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Albers-Warlé KI, Reijnders-Boerboom GTJA, Bijkerk V, Torensma B, Panhuizen IF, Snoeck MMJ, Fuchs-Buder T, Keijzer C, Dahan A, Warlé MC. A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM. Anesthesiology 2024; 141:365-374. [PMID: 38728093 DOI: 10.1097/aln.0000000000005050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a posttetanic count [PTC] of 1 to 2) and how to implement it has not been reached. The European Society of Anaesthesiology and Intensive Care does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia. METHODS Data from three trials investigating deep NMB during laparoscopic surgery with total intravenous anesthesia (n = 424) were pooled to analyze the required rocuronium dose, when to start continuous infusion, and how to adjust. The resulting algorithm was validated (n = 32) and compared to the success rate in ongoing studies in which the algorithm was not used (n = 180). RESULTS The mean rocuronium dose based on actual bodyweight for PTC 1 to 2 was (mean ± SD) 1.0 ± 0.27 mg · kg-1 ·h-1 in the trials, in which mean duration of surgery was 116 min. An induction dose of 0.6 mg ·kg-1 led to a PTC of 1 to 5 in a quarter of patients after a mean of 11 min. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a 15-min wait after PTC of 0 for return of PTC to 1 or higher. Using the proposed algorithm, a mean 76% of all 5-min measurements throughout surgery were on target PTC 1 to 2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0 to 20 patients (42% on target, P ≤ 0.001, Cohen's d = 1.4 [95% CI, 0.9 to 1.8]) to 81 to 100 patients (61% on target, P ≤ 0.05, Cohen's d = 0.7 [95% CI, 0.1 to 1.2]). CONCLUSIONS This study proposes a dosing algorithm for deep NMB with rocuronium in patients receiving total intravenous anesthesia. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | | | - Veerle Bijkerk
- Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Bart Torensma
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ivo F Panhuizen
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marc M J Snoeck
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Thomas Fuchs-Buder
- Département d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Nancy/Brabois, Nancy, France
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
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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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Li X, Ye Z, Cui M, Hu A, Li X, Chen Q, Zhao G, Ye F. Dexmedetomidine decreases the 50% effective dose (ED50) of intravenous propofol required to prevent tracheal intubation response in Beagles. J Am Vet Med Assoc 2022; 261:74-79. [PMID: 36315451 DOI: 10.2460/javma.22.01.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE To determine the 50% effective dose (ED50) of intravenous propofol required for successfully preventing tracheal intubation response in Beagles co-induced with dexmedetomidine. ANIMALS 36 adult male Beagles. PROCEDURES The dogs were randomly assigned to either group D1, group D2, or group C (received 1 µg/kg, 2 µg/kg dexmedetomidine intravenously, or the same amount of normal saline as dexmedetomidine, 10 mL). The first dog in each group received 6 mg/kg of propofol for induction. The pump speed of propofol was 600 mL/h. The dosage varied with increments or decrements of 0.5 mg/kg based on the Dixon up-and-down method. The duration of eye-opening after propofol administration was recorded. Changes in heart rate (HR) and respiratory rate (RR) were recorded at 5 timepoints: after entering the operation room and prior to propofol administration (T1), 1 and 3 min after propofol administration (T2 and T3), 3 and 5 min after intubation (T4 and T5). RESULTS The required ED50 of propofol that prevented tracheal intubation response in D1, D2, and C groups were 6.4 mg/kg (95% CI, 6.1 to 6.7 mg/kg), 5.8 mg/kg (95% CI, 5.67 to 6 mg/kg), and 8.3 mg/kg (95% CI, 8 to 8.5 mg/kg), respectively. The recovery time of group D2 was significantly longer than that of groups D1 and C (P < .05). The differences in HR among the 3 groups were significant from T2 up to T5 timepoint (P < .05). The differences in RR among the 3 groups were significant at T2 and T3 timepoints (P < .05). CLINICAL RELEVANCE Dexmedetomidine pre-injection reduces the amount of propofol required for endotracheal intubation response in Beagles, thereby reducing the respiratory inhibition induced by propofol.
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Affiliation(s)
- Xiaona Li
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Zhihui Ye
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Mengxue Cui
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - An Hu
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xiangyu Li
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Qicheng Chen
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - GaoFeng Zhao
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Fei Ye
- Department of Anesthesiology, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
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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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Ahlström S, Bergman P, Jokela R, Ottensmann L, Ahola-Olli A, Pirinen M, Olkkola KT, Kaunisto MA, Kalso E. First genome-wide association study on rocuronium dose requirements shows association with SLCO1A2. Br J Anaesth 2021; 126:949-957. [PMID: 33676726 PMCID: PMC8132880 DOI: 10.1016/j.bja.2021.01.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 12/18/2020] [Accepted: 01/12/2021] [Indexed: 12/17/2022] Open
Abstract
Background Rocuronium, a common neuromuscular blocking agent, is mainly excreted unchanged in urine (10–25%) and bile (>70%). Age, sex, liver blood flow, smoking, medical conditions, and ethnic background can affect its pharmacological actions. However, reasons for the wide variation in rocuronium requirements are mostly unknown. We hypothesised that pharmacogenetic factors might explain part of the variation. Methods One thousand women undergoing surgery for breast cancer were studied. Anaesthesia was maintained with propofol (50–100 μg kg−1 min−1) and remifentanil (0.05–0.25 μg kg−1 min−1). Neuromuscular block was maintained with rocuronium to keep the train-of-four ratio at 0–10%. DNA was extracted from peripheral blood and genotyped with a next-generation genotyping array. The genome-wide association study (GWAS) was conducted using an additive linear regression model with PLINK software. The FINEMAP tool and data from the Genotype-Tissue Expression project v8 were utilised to study the locus further. Results The final patient population comprised 918 individuals. Of the clinical variables tested, age, BMI, ASA physical status, and total dose of propofol correlated significantly (all P<0.001) with the rocuronium dose in a linear regression model. The GWAS highlighted one genome-wide significant locus in chromosome 12. The single-nucleotide polymorphisms (SNPs) with the most significant evidence of association were located in or near SLCO1A2. The two top SNPs, rs7967354 (P=5.3e−11) and rs11045995 (P=1.4e−10), and the clinical variables accounted for 41% of the variability in rocuronium dosage. Conclusions Genetic variation in the gene SLCO1A2, encoding OATP1A2, an uptake transporter, accounted for 4% of the variability in rocuronium consumption. The underlying mechanism remains unknown.
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Affiliation(s)
- Sirkku Ahlström
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland.
| | - Paula Bergman
- Biostatistics Consulting, Department of Public Health, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Ritva Jokela
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Linda Ottensmann
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Ari Ahola-Olli
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Matti Pirinen
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland; Helsinki Institute for Information Technology and Department of Mathematics and Statistics, University of Helsinki, Helsinki, Finland; Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Mari A Kaunisto
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Eija 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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Ida KK, Van-Wijnsberghe AS, Tutunaru A, Limpens V, Sauvage A, Serteyn D, Sandersen C. Onset and duration of cis-atracurium neuromuscular block during fentanyl and lidocaine infusions in isoflurane-anaesthetised dogs. Vet Rec 2020; 187:e33. [PMID: 31974268 DOI: 10.1136/vr.105522] [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: 04/19/2019] [Revised: 11/12/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND This retrospective study assessed the onset and duration of the neuromuscular block (NMB) induced by cis-atracurium 0.15 mg/kg intravenously with and without fentanyl or lidocaine infusions in 45 isoflurane-anaesthetised dogs. METHODS Dogs with neuromuscular function assessed by a calibrated train-of-four (TOF) monitor with stimulation (every 13 s) of the peroneal nerve were included. The onset and duration of the NMB were defined as the time from cis-atracurium administration until TOF=0 and the time during TOF=0 display, respectively. RESULTS The NMB onset was shorter during fentanyl (mean±sd) (1.9±0.7 minutes; P=0.0042) and lidocaine (2.0±0.7 minutes; P=0.0154) compared with control (2.9±0.8 minutes). The NMB duration was shorter in the fentanyl (27.5±7.3 minutes; P=0.0491), but not in the lidocaine group (32.3±6.9 minutes; P=0.0790), compared with control (33.7±9.1 minutes). The NMB onset was poorly but significantly correlated with the dose of fentanyl and lidocaine administered before cis-atracurium (r=-0.3396; P=0.0225). The fentanyl and lidocaine groups received more crystalloid and colloid boluses than the control. CONCLUSIONS Fentanyl and lidocaine shortened the NMB onset and the former decreased the NMB duration. Further prospective studies are required to clarify whether this was associated with an indirect decrease in blood pressure or a direct interaction between cis-atracurium and fentanyl and lidocaine.
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Affiliation(s)
- Keila K Ida
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | | | - Alexandru Tutunaru
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Véronique Limpens
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Aurélie Sauvage
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Didier Serteyn
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Charlotte Sandersen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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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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Gao W, Sha B, Zhao Y, Fan Z, Liu L, Shen X. Comparison of simultaneous and sequential administration of fentanyl-propofol for surgical abortion: a randomized single-blinded controlled trial. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2016; 45:1045-1050. [PMID: 27707001 DOI: 10.1080/21691401.2016.1239106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Propofol lipid emulsion (PLE) is a nanosized sedative, and it is used with a combination of salted antalgic prodrug, fentanyl citrate (FC). To illustrate the synergistic effect of mixing, we compared the sedation/analgesia resulting from simultaneous and sequential administration in surgically induced abortion (No. ChiCTR-IPC-15006153). Simultaneous group showed lower bispectral index, blood pressure, and heart rate, when cannula was inserted into the uterus. It also showed less frequency of hypertension, sinus tachycardia, movement, pain at the injection site, and additional FC. Therefore, premixing of PLE and FC enhanced the sedation and analgesia; stabilized the hemodynamics; lessened the incidence of movement and injection pain; and reduced the requirement of drugs.
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Affiliation(s)
- Wei Gao
- a Department of Anesthesiology , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , P.R. China
| | - Baoyong Sha
- b School of Basic Medical Science, Xi'an Medical University , Xi'an , P.R. China
| | - Yuan Zhao
- a Department of Anesthesiology , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , P.R. China
| | - Zhe Fan
- a Department of Anesthesiology , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , P.R. China
| | - Lin Liu
- a Department of Anesthesiology , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , P.R. China
| | - Xin Shen
- a Department of Anesthesiology , The First Affiliated Hospital of Xi'an Jiaotong University , Xi'an , P.R. China
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