF) and non-MOF. METHODS This was a retrospective review of patients in mixed ICUs from 2 tertiary medical centers who received CI rocuronium between January 2018 and July 2019. RESULTS A total of 46 unique rocuronium infusions were utilized for 40 patients during the evaluation period. Of these, 37% had MOF, and 41% had at least 1 organ fail during the rocuronium infusion. The median starting and maximum dose was 8 µg/kg/min. Overall, 64% of train of 4 (TOF) measurements were a TOF 0 (T0) or TOF 1 (T1), with a higher percentage of T0 or T1 in the MOF group compared with the non-MOF group (75% vs 50%). The median time to recovery was more than twice as long for the MOF compared with the non-MOF group (10 vs 4.6 hours). ICU-acquired weakness was diagnosed in 27% of survivors. CONCLUSION AND RELEVANCE In ICU patients with MOF, continuous rocuronium infusions were associated with deep levels of paralysis and prolonged recovery times. If neuromuscular blockade is required for critically ill patients, alternative strategies could be considered.
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Affiliation(s)
- Lara M Groetzinger
- University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, PA, USA
| | | | - Ryan M Rivosecchi
- University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, PA, USA
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Tezcan B, Turan S, Özgök A. Current Use of Neuromuscular Blocking Agents in Intensive Care Units. Turk J Anaesthesiol Reanim 2019; 47:273-281. [PMID: 31380507 DOI: 10.5152/tjar.2019.33269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 10/08/2018] [Indexed: 11/22/2022] Open
Abstract
Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.
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Affiliation(s)
- Büşra Tezcan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Sema Turan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
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