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van den Bersselaar LR, Heytens L, Silva HCA, Reimann J, Tasca G, Díaz‐Cambronero Ó, Løkken N, Hellblom A, Hopkins PM, Rueffert H, Bastian B, Vilchez JJ, Gillies R, Johannsen S, Veyckemans F, Muenster T, Klein A, Litman R, Jungbluth H, Riazi S, Voermans NC, Snoeck MMJ. European Neuromuscular Centre consensus statement on anaesthesia in patients with neuromuscular disorders. Eur J Neurol 2022; 29:3486-3507. [PMID: 35971866 PMCID: PMC9826444 DOI: 10.1111/ene.15526] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 06/01/2022] [Revised: 07/05/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Patients with neuromuscular conditions are at increased risk of suffering perioperative complications related to anaesthesia. There is currently little specific anaesthetic guidance concerning these patients. Here, we present the European Neuromuscular Centre (ENMC) consensus statement on anaesthesia in patients with neuromuscular disorders as formulated during the 259th ENMC Workshop on Anaesthesia in Neuromuscular Disorders. METHODS International experts in the field of (paediatric) anaesthesia, neurology, and genetics were invited to participate in the ENMC workshop. A literature search was conducted in PubMed and Embase, the main findings of which were disseminated to the participants and presented during the workshop. Depending on specific expertise, participants presented the existing evidence and their expert opinion concerning anaesthetic management in six specific groups of myopathies and neuromuscular junction disorders. The consensus statement was prepared according to the AGREE II (Appraisal of Guidelines for Research & Evaluation) reporting checklist. The level of evidence has been adapted according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system. The final consensus statement was subjected to a modified Delphi process. RESULTS A set of general recommendations valid for the anaesthetic management of patients with neuromuscular disorders in general have been formulated. Specific recommendations were formulated for (i) neuromuscular junction disorders, (ii) muscle channelopathies (nondystrophic myotonia and periodic paralysis), (iii) myotonic dystrophy (types 1 and 2), (iv) muscular dystrophies, (v) congenital myopathies and congenital dystrophies, and (vi) mitochondrial and metabolic myopathies. CONCLUSIONS This ENMC consensus statement summarizes the most important considerations for planning and performing anaesthesia in patients with neuromuscular disorders.
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Affiliation(s)
- Luuk R. van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Luc Heytens
- Malignant Hyperthermia Research Unit, Departments of Anaesthesiology and NeurologyUniversity Hospital Antwerp, University of Antwerp and Born Bunge InstituteAntwerpBelgium
| | - Helga C. A. Silva
- Malignant Hyperthermia Unit, Department of Surgery, Discipline of Anaesthesia, Pain, and Intensive CareSão Paulo Federal UniversitySão PauloBrazil
| | - Jens Reimann
- Department of NeurologyUniversity of Bonn Medical CentreBonnGermany
| | - Giorgio Tasca
- UOC of NeurologyA. Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health CareRomeItaly
| | - Óscar Díaz‐Cambronero
- Malignant Hyperthermia Unit, Department of AnaesthesiologyPerioperative Medicine Research Group, La Fe University and Polytechnic HospitalValenciaSpain
| | - Nicoline Løkken
- Copenhagen Neuromuscular CentreRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Anna Hellblom
- Department of Intensive and Perioperative CareSkåne University Hospital LundLundSweden
| | - Philip M. Hopkins
- Leeds Institute of Medical Research at St James'sUniversity of Leeds and Malignant Hyperthermia Investigation Unit, St James's University HospitalLeedsUK
| | - Henrik Rueffert
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Börge Bastian
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Juan Jesus Vilchez
- Neuromuscular Centre, La Fe Hospital UIP and ERN EURO‐NMDNeuromuscular Research Group at La Fe IIS and CIBERERValenciaSpain
| | - Robyn Gillies
- Malignant Hyperthermia Diagnostic Unit, Department of Anaesthesia and Pain ManagementRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, Centre for Malignant HyperthermiaUniversity Hospital WürzburgWürzburgGermany
| | - Francis Veyckemans
- Paediatric Anaesthesia ClinicJeanne de Flandre Hospital, Lille University Hospital CentreLilleFrance
| | - Tino Muenster
- Department of Anaesthesia and Intensive Care MedicineHospital of the Order of St John of GodRegensburgGermany
| | - Andrea Klein
- Department of Paediatric NeurologyUniversity Children's Hospital UKBBBaselSwitzerland,Division of Neuropaediatrics, Development, and Rehabilitation, Department of Paediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Ron Litman
- Department of Anaesthesiology and Critical CareChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular ServiceEvelina's Children Hospital, Guy's and St Thomas' Hospital National Health Service Foundation TrustLondonUK,Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology and Pain MedicineUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Marc M. J. Snoeck
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands
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Hübner M, Kusamura S, Villeneuve L, Al-Niaimi A, Alyami M, Balonov K, Bell J, Bristow R, Guiral DC, Fagotti A, Falcão LFR, Glehen O, Lambert L, Mack L, Muenster T, Piso P, Pocard M, Rau B, Sgarbura O, Somashekhar SP, Wadhwa A, Altman A, Fawcett W, Veerapong J, Nelson G. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management. Eur J Surg Oncol 2020; 46:2292-2310. [PMID: 32873454 DOI: 10.1016/j.ejso.2020.07.041] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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Affiliation(s)
- Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland.
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Clinical Research and Epidemiological Unit, Department of Public Health, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Ahmed Al-Niaimi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, USA
| | - John Bell
- Department of Anesthesiology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Robert Bristow
- Department of Obstetrics and Gynecologic Oncology, University of California, Irvine School of Medicine, Orange, USA
| | - Delia Cortés Guiral
- Department of General Surgery (Peritoneal Surface Surgical Oncology). University Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Luiz Fernando R Falcão
- Discipline of Anesthesiology, Pain and Critical Care Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Olivier Glehen
- Department of Digestive Surgery, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lloyd Mack
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tino Muenster
- Department of Anaesthesiology and Intensive Care Medicine. Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier (ICM), University of Montpellier, Montpellier, France
| | - S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Bengaluru, India
| | - Anupama Wadhwa
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - William Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, La Jolla, CA, USA
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Hoelzig H, Muenster T, Blanke S, Kloess G, Garmasukis R, Koenig A. Ivory vs. osseous ivory substitutes-Non-invasive diffractometric discrimination. Forensic Sci Int 2020; 308:110159. [PMID: 32006880 DOI: 10.1016/j.forsciint.2020.110159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 11/29/2022]
Abstract
A new discrimination method for the bioapatite materials bone, antler and ivory was developed using X-ray diffractometry and comprises non-invasive measurements in order to take valuable objects into account. Our approach deals with the analysis of peak intensity ratios resulting from several measurements on each object. For instance, the intensity ratio of the apatite reflections 002 and 310 has been described in the literature as representing the degree of apatite crystal orientation and varies depending on the sample orientation. The decisive factor for the material identification is the value dispersion of intensity ratios resulting from the total of all measurements on one object. This pattern of data points, visualised via kernel density estimation (KDE), is characteristic for ivory, bone and antler, respectively, and enables the discrimination of these materials. The observation is justifiable since apatite crystal orientation adapts to the collagen fibre arrangement which shows major differences between different sorts of bioapatite materials. The patterns of data points were received via analysis of 88 objects made of bone (n = 30), antler (n = 27) and ivory (n = 31). In order to verify several identifications X-ray computer tomography was supplemented. The presented method usefully supplements already existing approaches concerning microscopic, elementary and biochemical analyses.
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Affiliation(s)
- H Hoelzig
- Institute of Mineralogy, Crystallography and Materials Science, Leipzig University, Germany.
| | - T Muenster
- Institute of Mineralogy, Crystallography and Materials Science, Leipzig University, Germany
| | - S Blanke
- Institute of Mineralogy, Crystallography and Materials Science, Leipzig University, Germany
| | - G Kloess
- Institute of Mineralogy, Crystallography and Materials Science, Leipzig University, Germany
| | - R Garmasukis
- Institute of Mineralogy, Crystallography and Materials Science, Leipzig University, Germany
| | - A Koenig
- Department of Prosthodontics and Material Sciences, Leipzig University, Germany
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Sippl P, Ganslandt T, Prokosch HU, Muenster T, Toddenroth D. Machine Learning Models of Post-Intubation Hypoxia During General Anesthesia. Stud Health Technol Inform 2017; 243:212-216. [PMID: 28883203] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Fine-meshed perioperative measurements are offering enormous potential for automatically investigating clinical complications during general anesthesia. In this study, we employed multiple machine learning methods to model perioperative hypoxia and compare their respective capabilities. After exporting and visualizing 620 series of perioperative vital signs, we had ten anesthesiologists annotate the subjective presence and severity of temporary post-intubation oxygen desaturation. We then applied specific clustering and prediction methods on the acquired annotations, and evaluated their performance in comparison to the inter-rater agreement between experts. When reproducing the expert annotations, the sensitivity and specificity of multi-layer neural networks substantially outperformed clustering and simpler threshold-based methods. The achieved performance of our best automated hypoxia models thereby approximately equaled the observed agreement between different medical experts. Furthermore, we deployed our classification methods for processing unlabeled inputs to estimate the incidence of hypoxic episodes in another sizeable patient cohort, which attests to the feasibility of using the approach on a larger scale. We interpret that our machine learning models could be instrumental for computerized observational studies of the clinical determinants of post-intubation oxygen deficiency. Future research might also investigate potential benefits of more advanced preprocessing approaches such as automated feature learning.
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Affiliation(s)
- Philipp Sippl
- Medical Informatics, Univ. of Erlangen-Nürnberg, Erlangen
| | - Thomas Ganslandt
- Medical Center for Information and Communication Technology, University Hospital Erlangen
| | | | - Tino Muenster
- Dept of Anaesthesiology & Intensive Care, University Hospital Erlangen
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Toddenroth D, Ganslandt T, Drescher C, Weith T, Prokosch HU, Schuettler J, Muenster T. Algorithmic Summaries of Perioperative Blood Pressure Fluctuations. Stud Health Technol Inform 2016; 228:532-536. [PMID: 27577440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Automated perioperative measurements such as cardiovascular monitoring data are commonly compared to established upper and lower thresholds, but could also allow for more complex interpretations. Analyzing such time series in extensive electronic medical records for research purposes may itself require customized automation, so we developed a set of algorithms for quantifying different aspects of temporal fluctuations. We implemented conventional measures of dispersion, summaries of absolute gradients between successive values, and Poincaré plots. We aggregated the severity and duration of hypotensive episodes by calculating the average area under different mean arterial pressure (MAP) thresholds. We applied these methods to 30,452 de-identified MAP series, and analyzed the similarity between alternative indices via hierarchical clustering. To explore the potential utility of these propositional metrics, we computed their statistical association with presumed complications due to cardiovascular instability. We observed that hierarchical clustering reliably segregated features that had been designed to quantify dissimilar aspects. Summaries of temporary hypotension turned out to be significantly increased among patient subgroups with subsequent signs of a complicated recovery. These associations were even stronger for measures that were specifically geared to capturing short-term MAP variability. These observations suggest the potential capability of our proposed algorithms for quantifying heterogeneous aspects of short-term MAP fluctuations. Future research might also target a wider selection of outcomes and other attributes that may be subject to intraoperative variability.
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Affiliation(s)
| | - Thomas Ganslandt
- Medical Center for Information and Communication Technology, University Hospital Erlangen, Germany
| | | | - Thomas Weith
- Dept of Anaesthesiology & Intensive Care, University Hospital Erlangen, Germany
| | | | - Juergen Schuettler
- Dept of Anaesthesiology & Intensive Care, University Hospital Erlangen, Germany
| | - Tino Muenster
- Dept of Anaesthesiology & Intensive Care, University Hospital Erlangen, Germany
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Huehne K, Leis S, Muenster T, Wehrfritz A, Winter S, Maihöfner C, Foertsch T, Croner R, Reis A, Winterpacht A, Rautenstrauss B. High post surgical opioid requirements in Crohn's disease are not due to a general change in pain sensitivity. Eur J Pain 2012; 13:1036-42. [DOI: 10.1016/j.ejpain.2008.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 12/01/2008] [Accepted: 12/14/2008] [Indexed: 11/30/2022]
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Schmitt HJ, Muenster T. Anesthesia in patients with neuromuscular disorders. Minerva Anestesiol 2009; 75:632-637. [PMID: 19078898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Neuromuscular disorders (NMDs) are a heterogeneous group of neurological and muscular diseases. Patients present with typical features such as wasting and weakness of skeletal muscles. However, despite these common clinical signs, underlying etiologies are nearly as multifaceted as the number of the diseases. For the anesthesiologist, it is very important to know the origin of a particular disease to select an appropriate anesthetic technique. Patients with NMDs are markedly sensitive to several anesthetics. Many reported anesthesia-related complications were caused by the administration of drugs like depolarizing and non-depolarizing muscle relaxants, volatile anesthetics, or respiratory and cardiovascular depressant agents.
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Affiliation(s)
- H J Schmitt
- Department of Anesthesiology, Friedrich-Alexander University, Erlangen-Nürnberg, Erlangen, Germany.
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Muenster T, Forst J, Goerlitz P, Schmitt HJ. Reversal of rocuronium-induced neuromuscular blockade by pyridostigmine in patients with Duchenne muscular dystrophy. Paediatr Anaesth 2008; 18:251-5. [PMID: 18230069 DOI: 10.1111/j.1460-9592.2008.02417.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect and safety of pyridostigmine for the reversal of a neuromuscular block (NMB) in patients with Duchenne muscular dystrophy (DMD). In patients with DMD recovery from a rocuronium-induced NMB is markedly delayed. METHODS Fourteen DMD patients (aged between 11 and 19 years) scheduled for elective scoliosis repair were studied. Following tracheal intubation without muscle relaxant, all patients received a single dose of rocuronium 0.6 mg.kg(-1). NMB was monitored by acceleromyography at the adductor pollicis muscle. When the first twitch height (T1) of the train-of-four (TOF) had recovered to 25% seven patients received either pyridostigmine 0.1 mg.kg(-1) (the anticholinergic drug with a long duration of action) or saline in a blinded manner. The times to attain TOF ratio of 0.9 were recorded. For comparison the Mann-Whitney U-test was used. RESULTS Recovery to TOF ratio of 0.9 was significantly (P < 0.05) accelerated by pyridostigmine [84 (median), 57-141(range)] compared with controls (148, 84-243 min). The recovery time (time between T1 of 25% and TOF of 90%) was also significantly (P < 0.01) shortened by pyridostigmine (15, 8-49 vs 76, 43-144 min, respectively). Time to recovery of T(1) to 90% was not different between the groups (108, 63-134 vs 169. 61-208 min, respectively). CONCLUSIONS Pyridostigmine 0.1 mg.kg(-1) effectively reversed a rocuronium-induced NMB in DMD patients.
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Affiliation(s)
- Tino Muenster
- Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Muenster T, Schmidt J, Wick S, Forst J, Schmitt HJ. Rocuronium 0.3 mg x kg-1 (ED95) induces a normal peak effect but an altered time course of neuromuscular block in patients with Duchenne's muscular dystrophy. Paediatr Anaesth 2006; 16:840-5. [PMID: 16884467 DOI: 10.1111/j.1460-9592.2006.01870.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In patients with Duchenne's muscular dystrophy (DMD) recovery from neuromuscular block is delayed. It has been assumed that this is because of a higher potency of muscle relaxants in this patient cohort. We determined the peak effect, and the time course of action of rocuronium 0.3 mg x kg(-1) (ED(95)) in DMD patients. METHODS Twenty-four patients (12 with DMD and 12 controls; aged 10-18 years) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of rocuronium 0.3 mg x kg(-1). The complete time course of action as onset, peak effect and spontaneous recovery was recorded. RESULTS The onset time (s) to maximum block was significantly (P < 0.01) prolonged in DMD patients (median: 315; range: 120-465) compared with controls (195, 75-270). The peak effect (% twitch depression relative to baseline) was not different between the groups (DMD: 59-100; controls: 28-100). In the DMD group, recovery was significantly (P < 0.01) delayed compared with controls at all recorded time points. The clinical duration (min) was 40.3 (22-89) in the DMD group vs 9.8 (6-17) in the control group (P < 0.01). CONCLUSIONS The similar peak effect in both groups does not confirm the thesis of rocuronium having a higher potency in DMD patients. The documented very long recovery after the ED(95) of rocuronium emphasizes the need for careful assessment of neuromuscular function in DMD patients.
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Affiliation(s)
- Tino Muenster
- Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Schmidt J, Muenster T, Wick S, Forst J, Schmitt HJ. Onset and duration of mivacurium-induced neuromuscular block in patients with Duchenne muscular dystrophy †. Br J Anaesth 2005; 95:769-72. [PMID: 16183677 DOI: 10.1093/bja/aei249] [Citation(s) in RCA: 24] [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: 11/14/2022] Open
Abstract
BACKGROUND To determine the response to mivacurium, we prospectively studied onset time and complete spontaneous recovery from mivacurium-induced neuromuscular block in patients with Duchenne muscular dystrophy (DMD). METHODS Twelve boys with DMD, age 5-14 yr, seven of them wheelchair-bound, ASA II-III, and 12 age- and sex-matched controls (ASA I) were enrolled in the study. Anaesthesia was induced with fentanyl 2-3 microg kg(-1) and propofol 3-4 mg kg(-1) titrated to effect, and maintained by continuous i.v. infusion of propofol 8-12 mg kg(-1) and remifentanil as required. The lungs were ventilated with oxygen in air. Neuromuscular transmission was assessed by acceleromyography using train-of-four (TOF) stimulation every 15 s. After baseline readings, a single dose of mivacurium 0.2 mg kg(-1) was given. The following variables were recorded: (i) lag time; (ii) onset time; (iii) peak effect; (iv) recovery of first twitch from the TOF response to 10, 25 and 90% (T(10), T(25), T(90)) relative to baseline; (v) recovery index (time between 25 and 75% recovery of first twitch); and (vi) recovery time (time between 25% recovery of first twitch and recovery of TOF ratio to 90%). For comparison between the groups the Mann-Whitney U-test was applied. RESULTS There were no differences between the groups in lag time, onset time and peak effect. However, all recorded recovery indices were significantly (P<0.05) prolonged in the DMD group. The median (range) for time points T(10), T(25) and T(90) in the DMD and control group was 12.0 (8-16) vs 8.4 (5-15) min, 14.1 (9-20) vs 10.5 (7-17) min and 26.9 (15-40) vs 15.9 (12-23) min, respectively. The recovery index and recovery time were similarly prolonged in the DMD group. CONCLUSIONS These results support the assumption that mivacurium-induced neuromuscular block is prolonged in patients with DMD.
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Affiliation(s)
- J Schmidt
- Department of Anaesthesiology, Friedrich-Alexander University, Erlangen-Nuremberg, Krankenhausstrasse 12, D-91054 Erlangen, Germany
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Wick S, Muenster T, Schmidt J, Forst J, Schmitt HJ. Onset and Duration of Rocuronium-induced Meeting Abstracts in Patients with Duchenne Muscular Dystrophy. Anesthesiology 2005; 102:915-9. [PMID: 15851877 DOI: 10.1097/00000542-200505000-00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [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: 11/25/2022]
Abstract
Background
In patients with Duchenne muscular dystrophy (DMD) the response to nondepolarizing muscle relaxants is scarcely documented and conflicting. The current study was conducted to determine the time to peak effect and the time for complete spontaneous recovery after a single dose of 0.6 mg/kg of rocuronium in patients with DMD.
Methods
Twenty-four patients (12 with DMD, 12 controls, aged 10-16 yr) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of 0.6 mg/kg of rocuronium. The complete time course of onset and spontaneous recovery were recorded
Results
Significant (P < 0.01) increase in the onset times to 95% neuromuscular block was observed in DMD patients (median, 203 s; range, 90-420 s) compared with controls (median, 90 s; range, 60-195 s). The time between rocuronium administration and recovery of first twitch of the train-of-four to 90% was significantly (P < 0.01) prolonged in DMD compared with controls (median, 132 min; range, 61-209 min versus 39 min; 22-55 min). The recovery index was also significantly prolonged in the DMD group compared with controls (median, 28 min, range, 15-70 min versus 8 min; 3-14 min).
Conclusions
The most striking and surprising result of this study is the delayed onset of blockade in DMD after a standard dose of rocuronium. This effect should be kept in mind in situations when a rapid airway protection is necessary in DMD patients. The documented very long recovery from rocuronium-induced block emphasizes the need for careful assessment of neuromuscular function in DMD patients.
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Affiliation(s)
- Stefanie Wick
- Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Schmidt J, Irouschek A, Muenster T, Hemmerling TM, Albrecht S. A priming technique accelerates onset of neuromuscular blockade at the laryngeal adductor muscles. Can J Anaesth 2005; 52:50-4. [PMID: 15625256 DOI: 10.1007/bf03018580] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [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: 12/19/2022] Open
Abstract
PURPOSE Priming is a known technique to accelerate onset of neuromuscular blockade (NMB). Its effect on NMB of the larynx has not been studied yet. METHODS We compared a priming technique with a bolus application of rocuronium on the onset of NMB at the laryngeal adductor and the adductor pollicis muscles (AP). In 30 female patients, after induction of anesthesia a tube with a surface electrode was placed into the trachea prior to the administration of any neuromuscular blocking agent to monitor electromyography (EMG) of the laryngeal adductor muscles. Neuromuscular monitoring consisted of EMG of the laryngeal adductor muscles and the left AP. Patients were randomized into two groups. After transcutaneous stimulation of the recurrent laryngeal nerve and ulnar nerve, a bolus of rocuronium 0.6 mg x kg(-1) (Bolus group) or a priming dose of rocuronium 0.06 mg x kg(-1) followed by rocuronium 0.54 mg x kg(-1) three minutes later (Priming group) were injected. Lag time, onset 90%, onset time and peak effect of NMB were recorded and compared; a P < 0.05 was considered significant. RESULTS The onset 90% and onset time measured at the laryngeal adductor muscles (onset: 44.7 +/- 7.4 vs 74.0 +/- 23.8 sec) and at the AP (onset: 105.4 +/- 29.9 vs 139.2 +/- 51.5 sec) were significantly shorter in the Priming group than in the Bolus group. Within groups, the onset times were significantly shorter at the laryngeal muscles in comparison to AP. CONCLUSION Our results indicate that a priming technique with rocuronium significantly accelerates the onset of NMB at the laryngeal adductor muscles. Our results further support the use of rocuronium as an alternative to succinylcholine for rapid sequence induction.
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Affiliation(s)
- Joachim Schmidt
- Department of Anesthesiology, University of Erlangen-Nuremberg, Krankenhausstr. 12, D-91054 Erlangen, Germany.
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