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Han J, Jung YH, Kim MK, Min S. Anesthetic management of a patient with spinal and bulbar muscular atrophy (Kennedy's disease) : Case report with brief literature review. DIE ANAESTHESIOLOGIE 2024; 73:531-534. [PMID: 38942900 DOI: 10.1007/s00101-024-01430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/07/2024] [Accepted: 05/21/2024] [Indexed: 06/30/2024]
Affiliation(s)
- Jiwon Han
- Department of Anaesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110 Deokan-ro, 14353, Gwangmyeong-si, Gyeonggi-do, Korea (Republic of)
| | - Yong Hun Jung
- Department of Anaesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110 Deokan-ro, 14353, Gwangmyeong-si, Gyeonggi-do, Korea (Republic of)
| | - Min Kyoung Kim
- Department of Anaesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110 Deokan-ro, 14353, Gwangmyeong-si, Gyeonggi-do, Korea (Republic of)
| | - Seihee Min
- Department of Anaesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110 Deokan-ro, 14353, Gwangmyeong-si, Gyeonggi-do, Korea (Republic of).
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Frenkel M, Lien CA. Eliminating residual neuromuscular blockade: a literature review. ANNALS OF TRANSLATIONAL MEDICINE 2024; 12:65. [PMID: 39118951 PMCID: PMC11304418 DOI: 10.21037/atm-23-1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/14/2023] [Indexed: 08/10/2024]
Abstract
Background and Objective Although millions of patients receive neuromuscular blocking agents (NMBAs) each year as part of an anesthetic, residual neuromuscular blockade (NMB) remains a too-frequent occurrence and its adverse consequences continue to negatively impact patient outcomes. The goal of this manuscript is to provide clinicians with the information they need to decrease the incidence of residual NMB. Methods Published literature was reviewed and incorporated into the narrative as appropriate. Search terms for articles included nondepolarizing NMBAs, residual NMB, monitoring depth of NMB, qualitative monitoring, quantitative monitoring, reversal agents, sugammadex, and anticholinesterases. Key Content and Findings This review will define what is currently considered adequate recovery of neuromuscular function, discuss and compare the different modalities to determine the depth of NMB, discuss the currently available NMBAs-including their durations of action and dosing, describe the incidence and complications associated with residual NMB, and discuss reversal of nondepolarizing NMB with neostigmine or sugammadex. Nondepolarizing NMBAs are commonly used as part of a general anesthetic. Understanding the pharmacology of the neuromuscular blocking and reversal agent, in combination with quantitative monitoring of depth of NMB is essential to avoid residual paralysis. Conclusions Quantitative monitoring and dosing of either neostigmine or sugammadex based on the results of monitoring is essential to eliminate residual NMB associated with the use of nondepolarizing NMBAs.
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Affiliation(s)
- Mogen Frenkel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cynthia A Lien
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Schneider A, Tramèr MR, Keli-Barcelos G, Elia N. Sugammadex and neuromuscular disease: a systematic review with assessment of reporting quality and content validity. Br J Anaesth 2024:S0007-0912(24)00309-X. [PMID: 38997841 DOI: 10.1016/j.bja.2024.05.015] [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: 02/11/2024] [Revised: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Efficacy and safety of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) in patients with neuromuscular diseases remains unclear. We summarised the available evidence and evaluated the quality of data reporting and the validity of published reports. METHODS We searched for reports (any design) on the usage of sugammadex (any regimen) for the reversal of an NMBA in patients (any age) with any neuromuscular disease. We used a modified CARE checklist (maximum score 23) to assess the quality of data reporting and an original specific validity checklist (maximum score 41) that was developed through a Delphi process. RESULTS We retrieved 126 observational reports (386 patients). Most dealt with myasthenia gravis patients receiving rocuronium. The train-of-four ratio returned to ≥0.9 in 258 of 265 (97.4%) patients in whom neuromonitoring was used. Adverse events occurred in 14 of 332 (4.2%) patients in whom adverse events were reported as present or absent. In 90 case reports, the median score of the 23-point CARE checklist was 13.5 (inter-quartile range [IQR] 11-16). In all 126 reports, the median score of the 41-point validity checklist was 23 (IQR 20-27). Scores were positively correlated. CONCLUSIONS These uncontrolled observations (of mainly low to moderate quality and validity) do not allow confident assessment of the efficacy and safety of sugammadex for the reversal of NMBAs in patients with neuromuscular diseases. Reporting of observational data should follow established guidelines, include specific information to ensure validity, and emphasise what the new data add to current knowledge. SYSTEMATIC REVIEW PROTOCOL PROSPERO 2019 (CRD42019119924).
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Affiliation(s)
- Alexis Schneider
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Martin R Tramèr
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Gleicy Keli-Barcelos
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Carr SG, Clifton JC, Freundlich RE, Fowler LC, Sherwood ER, McEvoy MD, Robertson A, Dunworth B, McCarthy KY, Shotwell MS, Kertai MD. Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study. Anesth Analg 2024; 138:517-529. [PMID: 38364243 PMCID: PMC10878712 DOI: 10.1213/ane.0000000000006722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.
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Affiliation(s)
- Shane G. Carr
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob C. Clifton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brent Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen Y. McCarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Krall JTW, Chakravartty A, Caress JB, Files DC. Identification and Management of Acute Neuromuscular Respiratory Failure in the ICU. Chest 2023; 164:1454-1461. [PMID: 38070961 DOI: 10.1016/j.chest.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 12/18/2023] Open
Abstract
Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder.
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Affiliation(s)
- Jennifer T W Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Akash Chakravartty
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - James B Caress
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
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Niezgoda A, Biegański G, Wachowiak J, Czarnota J, Siemionow K, Heydemann A, Ziemiecka A, Sikorska MH, Bożyk K, Siemionow M. Assessment of Motor Unit Potentials Duration as the Biomarker of DT-DEC01 Cell Therapy Efficacy in Duchenne Muscular Dystrophy Patients up to 12 Months After Systemic-Intraosseous Administration. Arch Immunol Ther Exp (Warsz) 2023; 71:24. [PMID: 37999748 PMCID: PMC10673998 DOI: 10.1007/s00005-023-00691-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Abstract
Duchenne muscular dystrophy (DMD) is a lethal X-linked disease caused by mutations in the dystrophin gene, leading to muscle degeneration and wasting. Electromyography (EMG) is an objective electrophysiological biomarker of muscle fiber function in muscular dystrophies. A novel, DT-DEC01 therapy, consisting of Dystrophin Expressing Chimeric (DEC) cells created by fusing allogeneic myoblasts from normal donors with autologous myoblasts from DMD-affected patients, was assessed for safety and preliminary efficacy in boys of age 6-15 years old (n = 3). Assessments included EMG testing of selected muscles of upper (deltoideus, biceps brachii) and lower (rectus femoris and gastrocnemius) extremities at the screening visit and at 3, 6, and 12 months following systemic-intraosseous administration of a single low dose of DT-DEC01 therapy (Bioethics Committee approval no. 46/2019). No immunosuppression was administered. Safety of DT-DEC01 was confirmed by the lack of therapy-related Adverse Events or Serious Adverse Events up to 22 months following DT-DEC01 administration. EMG of selected muscles of both, ambulatory and non-ambulatory patients confirmed preliminary efficacy of DT-DEC01 therapy by an increase in motor unit potentials (MUP) duration, amplitudes, and polyphasic MUPs at 12 months. This study confirmed EMG as a reliable and objective biomarker of functional assessment in DMD patients after intraosseous administration of the novel DT-DEC01 therapy.
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Affiliation(s)
- Adam Niezgoda
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Grzegorz Biegański
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Krzysztof Siemionow
- Dystrogen Therapeutics Corp., Chicago, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahlke Heydemann
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, USA
- Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | | | - Maria Siemionow
- Dystrogen Therapeutics Corp., Chicago, IL, USA.
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA.
- Chair and Department of Traumatology, Orthopedics and Surgery of the Hand, Poznan University of Medical Sciences, Poznan, Poland.
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Yoon JJ, Anderson AL, Niesen AD. Undiagnosed Lambert-Eaton Myasthenic Syndrome in the Era of Sugammadex: A Case Report. Clin Neuropharmacol 2023; 46:205-208. [PMID: 37962306 DOI: 10.1097/wnf.0000000000000569] [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: 09/13/2023]
Abstract
OBJECTIVE In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. METHODS We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. RESULTS Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. CONCLUSIONS Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.
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Affiliation(s)
| | - Alexandra L Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam D Niesen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Siemionow M, Biegański G, Niezgoda A, Wachowiak J, Czarnota J, Siemionow K, Ziemiecka A, Sikorska MH, Bożyk K, Heydemann A. Safety and Efficacy of DT-DEC01 Therapy in Duchenne Muscular Dystrophy Patients: A 12 - Month Follow-Up Study After Systemic Intraosseous Administration. Stem Cell Rev Rep 2023; 19:2724-2740. [PMID: 37707670 PMCID: PMC10661797 DOI: 10.1007/s12015-023-10620-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
Duchenne Muscular Dystrophy (DMD) is a progressive and fatal muscle-wasting disease with no known cure. We previously reported the preliminary safety and efficacy up to six months after the administration of DT-DEC01, a novel Dystrophin Expressing Chimeric (DEC) cell therapy created by fusion of myoblasts of DMD patient and the normal donor. In this 12-month follow-up study, we report on the safety and functional outcomes of three DMD patients after the systemic intraosseous administration of DT-DEC01. The safety of DT-DEC01 was confirmed by the absence of Adverse Events (AE) and Severe Adverse Events (SAE) up to 21 months after intraosseous DT-DEC01 administration. The lack of presence of anti-HLA antibodies and Donors Specific Antibodies (DSA) further confirmed DT-DEC01 therapy safety. Functional assessments in ambulatory patients revealed improvements in 6-Minute Walk Test (6MWT) and timed functions of North Star Ambulatory Assessment (NSAA). Additionally, improvements in PUL2.0 test and grip strength correlated with increased Motor Unit Potentials (MUP) duration recorded by Electromyography (EMG) in both ambulatory and non-ambulatory patients. DT-DEC01 systemic effect was confirmed by improved cardiac and pulmonary parameters and daily activity recordings. This follow-up study confirmed the safety and preliminary efficacy of DT-DEC01 therapy in DMD-affected patients up to 12 months after intraosseous administration. DT-DEC01 introduces a novel concept of personalized myoblast-based cellular therapy that is irrespective of the mutation type, does not require immunosuppression or the use of viral vectors, and carries no risk of off target mutations. This establishes DT-DEC01 as a promising and universally effective treatment option for all DMD patients.
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Affiliation(s)
- Maria Siemionow
- Chair and Department of Traumatology, Orthopedics and Surgery of the Hand, Poznan University of Medical Sciences, 61‑545, Poznan, Poland.
- Dystrogen Therapeutics Corp., Chicago, IL, 60609, USA.
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, 60612, USA.
| | - Grzegorz Biegański
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, 60‑572, Poznan, Poland
| | - Adam Niezgoda
- Department of Neurology, Poznan University of Medical Sciences, 60-355, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, 60-572, Poznan, Poland
| | | | - Krzysztof Siemionow
- Dystrogen Therapeutics Corp., Chicago, IL, 60609, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | | | | | | | - Ahlke Heydemann
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, 60612, USA
- Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL, 60612, USA
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Hien VV, Tu NH, Thu ND. Propofol TCI or sevoflurane anesthesia without muscle relaxant for thoracoscopic thymectomy in myasthenia gravis patients: a prospective, observational study. BMC Anesthesiol 2023; 23:349. [PMID: 37865733 PMCID: PMC10589925 DOI: 10.1186/s12871-023-02296-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) patients interact unpredictably with anesthetic agents, including neuromuscular blocking agents. Here, we investigate the effectiveness of general anesthesia without muscle relaxants using either propofol via target-controlled infusion systems (TCI) or sevoflurane in MG patients undergoing thoracoscopic thymectomy. METHODS This prospective, open-label, observational study was conducted in a university hospital. We included 90 myasthenic patients undergoing thoracoscopic thymectomy with general anesthesia. Patients received induction and maintenance anesthesia with propofol TCI (group P, n = 45) or induction with propofol 2-3 mg.kg-1 and maintenance anesthesia with sevoflurane (group S, n = 45). In both groups, the procedure was performed under the guidance of entropy with sufentanil but not a muscle relaxant. Intubation conditions, hemodynamic changes, respiratory function, neuromuscular transmission, arterial blood gas, and complications were evaluated. RESULTS All patients achieved good intubation conditions. Hemodynamic instability was more frequent in group S than in group P, mostly in the induction stage, and was controllable. The reduction in the intraoperative train-of-four ratio from baseline at 30 min, 60 min, and 90 min in group S was 10.3%, 14.2%, and 14.3%, respectively, significantly higher than that in group P (6.8%, 7.2%, and 8.4%, respectively), which completely recovered at the end of the surgery. All patients were extubated in the operating room without complications. No other significant differences between the groups were observed. CONCLUSIONS Anesthesia with propofol TCI or sevoflurane without muscle relaxants in MG patients offered safe and effective conditions for thoracoscopic thymectomy. Sevoflurane achieved higher levels of intraoperative muscular relaxation than propofol TCI. Postoperative neuromuscular function was not affected by these anesthetics.
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Affiliation(s)
- Vo Van Hien
- Department of Anesthesiology, Military Hospital 103, Vietnam Military Medical University, No.261 Phung Hung Street, Ha Dong District, Hanoi, 12108, Vietnam
- Department of Anesthesiology, National Burn Hospital, Vietnam Military Medical University, No.263 Phung Hung Street, Ha Dong District, Hanoi, 12108, Vietnam
| | - Nguyen Huu Tu
- Department of Anesthesia and Critical Care, Hanoi Medical University, No.1 Ton That Tung Street, Dong Da District, Hanoi, 116177, Vietnam
| | - Nguyen Dang Thu
- Department of Anesthesiology, Military Hospital 103, Vietnam Military Medical University, No.261 Phung Hung Street, Ha Dong District, Hanoi, 12108, Vietnam.
- Department of Musculoskeletal Functional Research and Regeneration, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, Hiroshima, 734-8553, Japan.
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Baniak LM, Orbell SL, Luyster FS, Henker R, Strollo PJ. Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway. Sleep Med Rev 2023; 67:101712. [PMID: 36442290 DOI: 10.1016/j.smrv.2022.101712] [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: 06/30/2022] [Revised: 10/14/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
Abstract
Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.
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Affiliation(s)
- Lynn M Baniak
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Staci L Orbell
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Faith S Luyster
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Henker
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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11
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Wang HC, Lu CW, Lin TY, Chang YY. Unexpected delayed reversal of rocuronium-induced neuromuscular blockade by sugammadex: A case report and review of literature. World J Clin Cases 2022; 10:13138-13145. [PMID: 36569003 PMCID: PMC9782926 DOI: 10.12998/wjcc.v10.i35.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Rocuronium, a nondepolarizing muscle relaxant, is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery. Sugammadex, the selective reversal agent of rocuronium, fully reverses the neuromuscular blockade (NMB) at the end of surgery. Most reports show that sugammadex rapidly achieves a ratio of train-of-four (TOF), a quantitative method of neuromuscular monitoring, of 0.9 which ensures adequate recovery for safe extubation. However, very rare patients with neuromuscular diseases may respond poorly to sugammadex.
CASE SUMMARY A 69-year-old female presented with abdominal fullness and nausea, and was diagnosed with gastroparesis. She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium (0.7 mg/kg). At the end of surgery, sugammadex 3.6 mg/kg was administered when TOF showed 2 counts. Afterward, the TOF ratio recovered to 0.65 in 30 min. She was awake but could not fully open her eyelids. The tidal volume during spontaneous breathing was low. After additional doses of sugammadex (up to 7.3 mg/kg) in the following 3 h, the TOF ratio was 0.9, and the endotracheal tube was smoothly removed. After excluding possible mechanisms underlying the prolonged recovery course, we speculated our patient may have had an undiagnosed neuromuscular disease, hinted by her involuntary movement of the tongue and mouth. Furthermore, her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.
CONCLUSION In our case, both prolonged rocuronium-induced NMB and poor response to sugammadex were noted. To optimize the dose of rocuronium, perioperative TOF combined with other neuromuscular monitoring is suggested.
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Affiliation(s)
- Hao-Chen Wang
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
| | - Cheng-Wei Lu
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Chung-Li 320, Taiwan
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Chung-Li 320, Taiwan
| | - Ya-Ying Chang
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei City 220, Taiwan
- International Program in Engineering for Bachelor, Yuan Ze University, Chung-Li 320, Taiwan
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12
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van den Bersselaar LR, Heytens L, Silva HCA, Reimann J, Tasca G, Díaz‐Cambronero Ó, Løkken N, Hellblom A, Hopkins PM, Rueffert H, Bastian B, Vilchez JJ, Gillies R, Johannsen S, Veyckemans F, Muenster T, Klein A, Litman R, Jungbluth H, Riazi S, Voermans NC, Snoeck MMJ. European Neuromuscular Centre consensus statement on anaesthesia in patients with neuromuscular disorders. Eur J Neurol 2022; 29:3486-3507. [PMID: 35971866 PMCID: PMC9826444 DOI: 10.1111/ene.15526] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/05/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Patients with neuromuscular conditions are at increased risk of suffering perioperative complications related to anaesthesia. There is currently little specific anaesthetic guidance concerning these patients. Here, we present the European Neuromuscular Centre (ENMC) consensus statement on anaesthesia in patients with neuromuscular disorders as formulated during the 259th ENMC Workshop on Anaesthesia in Neuromuscular Disorders. METHODS International experts in the field of (paediatric) anaesthesia, neurology, and genetics were invited to participate in the ENMC workshop. A literature search was conducted in PubMed and Embase, the main findings of which were disseminated to the participants and presented during the workshop. Depending on specific expertise, participants presented the existing evidence and their expert opinion concerning anaesthetic management in six specific groups of myopathies and neuromuscular junction disorders. The consensus statement was prepared according to the AGREE II (Appraisal of Guidelines for Research & Evaluation) reporting checklist. The level of evidence has been adapted according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system. The final consensus statement was subjected to a modified Delphi process. RESULTS A set of general recommendations valid for the anaesthetic management of patients with neuromuscular disorders in general have been formulated. Specific recommendations were formulated for (i) neuromuscular junction disorders, (ii) muscle channelopathies (nondystrophic myotonia and periodic paralysis), (iii) myotonic dystrophy (types 1 and 2), (iv) muscular dystrophies, (v) congenital myopathies and congenital dystrophies, and (vi) mitochondrial and metabolic myopathies. CONCLUSIONS This ENMC consensus statement summarizes the most important considerations for planning and performing anaesthesia in patients with neuromuscular disorders.
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Affiliation(s)
- Luuk R. van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Luc Heytens
- Malignant Hyperthermia Research Unit, Departments of Anaesthesiology and NeurologyUniversity Hospital Antwerp, University of Antwerp and Born Bunge InstituteAntwerpBelgium
| | - Helga C. A. Silva
- Malignant Hyperthermia Unit, Department of Surgery, Discipline of Anaesthesia, Pain, and Intensive CareSão Paulo Federal UniversitySão PauloBrazil
| | - Jens Reimann
- Department of NeurologyUniversity of Bonn Medical CentreBonnGermany
| | - Giorgio Tasca
- UOC of NeurologyA. Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health CareRomeItaly
| | - Óscar Díaz‐Cambronero
- Malignant Hyperthermia Unit, Department of AnaesthesiologyPerioperative Medicine Research Group, La Fe University and Polytechnic HospitalValenciaSpain
| | - Nicoline Løkken
- Copenhagen Neuromuscular CentreRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Anna Hellblom
- Department of Intensive and Perioperative CareSkåne University Hospital LundLundSweden
| | - Philip M. Hopkins
- Leeds Institute of Medical Research at St James'sUniversity of Leeds and Malignant Hyperthermia Investigation Unit, St James's University HospitalLeedsUK
| | - Henrik Rueffert
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Börge Bastian
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Juan Jesus Vilchez
- Neuromuscular Centre, La Fe Hospital UIP and ERN EURO‐NMDNeuromuscular Research Group at La Fe IIS and CIBERERValenciaSpain
| | - Robyn Gillies
- Malignant Hyperthermia Diagnostic Unit, Department of Anaesthesia and Pain ManagementRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, Centre for Malignant HyperthermiaUniversity Hospital WürzburgWürzburgGermany
| | - Francis Veyckemans
- Paediatric Anaesthesia ClinicJeanne de Flandre Hospital, Lille University Hospital CentreLilleFrance
| | - Tino Muenster
- Department of Anaesthesia and Intensive Care MedicineHospital of the Order of St John of GodRegensburgGermany
| | - Andrea Klein
- Department of Paediatric NeurologyUniversity Children's Hospital UKBBBaselSwitzerland,Division of Neuropaediatrics, Development, and Rehabilitation, Department of Paediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Ron Litman
- Department of Anaesthesiology and Critical CareChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular ServiceEvelina's Children Hospital, Guy's and St Thomas' Hospital National Health Service Foundation TrustLondonUK,Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology and Pain MedicineUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Marc M. J. Snoeck
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands
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Sá AF, Pereira R, Lourenço S, Barros F, Oliveira C, Esteves S. Pitfalls of cubital electrical nerve stimulation for neuromuscular transmission monitoring: A case report of familial amyloid polyneuropathy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:578-582. [PMID: 36241515 DOI: 10.1016/j.redare.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/24/2021] [Indexed: 06/16/2023]
Abstract
Transthyretin familial amyloid polyneuropathy (FAP) is a rare autosomal dominant disease that provokes systemic deposition of amyloid. It affects the nervous system and it is characterized by progressive sensory, motor, and autonomic neuropathy. Patients with FAP often require surgery and anesthetic care for hepatic transplantation and cardioverter-defibrillator/pacemaker implantation. Peripheric neuropathy is a common finding, but there are no reported cases of its interference with anesthetic neuromuscular transmission monitoring. We report a case of a FAP patient where lack of awareness and distracting factors led to misinterpretation of neuromuscular monitoring and unnecessary sedation and ventilation in the post anesthetic care unit. FAP may interfere with the usual cubital nerve neuromuscular monitoring. Anesthesiologists should be aware of potential neuromuscular compromise to find the best monitoring location for each patient. Sugammadex was safe and reliable in the antagonism of rocuronium neuromuscular blockade in this case, despite the lack of adequate quantitative monitoring.
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Affiliation(s)
- A F Sá
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - R Pereira
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - S Lourenço
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - F Barros
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - C Oliveira
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - S Esteves
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
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14
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Russo LP, Haddad D, Bauman D, Fam MM. The Use of Enhanced Recovery After Surgery Protocols and Sugammadex in a Friedreich Ataxia Patient Who Underwent Robotic Surgery: A Case Report of a Patient Who Required No Postoperative Opioids and Was Discharged Home Earlier Than Anticipated. Cureus 2022; 14:e29590. [PMID: 36312625 PMCID: PMC9595352 DOI: 10.7759/cureus.29590] [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] [Accepted: 09/26/2022] [Indexed: 11/20/2022] Open
Abstract
Robotic surgery has shown to have numerous benefits over traditional and laparoscopic surgery, namely, superior precision and improved recovery with shorter hospital stays. However, robotic surgery also presents several issues, including hemodynamic changes related to positioning and the use of pneumoperitoneum. These matters can be problematic in patients with neuromuscular conditions such as Friedreich ataxia (FRDA). Due to a baseline weakened musculature and a higher prevalence of cardiac disease and scoliosis, patients with FRDA may not be as likely to tolerate the cardiopulmonary physiologic changes associated with robotic surgery. Additionally, positioning for robotic surgery can be challenging in FRDA patients who have progressed to spasticity and contractures. To the best of our knowledge, there are no case reports of approaches specifically discussing anesthesia management for robotic surgery in the FRDA patient population. Anesthesia in general must be carefully planned in FRDA patients to allow for the best possible recovery and minimize complications. Due to the underlying neuromuscular compromise seen in these patients, their ability to recover from the pharmacologic and physiologic changes associated with anesthesia can be more difficult. They are prone to sensitivity to opioids, sedatives, and neuromuscular blocking agents (NMBAs) and are less likely to tolerate hemodynamic changes. Our review revealed no literature to suggest the routine use of Enhanced Recovery After Surgery (ERAS) protocols in FRDA patients or in patients with neuromuscular disease in general. The use of sugammadex has also been shown to be safe, and literature suggests superiority in both the general population and those with neuromuscular conditions. Our understanding is that there is very limited literature in regard to the safe use of sugammadex in FRDA patients.
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15
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Montané-Muntané M, Vidal-Sánchez J, Rivas E, Martínez-Pallí G. Perioperative management of immune-mediated necrotizing myositis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2022; 72:432-433. [PMID: 35296427 PMCID: PMC9373675 DOI: 10.1016/j.bjane.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 02/27/2022] [Accepted: 03/05/2022] [Indexed: 11/03/2022]
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16
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Han W, Lee JM, Park DH, Lee CA, Jeong CY, Yang HS. Adverse events of sugammadex that occurred in a Korean population. Anesth Pain Med (Seoul) 2022; 17:191-198. [PMID: 35378568 PMCID: PMC9091674 DOI: 10.17085/apm.21096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background With increasing use, the incidence of adverse events associated with sugammadex, a neuromuscular blockade reverser, is increasing. This study aimed to identify and analyze cases of adverse events caused by sugammadex reported in Korean population. Methods Out of a total of 12 cases detected using various keywords in the Korean Journal of Anesthesia, Anesthesia and Pain Medicine (Seoul), KoreaMed, PubMed, EMBASE, Web of Science, and The Cochrane Library-CENTRAL from 2013 to December 2020, 10 cases directly associated with sugammadex were selected. Results Adverse events included five cases of anaphylaxis, one case of cardiac arrest, one case of profound bradycardia, one case of negative pressure pulmonary edema, and two cases of incomplete recovery. Three patients had American Society of Anesthesiologists physical status ≥ 3, two had emergency surgery, and two had a history of allergic reaction. Neuromuscular monitoring was applied in nine cases. The average dose of sugammadex was 2.87 mg/kg, and there were six cases in which one full vial was used, regardless of the state of neuromuscular recovery. Sugammadex was administered immediately after surgery in two cases, at train of four (TOF) 0 in four cases, at TOF 3 in one case, and after evaluation of the clinical signs only with no neuromuscular monitoring in one case. Conclusions Even with neuromuscular monitoring, an excessive dose of sugammadex was observed. Given that adverse events tend to occur within 10 min of administration, continuous monitoring is important even after administration.
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Affiliation(s)
| | | | | | | | | | - Hong Seuk Yang
- Corresponding author: Hong Seuk Yang, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: +82-42-220-8921, Fax: +82-42-611-3882 E-mail:
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17
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Cullom C, Vo V, McCabe MD. Orthotopic Heart Transplantation in Manifesting Carrier of Duchenne Muscular Dystrophy. J Cardiothorac Vasc Anesth 2021; 36:2593-2599. [PMID: 34670720 DOI: 10.1053/j.jvca.2021.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022]
Affiliation(s)
| | - Victoria Vo
- Department of Anesthesiology, Loma Linda University, Loma Lina, CA
| | - Melissa D McCabe
- Department of Anesthesiology, Loma Linda University, Loma Lina, CA.
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18
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Sá AF, Pereira R, Lourenço S, Barros F, Oliveira C, Esteves S. Pitfalls of cubital electrical nerve stimulation for neuromuscular transmission monitoring: a case report of familial amyloid polyneuropathy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00140-7. [PMID: 34565572 DOI: 10.1016/j.redar.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 11/30/2022]
Abstract
Transthyretin familial amyloid polyneuropathy (FAP) is a rare autosomal dominant disease that provokes systemic deposition of amyloid. It affects the nervous system and it is characterized by progressive sensory, motor, and autonomic neuropathy. Patients with FAP often require surgery and anesthetic care for hepatic transplantation and cardioverter-defibrillator/pacemaker implantation. Peripheric neuropathy is a common finding, but there are no reported cases of its interference with anesthetic neuromuscular transmission monitoring. We report a case of a FAP patient where lack of awareness and distracting factors led to misinterpretation of neuromuscular monitoring and unnecessary sedation and ventilation in the post anesthetic care unit. FAP may interfere with the usual cubital nerve neuromuscular monitoring. Anesthesiologists should be aware of potential neuromuscular compromise to find the best monitoring location for each patient. Sugammadex was safe and reliable in the antagonism of rocuronium neuromuscular blockade in this case, despite the lack of adequate quantitative monitoring.
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Affiliation(s)
- A F Sá
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - R Pereira
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - S Lourenço
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - F Barros
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - C Oliveira
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - S Esteves
- Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
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19
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Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan. Eur J Anaesthesiol 2021; 38:850-855. [PMID: 34226417 DOI: 10.1097/eja.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it. OBJECTIVES To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex. DESIGN A retrospective cohort study. SETTING Nationwide acute in-patient care database. PATIENTS A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals. MAIN OUTCOME MEASURES The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy. RESULTS There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035. CONCLUSIONS Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.
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Suzuki Y, Doi M, Nakajima Y. General anesthesia with remimazolam in a patient with mitochondrial encephalomyopathy: a case report. JA Clin Rep 2021; 7:51. [PMID: 34164752 PMCID: PMC8222447 DOI: 10.1186/s40981-021-00454-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background Systemic anesthetic management of patients with mitochondrial disease requires careful preoperative preparation to administer adequate anesthesia and address potential disease-related complications. The appropriate general anesthetic agents to use in these patients remain controversial. Case presentation A 54-year-old woman (height, 145 cm; weight, 43 kg) diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes underwent elective cochlear implantation. Infusions of intravenous remimazolam and remifentanil guided by patient state index monitoring were used for anesthesia induction and maintenance. Neither lactic acidosis nor prolonged muscle relaxation occurred in the perioperative period. At the end of surgery, flumazenil was administered to antagonize sedation, which rapidly resulted in consciousness. Conclusions Remimazolam administration and reversal with flumazenil were successfully used for general anesthesia in a patient with mitochondrial disease.
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Affiliation(s)
- Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
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21
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Welhengama C, Hall A, Hunter JM. Neuromuscular blocking drugs in the critically ill. BJA Educ 2021; 21:258-263. [PMID: 34178382 DOI: 10.1016/j.bjae.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/17/2022] Open
Affiliation(s)
- C Welhengama
- St. Helen's and Knowsley Teaching Hospitals, Prescot, UK
| | - A Hall
- Liverpool University Foundation Trust, Liverpool, UK
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22
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Mehta SD, Leavitt WL, Alex G, Saynhalath R, Kiss E. Endotracheal Intubation Using Alfentanil in a Pediatric Patient with a Mitochondrial Myopathy and Gastroparesis. J Pediatr Genet 2021; 10:53-56. [PMID: 33552640 DOI: 10.1055/s-0040-1702153] [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: 11/14/2019] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
Abstract
Children with mitochondrial disorders represent a subset of patients who require unique anesthetic considerations. Routinely administered medications for general anesthesia, such as propofol, have been shown to increase the risk of developing metabolic acidosis. In addition, both depolarizing and nondepolarizing neuromuscular blockers are contraindicated due to the risk of hyperkalemic cardiac arrest and worsening of preexisting muscle weakness, respectively. These limitations pose challenges while choosing appropriate medications for induction of general anesthesia, especially when the risk of aspiration is high. We present a novel case of using inhaled sevoflurane and intravenous alfentanil to facilitate intubation in a 4-year-old girl with a complex 1 mitochondrial disorder suffering from severe gastroparesis and esophageal dysmotility.
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Affiliation(s)
- Sonia D Mehta
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Wendy L Leavitt
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Gijo Alex
- Division of Pediatric Anesthesiology, Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, United States
| | - Rita Saynhalath
- Division of Pediatric Anesthesiology, Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, United States
| | - Edgar Kiss
- Division of Pediatric Anesthesiology, Department of Anesthesiology, UT Southwestern Medical Center, Dallas, Texas, United States
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Mogane PN. Sugammadex. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There are a large number of publications which describe the use of cyclodextrins (CDs) in numerous fields, including biomedicine, cosmetics, food industry, wastewater remediation and catalysis. These drugs contain a number of glucose monomers in a ring, creating a cone shape: α (alpha), β (beta), and γ (gamma) cyclodextrins with 6, 7 and 8 glucose subunits respectively. With a hydrophobic interior and hydrophilic exterior, they can form complexes with hydrophobic compounds often conferring solubility and stability to other drugs. The inclusion compounds of cyclodextrins with hydrophobic molecules are able to penetrate body tissues; these can be used to release biologically active compounds under specific conditions.
Sugammadex is a unique, selective relaxant binding agent (SRBA) which reverses aminosteroid-induced neuromuscular blockade. It is an alternative to anticholinesterases in anaesthesia and allows use and reversal of rocuronium as a substitute for suxamethonium for rapid sequence induction (RSI).
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24
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Grigg E. Sugammadex and neuromuscular reversal: special focus on neonatal and infant populations. Curr Opin Anaesthesiol 2020; 33:374-380. [DOI: 10.1097/aco.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Yan P, Wu X, Cai F, Chen Y, Huang Y, Li G, Lai K. Efficacy and safety of sugammadex in anesthesia of cardiac surgery: A retrospective study. J Clin Anesth 2020; 65:109845. [PMID: 32464476 DOI: 10.1016/j.jclinane.2020.109845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/15/2020] [Accepted: 04/18/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Pianpian Yan
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China
| | - Xijie Wu
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China
| | - Feifei Cai
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China
| | - Yongcong Chen
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China
| | - Yiting Huang
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China
| | - Gang Li
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China.
| | - Keke Lai
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361002, China.
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