Newer agents for rapid sequence intubation: etomidate and rocuronium

Neuromuscular Blocking Agents and Rapid Sequence Induction for Laparoscopic Pyloromyotomy: Impact on Time to Extubation and Perioperative Complications

INTRODUCTION

 Infants with hypertrophic pyloric stenosis have gastric outlet obstruction, indicating a pyloromyotomy. To prevent aspiration, a rapid sequence induction (RSI) of anesthesia used to be preferred. However, due to concerns about the side-effects of this technique in infants, a modified RSI with gentle mask ventilation is nowadays mostly used. This research investigates if induction with succinylcholine (classic RSI), cisatracurium (modified RSI), or no neuromuscular blocking agent (NMBA) influences time until extubation and incidence of complications in infants undergoing laparoscopic pyloromyotomy.

MATERIALS AND METHODS

 A retrospective chart review was performed, observing infants undergoing laparoscopic pyloromyotomy in Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, from January 2007 until July 2015. Baseline preoperative data, anesthesia and operation details, time to extubation, and reported complications were gathered. Inclusion criteria were maintenance of anesthesia with sevoflurane and a registered extubation time. Exclusion criteria were the use of combinations of NMBAs, repyloromyotomy, and conversion to laparotomy.

RESULTS

 A total of 168 patients were included, of which 21 received succinylcholine, 107 cisatracurium, and 40 no NMBA. Mean duration of surgery was 29 minutes in all three groups; mean duration of anesthesia was 89, 82, and 77 minutes; mean time to extubation was 26, 25, and 23 minutes, respectively, without statistically significant difference. Complications were evenly distributed, no aspiration occurred.

CONCLUSION

 The use of succinylcholine, cisatracurium, or no NMBA at induction of anesthesia in infants undergoing laparoscopic pyloromyotomy had no statistically significant effect on time until extubation and complication rates. A modified RSI seems to be safe and effective in these cases.

Emergency Intubations in a High-Volume Pediatric Emergency Department

INTRODUCTION

Resuscitation of critically ill children can be chaotic, and emergency airway management is often fraught with difficulties. This study aimed to characterize the Singaporean landscape of tracheal intubation in a pediatric emergency unit, placing emphasis on safety outcomes, procedural process of care, and provider training.

METHODS

A retrospective review of all cases presented to the KK Women's and Children's Hospital from January 2009 to December 2013 with intubation carried out within the pediatric emergency unit was done. Medical records were accessed for data collection, and the information was subsequently used for analysis.

RESULTS

A total of 207 intubations were carried out in the pediatric emergency unit. The median age was 4 years (interquartile range, 11 months to 8 years). Oral tracheal intubation with the combination of sedation and paralysis was the main approach. Atropine was used for pretreatment in 156 cases (75.4%). Midazolam was the most commonly used induction agent, and succinylcholine was the most commonly used the paralytic agent. Intubation was achieved on the first attempt in 175 cases (84.5%). Postintubation sedation was initiated in 94 cases (45.4%). Postintubation paralysis was initiated in 50 cases (24.2%). Postintubation analgesia was initiated in 13 cases (6.3%). Twenty emergency intubations (9.7%) were associated with at least 1 tracheal intubation adverse event, with 7 cases (3.4%) having severe tracheal intubation adverse events. In 1 case (0.5%), the patient died within the pediatric emergency unit, and 27 patients (13.0%) did not survive to discharge from the hospital.

CONCLUSIONS

All tracheal intubations performed were successful. Variance still exists in tracheal intubation practice. Further elucidation of patient, practice, and provider factors will aid development of a bundle quality improvement intervention directed at addressing these factors.

Etomidate in pediatric anesthesiology: Where are we now?

Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

Drug-administration sequence of target-controlled propofol and remifentanil influences the onset of rocuronium. A double-blind, randomized trial

BACKGROUND

Remifentanil is known to cause bradycardia and hypotension, as well as the decreases of cardiac output (CO). We hypothesized that hemodynamic suppression by remifentanil would affect the onset time of rocuronium. This study investigated whether the onset of rocuronium was influenced by the drug-administration sequence during induction of anesthesia with target-controlled infusion of propofol and remifentanil.

METHODS

Healthy adult patients (n = 126) undergoing elective surgery under general anesthesia were randomized into two groups according to drug-administration sequence. In Remi-Pro-Rocu group (n = 62), remifentanil was infused first, followed by propofol. Then, rocuronium was administered lastly. In Pro-Rocu-Remi group (n = 64), propofol, rocuronium, and remifentanil were given in that order. As a primary outcome, the onset time of rocuronium was measured. Mean arterial pressure (MAP), heart rate (HR), CO, and stroke volume were recorded before anesthesia (T1), at injection of rocuronium (T2), immediately before and after intubation (T3 and T4).

RESULTS

In Remi-Pro-Roc group, the onset of rocuronium was delayed significantly compared with Pro-Rocu-Remi group [median (interquartile range); 130 (105-150) vs. 90 (71-100) s, P < 0.001]. At the time of rocuronium injection (T2), MAP, HR, and CO were significantly lower in Remi-Pro-Rocu group than Pro-Rocu-Remi group (P < 0.001).

CONCLUSION

The onset time of rocuronium is prolonged significantly by early administration of remifentanil during target-controlled infusion of propofol and remifentanil, and it may be due to the decreased CO caused by remifentanil.

Anaesthesia of farmed fish: implications for welfare

During their life cycle as farmed animals, there are several situations in which fish are subjected to handling and confinement. Netting, weighing, sorting, vaccination, transport and, at the end, slaughter are frequent events under farming conditions. As research subjects, fish may also undergo surgical procedures that range from tagging, sampling and small incisions to invasive procedures. In these situations, treatment with anaesthetic agents may be necessary in order to ensure the welfare of the fish. The main objective of this paper is to review our knowledge of the effects of anaesthetic agents in farmed fish and their possible implications for welfare. As wide variations in response to anaesthesia have been observed both between and within species, special attention has been paid to the importance of secondary factors such as body weight, water temperature and acute stress. In this review, we have limited ourselves to the anaesthetic agents such as benzocaine, metacaine (MS-222), metomidate hydrochloride, isoeugenol, 2-phenoxyethanol and quinaldine. Anaesthetic protocols of fish usually refer to one single agent, whereas protocols of human and veterinary medicine cover combinations of several drugs, each contributing to the effects needed in the anaesthesia. As stress prior to anaesthesia may result in abnormal reactions, pre-anaesthetic sedation is regularly used in order to reduce or avoid stress and is an integral part of the veterinary protocols of higher vertebrates. Furthermore, the anaesthetic agents that are used in order to obtain general anaesthesia are combined with analgesic agents that target nociception. The increased use of such combinations in fish is therefore included as a special section. Anaesthetic agents are widely used to avoid stress during various farming procedures. While several studies report that anaesthetics are effective in reducing the stress associated with confinement and handling, there are indications that anaesthesia may in itself induce a stress response, measured by elevated levels of cortisol. MS-222 has been reported to elicit high cortisol release rates immediately following exposure, while benzocaine causes a bimodal response. Metomidate has an inhibitory effect on cortisol in fish and seems to induce the lowest release of cortisol of the agents reported in the literature. Compared to what is observed following severe stressors such as handling and confinement, the amount of cortisol released in response to anaesthesia appears to be low but may represent an extra load under otherwise stressful circumstances. Furthermore, anaesthetics may cause secondary adverse reactions such as acidosis and osmotic stress due to respiratory arrest and insufficient exchange of gas and ions between the blood and the water. All in all, anaesthetics may reduce stress and thereby improve welfare but can also have unwanted side effects that reduce the welfare of the fish and should therefore always be used with caution. Finally, on the basis of the data reported in the literature and our own experience, we recommend that anaesthetic protocols should always be tested on a few fish under prevailing conditions in order to ensure an adequate depth of anaesthesia. This recommendation applies whether a single agent or a combination of agents is used, although it appears that protocols comprising combinations of agents provide wider safety margins. The analgesic effects of currently used agents, in spite of their proven local effects, are currently being debated as the agents are administrated to fish via inhalation rather than locally at the target site. We therefore recommend that all protocols of procedures requiring general anaesthesia should be complemented by administration of agents with analgesic effect at the site of tissue trauma.