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Rollinson TC, McDonald LA, Rose J, Eastwood G, Costa-Pinto R, Modra L, Maeda A, Bacolas Z, Anstey J, Bates S, Bradley S, Dumbrell J, French C, Ghosh A, Haines K, Haydon T, Hodgson CL, Holmes J, Leggett N, McGain F, Moore C, Nelson K, Presneill J, Rotherham H, Said S, Young M, Zhao P, Udy A, Neto AS, Chaba A, Bellomo R. Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19. J Crit Care 2024; 79:154469. [PMID: 37992464 DOI: 10.1016/j.jcrc.2023.154469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain. METHODS Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position. RESULTS We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001). CONCLUSION During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.
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Affiliation(s)
- Thomas C Rollinson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia; Institute for Breathing and Sleep, Melbourne, VIC, Australia.
| | - Luke A McDonald
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Joleen Rose
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Samantha Bates
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Scott Bradley
- Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia
| | - Jodi Dumbrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Craig French
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Angaj Ghosh
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Kimberley Haines
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Tim Haydon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Carol L Hodgson
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Jennifer Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Nina Leggett
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Forbes McGain
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Cara Moore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Hannah Rotherham
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Simone Said
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Meredith Young
- Department of Intensive Care, Alfred Health, VIC, Australia
| | - Peinan Zhao
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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Chaves-Cardona HE, Fouda EA, Hernandez-Torres V, Torp KD, Logvinov II, Heckman MG, Renew JR. Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:393-400. [PMID: 37137388 PMCID: PMC10362458 DOI: 10.1016/j.bjane.2023.04.004] [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: 11/22/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. METHODS One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg-1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. RESULTS Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. CONCLUSIONS The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. CLINICAL TRIAL NUMBER AND REGISTRY URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.
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Affiliation(s)
- Harold E Chaves-Cardona
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Eslam A Fouda
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Vivian Hernandez-Torres
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Klaus D Torp
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Ilana I Logvinov
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Michael G Heckman
- Mayo Clinic Jacksonville, Division of Clinical Trials and Biostatistics, Florida, USA
| | - Johnathan Ross Renew
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA.
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Martyn JAJ, Sparling JL, Bittner EA. Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review. Br J Anaesth 2023; 130:39-50. [PMID: 36175185 DOI: 10.1016/j.bja.2022.08.009] [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: 04/11/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023] Open
Abstract
Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.
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Affiliation(s)
- J A Jeevendra Martyn
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jamie L Sparling
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Rodríguez-Blanco J, Rodríguez-Yanez T, Rodríguez-Blanco JD, Almanza-Hurtado AJ, Martínez-Ávila MC, Borré-Naranjo D, Acuña Caballero MC, Dueñas-Castell C. Neuromuscular blocking agents in the intensive care unit. J Int Med Res 2022; 50:3000605221128148. [PMID: 36173012 PMCID: PMC9528036 DOI: 10.1177/03000605221128148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.
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Affiliation(s)
- Jonathan Rodríguez-Blanco
- Divission of Pain Medicine, Department of Anesthesiology, University of Antioquia, Medellin, Colombia
| | - Tomás Rodríguez-Yanez
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | | | | | - Diana Borré-Naranjo
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | - Carmelo Dueñas-Castell
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
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Liu C, Xiao K, Xie L. Advances in the Regulation of Macrophage Polarization by Mesenchymal Stem Cells and Implications for ALI/ARDS Treatment. Front Immunol 2022; 13:928134. [PMID: 35880175 PMCID: PMC9307903 DOI: 10.3389/fimmu.2022.928134] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/16/2022] [Indexed: 12/03/2022] Open
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a common condition with high mortality. ALI/ARDS is caused by multiple etiologies, and the main clinical manifestations are progressive dyspnea and intractable hypoxemia. Currently, supportive therapy is the main ALI/ARDS treatment, and there remains a lack of targeted and effective therapeutic strategies. Macrophages are important components of innate immunity. M1 macrophages are pro-inflammatory, while M2 macrophages are anti-inflammatory and promote tissue repair. Mesenchymal stem cells (MSCs) are stem cells with broad application prospects in tissue regeneration due to their multi-directional differentiation potential along with their anti-inflammatory and paracrine properties. MSCs can regulate the balance of M1/M2 macrophage polarization to improve the prognosis of ALI/ARDS. In this paper, we review the mechanisms by which MSCs regulate macrophage polarization and the signaling pathways associated with polarization. This review is expected to provide new targets for the treatment of ALI/ARDS.
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Affiliation(s)
- Chang Liu
- School of Medicine, Nankai University, Tianjin, China
- Center of Pulmonary & Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
| | - Kun Xiao
- Center of Pulmonary & Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
- *Correspondence: Kun Xiao, ; Lixin Xie,
| | - Lixin Xie
- Center of Pulmonary & Critical Care Medicine, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China
- *Correspondence: Kun Xiao, ; Lixin Xie,
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Palamim CVC, Boschiero MN, Faria AG, Valencise FE, Marson FAL. Opioids in COVID-19: Two Sides of a Coin. Front Pharmacol 2022; 12:758637. [PMID: 35069193 PMCID: PMC8770909 DOI: 10.3389/fphar.2021.758637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/29/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.
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Affiliation(s)
- Camila Vantini Capasso Palamim
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Matheus Negri Boschiero
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Aléthea Guimarães Faria
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Felipe Eduardo Valencise
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
| | - Fernando Augusto Lima Marson
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, Brazil
- Laboratory of Human and Medical Genetics, São Francisco University, Bragança Paulista, Brazil
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