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Girard T, Savoldelli GL. Failed spinal anesthesia for cesarean delivery: prevention, identification and management. Curr Opin Anaesthesiol 2024; 37:207-212. [PMID: 38362822 PMCID: PMC11062602 DOI: 10.1097/aco.0000000000001362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important. RECENT FINDING Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery. SUMMARY Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.
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Affiliation(s)
- Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Basel
| | - Georges L. Savoldelli
- Division of Anaesthesia, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine. Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Buddeberg BS, Seeberger E, Bläsi C, Dutilh G, Steiner LA, Bandschapp O, Palanisamy A, Girard T. Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial. Int J Obstet Anesth 2024; 58:103968. [PMID: 38485584 DOI: 10.1016/j.ijoa.2023.103968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 05/07/2024]
Abstract
BACKGROUND Hypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. METHODS Term pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. RESULTS Data from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. CONCLUSION Omission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.
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Affiliation(s)
- B S Buddeberg
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland.
| | - E Seeberger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - C Bläsi
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - G Dutilh
- Department of Clinical Research, University of Basel, Switzerland
| | - L A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - O Bandschapp
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - A Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - T Girard
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
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Urech FL, Girard T, Brunner M, Schoetzau A, Lapaire O. Does delayed cord clamping result in higher maternal blood loss in primary cesarean sections? A retrospective comparative study. J Perinat Med 2024; 0:jpm-2023-0450. [PMID: 38676940 DOI: 10.1515/jpm-2023-0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/14/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVES The University Hospital Basel implemented delayed umbilical cord clamping of 30-60 s in all laboring women on April 1, 2020. This practice has been widely researched showing substantial benefit for the neonate. Few studies focused on maternal blood loss. The objective of our retrospective comparative study was to assess the impact of immediate vs. delayed cord clamping on maternal blood loss in primary scheduled cesarean sections. METHODS We analyzed data of 98 women with singleton gestations undergoing primary scheduled cesarean section at term. Data from procedures with early cord clamping (ECC) were compared to those after implementation of delayed cord clamping (DCC). Primary outcomes were perioperative change in maternal hemoglobin levels, estimated and calculated blood loss. Secondary outcomes included duration of cesarean section and neonatal data. RESULTS There was a statistically significant difference in the mean perioperative decline of hemoglobin of 10.4 g/L (SD=7.92) and 18.7 g/L (SD=10.4) between the ECC and DCC group, respectively (p<0.001). The estimated (482 mL in ECC vs. 566 mL in DCC (p=0.011)) and the calculated blood loss (438 mL in ECC vs. 715 mL in DCC (p=0.002)) also differed significantly. Secondary outcomes showed no significant differences. CONCLUSIONS In our study DCC resulted in a statistically significant higher maternal blood loss. In our opinion the widely researched neonatal benefit of DCC outweighs the risk of higher maternal blood loss in low-risk patients. However, maternal risks must be minimized, improvements to preoperative blood management and operative techniques are required.
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Affiliation(s)
- Fabia L Urech
- Department of Anesthesiology, 30262 University Hospital Basel , Basel, Switzerland
| | - Thierry Girard
- Department of Anesthesiology, 30262 University Hospital Basel , Basel, Switzerland
| | - Maya Brunner
- Department of Anesthesiology, 30262 University Hospital Basel , Basel, Switzerland
| | - Andreas Schoetzau
- Department of Obstetrics and Antenatal Care, 30262 University Hospital Basel , Basel, Switzerland
| | - Olav Lapaire
- Department of Obstetrics and Antenatal Care, 30262 University Hospital Basel , Basel, Switzerland
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Voermans NC, Yang C, Schouten M, Girard T, Stowell K, Riazi S, Kamsteeg EJ, Snoeck M. The use of guidelines to assess the risk of malignant hyperthermia in individuals with an RYR1 variant. Neuromuscul Disord 2024; 35:40-41. [PMID: 38007345 DOI: 10.1016/j.nmd.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 10/13/2023] [Indexed: 11/27/2023]
Affiliation(s)
- N C Voermans
- Neuromuscular Center Nijmegen, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Center, The Netherlands
| | - C Yang
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M Schouten
- Department of Human Genetics, Radboud university medical center, Nijmegen, The Netherlands
| | - T Girard
- Clinic for Anaesthesia and Malignant Hyperthermie Investigation Unit, University Hospital Basel, Basel, Switzerland
| | - K Stowell
- School of Natural Sciences, Massey University, Palmerston North, New Zealand
| | - S Riazi
- Department of Anesthesia, Malignant Hyperthermia Investigation Unit, University Health Network, University of Toronto, Toronto, Canada
| | - E J Kamsteeg
- Department of Human Genetics, Radboud university medical center, Nijmegen, The Netherlands
| | - M Snoeck
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
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Noda Y, Miyoshi H, Benucci S, Gonzalez A, Bandschapp O, Girard T, Treves S, Zorzato F. Functional characterization of RYR1 variants identified in malignant hyperthermia susceptible individuals. Neuromuscul Disord 2023; 33:951-963. [PMID: 37996280 DOI: 10.1016/j.nmd.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023]
Abstract
Malignant hyperthermia is a pharmacogenetic disorder triggered by halogenated anesthetic agents in genetically predisposed individuals. Approximately 70 % of these individuals carry mutations in RYR1, the gene encoding the ryanodine receptor calcium channel of skeletal muscle. In this study, we performed functional analysis of 5 RYR1 variants identified in members from 8 families who had been diagnosed by the IVCT. Of the 68 individuals enrolled in the study, 43 were diagnosed as MHS, 23 as MHN, and 2 individuals were not tested. Here we demonstrate that the 5 RyR1 variants cause hypersensitivity to RyR1 agonist-mediated calcium release. According to the EMHG scoring matrix these five genetic variants can be classified as follows: c.8638G>A (p.E2880K) and c.11314C>T (p.R3772W) likely pathogenic, c.11416G>A (p.G3806R), c.14627A>G (p.K4876R) and c.14813T>C (p.I4938T), pathogenic (RefSeq NM_000540.3). We propose that the newly functionally characterized RYR1 variants, be included in the panel of variants to be used for the molecular diagnosis of MHS.
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Affiliation(s)
- Yuko Noda
- Departments of Biomedicine and Neurology, Basel University Hospital, Hebelstrasse 20, Basel 4031, Switzerland; Department of Anesthesiology, Hiroshima University Hospital, 1-2-3 Kasumi Minami-ku Hiroshima, 734-8551, Japan
| | - Hirotsugu Miyoshi
- Department of Anesthesiology, Hiroshima University Hospital, 1-2-3 Kasumi Minami-ku Hiroshima, 734-8551, Japan
| | - Sofia Benucci
- Departments of Biomedicine and Neurology, Basel University Hospital, Hebelstrasse 20, Basel 4031, Switzerland
| | | | | | - Thierry Girard
- Anesthesiology, Spitalstrasse 21, Basel 4031, Switzerland
| | - Susan Treves
- Departments of Biomedicine and Neurology, Basel University Hospital, Hebelstrasse 20, Basel 4031, Switzerland; Department of Life Science and Biotechnology, University of Ferrara, Via Borsari 46, Ferrara 44100, Italy.
| | - Francesco Zorzato
- Departments of Biomedicine and Neurology, Basel University Hospital, Hebelstrasse 20, Basel 4031, Switzerland; Department of Life Science and Biotechnology, University of Ferrara, Via Borsari 46, Ferrara 44100, Italy.
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Lewald H, Girard T. Analgesia after cesarean section - what is new? Curr Opin Anaesthesiol 2023; 36:288-292. [PMID: 36994740 PMCID: PMC10609703 DOI: 10.1097/aco.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
PURPOSE OF REVIEW Cesarean section is the most frequent surgical intervention, and pain following cesarean delivery unfortunately remains a common issue. The purpose of this article is to highlight the most effective and efficient options for postcesarean analgesia and to summarize current guidelines. RECENT FINDINGS The most effective form of postoperative analgesia is through neuraxial morphine. With adequate dosing, clinically relevant respiratory depression is extremely rare. It is important to identify women with increased risk of respiratory depression, as they might require more intensive postoperative monitoring. If neuraxial morphine cannot be used, abdominal wall block or surgical wound infiltration are very valuable alternatives. A multimodal regimen with intraoperative intravenous dexamethasone, fixed doses of paracetamol/acetaminophen, and nonsteroidal anti-inflammatory drugs reduce postcesarean opioid use. As the use of postoperative lumbar epidural analgesia impairs mobilization, double epidural catheters with lower thoracic epidural analgesia are a possible alternative. SUMMARY Adequate analgesia following cesarean delivery is still underused. Simple measures, such as multimodal analgesia regimens should be standardized according to institutional circumstances and defined as part of a treatment plan. Neuraxial morphine should be used whenever possible. If it cannot be used, abdominal wall blocks or surgical wound infiltration are good alternatives.
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Affiliation(s)
- Heidrun Lewald
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University of Munich
- MVZ Perioperative Medicine Munich
- Frauenklinik Dr. Geisenhofer, Munich, Germany
| | - Thierry Girard
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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Annecke T, Lier H, Girard T, Korte W, Pfanner G, Schlembach D, Tiebel O, von Heymann C. [Peripartum hemorrhage, diagnostics and treatment : Update of the S2k guidelines AWMF 015/063 from August 2022]. Anaesthesiologie 2022; 71:952-958. [PMID: 36434271 PMCID: PMC9729152 DOI: 10.1007/s00101-022-01224-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 06/16/2023]
Abstract
The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.
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Affiliation(s)
- T Annecke
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Köln-Merheim, Kliniken Köln, Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109, Köln, Deutschland.
| | - H Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | - T Girard
- Klinik für Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - W Korte
- Hämostase- und Hämophiliezentrum, Zentrum für Labormedizin Sankt Gallen, Sankt Gallen, Schweiz
| | - G Pfanner
- Anästhesie und Intensivmedizin, Landeskrankenhaus Feldkirch, Feldkirch, Österreich
| | - D Schlembach
- Klinik für Geburtsmedizin, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | - O Tiebel
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsklinikum Dresden, Dresden, Deutschland
| | - C von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
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Schlesinger T, Becke-Jakob K, Girard T, Greve S, Meybohm P, Kranke P. [The epidural blood patch-Gold standard in treatment of postdural puncture headache and original task of obstetric anesthesia]. Anaesthesiologie 2022; 71:724-726. [PMID: 35925171 DOI: 10.1007/s00101-022-01153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Tobias Schlesinger
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Karin Becke-Jakob
- Anästhesie, Kinderanästhesie und Intensivmedizin, Klinik Hallerwiese-Cnopfsche Kinderklinik, Diakoneo KdöR, Nürnberg, Deutschland
| | - Thierry Girard
- Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - Susanne Greve
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Patrick Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Johnston JJ, Dirksen RT, Girard T, Hopkins PM, Kraeva N, Ognoon M, Radenbaugh KB, Riazi S, Robinson RL, Saddic, III LA, Sambuughin N, Saxena R, Shepherd S, Stowell K, Weber J, Yoo S, Rosenberg H, Biesecker LG. Updated variant curation expert panel criteria and pathogenicity classifications for 251 variants for RYR1-related malignant hyperthermia susceptibility. Hum Mol Genet 2022; 31:4087-4093. [PMID: 35849058 PMCID: PMC9703808 DOI: 10.1093/hmg/ddac145] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 12/29/2022] Open
Abstract
The ClinGen malignant hyperthermia susceptibility (MHS) variant curation expert panel specified the American College of Medical Genetics and Genomics/Association of Molecular Pathologists (ACMG/AMP) criteria for RYR1-related MHS and a pilot analysis of 84 variants was published. We have now classified an additional 251 variants for RYR1-related MHS according to current ClinGen standards and updated the criteria where necessary. Criterion PS4 was modified such that individuals with multiple RYR1 variants classified as pathogenic (P), likely pathogenic (LP), or variant of uncertain significance (VUS) were not considered as providing evidence for pathogenicity. Criteria PS1 and PM5 were revised to consider LP variants at the same amino-acid residue as providing evidence for pathogenicity at reduced strength. Finally, PM1 was revised such that if PS1 or PM5 are used PM1, if applicable, should be downgraded to supporting. Of the 251 RYR1 variants, 42 were classified as P/LP, 16 as B/LB, and 193 as VUS. The primary driver of 175 VUS classifications was insufficient evidence supporting pathogenicity, rather than evidence against pathogenicity. Functional data supporting PS3/BS3 was identified for only 13 variants. Based on the posterior probabilities of pathogenicity and variant frequencies in gnomAD, we estimated the prevalence of individuals with RYR1-related MHS pathogenic variants to be between 1/300 and 1/1075, considerably higher than current estimates. We have updated ACMG/AMP criteria for RYR1-related MHS and classified 251 variants. We suggest that prioritization of functional studies is needed to resolve the large number of VUS classifications and allow for appropriate risk assessment. RYR1-related MHS pathogenic variants are likely to be more common than currently appreciated.
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Affiliation(s)
- Jennifer J Johnston
- To whom correspondence should be addressed at: Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, 50 South Drive Room 5139, Bethesda, MD 20892, USA. Tel: +1 3015943981; Fax: 301-480-0353;
| | - Robert T Dirksen
- Department of Pharmacology and Physiology, University of Rochester Medical School, Rochester, NY 14642, USA
| | - Thierry Girard
- Department of Anesthesiology, University of Basel, Basel, CH-4031, Switzerland
| | - Phil M Hopkins
- MH Unit, Leeds Institute of Medical Research at St James’s, University of Leeds, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Natalia Kraeva
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, M5G 2C4, Canada
| | - Mungunsukh Ognoon
- Consortium for Health and Military Performance, Uniformed Services University Health Science, Bethesda, MD 20814, USA
| | - K Bailey Radenbaugh
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sheila Riazi
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, M5G 2C4, Canada
| | - Rachel L Robinson
- North East & Yorkshire Genomic Laboratory Hub, St. James University Hospital, Leeds LS9 7TF, UK
| | - Louis A Saddic, III
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Nyamkhishig Sambuughin
- Consortium for Health and Military Performance, Uniformed Services University Health Science, Bethesda, MD 20814, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Sarah Shepherd
- North East & Yorkshire Genomic Laboratory Hub, St. James University Hospital, Leeds LS9 7TF, UK
| | - Kathryn Stowell
- School of Natural Sciences, Massey University, Palmerston North 4474, New Zealand
| | - James Weber
- Prevention Genetics, Marshfield, WI 54449, USA
| | - Seeley Yoo
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Henry Rosenberg
- MH Association of the United States, Sherburne, NY 13460, USA
| | - Leslie G Biesecker
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Bessette L, Florica B, Fournier PA, Girard T, Naik L, Sholter D, Baer P. POS0288 A CANADIAN RETROSPECTIVE CHART REVIEW EVALUATING CONCOMITANT METHOTREXATE DE-ESCALATION PATTERNS IN RA PATIENTS TREATED WITH BIOLOGIC OR TARGETED SYNTHETIC DMARDS. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundRheumatoid arthritis (RA) guidelines recommend methotrexate (MTX) as anchor therapy in combination with biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). However, its tolerability is challenging with a significant proportion of patients not adhering to their prescribed MTX regimen following b/tsDMARD initiation. Rates of MTX tapering and withdrawal have been reported elsewhere but Canadian data are lacking.ObjectivesThis multi-centre, retrospective chart-based cohort study assessed the frequency of MTX withdrawal or tapering following initiation of a b/tsDMARD in Canadian adults with RA.MethodsPatients were eligible if they received MTX for ≥3 months before initiation of a b/tsDMARD that was then prescribed continuously for ≥18 months and was initiated in combination with MTX. Patients taking oral prednisone or equivalent at a dose >10 mg per day, and those whose b/tsDMARD was prescribed prior to 2014, were excluded.ResultsData from 889 patients were included in the analysis. Mean age was 50.6 years and 72.6% were female. Mean time since diagnosis was approximately 8 years. Of the 46.1% of patients with a documented assessment of disease status at baseline, 62.7% of patients had high disease activity. Baseline mean (SD) MTX dose was 18.9 (6.63) mg/week, administered orally (57.4%), subcutaneously (41.3%), or intramuscularly (1.2%). Overall, 270 (30.4%) patients either tapered (123, 13.8%) or discontinued (147, 16.5%) their MTX within 2 years of initiating the b/tsDMARD. Methotrexate dose was unchanged for 582 (65.5%) subjects and increased for 37 (4.2%) subjects. The prescribed b/tsDMARD was most often a tumor necrosis factor inhibitor (TNFi,52.1%), followed by a Janus kinase inhibitor (JAKi, 18.3%), other modes of action (OMA) which included abatacept and rituximab (17.7%) and interleukin-6 inhibitor (IL-6i, 11.9%). The b/tsDMARD type with the highest frequency of MTX Taper or Discontinued was IL-6i (37 patients, 34.9%) followed by TNFi (144 patients, 31.1%), JAKi (47 patients, 28.8%) and OMA (44 patients, 28.0%). In the MTX Discontinued group, the most common reasons for MTX discontinuation were patient decision (27.2%) and adverse events (24.5%). In the MTX Tapered group, the most common reasons for MTX dose change were planned tapering (36.6%) and adverse events (29.3%). In the MTX Increased group, insufficient clinical response (73.0%) was the most common reason provided for MTX dose change. Baseline factors associated with MTX dose discontinuation and tapering by multiple logistic regression were a shorter time since diagnosis (Odds ratio [OR]: 0.981; 95% confidence interval [CI]: 0.964 – 0.999. P=0.0401), use of non-DMARD medications excluding steroids (OR: 0.683; 95%CI: 0.503 – 0.929. P=0.0150) and a greater number of comorbidities (OR: 1.054; 95%CI: 1.001 – 1.110. P=0.0444). The mean (SD) weekly MTX dose at the end of the data extraction period was 14.13 (4.81) mg for the MTX Tapered group, with 109 (88.6%) subjects taking a weekly MTX dose ≥10 mg. In the MTX Increased group the mean (SD) weekly MTX dose was 22.3 (3.74) mg. Interpretation of the effect of MTX dose on disease activity, fatigue, pain and functional status is challenging due to missing data, but most patients in all 4 groups transitioned to low disease activity or remission during the study period.ConclusionMethotrexate withdrawal or tapering occurred in 30.4% of Canadians with RA within two years following b/tsDMARD initiation. There was no evidence of worsening disease activity in these patients. These proportion of Canadian RA patients who reduce or discontinue MTX after the initiation of a ts/bDMARD are generally consistent with those reported in other regions of the world.AcknowledgementsAbbVie Corp. funded the research for this study and provided writing support for this abstract. AbbVie participated in the study design; study research; collection, analysis, and interpretation of data; and writing, reviewing, and approving this abstract for submission. All authors had access to the data; participated in the development, review, and approval of the abstract; and agreed to submit this abstract to EULAR 2022.AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. Medical writing support was provided by John Howell PhD of McDougall Scientific and funded by AbbVie, Inc.Disclosure of InterestsLouis Bessette Speakers bureau: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Lilly, Novartis, Sanofi, Sandoz, Gilead, Fresenius Kabi, Consultant of: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Lilly, Novartis, Sanofi, Sandoz, Gilead, Fresenius Kabi, Grant/research support from: Amgen, BMS, Janssen, UCB, AbbVie, Pfizer, Merck, Lilly, Novartis, Sanofi, Sandoz, Gilead, Fresenius Kabi, Brandusa Florica Speakers bureau: AbbVie, Amgen, Lilly, Pfizer, Janssen, Novartis, Merck, Consultant of: AbbVie, Amgen, Lilly, Pfizer, Janssen, Novartis, Merck, Grant/research support from: AbbVie, Amgen, Lilly, Pfizer, Janssen, Novartis, Merck, Pierre-André Fournier Shareholder of: AbbVie, Employee of: AbbVie, Tanya Girard Shareholder of: AbbVie, Employee of: AbbVie, Latha Naik Speakers bureau: AbbVie, Consultant of: AbbVie, Grant/research support from: AbbVie, Dalton Sholter Speakers bureau: AbbVie, Amgen, BMS, Celgene, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Amgen, BMS, Celgene, Gilead, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, Sandoz, UCB, Philip Baer Speakers bureau: Abbvie, Amgen, Lilly, Pfizer, Janssen, Teva, Fresenius Kabi, Viatris, Opticann, Novartis, Organon, Gilead, Celltrion, Astra Zeneca, GSK, Consultant of: Abbvie, Amgen, Lilly, Pfizer, Janssen, Teva, Fresenius Kabi, Viatris, Opticann, Novartis, Organon, Gilead, Celltrion, Astra Zeneca, GSK, Grant/research support from: Abbvie, Amgen, Lilly, Pfizer, Janssen, Teva, Fresenius Kabi, Viatris, Opticann, Novartis, Organon, Gilead, Celltrion, Astra Zeneca, GSK
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Choquette D, Chandran V, Laliberté MC, Fournier PA, Girard T, Sutton M, Gladman DD. AB0895 Residual burden and disease activity of Canadian PsA patients treated with advanced therapies: preliminary results from a multiple registry analysis (UNISON-PsA). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundGiven the availability of advanced therapies in PsA with different modes of action, it is of interest to characterize their impact on overall clinical outcomes.ObjectivesTo describe residual disease activity in Canadians with PsA treated with advanced therapies.MethodsMulti-region, observational, retrospective analysis of data from Rhumadata (Quebec) and International Psoriasis and Arthritis Research Team (IPART) Canadian registries was performed. Data from each registry and region were analyzed separately using a common statistical analysis plan to generate descriptive statistics. Patients included in the registries were eligible if they were adults at the time of PsA diagnosis and were treated with an advanced therapy for ≥6 months initiated between January 2010 and December 2019. Residual disease activity was defined as failing to achieve MDA (defined as achieving ≥5 of: TJC ≤1; SJC ≤1; PASI ≤1 or BSA ≤3%; patient pain VAS score of ≤15 mm; patient global disease activity VAS score of ≤20 mm; HAQ score ≤0.5; and tender entheseal points ≤1) (primary endpoint), or DAPSA score ≥14 (secondary endpoint) within 6 months of initiation of an advanced therapy (TNFi, IL-12/23i, IL-17i, PDE4i, CTLA4i or JAKi).Results1,866 subjects (Atlantic [IPART; Newfoundland]: N=83; Quebec [Rhumadata]: N=687; Ontario [IPART]: N=966; West [IPART; British Columbia, Manitoba]: N=130) were included in this preliminary analysis. Baseline characteristics are presented in Table 1. Overall, 899 were receiving their 1st advanced therapy, 464 were receiving their 2nd, and 264 had received ≥3. The most common therapy class was TNFi, followed by IL-17i. 18/21 (85.7%) subjects in the Atlantic region with an assessment, 184/246 (74.8%) in Quebec, 391/571 (68.1%) in Ontario, and 30/43 (69.8%) in Western Canada failed to achieve MDA within 6 months following advanced therapy initiation. Failure to achieve MDA within the allotted period was higher among patients receiving an IL-17i compared with a TNFi. There was no appreciable effect of lines of therapy. Also, 74 of 110 (67.3%) patients with an assessment in Quebec, 201/365 (55.1%) in Ontario and 3/3 (100%) in the West failed to achieve at least low disease activity (LDA; DAPSA ≤14) within 6 months following initiation of an advanced therapy. Data were not available for the Atlantic region. The proportion of patients not achieving LDA by advanced therapy was similar for those receiving a TNFi and IL-17i but increased with line of therapy.Table 1.Patient demographic and baseline characteristics, and response to treatmentAtlantic (N=83)Quebec (N=687)Ontario (N=966)West (N=130)Age (years, mean [SD])50.3 (11.1)50.7 (12.1)49.1 (12.9)46.7 (12.1)Female (n [%])44/83 (53.0)346/687 (50.4)427/966 (44.2)81/128 (62.3)BMI (kg/m2, n, mean [SD])15, 30.8 (3.6)553, 29.6 (6.6)579, 30.6 (6.9)45, 32.8 (10.6)Time since diagnosis (years, N, mean [SD])83, 8.7 (8.7)687, 7.1 (7.9)895, 11.7 (11.1)74, 11.7 (8.9)HLA-B27 positive (n/N [%])N/A58/335 (17.3)86/648 (13.3)N/APresence of EAMs (n/N [%])4/44 (9.1)27/687 (3.9)65/693 (9.4)2/33 (6.1%)Fulfillment of CASPAR (n/N [%])N/A391/687 (56.9)100/100 (100)N/ATherapy class (n [%]):*TNFi66 (79.5)478 (69.6)651 (67.3)104 (80.0)IL-17i11 (13.3)106 (15.4)191 (19.9)21 (16.2)IL-12/23i6 (7.2)33 (4.8)124 (12.9)5 (3.9)PDE4i48 (7.0)Other22 (3.2)Failure to achieve MDA within 6 months of starting therapy (n/N [%])**18/21 (87.5)184/246 (74.8)391/571 (68.1)30/43 (69.8)Failure to achieve DAPSA ≤14 within 6 months of starting therapy (n/N [%])**N/A74/110 (67.3)201/365 (55.1)3/3 (100.0)*Patients may be taking >1 advanced therapy, **Not all patients had assessments of disease activity.ConclusionPreliminary data show approximately three quarters of Canadians with PsA failed to achieve MDA or LDA within 6 months of initiating an advanced therapy. Disease duration is a possible explanation for not achieving MDA or LDA; better therapeutic approaches are needed to achieve these outcomes in patients with PsA.AcknowledgementsThe authors wish to thank Dr. Steve Ramkissoon, for supporting the statistical analysis of the IPART registry. Medical writing and statistical support (funded by Abbvie) were provided by John Howell and Hong Chen, respectively, from McDougall Scientific. Financial support for the study was provided by AbbVie. AbbVie participated in the design of the study, interpretation of data, review, and approval of this publication. All authors contributed to the development of the publication and maintained control over the final content.Disclosure of InterestsDenis Choquette Speakers bureau: Amgen, Abbvie, CIHR, Novartis, Pfizer, Fresenius-Kabi, Eli Lilly, Sandoz, Tevapharm, Consultant of: Amgen, Abbvie, CIHR, Novartis, Pfizer, Fresenius-Kabi, Eli Lilly, Sandoz, Tevapharm, Grant/research support from: Rhumadata is supported through grants and research contracts from Amgen, Abbvie, CIHR, Novartis, Pfizer, Fresenius-Kabi, Eli Lilly, Sandoz, Tevapharm., Vinod Chandran Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Janssen, Novartis, UCB, Pfizer, Employee of: Spouse is an employee of AstraZeneca, Marie-Claude Laliberté Shareholder of: AbbVie Corp., Employee of: AbbVie Corp., Pierre-André Fournier Shareholder of: AbbVie Corp., Employee of: AbbVie Corp., Tanya Girard Shareholder of: AbbVie Corp., Employee of: AbbVie Corp., Mitchell Sutton: None declared, Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Galapagos, Gilead, Eli Lilly, Janssen Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, UCB
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Helmer P, Schlesinger T, Hottenrott S, Papsdorf M, Wöckel A, Sitter M, Skazel T, Wurmb T, Türkmeneli I, Härtel C, Hofer S, Alkatout I, Messroghli L, Girard T, Meybohm P, Kranke P. [Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]. Anaesthesist 2022; 71:181-189. [PMID: 35244736 DOI: 10.1007/s00101-022-01098-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 12/20/2022]
Abstract
Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.
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Affiliation(s)
- Philipp Helmer
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Schlesinger
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Sebastian Hottenrott
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Michael Papsdorf
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Achim Wöckel
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Magdalena Sitter
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Skazel
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Thomas Wurmb
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Ismail Türkmeneli
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph Härtel
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesie, Intensiv‑, Notfallmedizin und Schmerztherapie, Westpfalz-Klinikum, Kaiserslautern, Deutschland
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe (Frauenheilkunde), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Leila Messroghli
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Thierry Girard
- Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - Patrick Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Helmer P, Schlesinger T, Hottenrott S, Papsdorf M, Wöckel A, Diessner J, Stumpner J, Sitter M, Skazel T, Wurmb T, Härtel C, Hofer S, Alkatout I, Girard T, Meybohm P, Kranke P. [Patient blood management in the preparation for birth, obstetrics and postpartum period]. Anaesthesist 2022; 71:171-180. [PMID: 35234987 DOI: 10.1007/s00101-022-01109-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 01/17/2023]
Abstract
The implementation of patient blood management (PBM) is increasingly becoming standard in operative medicine. Recently, interest has also been shown for the vulnerable collective of pregnant women and neonates. As the information regarding anesthesiological procedures for pregnant women and the peripartum period including an informed consent process should be carried out long before childbirth, this provides a good possibility in this connection to incorporate PBM. An anesthesiological risk estimation as well as the diagnostic workup and treatment of potential anemia should be carried out during the pregnancy. Furthermore, loss of blood in anticipation of bleeding complications should be reduced by interdisciplinary preventive measures and an individually coordinated postpartum care should be organized. This results in an early diagnosis of anemia or iron deficiency with subsequent treatment also postpartum, analogous to the prepartum period.
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Affiliation(s)
- Philipp Helmer
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Schlesinger
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Sebastian Hottenrott
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Michael Papsdorf
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Achim Wöckel
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Joachim Diessner
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Jan Stumpner
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Magdalena Sitter
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Skazel
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Thomas Wurmb
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph Härtel
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesie, Intensiv‑, Notfallmedizin und Schmerztherapie, Westpfalz-Klinikum, Kaiserslautern, Deutschland
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe (Frauenheilkunde), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Thierry Girard
- Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - Patrick Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Gonzalez A, Girard T, Dell-Kuster S, Urwyler A, Bandschapp O. BMI and malignant hyperthermia pathogenic ryanodine receptor type 1 sequence variants in Switzerland: A retrospective cohort analysis. Eur J Anaesthesiol 2021; 38:751-757. [PMID: 33259453 DOI: 10.1097/eja.0000000000001399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ryanodine receptor type 1 (RYR1) sequence variants are pathogenic for malignant hyperthermia. Variant carriers have a subtle increase in resting myoplasmic calcium concentration compared with nonaffected individuals, but whether this has metabolic effects in daily life is unknown. OBJECTIVES We analysed the potential effect of malignant hyperthermia-pathogenic RYR1 sequence variants on BMI as a single factor. Due to the heterogeneity of genetic variants predisposing to malignant hyperthermia, and to incomplete information about their regional distribution, we describe the prevalence of RYR1 variants in our population. DESIGN A retrospective cohort study. SETTING A single University hospital. PATIENTS Patients from malignant hyperthermia families with pathogenic RYR1 sequence variants were selected if BMI was available. OUTCOME MEASURES BMI values were compared amongst malignant hyperthermia susceptible (MHS) and malignant hyperthermia-negative individuals using hierarchical multivariable analyses adjusted for age and sex and considering family clustering. Variant prevalence was calculated. RESULTS The study included 281 individuals from 42 unrelated malignant hyperthermia families, 109 of whom were MHS and carriers of the familial RYR1 sequence variants. Median [IQR] BMI in MHS individuals with pathogenic RYR1 variants was 22.5 kg m-2 [21.3 to 25.6 kg m-2]. In malignant hyperthermia-negative individuals without variants, median BMI was 23.4 kg m-2 [21.0 to 26.3 kg m-2]. Using multivariable regression adjusted for age and sex, the mean difference was -0.73 (95% CI -1.51 to 0.05). No carrier of a pathogenic RYR1 sequence variant was found to have BMI higher than 30 kg m-2. Only 10 RYR1 variants from the list of the European MH Group were found in our cohort, the most common being p.Val2168Met (39% of families), p.Arg2336His (24%) and p.Arg614Cys (12%). CONCLUSION The observed tendency towards lower BMI values in carriers of malignant hyperthermia-pathogenic RYR1 sequence variants points to a possible protective effect on obesity. This study confirms regional differences of the prevalence of malignant hyperthermia-pathogenic RYR1 sequence variants, with just three variants covering 75% of Swiss MHS families. TRIAL REGISTRATION This manuscript is based on a retrospective analysis.
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Affiliation(s)
- Asensio Gonzalez
- From the Department for Anesthesia, Interdisciplinary Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital (AG, TG, SD-K, AU, OB) and Basel Institute for Clinical Epidemiology and Biostatistics (SD-K), University of Basel, Basel, Switzerland
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Treves S, Girard T, Zorzato F. Functional Characterization of Endogenously Expressed Human RYR1 Variants. J Vis Exp 2021. [PMID: 34180878 DOI: 10.3791/62196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
More than 700 variants in the RYR1 gene have been identified in patients with different neuromuscular disorders including malignant hyperthermia susceptibility, core myopathies and centronuclear myopathy. Because of the diverse phenotypes linked to RYR1 mutations it is fundamental to characterize their functional effects to classify variants carried by patients for future therapeutic interventions and identify non-pathogenic variants. Many laboratories have been interested in developing methods to functionally characterize RYR1 mutations expressed in patients' cells. This approach has numerous advantages, including: mutations are endogenously expressed, RyR1 is not over-expressed, use of heterologous RyR1 expressing cells is avoided. However, since patients may present mutations in different genes aside RYR1, it is important to compare results from biological material from individuals harboring the same mutation, with different genetic backgrounds. The present manuscript describes methods developed to study the functional effects of endogenously expressed RYR1 variants in: (a) Epstein Barr virus immortalized human B-lymphocytes and (b) satellite cells derived from muscle biopsies and differentiated into myotubes. Changes in the intracellular calcium concentration triggered by the addition of a pharmacological RyR1 activators are then monitored. The selected cell type is loaded with a ratiometric fluorescent calcium indicator and intracellular [Ca2+] changes are monitored either at the single cell level by fluorescence microscopy or in cell populations using a spectrofluorometer. The resting [Ca2+], agonist dose response curves are then compared between cells from healthy controls and patients harboring RYR1 variants leading to insight into the functional effect of a given variant.
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Affiliation(s)
- Susan Treves
- Department of Biomedicine, Basel University Hospital; Department of Life Sciences, University of Ferrara;
| | | | - Francesco Zorzato
- Department of Biomedicine, Basel University Hospital; Department of Life Sciences, University of Ferrara
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Johnston JJ, Dirksen RT, Girard T, Gonsalves SG, Hopkins PM, Riazi S, Saddic LA, Sambuughin N, Saxena R, Stowell K, Weber J, Rosenberg H, Biesecker LG. Variant curation expert panel recommendations for RYR1 pathogenicity classifications in malignant hyperthermia susceptibility. Genet Med 2021; 23:1288-1295. [PMID: 33767344 PMCID: PMC8263483 DOI: 10.1038/s41436-021-01125-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose As a ClinGen Expert Panel (EP) we set out to adapt the ACMG pathogenicity criteria for classification of RYR1 variants as related to autosomal dominantly-inherited malignant hyperthermia (MH). Methods We specified ACMG/AMP criteria for variant classification for RYR1 and MH. Proposed rules were piloted on 84 variants. We applied quantitative evidence calibration for several criteria using likelihood ratios based on the Bayesian framework. Results Seven ACMG/AMP criteria were adopted without changes, nine were adopted with RYR1-specific modifications, and ten were dropped. The in silico (PP3 and BP4) and hot spot criteria (PM1) were evaluated quantitatively. REVEL gave an odds ratio (OR) of 23:1 for PP3 and 14:1 for BP4 using trichotomized cut-offs of ≥0.85 (pathogenic) and ≤0.5 (benign). The PM1 hotspot criterion had an OR of 24:1. PP3 and PM1 were implemented at moderate strength. Applying the revised ACMG criteria to 44 recognized MH variants, 29 were classified as pathogenic, 13 as likely pathogenic, and two as variants of uncertain significance. Conclusion Curation of these variants will facilitate classification of RYR1/MH genomic testing results, which is especially important for secondary findings analyses. Our approach to quantitatively calibrating criteria is generalizable to other variant curation expert panels.
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Affiliation(s)
- Jennifer J Johnston
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Robert T Dirksen
- Department of Pharmacology and Physiology, University of Rochester Medical School, Rochester, NY, USA
| | - Thierry Girard
- Department of Anesthesiology, University of Basel, Basel, Switzerland
| | - Stephen G Gonsalves
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Philip M Hopkins
- MH Unit, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Sheila Riazi
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Louis A Saddic
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Nyamkhishig Sambuughin
- Consortium for Health and Military Performance, Uniformed Services University Health Science, Bethesda, MD, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathryn Stowell
- School of Fundamental Sciences, Massey University, Palmerston North, New Zealand
| | | | | | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.,NIH Intramural Sequencing Center, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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Heesen M, Girard T, Klimek M. Noradrenaline - at best it is not worse. A comparison with phenylephrine in women undergoing spinal anaesthesia for caesarean section. Anaesthesia 2021; 76:743-747. [PMID: 33406274 DOI: 10.1111/anae.15363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/01/2022]
Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - T Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia 2021; 76:655-664. [PMID: 33399225 DOI: 10.1111/anae.15317] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.
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Affiliation(s)
- P M Hopkins
- Malignant Hyperthermia Unit, St James's University Hospital, and University of Leeds, Leeds, UK
| | - T Girard
- Department of Anaesthesia and Research, University of Basel, Switzerland
| | - S Dalay
- Department of Anaesthesia, Worcestershire Acute Hospitals NHS Trust, UK
| | - B Jenkins
- Department of Anaesthesia, University Hospitals of Cardiff, UK
| | - A Thacker
- Department of Anaesthesia, University Hospitals of Coventry and Warwickshire, UK
| | - M Patteril
- Department of Anaesthesia, University Hospitals of Coventry and Warwickshire, UK
| | - E McGrady
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
It is timely to consider the utility and practicability of screening for malignant hyperthermia susceptibility using genomic testing. Here the authors pose a simple, but bold question: what would it take to end deaths from malignant hyperthermia? The authors review recent advances and propose a scientific and clinical pathway toward this audacious goal to provoke discussion in the field.
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Affiliation(s)
- Leslie G Biesecker
- Medical Genomics and Medical Genetics Branch, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Robert T. Dirksen
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Thierry Girard
- Department Anesthesiology, University Hospital Basel, University of Basel, Switzerland
| | - Philip Hopkins
- Department of Anaesthesia, University of Leeds, Leeds, United Kingdom
| | - Sheila Riazi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Kathryn Stowell
- Department of Biochemistry, Massey University, Palmerston North, New Zealand
| | - James Weber
- Prevention Genetics, Marshfield, Wisconsin, USA
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Riazi S, Kraeva N, Girard T. Perioperative genetic screening: entering a new era. Br J Anaesth 2020; 125:859-862. [DOI: 10.1016/j.bja.2020.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 11/15/2022] Open
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21
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Monod C, Girard T. Mehrlingsschwangerschaften. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:702-712. [PMID: 33242903 DOI: 10.1055/a-1070-6858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Rüffert H, Bastian B, Bendixen D, Girard T, Heiderich S, Hellblom A, Hopkins PM, Johannsen S, Snoeck MM, Urwyler A, Glahn KPE. Consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients from the European Malignant Hyperthermia Group. Br J Anaesth 2020; 126:120-130. [PMID: 33131754 DOI: 10.1016/j.bja.2020.09.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/24/2020] [Accepted: 09/26/2020] [Indexed: 11/15/2022] Open
Abstract
Malignant hyperthermia is a potentially fatal condition, in which genetically predisposed individuals develop a hypermetabolic reaction to potent inhalation anaesthetics or succinylcholine. Because of the rarity of malignant hyperthermia and ethical limitations, there is no evidence from interventional trials to inform the optimal perioperative management of patients known or suspected with malignant hyperthermia who present for surgery. Furthermore, as the concentrations of residual volatile anaesthetics that might trigger a malignant hyperthermia crisis are unknown and manufacturers' instructions differ considerably, there are uncertainties about how individual anaesthetic machines or workstations need to be prepared to avoid inadvertent exposure of susceptible patients to trigger anaesthetic drugs. The present guidelines are intended to bundle the available knowledge about perioperative management of malignant hyperthermia-susceptible patients and the preparation of anaesthesia workstations. The latter aspect includes guidance on the use of activated charcoal filters. The guidelines were developed by members of the European Malignant Hyperthermia Group, and they are based on evaluation of the available literature and a formal consensus process. The most crucial recommendation is that malignant hyperthermia-susceptible patients should receive anaesthesia that is free of triggering agents. Providing that this can be achieved, other key recommendations include avoidance of prophylactic administration of dantrolene; that preoperative management, intraoperative monitoring, and care in the PACU are unaltered by malignant hyperthermia susceptibility; and that malignant hyperthermia patients may be anaesthetised in an outpatient setting.
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Affiliation(s)
- Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin, Schmerztherapie, Helios Klinik Schkeuditz, Leipzig-Schkeuditz, Germany; Department of Anaesthesiology and Intensive Care Medicine, MH Centre, University Hospital Leipzig, Leipzig, Germany.
| | - Börge Bastian
- Department of Anaesthesiology and Intensive Care Medicine, MH Centre, University Hospital Leipzig, Leipzig, Germany
| | - Diana Bendixen
- Danish Malignant Hyperthermia Centre, Department of Anaesthesia, University Hospital Herlev, Copenhagen, Denmark
| | - Thierry Girard
- Department of Anaesthesia and Research, University of Basel, Basel, Switzerland
| | - Sebastian Heiderich
- Clinic of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Anna Hellblom
- Department of Anaesthesia, University Hospital, Lund, Sweden
| | - Philip M Hopkins
- Malignant Hyperthermia Unit, St James's University Hospital, Leeds, UK
| | - Stephan Johannsen
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Marc M Snoeck
- Department of Anaesthesiology, Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Albert Urwyler
- Department of Anaesthesia and Research, University of Basel, Basel, Switzerland
| | - Klaus P E Glahn
- Danish Malignant Hyperthermia Centre, Department of Anaesthesia, University Hospital Herlev, Copenhagen, Denmark
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Gupta A, von Heymann C, Magnuson A, Alahuhta S, Fernando R, Van de Velde M, Mercier FJ, Schyns-van den Berg AMJV, Bryon B, Soetens F, Dewandre PY, Lambert G, Christiaen J, Schepers R, Van Houwe P, Kalmar A, Vanoverschelde H, Bauters M, Roofthooft E, Devroe S, Van de Velde M, Jadrijevic A, Jokic A, Marin D, Sklebar I, Mihaljević S, Kosinova M, Stourac P, Adamus M, Kufa C, Volfová I, Zaoralová B, Froeslev-Friis C, Mygil B, Krebs Albrechtsen C, Kavasmaa T, Alahuhta S, Mäyrä A, Mennander S, Rautaneva K, Hiekkanen T, Kontinen V, Linden K, Toivakka S, Boselli E, Greil PÉ, Mascle O, Courbon A, Lutz J, Simonet T, Barbier M, Hlioua T, Meniolle d’Hauthville F, Quintin C, Bouattour K, Lecinq A, Soued M, Bonnet MP, Carbonniere M, Fischer C, Picard PC, Bonnin M, Storme B, Bouthors AS, Detente T, Nguyen Troung M, Keita H, Nebout S, Osse L, Delmas A, Vial F, Kaufner L, Hoefing C, Mueller S, Becke K, Blobner M, Lewald H, Schaller SJ, Muggleton E, Bette B, Neumann C, Weber S, Grünewald M, Ohnesorge H, Helf A, Jelting Y, Kranke P, von Heymann C, Welfle S, Staikou C, Stavrianopoulou A, Tsaroucha A, Kalopita K, Loukeri A, Valsamidis D, Matsota P, Thorsteinsson A, Tome R, Eidelman LA, Davis A, Orbach-Zinger S, Ioscovich A, Ramona I, De Simone L, Pesetti B, Brazzi L, Zito A, Camorcia M, Della Rocca G, Aversano M, Frigo MG, Todde C, Morina Q, Macas A, Keraitiene G, Rimaitis K, Borg F, Tua C, Kuijpers-Visser AG, Schyns-van den Berg A, Hollmann MW, Van den Berg T, Koolen E, Dons I, van der Knijff A, van der Marel C, Ruysschaert N, Pelka M, Pluymakers C, Koopman S, Teunissen AJ, Cornelisse D, van Dasselaar N, Verdouw B, Beenakkers I, Dahl V, Hagen R, Vivaldi F, Eriksen JR, Wiszt R, Aslam Tayyaba N, Ringvold EM, Chutkowski R, Skirecki T, Wódarski B, Faria MA, Ferreira A, Sampaio AC, Ferreira I, Matias B, Teixeira J, Araujo R, Cabido H, Fortuna R, Lemos P, Cardoso C, Moura F, Pereira C, Pereira S, Tavares F, Vasconcelos P, Abecasis M, Lança F, Muchacho P, Ormonde L, Guedes-Araujo I, Pinho-Oliveira V, Paredes P, Bentes C, Gouveia F, Milheiro A, Castanheira C, Neves M, Pacheco V, Cortez M, Tranquada R, Tareco G, Furtado I, Pereira E, Marinho L, Seabra M, Bulasevic A, Kendrisic M, Jovanovic L, Pujić B, Kutlesic M, Grochova M, Simonova J, Pavlovic G, Rozman A, Blajic I, Graovac D, Stopar Pintraic T, Chiquito T, Monedero P, Carlos-Errea DJ, Guillén-Casbas R, Veiga-Gil L, Basso M, Garcia Bartolo C, Hernandez C, Ricol L, De Santos MP, Gràcia Solsona JA, López-Baamonde M, Magaldi Mendaña M, Plaza Moral AM, Vendrell M, Trillo L, Perez Garcia AR, Alamillo Salas C, Moret E, Ramió L, Aguilar Sanchez JL, Soler Pedrola M, Valldeperas Hernandez MI, Aldalur G, Bárcena E, Herrera J, Iturri F, Martínez A, Martínez L, Serna R, Gilsanz F, Guasch Arevalo E, Iannuccelli F, Latorre J, Rodriguez Roca C, Pérez Pardo OC, Sierra Biddle N, Suárez Cendaña C, Hernández González L, Remacha González C, Sánchez Nuez R, Anta D, Beleña JM, García-Cuadrado C, Garcia I, Manrique S, Suarez E, Hein A, Arbman E, Hansson H, Tillenius M, Al-Taie R, Ledin-Eriksson S, Lindén-Söndersö A, Rosén O, Austruma E, Gillberg L, Darvish B, Gupta A, Nordstöm JL, Persson J, Rosenberg J, Brühne L, Forshammar J, Ugarph Edfeldt M, Rolfsson H, Hellblom A, Levin K, Rabow S, Thorlacius K, Bansch P, Robertson (Baeriswyl) M, Stamer U, Mathivon S, Savoldelli G, Auf der Maur P, Filipovic M, Dullenkopf A, Brunner M, Girard T, Vonlanthen C, Ozbilgin S, Gunaydin D B, Corman Dincer P, Tas Tuna A. Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study. Br J Anaesth 2020; 125:1045-1055. [PMID: 33039123 DOI: 10.1016/j.bja.2020.07.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/05/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. METHODS Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. RESULTS A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. CONCLUSIONS Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.
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Affiliation(s)
- Anil Gupta
- Department of Perioperative Medicine and Intensive Care and Institution of Physiology and Pharmacology, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Roshan Fernando
- Department of Anesthesiology and Intensive Care Medicine, The Womens Wellness and Research Centre, Doha, Qatar
| | | | - Frédéric J Mercier
- Département d'Anesthésie, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay, France
| | - Alexandra M J V Schyns-van den Berg
- Department of Anesthesiology, Albert Schweitzer Ziekenhuis, Dordrecht and Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
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Silvani A, Bucalo F, Voekt C, Tobler D, Girard T. Platypnea-orthodeoxia syndrome: an unusual cause of breathlessness in late pregnancy. Int J Obstet Anesth 2020; 44:122-125. [PMID: 32947104 DOI: 10.1016/j.ijoa.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/08/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
A pregnant patient with shortness of breath and arterial oxygen desaturation is presented. The primary and tentative initial diagnosis was pulmonary embolism. Her desaturation and dyspnea were aggravated in the upright compared with the supine position. The minimal response to supplemental oxygen suggested right-to-left shunting, which was confirmed by echocardiography. Shunting was minimal in the supine and maximal in the upright position, leading to the diagnosis of platypnea-orthodeoxia syndrome. By two weeks postpartum the patient's symptoms had resolved and shunting was undetectable.
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Affiliation(s)
- A Silvani
- Department of Anesthesiology, University Hospital Basel, University of Basel, Switzerland
| | - F Bucalo
- Department of Anesthesiology, University Hospital Basel, University of Basel, Switzerland
| | - C Voekt
- Department of Obstetrics, Womeńs Hospital Grabs, Switzerland
| | - D Tobler
- Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - T Girard
- Department of Anesthesiology, University Hospital Basel, University of Basel, Switzerland.
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Glahn KP, Bendixen D, Girard T, Hopkins PM, Johannsen S, Rüffert H, Snoeck MM, Urwyler A. Availability of dantrolene for the management of malignant hyperthermia crises: European Malignant Hyperthermia Group guidelines. Br J Anaesth 2020; 125:133-140. [DOI: 10.1016/j.bja.2020.04.089] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/28/2022] Open
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Kranke P, Weibel S, Sitter M, Meybohm P, Girard T. [Obstetric Anesthesia During the SARS-CoV-2 Pandemic - a Brief Overview of Published Recommendations for Action by National and International Specialist Societies and Committees]. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:266-274. [PMID: 32274774 PMCID: PMC7295301 DOI: 10.1055/a-1144-5562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The most common human corona viruses cause common colds. But three of these viruses cause more serious, acute diseases; Middle East Respiratory Syndrome (MERS by MERS-CoV), Severe Acute Respiratory Syndrome (SARS) by SARS-CoV and COVID-19 by SARS-CoV-2. The current outbreak was classified by the WHO as a "global public health emergency". Despite all efforts to reduce the surgical lists and to cancel or postpone non-time-critical surgical interventions, some surgical and anesthetic interventions outside of intensive care medicine are still necessary and must be performed. This is particularly true for obstetric interventions and neuraxial labor analgesia. Workload in the delivery room is presumably not going to decrease and planned cesarean sections cannot be postponed. In the meantime, the clinical course and outcome of some COVID-19 patients with an existing pregnancy or peripartum courses have been reported. There are already numerous recommendations from national and international bodies regarding the care of such patients. Some of these recommendations will be summarized in this manuscript. The selection of aspects should by no means be seen as a form of prioritization. The general treatment principles in dealing with COVID-19 patients and the recommendations for action in intensive care therapy also apply to pregnant and postpartum patients. In this respect, there are naturally considerable redundancies and only a few aspects apply strictly or exclusively to the cohort of obstetric patients. In summary, at present it must be stated that the general care recommendations that also apply to non-COVID-19 patients are initially valid with regard to obstetric anesthesia. Nevertheless, the special requirements on the part of hygiene and infection protection result in special circumstances that should be taken into account when caring for pregnant patients from an anesthetic point of view. These relate to both medical aspects, but also to a particular extent logistics issues with regard to spatial separation, staffing and material resources.
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Buddeberg BS, Fernandes NL, Vorster A, Cupido BJ, Lombard CJ, Swanevelder JL, Girard T, Dyer RA. Cardiac Structure and Function in Morbidly Obese Parturients: An Echocardiographic Study. Anesth Analg 2020; 129:444-449. [PMID: 29878938 DOI: 10.1213/ane.0000000000003554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The increasing prevalence of obesity worldwide is a major threat to global health. Cardiac structural and functional changes are well documented for obesity as well as for pregnancy, but there is limited literature on morbidly obese parturients. We hypothesized that there are both cardiac structural and functional differences between morbidly obese pregnant women and pregnant women of normal body mass index (BMI). METHODS This prospective cross-sectional study was performed in 2 referral maternity units in Cape Town, South Africa, over a 3-month period. Forty morbidly obese pregnant women of BMI ≥40 kg·m (group O) were compared to 45 pregnant women of BMI ≤30 kg·m (group N). Cardiac structure and function were assessed by transthoracic echocardiography, according to the recommendations of the British Society of Echocardiography. The 2-sample t-test with unequal variances was used for the comparison of the mean values between the groups. RESULTS Acceptable echocardiographic images were obtained in all obese women. Statistical significance was defined as P < .0225 after applying the Benjamini-Hochberg correction for multiple testing. Mean (standard deviation) mean arterial pressure was higher in group O (91 [8.42] vs 84 [9.49] mm Hg, P < .001). There were no between-group differences in heart rate, stroke volume, or cardiac index (84 [12] vs 79 [13] beats·minute, P = .103; 64.4 [9.7] vs 59.5 [13.5] mL, P = .069; 2551 [474] vs 2729 [623] mL·minute·m, P = .156, for groups O and N, respectively). Stroke volume index was lower, and left ventricular mass was higher in group O (30.14 [4.51] vs 34.25 [7.00] mL·m, P = .003; 152 [24] vs 115 [29] g, P < .001). S' septal was lower in group O (8.43 [1.20] vs 9.25 [1.64] cm·second, P = .012). Considering diastolic function, isovolumetric relaxation time was significantly prolonged in group O (73 [15] vs 61 [15] milliseconds, P < .001). The septal tissue Doppler index E' septal was lower in group O (9.08 [1.69] vs 11.28 [3.18], P < .001). There were no between-group differences in E' average (10.7 [2.3] vs 12.0 [2.7], P = .018, O versus N) or E/E' average (7.85 [1.77] vs 7.27 [1.68], P = .137, O versus N). Right ventricular E'/A' was lower in group O (1.07 [0.47] vs 1.29 [0.32], P = .016). CONCLUSIONS Cardiac index did not differ between obese pregnant women and those with normal BMI. Their increased left ventricular mass and lower stroke volume index could indicate a limited adaptive reserve. Obese women had minor decreases in septal left ventricular tissue Doppler velocity, but the E/E' average values did not suggest clinically significant diastolic dysfunction.
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Affiliation(s)
- Bigna S Buddeberg
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.,Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - Nicole L Fernandes
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Adri Vorster
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Blanche J Cupido
- Department of Cardiology, University of Cape Town and Groote Schuur Hospital, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - Carl J Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Justiaan L Swanevelder
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Thierry Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - Robert A Dyer
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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Heesen M, Hilber N, Rijs K, Rossaint R, Girard T, Mercier FJ, Klimek M. A systematic review of phenylephrine vs. noradrenaline for the management of hypotension associated with neuraxial anaesthesia in women undergoing caesarean section. Anaesthesia 2020; 75:800-808. [PMID: 32012226 DOI: 10.1111/anae.14976] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2019] [Indexed: 01/15/2023]
Abstract
Phenylephrine is recommended for the management of hypotension after spinal anaesthesia in women undergoing caesarean section. Noradrenaline, an adrenergic agonist with weak β-adrenergic activity, has been reported to have a more favourable haemodynamic profile than phenylephrine. However, there are concerns that noradrenaline may be associated with a higher risk of fetal acidosis, defined as an umbilical artery pH < 7.20. We performed a systematic review of trials comparing noradrenaline with phenylephrine, concentrating on primary outcomes of fetal acidosis and maternal hypotension. We identified 13 randomised controlled trials including 2002 patients. Heterogeneity among the studies was high, and there were too few data to calculate a pooled effect estimate. Fetal acidosis was assessed in four studies that had a low risk of bias and a low risk of confounding, that is, studies which used a prophylactic vasopressor and where women received the allocated vasopressor only. There were no significant differences between these studies. No significant differences were observed for hypotension. Two trials found a significantly lower incidence of bradycardia when using noradrenaline. Cardiac output was significantly higher after noradrenaline in two of three studies. For other secondary outcomes including nausea, vomiting and Apgar scores at 1 and 5 min, no studies found significant differences. The evidence so far is too limited to support an advantage of noradrenaline over phenylephrine. Concerns of a deleterious effect of noradrenaline on fetal blood gas status cannot currently be assuaged by the available data from randomised controlled studies.
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Affiliation(s)
- M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - N Hilber
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - R Rossaint
- Department of Anaesthesia, University Hospital RWTH Aachen, Aachen, Germany
| | - T Girard
- Department of Anaesthesia, University Hospital Basel, Basel, Switzerland
| | - F J Mercier
- Department of Anaesthesia, A. Béclère Hospital - APHP & Paris-Saclay University, Clamart, France
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hösli I. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020; 301:627-641. [PMID: 31728665 PMCID: PMC7033066 DOI: 10.1007/s00404-019-05374-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
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Affiliation(s)
- Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, Insel Hospital, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
| | - Yvan Vial
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | | | - David Baud
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - René Hornung
- Department of Obstetrics and Gynaecology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Irene Hösli
- Clinic of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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Becke K, Jöhr M, Girard T. Einleitung von nicht nüchternen Patienten am Beispiel von Schwangeren und Kindern. Anasthesiol Intensivmed Notfallmed Schmerzther 2019; 54:617-628. [DOI: 10.1055/a-0720-3936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
ZusammenfassungDie klassische Technik der Rapid Sequence Induction (RSI) ist eine fundamentale Form der Anästhesieeinleitung bei nicht nüchternen Patienten zur Verhinderung der Aspiration von Mageninhalt. Schwangere und Kinder sind aufgrund ihrer Hypoxiegefährdung eine besondere Herausforderung; das klassische RSI-Konzept „Induktion – Apnoe – (Krikoiddruck –) Intubation“ muss bei ihnen zugunsten einer kontrollierten Technik mit Erhalt der Oxygenierung modifiziert werden.
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Girard T, Bandschapp O. Maligne Hyperthermie: Diagnostik konkret. Anasthesiol Intensivmed Notfallmed Schmerzther 2019; 54:538-548. [DOI: 10.1055/a-0725-7554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
ZusammenfassungSowohl in der präoperativen Visite als auch bei intraoperativ verdächtigen Zwischenfällen kann sich die Frage nach einer Abklärung auf maligne Hyperthermie ergeben. Heute stehen mit molekulargenetischen Methoden und mit der Muskelbiopsie und Kontrakturtest 2 grundsätzliche verschiedene Testmethoden zur Verfügung. Beide diagnostischen Methoden haben Vor- und Nachteile – und ergänzen sich.
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Melber A, Jelting Y, Huber M, Keller D, Dullenkopf A, Girard T, Kranke P. Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015). Int J Obstet Anesth 2019; 39:12-21. [DOI: 10.1016/j.ijoa.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 12/04/2018] [Accepted: 12/15/2018] [Indexed: 12/12/2022]
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Wastiaux A, Defour T, Girard T. Étude de la santé de 1048 adolescents fragiles : un enjeu de dépistage, de soin, de prévention en particulier des IST et des cancers induits par des infections chroniques. Med Mal Infect 2019. [DOI: 10.1016/j.medmal.2019.04.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Naccache M, Paugam A, Girard T. Bilharziose urogénitale chez les jeunes migrants : prescrire n’est pas guérir ! Med Mal Infect 2019. [DOI: 10.1016/j.medmal.2019.04.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wastiaux A, Girard T. Santé sexuelle et prévalence des IST bactériennes dans une population d’adolescents fragiles, migrants et non-migrants. Med Mal Infect 2019. [DOI: 10.1016/j.medmal.2019.04.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gabriel L, Young J, Hoesli I, Girard T, Dell-Kuster S. Generalisability of randomised trials of the programmed intermittent epidural bolus technique for maintenance of labour analgesia: a prospective single centre cohort study. Br J Anaesth 2019; 123:e434-e441. [PMID: 31331592 DOI: 10.1016/j.bja.2019.02.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/25/2019] [Accepted: 02/02/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Several randomised controlled trials show that maintenance of labour epidural analgesia with programmed intermittent epidural bolus reduces the maternal motor block compared with maintenance with a continuous infusion. However, these trials were usually restricted to healthy nulliparous parturients. To assess the generalisability of these randomised controlled trials to 'real-world' conditions, we compared maternal motor function (modified Bromage score) over time between healthy nulliparous and parous women using routinely collected quality-control data. METHODS After ethical approval, all parturients receiving programmed intermittent epidural bolus labour analgesia between June 2013 and October 2014 were included in this prospective cohort study. Bupivacaine 0.1% with fentanyl 2 μg ml-1 was used allowing for patient-controlled bolus every 20 min. The maternal motor function (primary outcome) was regularly assessed from insertion of the epidural catheter until delivery. RESULTS Of the 839 parturients included, 553 (66%) were nulliparous and 286 (34%) were parous. The parous women had a shorter median duration of epidural analgesia (3 h 59 min vs 5 h 45 min) and a higher incidence of spontaneous delivery (66% vs 37%). The probability of being in a certain Bromage category at birth was similar in nulliparous and parous women in a general additive model adjusting for duration of epidural analgesia, number of rescue top-ups, and number of catheter manipulations (cumulative odds ratio: 1.18; 95% confidence interval: 0.98-1.41). Parous women required a higher time-weighted number and volume of rescue top-ups. CONCLUSIONS The results of the randomised controlled trials on a reduced motor block with programmed intermittent epidural bolus seem generalisable to parturients typically not included in these trials.
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Affiliation(s)
- L Gabriel
- University of Basel, Basel, Switzerland
| | - J Young
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - I Hoesli
- University of Basel, Basel, Switzerland; Department of Obstetrics and Antenatal Care, University Hospital Basel, Basel, Switzerland
| | - T Girard
- University of Basel, Basel, Switzerland; Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - S Dell-Kuster
- University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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Schwendimann R, Blatter C, Lüthy M, Mohr G, Girard T, Batzer S, Davis E, Hoffmann H. Adherence to the WHO surgical safety checklist: an observational study in a Swiss academic center. Patient Saf Surg 2019; 13:14. [PMID: 30918531 PMCID: PMC6419440 DOI: 10.1186/s13037-019-0194-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
Background The World Health Organization (WHO) Surgical Safety Checklist is used globally to ensure patient safety during surgery. Two years after its implementation in the University Hospital Basel's operating rooms, adherence to the protocol was evaluated. Methods This mixed method observational study took place in the surgical department of the University Hospital of Basel, Switzerland from April to August 2017. Data collection was via individual structured interviews with selected OR team members regarding checklist adherence and on-site non-participant observations of Team Time Out and Team Sign Out sequences in the OR. Data were subjected to thematic analysis and descriptive statistics compiled. Results Comprehensive local expert interviews indicated that individual, procedural and contextual variables influenced the application of the checklist. Facilitating factors included well-informed specialists who advocated the use of the Checklist, as well as teams focused on the checklist's intended process and on its content. In contrast, factors such as staff insecurity, a generally negative attitude towards the checklist, a lack of teamwork, and hesitance to complete the checklist, hindered its implementation.The checklist's application was evaluated in 104 on-site observations comprising of 72 Team Time Out (TTO) and 32 Team Sign Out (TSO) sections. Adherence to the protocol ranged between 96 and 100% in TTO and 22% in TSO respectively. Lack of implementation of the TSO was mainly due to the absence of one of the key OR team members, who were busy with other tasks or no longer present in the operating room. Conclusion The study illustrates factors, which foster and hinder consistent application of the WHO surgical safety checklist namely individual, procedural and contextual. It also demonstrates that the TTO was consistently and correctly applied, while the unavailability of key OR team members at sign-out time was the most common reason for omission or incomplete use of the TSO.
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Affiliation(s)
- René Schwendimann
- 1Patient Safety Office, University Hospital Basel, Spitalstrasse 22, 4031 Basel, Switzerland.,2Department Public Health DPH, Nursing Science, Faculty of Medicine, University of Basel; Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Catherine Blatter
- 2Department Public Health DPH, Nursing Science, Faculty of Medicine, University of Basel; Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Marc Lüthy
- 3Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Giulia Mohr
- 1Patient Safety Office, University Hospital Basel, Spitalstrasse 22, 4031 Basel, Switzerland
| | - Thierry Girard
- 3Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Siegfried Batzer
- 3Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Erica Davis
- 1Patient Safety Office, University Hospital Basel, Spitalstrasse 22, 4031 Basel, Switzerland
| | - Henry Hoffmann
- 4Department of Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
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Dell-Kuster S, Hoesli I, Lapaire O, Seeberger E, Steiner LA, Bucher HC, Girard T. Efficacy and safety of carbetocin given as an intravenous bolus compared with short infusion for Caesarean section - double-blind, double-dummy, randomized controlled non-inferiority trial. Br J Anaesth 2018; 118:772-780. [PMID: 28498927 DOI: 10.1093/bja/aex034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background Carbetocin is a synthetic oxytocin-analogue, which should be administered as bolus according to manufacturer's recommendations. A higher speed of oxytocin administration leads to increased cardiovascular side-effects. It is unclear whether carbetocin administration as short infusion has the same efficacy on uterine tone compared with bolus administration and whether haemodynamic parameters differ. Methods In this randomized, double-blind, non-inferiority trial, women undergoing planned or unplanned Caesarean section (CS) under regional anaesthesia received a bolus and a short infusion, only one of which contained carbetocin 100 mcg (double dummy). Obstetricians quantified uterine tone two, three, five and 10 min after cord-clamping by manual palpation using a linear analogue scale from 0 to 100. We evaluated whether the lower limit of the 95% CI of the difference in maximum uterine tone within the first five min after cord-clamping did not include the pre-specified non-inferiority limit of -10. Results Between December 2014 and November 2015, 69 patients were randomized to receive carbetocin as bolus and 71 to receive it as short infusion. Maximal uterine tone was 89 in the bolus and 88 in the short infusion group (mean difference -1.3, 95% CI -5.7 to 3.1). Bp, calculated blood loss, use of additional uterotonics, and side-effects were comparable. Conclusions Administration of carbetocin as short infusion does not compromise uterine tone and has similar cardiovascular side-effects as a slow i.v. bolus. In accordance with current recommendations for oxytocin, carbetocin can safely be administered as short -infusion during planned or unplanned CS. Clinical trial registration ClinicalTrials.gov NCT02221531 and www.kofam.ch SNCTP000001197.
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Affiliation(s)
- S Dell-Kuster
- Department of Anaesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland
| | - I Hoesli
- Basel Institute of Clinical Epidemiology and Biostatistics, University Basel, Basel, Switzerland.,Department of Clinical Research, University Basel, Basel, Switzerland
| | - O Lapaire
- Basel Institute of Clinical Epidemiology and Biostatistics, University Basel, Basel, Switzerland
| | - E Seeberger
- Department of Anaesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel, Switzerland
| | - L A Steiner
- Department of Anaesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel, Switzerland.,Department of Clinical Research, University Basel, Basel, Switzerland
| | - H C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland.,Department of Clinical Research, University Basel, Basel, Switzerland
| | - T Girard
- Department of Anaesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel, Switzerland
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Wong C, Girard T. Undertreated or overtreated? Opioids for postdelivery analgesia. Br J Anaesth 2018; 121:339-342. [DOI: 10.1016/j.bja.2018.05.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/28/2018] [Indexed: 02/02/2023] Open
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Wastiaux A, Levine M, Viard J, Matheron S, Girard T. Transition des adolescents infectés par le VIH par transmission mère–enfant : évaluation à 10 ans d’un modèle créé dans une structure hospitalière ambulatoire pour adolescents/jeunes adultes. Med Mal Infect 2018. [DOI: 10.1016/j.medmal.2018.04.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Zalai D, Van Reekum E, Girard T. The evaluation of the consensus sleep diary in patients with post-concussion insomnia. Sleep Med 2017. [DOI: 10.1016/j.sleep.2017.11.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kranke P, Annecke T, Bremerich DH, Chappell D, Girard T, Gogarten W, Hanß R, Kaufner L, Neuhaus S, Ninke T, Standl T, Weber S, Jelting Y, Volk T. [Update in Obstetric Anesthesia - Tried and Trusted Methods, Controversies and New Perspectives]. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52:815-826. [PMID: 29156486 DOI: 10.1055/s-0043-116682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the society for Obstetric anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years (first event on April 1, 2000, most recently held on February 27, 2016, in Munich): the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" [1], [2]."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.
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Kranke P, Annecke T, Bremerich DH, Chappell D, Girard T, Gogarten W, Hanß R, Kaufner L, Neuhaus S, Ninke T, Standl T, Weber S, Jelting Y, Volk T. [Update in Obstetric Anesthesia: Tried and Trusted Methods, Controversies and New Perspectives - Part 1]. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52:727-736. [PMID: 29050063 DOI: 10.1055/s-0043-104921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since 1975, a plethora of lectures within the context of annual meetings relevant for the clinical care has been summarized in "what's new in obstetric anesthesia" by the Society for Obstetric Anesthesia and Perinatology which can be recommended to everyone interested in anaesthesiology in the delivery room. After the death of Gerard W. Ostheimer, Professor of Anaesthesiology at Brigham and Women's Hospital in Boston, Massachusetts, it became renamed the Gerard W. Ostheimer "what's new in obstetric anesthesia" lecture to honor his contributions to regional anesthesia and obstetric anaesthesia. Each year the event held by selected professional representatives and their imprint in leading anesthesia journals give insight into a critical appraisal of recent literature and the possible consequences for - but not only - the anaesthetic delivery room practice.A similar event has been established in Germany for more than 16 years: the obstetrical anesthesia symposium of the academic working group "regional anesthesia and obstetrical anesthesia" 1, 2."Evergreens" or "hot topics" with regard to anaesthesiological delivery room practice are presented and discussed regularly. The lectures often reveal the subtle change of the issues being debated much earlier than traditional textbook chapters do. This manuscript summarizes important findings from the last symposium held in 2016. Part I focuses on relevant causes for maternal morbidity and mortality as well as preventive measures, pregnancy in obese patients and sepsis in obstetric anaesthesia. Part II addresses established standards and new perspectives in the direct obstetric setting regarding epidural analgesia, post-dural puncture headache, anaesthesia and analgesia during and after caesarean section, haemodynamic monitoring during cesarean section and postpartum haemorrhage.
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Duggan M, Morrell M, Frimpong K, Nair D, Girard T, Pandharipande P, Ely W, Jackson J. DEMENTIA IN THE ICU: THE VALIDITY OF THE AD8 IN CRITICALLY ILL ADULTS. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.3116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M.C. Duggan
- Medicine, Vanderbilt University, Nashville, Tennessee,
| | - M.E. Morrell
- Medicine, Vanderbilt University, Nashville, Tennessee,
| | - K. Frimpong
- Medicine, Vanderbilt University, Nashville, Tennessee,
| | - D.R. Nair
- Medicine, Vanderbilt University, Nashville, Tennessee,
| | - T. Girard
- Medicine, Vanderbilt University, Nashville, Tennessee,
- Department of Veteran Affairs, Nashville, Tennessee
| | - P.P. Pandharipande
- Medicine, Vanderbilt University, Nashville, Tennessee,
- Department of Veteran Affairs, Nashville, Tennessee
| | - W. Ely
- Medicine, Vanderbilt University, Nashville, Tennessee,
- Department of Veteran Affairs, Nashville, Tennessee
| | - J.C. Jackson
- Medicine, Vanderbilt University, Nashville, Tennessee,
- Department of Veteran Affairs, Nashville, Tennessee
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Girard T. Malignant hyperthermia – Always a concern? Trends in Anaesthesia and Critical Care 2017. [DOI: 10.1016/j.tacc.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Buddeberg BS, Girard T. Geburtshilfe: hypertensive Erkrankungen in der Schwangerschaft. Anasthesiol Intensivmed Notfallmed Schmerzther 2017; 52:184-195. [PMID: 28301886 DOI: 10.1055/s-0042-105990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hypertensive disorders of pregnancy are one of the most common complications in pregnancy. They are associated with a high maternal, fetal and neonatal morbidity and mortality. 99 % of all maternal deaths occur in developing countries, but we should not forget that even in highly developed countries mothers still die from the complications of hypertensive disorders of pregnancy. This term encompasses chronic hypertension as well as pregnancy specific disorders such as gestational hypertension and preeclampsia. The physiological changes of pregnancy can make the differentiation between benign symptoms of pregnancy and life threatening conditions challenging. In order to provide optimal care for these women, an interdisciplinary approach between all members of the obstetric care team is crucial. The current review article discusses new advances in the diagnosis and treatment of hypertensive disorders of pregnancy.
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Levano S, Gonzalez A, Singer M, Demougin P, Rüffert H, Urwyler A, Girard T. Resequencing array for gene variant detection in malignant hyperthermia and butyrylcholinestherase deficiency. Neuromuscul Disord 2017; 27:492-499. [PMID: 28259615 DOI: 10.1016/j.nmd.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 12/20/2016] [Accepted: 02/15/2017] [Indexed: 11/30/2022]
Abstract
Malignant hyperthermia (MH) and butyrylcholinestherase (BCHE) deficiency are two relevant pharmacogenetic disorders in anesthetic practice linked with sequence variants, the former in the RyR1 and CACNA1S genes, the latter in the BCHE gene. Genotyping for known pathogenic variants in these genes is useful to help identify susceptible individuals, and others may exist but remain unknown, because full-length sequence of these genes is, in general, not investigated. To facilitate this task, we developed a resequencing DNA array, the perioperative patient safety (POPS) array, to be able to screen the entire coding sequences of the RyR1, CACNA1S and BCHE genes. MH-susceptible individuals (n = 121) identified with the in vitro contracture test, the standard diagnostic tool for MH susceptibility, were genotyped with the arrays. Compared with capillary sequencing, call rates with the arrays could achieve 100% at maximal sensitivity, although to reduce false positive rates, sensitivity was adjusted to 0.85, 0.87 and 0.66 for RyR1, CACNA1S and BCHE respectively, with overall base call specificity exceeding 99%. Detection of 29 predetermined RyR1 variants in 44 individuals was successful in 97% of the cases, among them all 16 variants of established diagnostic value. In a trial application of the arrays, 21 MH-susceptible subjects with no known RyR1 or CACNA1S variants were screened, resulting in the discovery of new variants, all confirmed by capillary sequencing. In conclusion, arrays offer an efficient high-throughput alternative for diagnostic genotyping of candidate genes affecting MH susceptibility, BCHE deficiency and other neuromuscular disorders, simultaneously enabling a comprehensive search for rare variants in these genes.
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Affiliation(s)
- Soledad Levano
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Asensio Gonzalez
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland.
| | - Martine Singer
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Philippe Demougin
- Biozentrum, Life Sciences Training Facility, University of Basel, Switzerland
| | - Henrik Rüffert
- University of Leipzig, Helios Kliniken Leipziger Land Leipzig, Germany
| | - Albert Urwyler
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Thierry Girard
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
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