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Elshafie AMA, Ezzat Marzouq Sad Elrouby A, Mohamed Osman Y. Effectiveness of Sugammadex on muscle relaxant reversal in preterm neonates. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2171541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ahmed Mohamed Ahmed Elshafie
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Yasser Mohamed Osman
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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2
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Banoub R, Alalade E, Bryant J, Winch P, Tobias AJD. Allergic Reactions to Sugammadex: A Case Series and Review of the Literature. J Pediatr Pharmacol Ther 2023; 28:374-379. [PMID: 37795279 PMCID: PMC10547043 DOI: 10.5863/1551-6776-28.4.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 10/06/2023]
Abstract
Sugammadex is a novel agent for the reversal of neuromuscular blockade; it acts by encapsulating -rocuronium or vecuronium, eliminating the active compound from the circulation, thereby providing rapid and complete recovery even with profound or complete neuromuscular blockade. Clinical advantages, including reduced incidence of residual blockade, decreased nausea and vomiting, decreased dry mouth, less change in heart rate, and reduced pulmonary complications, have been demonstrated when comparing sugammadex to conventional agents, such as neostigmine, that inhibit acetylcholinesterase. Although generally safe and effective, anaphylactoid and allergic reactions have been reported with sugammadex. The potential for hypersensitivity reactions with sugammadex and previous reports from the literature, as well as diagnostic and treatment strategies, are presented in 3 pediatric cases.
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Affiliation(s)
- Rita Banoub
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - Emmanuel Alalade
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - Jason Bryant
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - Peter Winch
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | - and Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
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3
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Zhou S, Hu H, Ru J. Efficacy and safety of sugammadex sodium in reversing rocuronium-induced neuromuscular blockade in children: An updated systematic review and meta-analysis. Heliyon 2023; 9:e18356. [PMID: 37520945 PMCID: PMC10374931 DOI: 10.1016/j.heliyon.2023.e18356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
Objective In response to the differences in pharmacodynamic and pharmacokinetic characteristics of neuromuscular blocking agents between children and adults and limited studies which existing meta-analyses included, this study will update the safety and efficacy of sugammadex (Sug) sodium in reversing rocuronium-induced neuromuscular blockade in children. Methods Five electronic databases were searched for clinical trials on the safety and efficacy of Sug sodium in reversing rocuronium-induced neuromuscular block in children. A random-effects model was used to calculate the standardized mean difference (SMD) for primary outcomes. The relative risk (RR) was calculated for secondary outcomes. Results As of 2022-11-03, 18 out of 236 studies included 724 children in the intervention group and 478 children in the control group for meta-analysis. The results showed that compared with the control group, the time required for Train-of-Four Ratio (TOFR) to return to 0.9 and the extubation time were shortened in both 2 mg/kg and 4 mg/kg of Sug sodium, with statistically significant differences (TOFR ≥0.9: 2 mg/kg: SMD = -2.90; 95%CI: -3.75, -2.04; 4 mg/kg: -3.31; -4.79, -1.84; extubation time: 2 mg/kg: -2.95; -4.04, -1.85; 4 mg/kg: -1.57; -1.90, -1.23). Compared with the control group, the total incidence of adverse effects in the Sug group was lower (RR = 0.44; 0.24,0.82). Conclusions This review and meta-analysis suggest that Sug sodium is more effective and safer in reversing rocuronium-induced neuromuscular blockade in children than traditional antagonistic regimens or placebos.
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Affiliation(s)
- Sheng Zhou
- Department of Anesthesiology, Changzhou No.2 People's Hospital, Changzhou, Jiangsu, China
| | - Haiying Hu
- General Surgery Department, Changzhou West Taihu Hospital, Changzhou, Jiangsu, China
| | - Jianfen Ru
- Department of Anesthesiology, Changzhou No.2 People's Hospital, Changzhou, Jiangsu, China
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4
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Schlesinger T, Weibel S, Kranke P. Postoperative/postdischarge nausea and vomiting: evidence-based prevention and treatment. Curr Opin Anaesthesiol 2023; 36:109-116. [PMID: 36214542 DOI: 10.1097/aco.0000000000001200] [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: 12/27/2022]
Abstract
PURPOSE OF REVIEW Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remains a relevant issue in perioperative care. Especially in outpatient surgery, PONV can prevent discharge or lead to unplanned readmission. RECENT FINDINGS Evidence on prophylaxis and treatment of PONV is growing, but implementation remains poor. SUMMARY A liberal, universal PONV management is now endorsed by the guidelines. Specific evidence concerning prevention and (at-home) treatment of PDNV is still scarce.
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Affiliation(s)
- Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Wuerzburg, Germany
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5
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Ji SH, Huh KY, Oh J, Jeong HJ, Jang YE, Kim EH, Lee JH, Kim JT, Kim HS. Conventional reversal of rocuronium-induced neuromuscular blockade by sugammadex in Korean children: pharmacokinetics, efficacy, and safety analyses. Front Pharmacol 2023; 14:1127932. [PMID: 37124204 PMCID: PMC10133539 DOI: 10.3389/fphar.2023.1127932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/05/2023] [Indexed: 05/02/2023] Open
Abstract
Background: Sugammadex is known to reverse neuromuscular blockade induced by non-depolarizing agents. In children, the recommended dose for reversal of moderate neuromuscular blockade is 2 mg/kg. We investigated the pharmacokinetics and pharmacodynamics of sugammadex in Korean children. Methods: Children (2-17 years of age) undergoing brain or spine surgery were enrolled and randomly assigned to control (neostigmine) and 2, 4, or 8 mg/kg sugammadex groups. Following induction of anesthesia and monitoring of the response to train-of-four stimulation, 1 mg/kg rocuronium was intravenously administered. Upon reappearance of the second twitch to train-of-four stimulation, the study drug was administered according to group allocation. The plasma concentrations of rocuronium and sugammadex were serially measured at nine predefined time points following study drug administration. To determine efficacy, we measured the time elapsed from drug administration to recovery of T4/T1 ≥ 0.9. For pharmacokinetics, non-compartmental analysis was performed and we monitored adverse event occurrence from the time of study drug administration until 24 h post-surgery. Results: Among the 29 enrolled participants, the sugammadex (2 mg/kg) and control groups showed recovery times [median (interquartile range)] of 1.3 (1.0-1.9) and 7.7 (5.3-21.0) min, respectively (p = 0.002). There were no significant differences in recovery time among the participants in sugammadex groups. The pharmacokinetics of sugammadex were comparable to those of literature findings. Although two hypotensive events related to sugammadex were observed, no intervention was necessary. Conclusion: The findings of this pharmacokinetic analysis and efficacy study of sugammadex in Korean children indicated that sugammadex (2 mg/kg) may be safely administered for reversing moderate neuromuscular blockade. Some differences in pharmacokinetics of sugammadex were observed according to age. Clinical Trial Registration: http://clinicaltrials.gov (NCT04347486).
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Affiliation(s)
- Sang-Hwan Ji
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Young Huh
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jaeseong Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Jeong Jeong
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- *Correspondence: Hee-Soo Kim,
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Grześkowiak M, Bienert A, Wiczling P, Malec M, Grzelak J, Jarosz K, Ber J, Książkiewicz M, Rosada-Kurasińska J, Grześkowiak E, Bartkowska-Śniatkowska A. Population Pharmacokinetic-Pharmacodynamic Modeling and Probability of Target Attainment Analysis of Rocuronium and Sugammadex in Children Undergoing Surgery. Eur J Drug Metab Pharmacokinet 2023; 48:101-114. [PMID: 36477706 PMCID: PMC9823043 DOI: 10.1007/s13318-022-00809-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Probability of target attainment (PTA) curves are commonly used to support dose recommendations of antibiotics for different patient groups. In this study we propose PTA analysis to optimize sugammadex dosing in children. METHODS This study involved data from an observational cohort study of 30 American Society of Anesthesiologists (ASA) Physical Status I and II children undergoing surgery requiring muscle relaxation. All patients received 0.6 mg/kg rocuronium, with sugammadex administered at the end of surgery in three different doses (0.5, 1.0, and 2.0 mg/kg) to reverse the neuromuscular blockade. RESULTS The data were analyzed using a population Bayesian-based approach. The developed model was used to simulate pharmacokinetic-pharmacodynamic profiles for different patient groups and dosing regimens before the PTA analysis was performed to translate these simulations into a clinically useful measure. The target was defined as neuromuscular blockade reversal measured by Train-of-Four (TOF ratio > 90%) at 1.5, 3, and 5 min post sugammadex dose. The sugammadex doses leading to 90% PTA were determined for different patients' body weights, rocuronium doses, and time gaps between rocuronium and sugammadex administration assuming the model, priors, and gathered data. For comparison, PTA curves for a range of clinical scenarios are provided to illustrate the usefulness of PTA analysis in selecting the appropriate dose for a given patient. CONCLUSIONS The proposed PTA analysis is useful to support the sugammadex dose selection in different clinical scenarios. TRIAL REGISTRATION The study was registered by ClinicalTrials.gov under number NCT04851574 on 21 April 2021.
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Affiliation(s)
- Małgorzata Grześkowiak
- grid.22254.330000 0001 2205 0971Department of Teaching Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Bienert
- grid.22254.330000 0001 2205 0971Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Wiczling
- grid.11451.300000 0001 0531 3426Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdansk, Al. Gen. Hallera 107, 80-416 Gdansk, Poland
| | - Mirosław Malec
- grid.22254.330000 0001 2205 0971Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Grzelak
- grid.107950.a0000 0001 1411 4349Department of Clinical Nursing, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Konrad Jarosz
- grid.107950.a0000 0001 1411 4349Department of Clinical Nursing, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Justyna Ber
- grid.22254.330000 0001 2205 0971Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Jowita Rosada-Kurasińska
- grid.22254.330000 0001 2205 0971Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Edmund Grześkowiak
- grid.22254.330000 0001 2205 0971Department of Clinical Pharmacy and Biopharmacy, Poznan University of Medical Sciences, Poznan, Poland
| | - Alicja Bartkowska-Śniatkowska
- grid.22254.330000 0001 2205 0971Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
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Beltran RJ, Mpody C, Nafiu OO, Tobias JD. Association of Sugammadex or Neostigmine With Major Postoperative Pulmonary Complications in Children. Anesth Analg 2022; 135:1041-1047. [PMID: 35020682 DOI: 10.1213/ane.0000000000005872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent data in adult patients indicate that the use of sugammadex compared to neostigmine for reversal of neuromuscular block (NMB) was associated with a significant reduction in the risk of composite postoperative pulmonary complications. Despite the clinical significance of pulmonary complications in children, studies exploring the role of NMB reversal in the risk of these complications are currently unavailable. METHOD We performed a propensity score-matched retrospective study using the Pediatric Health Information System (PHIS) dataset spanning the years 2016 and 2020. We studied children <18 years who underwent elective, inpatient, noncardiac surgical procedures and received either neostigmine or sugammadex for reversal of NMB. Our primary outcome was major postoperative pulmonary complication, which we defined as the occurrence of either postoperative pneumonia or respiratory failure. RESULTS Our study included a study population of 33,819 children, of whom 23,312 (68.9%) received neostigmine and 10,507 (31.1%) received sugammadex. After propensity score matching (10,361 matched from each group), we found no evidence of a statistically significant association between the NMB reversal agent and the incidence of pulmonary complications (3.1% vs 3.1%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.05; P = .19). The components of pulmonary complications, including respiratory failure and pneumonia, were not statistically associated with the choice of NMB reversal agent. CONCLUSIONS Choice of NMB reversal agent does not appear to impact the incidence of major postoperative pulmonary complications. Further research is needed to determine whether our results carry forth across subpopulations defined by surgical specialty, the presence of complex chronic conditions, and anesthesia technique.
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Affiliation(s)
- Ralph J Beltran
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Ji S, Huh KY, Oh J, Jeong H, Jang Y, Kim E, Lee J, Kim J, Kim H. Reversal of rocuronium-induced intense neuromuscular blockade by sugammadex in Korean children: A pharmacokinetic and pharmacodynamic analysis. Clin Transl Sci 2022; 16:92-103. [PMID: 36181377 PMCID: PMC9841294 DOI: 10.1111/cts.13429] [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: 05/29/2022] [Revised: 08/09/2022] [Accepted: 09/21/2022] [Indexed: 02/06/2023] Open
Abstract
Sugammadex, a selective antagonist of steroidal non-depolarizing neuromuscular blocking agents, has been used in children in limited circumstances. However, neither pharmacokinetics (PKs) nor recovery profile of sugammadex for intense neuromuscular blockade reversal in children have been reported. This prospective study aimed to obtain a PK model of sugammadex and evaluate its efficacy and safety for intense neuromuscular blockade reversal in children. Forty children (age, 2-17 years) who underwent surgery that required early neuromuscular blockade reversal were enrolled. After neuromuscular blockade with 1 mg∙kg-1 of rocuronium, sugammadex (2, 4, and 8 mg∙kg-1 ) or a conventional dose of neostigmine (0.03 mg∙kg-1 ) was administered randomly after confirmation of zero post-tetanic count. The plasma concentrations of rocuronium and sugammadex were measured 2 min after rocuronium injection; immediately before, 2, 5, 15, 60, 120, 240, and 480 min after the study drug injection. Response to train-of-four stimulation was continuously recorded. Noncompartmental analysis and population PK modeling were performed. For pharmacodynamics, the recovery profile was measured. Three-compartment PK model was established for sugammadex. The median (interquartile range [IQR]) time from injection of 8 mg∙kg-1 of sugammadex to recovery of T4 /T1 greater than or equal to 0.9 at train-of-four stimulation was 1.1 (IQR: 0.88-1.8) min. No adverse events related to sugammadex were observed. We present a PK analysis of sugammadex for rocuronium-induced intense neuromuscular blockade reversal in children with its recovery profile. The time to recover T4 /T1 greater than or equal to 0.9 at train-of-four stimulation with 8 mg∙kg-1 of sugammadex was less than 3 min and comparable to that in adults.
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Affiliation(s)
- Sang‐Hwan Ji
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Ki Young Huh
- Seoul National University College of MedicineSeoulKorea,Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulKorea
| | - Jaeseong Oh
- Seoul National University College of MedicineSeoulKorea,Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulKorea
| | - Hee‐Jeong Jeong
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Young‐Eun Jang
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Eun‐Hee Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Ji‐Hyun Lee
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Jin‐Tae Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
| | - Hee‐Soo Kim
- Seoul National University College of MedicineSeoulKorea,Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea
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Anzai A, Utino A, Tosello G, Katayama H, Spir IAZ, Tristão LS, Nery MM, Anhesini M, Tiezzi OS, Spir PRN, Otani P, Bernado WM. Sugammadex in awakening from general anesthesia: systematic review and meta-analysis. Rev Assoc Med Bras (1992) 2022; 68:1130-1153. [PMID: 36228244 PMCID: PMC9575014 DOI: 10.1590/1806-9282.2022d687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Adriano Anzai
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Armelin Utino
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Giuliano Tosello
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Haroldo Katayama
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | | | | | - Mary Martins Nery
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Mauricio Anhesini
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | | | | | - Pericles Otani
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil
| | - Wanderley Marques Bernado
- Unimed, Center for Evidence-Based Medicine – Presidente Prudente (SP), Brazil.,Corresponding author:
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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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11
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Zhang R, Hu J, Li S, Xue B, Wang L, Bai J, Zheng J. Effects of age on sugammadex reversal of neuromuscular blockade induced by rocuronium in Chinese children: a prospective pilot trial. BMC Anesthesiol 2021; 21:248. [PMID: 34666673 PMCID: PMC8524895 DOI: 10.1186/s12871-021-01465-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 10/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sugammadex reverses neuromuscular blockade induced by steroidal relaxants. We compared the recovery for neuromuscular blockade reversal with sugammadex in children aged 1-12 years. METHODS From August 2019 to August 2020, patients who received 2.0 mg·kg- 1 sugammadex for neuromuscular blockade reversal after surgery were recruited. The primary outcome was the time for the train-of-four ratio (TOFR) to recover to 0.9; secondary outcomes included the incidence of the TOFR < 0.9, extubation time, length of stay at the post-anesthesia care unit, and adverse events. Hemodynamic parameters before and 5 min after sugammadex administration and vital signs in the recovery room were also recorded. RESULTS Eighty-six children were recruited (1 to < 3 years, n = 23; 3 to < 5 years, n = 33; 5 to ≤12 years, n = 30). Intergroup differences in the recovery of the TOFR to 0.9 were not statistically significant (F = 0.691, p = 0.504). Recurrence of the TOFR < 0.9 was not observed in any group. Five minutes after sugammadex administration, the heart rates of patients aged 3 to < 5 and 5 to ≤12 years were significantly lower than those at baseline (p < 0.05). Extubation time was similar in patients aged 1 to ≤12 years. Length of stay and end-tidal capnography at the post-anesthesia care unit as well as adverse events did not differ significantly. CONCLUSION A moderate (TOF count two) rocuronium-induced neuromuscular blockade can be effectively and similarly reversed with sugammadex 2 mg·kg- 1 in Chinese children aged 1-12 years. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR1900023715 (June 8, 2019).
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Affiliation(s)
- Ruidong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jie Hu
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shengde Li
- Department of Anesthesiology, Qingdao Women and Children's Hospital, Qingdao, Shandong, China
| | - Bin Xue
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Lu Wang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jie Bai
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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12
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Lemus R, Guider W, Gee SW, Humphrey L, Tobias JD. Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support. J Pain Symptom Manage 2021; 62:438-442. [PMID: 33677073 DOI: 10.1016/j.jpainsymman.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/19/2022]
Abstract
In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.
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Affiliation(s)
- Rafael Lemus
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA.
| | - Will Guider
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA; Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Samantha W Gee
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA; Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lisa Humphrey
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA; Division of Palliative Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
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13
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Li L, Jiang Y, Zhang W. Sugammadex for Fast-Track Surgery in Children Undergoing Cardiac Surgery: A Randomized Controlled Study. J Cardiothorac Vasc Anesth 2020; 35:1388-1392. [PMID: 32962936 DOI: 10.1053/j.jvca.2020.08.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of sugammadex for fast-track surgery in children undergoing cardiac surgery. DESIGN This was a prospective, randomized, controlled clinical study. SETTING University hospital. PARTICIPANTS The study comprised 60 children undergoing cardiac surgery. INTERVENTIONS The children in group S received sugammadex, 4 mg/kg, for reversal of neuromuscular block, and the children in group N received neostigmine, 30 µg/kg, and atropine, 15 µg/kg. MEASUREMENTS AND MAIN RESULTS The recovery time to a train-of-four of 0.9 and extubation time were significantly shorter in the group S than in group N (3.4 ± 1.2 min v 76.2 ± 20.5 min and 31.0 ± 6.4 min v 125.2 ± 21.6 min, respectively; p < 0.01). The heart rate after drug administration was higher in group S than in group N (102.7 ± 9.4 beats/min v 96.9 ± 8.5 beats/min; p = 0.03), whereas the mean arterial pressure after drug administration was similar in both groups. The length of hospital stay was shorter in group S (5.8 ± 1.0 v 6.5 ± 0.9 days; p = 0.03), and the hospitalization expenses were decreased in group S compared with that of group N ($1,036 ± $114 v $1,286 ± $187; p < 0.01). The incidence of postoperative atelectasis was less in group S than in group N (0 v 20%; p = 0.024). CONCLUSION Sugammadex can shorten the extubation time and reduce the incidence of postoperative atelectasis, with fewer adverse events, in children undergoing cardiac surgery. It may be beneficial to use sugammadex for fast-track surgery in children undergoing cardiac surgery.
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Affiliation(s)
- L Li
- Department of Anesthesiology, Wenzhou Central Hospital, Wenzhou, China
| | - Y Jiang
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - W Zhang
- Department of Anesthesiology, Women and Children's Hospital of Jiaxing University, Jiaxing, China.
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Bray JP, Adams DR, Phadke AS, Adams PS. Sugammadex Neuromuscular Blockade Reversal Associated With Lower Postoperative Arterial Carbon Dioxide Levels After Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:154-161. [PMID: 32768253 DOI: 10.1053/j.jvca.2020.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery. DESIGN Retrospective, cross-sectional study. SETTING Single-center, university-based, tertiary care hospital. PARTICIPANTS Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass. INTERVENTIONS Chart review. MEASUREMENTS AND MAIN RESULTS The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO2) values (coefficient -3.1, 95% confidence interval [CI] -5.9 to -0.4; p = 0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1-0.8; p = 0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p = 0.01) and lower PaCO2 values (coefficient -5.2, 95% CI -9.6 to -0.8; p = 0.021). CONCLUSION Sugammadex reversal was associated with lower postoperative PaCO2 values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal.
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Affiliation(s)
- Jacob P Bray
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas R Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Aparna S Phadke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phillip S Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Ames WA, Machovec K. An update on the management of PONV in a pediatric patient. Best Pract Res Clin Anaesthesiol 2020; 34:749-758. [PMID: 33288124 DOI: 10.1016/j.bpa.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 11/27/2022]
Abstract
Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. Assessment scores and prognostic tools enable the anesthesiologist to identify patients who are at a greater risk and appropriately apply more aggressive prophylactic, multi-drug strategies. New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.
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Affiliation(s)
- Warwick Aubrey Ames
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
| | - Kelly Machovec
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
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Abstract
Sugammadex reverses neuromuscular blockade by the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. In 2015, it was approved in the United States by the Food and Drug Administration for adult use. However, there are ongoing clinical trials investigating its use in the pediatric population. Before approval in adult use in the United States, several adverse effects were noted to occur in patients receiving sugammadex in clinical trials including prolonged QT interval, bradycardia, hypersensitivity reactions, and prolongation of coagulation parameters. Additional investigations further elucidated the risks of these adverse events. Sugammadex is approved for use in children older than 2 years in other countries in Europe and Asia. Investigations suggest that the efficacy, safety, and pharmacokinetic profile is similar in children when compared with adults. Published pediatric data favor the use of sugammadex in children older than 2 years, but there are some data in young children younger than 2 years. Case reports discuss the use of sugammadex in pediatric patients with neuromuscular diseases. Although sugammadex is typically used in the operating room for reversing neuromuscular blockade for surgical procedures, there is a small but important role for sugammadex use in the emergency department. In cases where rapid neurological examination is required after neuromuscular blockage with rocuronium or vecuronium, sugammadex can assist in facilitating a timely comprehensive neurological examination where pharmacologic or surgical management may depend on examination findings such as in the case of cerebral vascular accident, status epilepticus, or traumatic brain injury. Some clinicians have advocated for the use of sugammadex in the cannot intubate, cannot ventilate scenario. However, caution should be exercised in this situation as reversal of paralysis can take up to 22 minutes to occur.
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Effects of sugammadex on postoperative respiratory management in children with congenital heart disease: a randomized controlled study. Biomed Pharmacother 2020; 127:110180. [PMID: 32353822 DOI: 10.1016/j.biopha.2020.110180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early extubation can reduce pulmonary complications in children undergoing cardiac surgery. The aim of this study is to evaluate the effects of sugammadex for postoperative respiratory management in children with congenital heart disease. METHODS Sixty children with congenital heart disease undergoing elective cardiac surgery were divided into group S and group C (30 children in each group). When post tetanic twitches count (PTC) = 1-2 and train-of-four (TOF) = 0, the children in group S received sugammadex4 mg/kg for reversal of neuromuscular block at the end of surgery, and the children in group C received the same volume of normal saline. The recovery time to TOF of 0.9, the mechanical ventilation and extubation times were recorded. On the other side, the hemodynamic parameters before and 5 min after administration, and side effects were also recorded. The levels of C-reactive protein (CRP) and procalcitonin (PCT) before and 24 h after surgery were measured. RESULTS The recovery time to TOF of 0.9 and extubation time were significantly shorter in the group S than in the group C (4.2 ± 1.4 vs 108.2 ± 26.7 min, 66.3 ± 6.5 vs 171.6 ± 23.1 min, respectively, P < 0.01). The CRP and PCT levels were found to be increased in both groups at postoperative 24 h than before surgery. Further, the levels of PCT and CRP at postoperative 24 h were lower in group S when compared to group C (median, 7 vs 17.5 mg/ml, 1.76 vs 5.22 ng/ml, respectively, P < 0.05). There were no statistical differences observed between the two groups (P> 0.05) with respect to side effects. CONCLUSION Sugammadex is rapid and effective in reversing rocuronium-induced neuromuscular block, and significantly reduces the extubation time and the release of postoperative CRP and PCT in children with congenital heart diseases.
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18
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Korkmaz MO, Sayhan H, Guven M. Does sugammadex decrease the severity of agitation and complications in pediatric patients undergoing adenotonsillectomy? Saudi Med J 2020; 40:907-913. [PMID: 31522218 PMCID: PMC6790488 DOI: 10.15537/smj.2019.9.24485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives: To evaluate the effectiveness of sugammadex in reducing or eliminating postoperative agitation levels, early respiratory complications and nausea/vomiting in children undergoing adenotonsillectomy. Methods: A total of 70 patients (age range: 5-13 years) who underwent an adenotonsillectomy in the Otolaryngology Clinic, Sakarya University, Sakarya, Turkey between May 2015 and September 2017 were included in the study. The patients were randomized into a sugammadex group (Group S) and a neostigmine + atropine (Group N); each group contained 35 patients. Time to extubation, postoperative agitation levels, and early postoperative complications were evaluated and recorded. Data from both groups were statistically evaluated and compared. Results: The time to extubation was significantly shorter in Group S than Group N (p<0.05). Agitation scores during recovery were significantly lower in Group S than Group N (p<0.05). More complications were observed in Group N than in Group S; the number of patients seen coughing and experiencing nausea/vomiting in Group S was statistically significantly lower (p<0.05). Conclusion: This study demonstrated that the use of sugammadex results in less time to recovery and less agitation in comparison to conventional administration of neostigmine + atropine in the reversal of neuromuscular blocking after adenotonsillectomy.
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Affiliation(s)
- Muge O Korkmaz
- Otolaryngology Department, Sakarya University, Sakarya, Turkey. E-mail.
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19
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An J, Lee JH, Kim E, Woo K, Kim H, Lee D. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: A prospective randomized study. Medicine (Baltimore) 2020; 99:e19130. [PMID: 32049831 PMCID: PMC7035047 DOI: 10.1097/md.0000000000019130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. This study compared efficacy of sugammadex and pyridostigmine for reversal of rocuronium-induced light block or minimal block in children scheduled for elective entropion surgery. METHODS A prospective randomized study was conducted on 60 pediatric patients aged 1 to 11 years and scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using train-of-four (TOF) ulnar nerve stimulation. Patients were randomly assigned to 2 groups receiving sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg plus glycopyrrolate 0.01 mg/kg. Primary outcomes were time from reversal agents administration to TOF ratio 0.9 and time from reversal agent administration to TOF ratio 1.0. Time from TOF ratio 0.9 to extubation, time from TOF ratio 1.0 to extubation, and postoperative adverse events were also recorded. RESULTS There were no substantial differences in demographic variables. Time from reversal agents administration to TOF ratio 0.9 and time from reversal agents to TOF ratio 1.0 were significantly faster in sugammadex group: 1.30 ± 0.84 versus 3.53 ± 2.73 minutes (P < .001) and 2.75 ± 1.00 versus 5.73 ± 2.83 minutes (P < .001). Extubation time was shorter in sugammadex group. Incidence of skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction) was not statistically different between groups. Incidence of patients agitation in recovery room was lower in sugammadex group. CONCLUSION Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery lasting 30 to 60 minutes than did pyridostigmine plus glycopyrrolate, with no differences in incidence of adverse events between groups.
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Scheffenbichler FT, Rudolph MI, Friedrich S, Althoff FC, Xu X, Spicer AC, Patrocínio M, Ng PY, Deng H, Anderson TA, Eikermann M. Effects of high neuromuscular blocking agent dose on post-operative respiratory complications in infants and children. Acta Anaesthesiol Scand 2020; 64:156-167. [PMID: 31529484 DOI: 10.1111/aas.13478] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/15/2019] [Accepted: 09/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study evaluated the association between neuromuscular blocking agent dose and post-operative respiratory complications in infants and children. METHODS Data from 6507 general anaesthetics provided to children aged 0-10 years undergoing surgery were analysed to examine the effects of neuromuscular blocking agent dose on post-operative respiratory complications (primary endpoint) and secondary endpoints. Confounder-adjusted analyses addressed age, surgical duration, and comorbidity burden. RESULTS In confounder-adjusted analyses, high doses of neuromuscular blocking agents were associated with higher risk of post-operative respiratory complications (OR 2.27; 95% CI 1.12-4.59; P = .022). The effect was modified by age (P-for-interaction = .016) towards a more substantial risk in infants ≤1 year (OR 3.84; 95% CI 1.35-10.94; P = .012), by duration of surgery (P-for-interaction = .006) towards a higher difference in odds for surgeries <90 minutes (OR 4.25; 95% CI 1.19-15.18; P = .026), and by ASA physical status (P-for-interaction = .015) with a greater effect among patients with higher operative risk (ASA >1: OR 3.17; 95% CI 1.43-7.04; P = .005). Neostigmine reversal did not modify the association between neuromuscular blocking agents and post-operative respiratory complications (P-for-interaction = .38). Instrumental variable analysis confirmed that high doses of neuromuscular blocking agents were associated with post-operative respiratory complications (probit coefficient 0.25; 95% CI 0.04-0.46; P = .022), demonstrating robust results regarding concerns of unobserved confounding. CONCLUSIONS High dose of neuromuscular blocking agents is associated with post-operative respiratory complications. We have identified subcohorts of paediatric patients who are particularly vulnerable to the respiratory side-effects of neuromuscular blocking agents: infants, paediatric patients undergoing surgeries of short duration, and those with a high ASA risk score.
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Affiliation(s)
- Flora T. Scheffenbichler
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Maíra I. Rudolph
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Sabine Friedrich
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Friederike C. Althoff
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Aaron C. Spicer
- Department of Anesthesiology, Critical Care and Pain Medicine Boston Children’s Hospital and Harvard Medical School Boston MA USA
| | - Maria Patrocínio
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Pauline Y. Ng
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Adult Intensive Care Unit Queen Mary Hospital Hong Kong SAR China
| | - Hao Deng
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Thomas A. Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine Lucile Packard Children's Hospital Stanford University School of Medicine Stanford CA USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
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Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
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Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
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22
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An J, Kim E, Lee J, Kim H, Son J, Huh J, Woo K. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: a prospective randomized study. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.3.288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jihyun An
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Eunju Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jihyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyun Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jongcheol Son
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Joonyoung Huh
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Kyeongyoon Woo
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
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23
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Dadure C, Sabourdin N, Veyckemans F, Babre F, Bourdaud N, Dahmani S, Queiroz MD, Devys JM, Dubois MC, Kern D, Laffargue A, Laffon M, Lejus-Bourdeau C, Nouette-Gaulain K, Orliaguet G, Gayat E, Velly L, Salvi N, Sola C. Management of the child's airway under anaesthesia: The French guidelines. Anaesth Crit Care Pain Med 2019; 38:681-693. [PMID: 30807876 DOI: 10.1016/j.accpm.2019.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide French guidelines about "Airway management during paediatric anaesthesia". DESIGN A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. METHODS The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. RESULTS The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.
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Affiliation(s)
- Christophe Dadure
- Département d'anesthesiologie réanimation femme-mère-enfant, CHU de Lapeyronie, institut de génomique fonctionnelle, UMR 5203 CNRS - U 1191 Inserm, université de Montpellier, 34285 Montpellier, France.
| | - Nada Sabourdin
- Département d'anesthésiologie-réanimation hôpital Armand Trousseau, AP-HP, 26, avenue du Dr Arnold-Netter, 75012 Paris, France
| | - Francis Veyckemans
- Department of paediatric anaesthesia, Jeanne de Flandre hospital, university hospitals of Lille, 59037 Lille, France
| | - Florence Babre
- Department of anaesthesia, Bergonié institute, 33000 Bordeaux, France
| | - Nathalie Bourdaud
- Département d'Anesthésiologie Réanimation Pédiatrique, Hôpital Femme Mère Enfant, 69677 Bron, France
| | - Souhayl Dahmani
- Department of anaesthesia and intensive care. Robert-Debré university hospital, assistance publique Hôpitaux de Paris, Paris Diderot University, Paris Sorbonne Cité, Paris, Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, DHU PROTECT, Inserm U1141, Robert-Debré University Hospital, 75019 Paris, France
| | - Mathilde De Queiroz
- Département d'Anesthésiologie Réanimation Pédiatrique, Hôpital Femme Mère Enfant, 69677 Bron, France
| | - Jean-Michel Devys
- Service d'anesthésie-réanimation, fondation ophtalmologique Adolphe de Rothschild, 25, rue Manin, 75019 Paris, France
| | - Marie-Claude Dubois
- Service d'anesthésie-réanimation, fondation ophtalmologique Adolphe de Rothschild, 25, rue Manin, 75019 Paris, France
| | - Delphine Kern
- Departments of anaesthesia and intensive care, university hospital of Toulouse, place du Dr Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - Anne Laffargue
- Department of paediatric anaesthesia, Jeanne de Flandre hospital, university hospitals of Lille, 59037 Lille, France
| | - Marc Laffon
- Department of anesthesia and intensive care, university hospital and medical university François-Rabelais, Tours, France
| | - Corinne Lejus-Bourdeau
- Service d'anesthesie réanimation chirurgicale, Hôtel Dieu, Hôpital Mère Enfant, CHU de Nantes, 44093 Nantes cedex, France
| | - Karine Nouette-Gaulain
- Service d'anesthésie réanimation Pellegrin, hôpital Pellegrin, CHU de Bordeaux, place Amélie Raba Léon, 33000 Bordeaux, France; Université Bordeaux, Inserm U12-11, laboratoire de maladies rares: génétique et métabolisme (MRGM), 176, rue Léo-Saignat, 33000 Bordeaux, France
| | - Gilles Orliaguet
- Department of anaesthesia and intensive care, assistance publique Hôpitaux de Paris, Necker-Enfants Malades hospital, EA08 pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Paris Descartes University (Paris V), PRES Paris Sorbonne Cité, 75743 Paris, France
| | - Etienne Gayat
- Department of anesthesiology and Intensive care, Saint Louis, Lariboisière university hospital, université Paris Diderot, BioCANVAS, UMR-S 942, Inserm, 75010 Paris, France
| | - Lionel Velly
- Service d'anesthesie réanimation, CHU de Timone adultes, 264, rue St Pierre, 13005 MeCA, institut de neurosciences de la Timone, UMR 7289, Aix Marseille université, Marseille, France
| | - Nadège Salvi
- Department of anaesthesia and intensive care, assistance publique Hôpitaux de Paris, Necker-Enfants Malades Hospital, 75743 Paris, France
| | - Chrystelle Sola
- Département d'anesthesiologie réanimation femme-mère-enfant, CHU de Lapeyronie, institut de génomique fonctionnelle, UMR 5203 CNRS - U 1191 Inserm, université de Montpellier, 34285 Montpellier, France
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