Blocking Drugs Research Articles

Topical Anti-ulcerogenic Effect of the Beta-adrenergic Blockers on Diabetic Foot Ulcers: Recent Advances and Future Prospectives.

Patients with diabetes suffer from major complications like Diabetic Retinopathy, Diabetic Coronary Artery Disease, and Diabetic Foot ulcers (DFUs). Diabetes complications are a group of ailments whose recovery time is especially delayed, irrespective of the underlying reason. The longer duration of wound healing enhances the probability of problems like sepsis and amputation. The delayed healing makes it more critical for research focus. By understanding the molecular pathogenesis of diabetic wounds, it is quite easy to target the molecules involved in the healing of wounds. Recent research on beta-adrenergic blocking drugs has revealed that these classes of drugs possess therapeutic potential in the healing of DFUs. However, because the order of events in defective healing is adequately defined, it is possible to recognize moieties that are currently in the market that are recognized to aim at one or several identified molecular processes. The aim of this study was to explore some molecules with different therapeutic categories that have demonstrated favorable effects in improving diabetic wound healing, also called the repurposing of drugs. Various databases like PubMed/Medline, Google Scholar and Web of Science (WoS) of all English language articles were searched, and relevant information was collected regarding the role of beta-adrenergic blockers in diabetic wounds or diabetic foot ulcers (DFUs) using the relevant keywords for the literature review. The potential beta-blocking agents and their mechanism of action in diabetic foot ulcers were studied, and it was found that these drugs have a profound effect on diabetic foot ulcer healing as per reported literatures. There is a need to move forward from preclinical studies to clinical studies to analyze clinical findings to determine the effectiveness and safety of some beta-antagonists in diabetic foot ulcer treatment.

Safety and efficacy of the Tao facemask for positive pressure ventilation in morbidly obese patients

Purpose: Positive-pressure mask ventilation is an essential skill for individuals providing basic and advanced airway interventions in a variety of clinical settings. The C-E grip technique is most commonly used with standard facemasks to provide an effective seal that allows for positive pressure ventilation. The Tao mask is a novel facemask that utilises an ergonomic grip by using downwards pressure of the palm of the hand accompanied by midline jaw lift. Specifically, the technique to create a seal involves downwards pressure of the palm centred on the mask accompanied by a jaw lift with four fingers centred under the mandible. A previous comparison between the Tao and standard masks revealed superior performance across a cross-section of average patients. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to the standard mask in a subset of patients with morbid obesity as defined by a body mass index (BMI) greater than or equal to 40 kg/m2. Methods: This prospective crossover trial included 156 patients aged ⩾18 years at the Medical University of South Carolina who were scheduled for elective surgery under general endotracheal anaesthesia with a BMI of ⩾40 kg/m2 at the time of surgery. After the induction of general anaesthesia, but prior to the administration of a neuromuscular blocking drug (NMBD), each patient was ventilated with both the standard and Tao masks, and effectiveness was measured using both the Han and Warters scales. The process was repeated after the administration of an NMBD. Results: Data were collected and analysed from 153 individuals. The mean BMI was 50.7 ± 9.3 kg/m2. The Tao mask ventilation scores were significantly lower (more effective) than the standard mask scores on both the Han and Warters Scales before pre-NMBD ( p = 0.0002 and p < 0.001, respectively) and after post-NMBD ( p = 0.002 and p < 0.001, respectively). On the Warters Scale, it was significantly easier to ventilate with the Tao Mask pre-NMBD ( p = 0.0001). On the Han Scale, the Tao mask was significantly easier than the standard mask post-NMBD ( p = 0.03). With regard to mask sequence, the mean Warters scores were lower for the Tao mask pre-NMBD only when the standard mask was used first ( p = 0.002). Similarly, the difference in the mean Warters scores post-NBMD was significant only when the standard mask was used first ( p = 0.02). Conclusion: The Tao mask demonstrated equivalent safety and superior effectiveness in ventilating morbidly obese surgical patients despite a trial design that favoured the standard mask owing to anaesthetist experience. The use of the Tao mask may be particularly beneficial in clinical situations involving inexperienced operators or in patients for whom mask ventilation is likely to be difficult. ClinicalTrials.gov registration number: NCT03473366

Organophosphate Poisoning: Review of Prognosis and Management.

The high annual mortality rate of organophosphorus (OP) poisoning indicates that the treatment is mostly ineffective in this regard. It has been suggested to add calcium channel blocking (CCB) drugs or magnesium sulfate (MgSO4) to normal care to decrease the release of acetylcholine (ACh) at the cholinergic synapse. Moreover, the diagnosis of OP poisoning is chiefly based on clinical evidence. Oximes and atropine are the recognized antidotes of OP. However, low-priced medications such as MgSO4 and sodium bicarbonate (NaHCO3), as well as novel adjunct therapies, have been introduced recently. Furthermore, antioxidants are recommended for managing OP poisoning. In addition, hemoperfusion, fresh frozen plasma (FFP), and K-oximes are a number of innovative management modalities that deserve further evaluation. However, prevention seems to be the most effective management modality in this respect. Therefore, this study aimed to briefly discuss the controversies in OP poisoning management and present recent advances in its management and prognosis. The results of this study revealed that multiple factors including type of exposure, acetylcholinesterase (AChE) plasma level, time of hospitalization, and severity confirming OP poisoning should be considered to provide the best treatment strategy.

A Strategy of Killing Two Birds With One Stone for Blocking Drug Resistance Spread With Engineered Bdellovibrio bacteriovorus.

Drug-resistant pathogens significantly threaten human health and life. Simply killing drug-resistant pathogens cannot effectively eliminate their threat since the drug-resistant genes (DRGs) released from dead drug-resistant pathogens are difficult to eliminate and can further spread via horizontal gene transfer, leading to the spread of drug resistance. The development of antibacterial materials with sterilization and DRGs cleavage activities is highly crucial. Herein, a living system, Ce-PEA@Bdello, is fabricated with bacterial killing and DRGs cleavage activities for blocking bacterial drug resistance dissemination by engineered Bdellovibrio bacteriovorus (Bdello). Ce-PEA@Bdello is obtained by engineering Bdello with dopamine and a multinuclear cerium (IV) complex. Ce-PEA@Bdello can penetrate and eliminate kanamycin-resistant P. aeruginosa (KanR) biofilms via the synergistic effect of predatory Bdello and photothermal polydopamine under near-infrared light. Additionally, the DNase-mimicking ability of Ce-PEA@Bdello endows it with genome and plasmid DNA cleavage ability. An in vivo study reveals that Ce-PEA@Bdello can eliminate P. aeruginosa (KanR) and cleave DRGs in scald/burn infected wounds to block the spread of drug resistance and accelerate wound healing. This bioactive system constructed from natural living materials offers a promising means for blocking the spread of drug resistance.

Evidences of neurological injury caused by COVID-19 from glioma tissues and glioma organoids.

Despite the extensive neurological symptoms induced by COVID-19 and the identification of SARS-CoV-2 in post-mortem brain samples from COVID-19 patients months after death, the precise mechanisms of SARS-CoV-2 invasion into the central nervous system remain unclear due to the lack of research models. We collected glioma tissue samples from glioma patients who had a recent history of COVID-19 and examined the presence of the SARS-CoV-2 spike protein. Subsequently, spatial transcriptomic analyses were conducted on normal brain tissues, glioma tissues, and glioma tissues from glioma patients with recent COVID-19 history. Additionally, single-cell sequencing data from both glioma tissues and glioma organoids were collected and analyzed. Glioma organoids were utilized to evaluate the efficacy of potential COVID-19 blocking agents. Glioma tissues from glioma patients with recent COVID-19 history exhibited the presence of the SARS-CoV-2 spike protein. Differences between glioma tissues from glioma patients who had a recent history of COVID-19 and healthy brain tissues primarily manifested in neuronal cells. Notably, neuronal cells within glioma tissues of COVID-19 history demonstrated heightened susceptibility to Alzheimer's disease, depression, and synaptic dysfunction, indicative of neuronal aberrations. Expressions of SARS-CoV-2 entry factors were confirmed in both glioma tissues and glioma organoids. Moreover, glioma organoids were susceptible to pseudo-SARS-CoV-2 infection and the infections could be partly blocked by the potential COVID-19 drugs. Gliomas had inherent traits that render them susceptible to SARS-CoV-2 infection, leading to their representability of COVID-19 neurological symptoms. This established a biological foundation for the rationality and feasibility of utilization of glioma organoids as research and blocking drug testing model in SARS-CoV-2 infection within the central nervous system.

The Influence of Acid-Base Balance on Anesthetic Muscle Relaxants: A Comprehensive Review on Clinical Applications and Mechanisms.

Muscle relaxants have broad application in anesthesiology. They can be used for safe intubation, preparing the patient for surgery, or improving mechanical ventilation. Muscle relaxants can be classified based on their mechanism of action into depolarizing and non-depolarizing muscle relaxants and centrally acting muscle relaxants. Non-depolarizing neuromuscular blocking drugs (NMBDs) (eg, tubocurarine, atracurium, pipecuronium, mivacurium, pancuronium, rocuronium, vecuronium) act as competitive antagonists of nicotine receptors. By doing so, these drugs hinder the depolarizing effect of acetylcholine, thereby eliminating the potential stimulation of muscle fibers. Depolarizing drugs like succinylcholine and decamethonium induce an initial activation (depolarization) of the receptor followed by a sustained and steady blockade. These drugs do not act as competitive antagonists; instead, they function as more enduring agonists compared to acetylcholine itself. Many factors can influence the duration of action of these drugs. Among them, electrolyte disturbances and disruptions in acid-base balance can have an impact. Acidosis increases the potency of non-depolarizing muscle relaxants, while alkalosis induces resistance to their effects. In depolarizing drugs, acidosis and alkalosis produce opposite effects. The results of studies on the impact of acid-base balance disturbances on non-depolarizing relaxants have been conflicting. This work is based on the available literature and the authors' experience. This article aimed to review the use of anesthetic muscle relaxants in patients with acid-base disturbances.

Effect of single-dose intravenous lignocaine versus fentanyl on neuromuscular recovery time after general anesthesia in elective pediatric surgery: A randomized controlled pilot study

Abstract Background and Aims: Intravenous (IV) lignocaine is often used to prevent the airway response to extubation, especially in children to prevent respiratory adverse events. It is known to prolong the duration of action of neuromuscular blocking drugs, but data in children are limited. The primary objective of this study was to compare neuromuscular recovery time with IV lignocaine versus fentanyl, in pediatric patients undergoing elective surgery under general anesthesia (GA). Secondary objectives included the comparison of clinical parameters and respiratory complications. Material and Methods: A randomized double-blind pilot study was conducted in 42 children aged 2–8 years undergoing GA with neuromuscular blockade, who received either 1.5 mg/kg of lignocaine or 0.5 mcg/kg of fentanyl IV, just prior to giving reversal at a train of four (TOF) count of 2–3. Time to achieve a TOF ratio of 0.9 and extubation and hemodynamic and respiratory parameters were noted. Incidences of coughing, bucking, laryngospasm, etc., were also noted. P value < 0.05 was considered significant. Results: Demographic and operative data were similar. Time from reversal to TOF ratio of 0.9 was similar with both lignocaine (6.79 ± 3.03 mins) and fentanyl (6.79 ± 3.31 mins), P = 0.99. Time to extubation was also similar in both groups (8.14 ± 3.31 vs 9.19 ± 2.89 min), P = 0.28. Bucking incidence was higher with fentanyl (23.8%) vs lignocaine (9.5%), P = 0.41. Conclusions: Single-dose IV lignocaine administered before reversal did not prolong neuromuscular recovery time compared to fentanyl, with a similar (low) incidence of respiratory events in pediatric patients.

Accuracy and Precision of Three Acceleromyographs, Three Electromyographs, and a Mechanomyograph Measuring the Train-of-four Ratio in the Absence of Neuromuscular Blocking Drugs.

The accuracy and precision of currently available, widely used acceleromyograph and electromyograph neuromuscular blockade monitors have not been well studied. In addition, the normalization of the train-of-four ratio from acceleromyography (train-of-four ratio [T4/T1] divided by the baseline train-of-four ratio) has not been validated in comparison to mechanomyography. Enrolled patients had surgery under general anesthesia with a supraglottic airway and without any neuromuscular blocking drugs. Three acceleromyograph monitors, three electromyograph monitors, and a mechanomyograph built in the authors' laboratory were tested. Most patients had an electromyograph and the mechanomyograph on one arm and a third monitor on the contralateral arm. Train-of-four ratios were collected every 12 to 20 s for the duration of the anesthetic. At least 1,000 train-of-four ratios were recorded for each device. Gauge repeatability and reproducibility analysis was performed. Twenty-eight patients were enrolled. In total, 9,498 train-of-four ratio measurements were collected. Since no neuromuscular blocking drugs were used, the expected train-of-four ratio was 1.0. All of the acceleromyograph monitors produced overshoot in the train-of-four ratio (estimated means, 1.10 to 1.13) and substantial variability (gauge SDs, 0.07 to 0.18). Normalization of the train-of-four ratio measured by acceleromyography improved the estimated mean for each device (0.97 to 1.0), but the variability was not improved (gauge SDs, 0.06 to 0.17). The electromyograph and the mechanomyograph monitors produced minimal overshoot (estimated means, 0.99 to 1.01) and substantially less variation (gauge SDs, 0.01 to 0.02). For electromyography and mechanomyography, 0.3% of all train-of-four ratios were outside of the range 0.9 to 1.1. For acceleromyography, 27 to 51% of normalized train-of-four ratios were outside the range of 0.9 to 1.1. Three currently available acceleromyograph monitors produced overshoot and substantial variability that could be clinically significant. Normalization corrected the overshoot in the average results but did not reduce the wide variability. Three electromyograph monitors measured the train-of-four ratio with minimal overshoot and variability, similar to a mechanomyograph.

Comparison of the Effects of Rocuronium Bromide and Cisatracurium Besylate on Intubating Conditions and Haemodynamic Response.

Background General anaesthesia (GA) is predominantly important for conducting tracheal intubation; it should be quick and precise, having a prudent performance. It is preferable to use a neuromuscular blocking drug, which ideally should be highly potent, with a rapid onset and a short duration clinical effect in order to prevent the development of hypoxia during laryngoscopy and tracheal intubation and also avoid any changes in haemodynamics caused by the release of histamine, ganglion block, and anti-muscarinic actions. Thenon-depolarizing muscle relaxants rocuronium and cisatracurium don't have any noticeable independent side effects when used within the recommended dosage levels. Aim The aim was to compare the clinical efficacy of rocuronium bromide and cisatracurium besylate with respect to their property as muscle relaxants in producing favourable intubating conditions and to assess their haemodynamic stability.The objectives of the study were to evaluate the onset of action and any undesirable effects. Methods Between the ages of 20 to 60 years, 60 patients of either gender, divided randomly into groups of 30 each, of American Society of Anesthesiologists(ASA) physical status classification I and II, were put for elective surgical procedures to be done under general anaesthesia. Patients were given 0.6 mg kg-1 IV of rocuronium in Group R and 0.15 mg kg-1 IV of cisatracurium in Group C. After injecting the muscle relaxants, parameters were measured 60, 90, 120, 150, 180, 240, and 300 seconds later. Result Demographical variables like age, gender, and ASA physical status of the two groups were analogous. Group R had good to excellent/favourable intubating conditions by 90 seconds, and Group C by 240 seconds with comparable haemodynamic stability. The onset of action was significantly faster in Group R (92 ± 7.61 seconds) than in Group C (188 ± 40.88 seconds). Conclusion Rocuronium produced favourable intubating conditions having good haemodynamic stability and a statistically significant (p < 0.00001) faster onset of action in comparison to cisatracurium.

Association between protein intake and muscle wasting in critically ill children: A prospective cohort study.

Survival from pediatric critical illness in high-income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness. A prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10. Thirty-four children (median age 6.65 [0.47-57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed-up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: -0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: -0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C-reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: -0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063). Our study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting.

GABA/baclofen stabilizes PD-L1 and enhances immunotherapy of breast cancer

The programmed death-ligand 1 (PD-L1) on the surface of tumor cells binds to the receptor programmed cell death protein 1 (PD-1) on effector T cells, thereby inhibiting the anti-tumor immune response. Immune checkpoint blockade (ICB) therapy targeting PD-1/PD-L1 has been approved for the treatment of human cancers with lasting clinical benefit. However, many cancer patients did not respond to anti-PD-1/PD-L1 antibody blocking therapy or drugs targeting PD-1/PD-L1. Recent studies have shown that the response to PD-1/PD-L1 blockade may be related to the PD-L1 abundance of tumor cells. Therefore, it is of crucial significance to find drugs to regulate the expression of PD-L1, which can provide new strategies to improve the response rate and efficacy of PD-1/PD-L1 blocking in cancer treatment. Here, we found that GABA and baclofen, upregulates the protein level of PD-L1 by reducing the mRNA and protein levels of STUB1, a E3 ubiquitin ligase, thereby decreasing the interaction between STUB1 and PD-L1, and ultimately stabilizing PD-L1. Notably, GABA and baclofen did not affect cell proliferation in vitro, while in the treatment of breast cancer in mice, the therapeutic effect of baclofen combined with anti-PD-L1 antibody is significantly better than that of using anti-PD-L1 antibody alone by stimulating tumor infiltration of CD8+ T cells and antitumor immunity. Taken together, we unveiled a previously unappreciated role of GABA/baclofen in stabilizing PD-L1 and enhancing the immunotherapy of breast cancer.

Autoantibody-Mediated Depletion of IL-1RA in Still’s Disease and Potential Impact of IL-1 Targeting Therapies

BackgroundAdult-onset Still’s disease (AOSD) and systemic juvenile idiopathic arthritis (sJIA) resemble a continuum of a rare, polygenic IL-1β-driven disease of unknown etiology.ObjectiveIn the present study we sought to investigate a potential role of recently described autoantibodies neutralizing the interleukin-1(IL-1)-receptor antagonist (IL-1-Ra) in the pathogenesis of Still’s disease.MethodsSerum or plasma samples from Still’s disease patients (AOSD, n = 23; sJIA, n = 40) and autoimmune and/or inflammatory disease controls (n = 478) were analyzed for autoantibodies against progranulin (PGRN), IL-1Ra, IL-18 binding protein (IL-18BP), and IL-36Ra, as well as circulating IL-1Ra and IL-36Ra levels by ELISA. Biochemical analyses of plasma IL-1Ra were performed by native Western blots and isoelectric focusing. Functional activity of the autoantibodies was examined by an in vitro IL-1β-signaling reporter assay.ResultsAnti-IL-1-Ra IgG were identified in 7 (27%) out of 29 Still’s disease patients, including 4/23 with AOSD and 3/6 with sJIA and coincided with a hyperphosphorylated isoform of endogenous IL-1Ra. Anti-IL-36Ra antibodies were found in 2 AOSD patients. No anti-PGRN or anti-IL-18BP antibodies were detected. Selective testing for anti-IL-1Ra antibodies in an independent cohort (sJIA, n = 34) identified 5 of 34 (14.7%) as seropositive. Collectively, 8/12 antibody-positive Still’s disease patients were either new-onset active disease or unresponsive to IL-1 blocking drugs. Autoantibody-seropositivity associated with decreased IL-1Ra plasma/serum levels. Seropositive plasma impaired in vitro IL-1Ra bioactivity, which could be reversed by anakinra or canakinumab treatment.ConclusionAutoantibodies neutralizing IL-1Ra may represent a novel patho-mechanism in a subgroup of Still’s disease patients, which is sensitive to high-dose IL-1 blocking therapy.

The effectiveness of prehospital rapid sequence intubation in critically ill patients

Background Tracheal intubation in critically sick patients presents a significant risk of complications attributable to variables such as respiratory failure, hemodynamic instability, and drug sensitivity. Present recommendations mostly depend on expert opinion and data from elective intubations, lacking substantial evidence from randomized controlled trials (RCTs) in critical care environments (ICU, ED, general wards). This systematic review sought to assess high-quality evidence-based methods for intubation in critically sick patients, concentrating on pharmacological agents, techniques, and equipment. Methods A thorough search of PubMed, BioMed Central, Embase, and the Cochrane Central Register of Clinical Trials found pertinent randomized controlled trials examining treatments aimed at enhancing the success rate and safety of tracheal intubation in critically sick patients. A meta-analysis was conducted when applicable. Results Intubation problems in critically sick patients vary from 4.2% to 39%. Pre-oxygenation by non-invasive ventilation (NIV) has shown enhanced effectiveness over conventional techniques in extending safe apnea duration and minimizing desaturation. Although high-flow nasal cannula (HFNC) enhanced comfort, its advantages for apneic oxygenation were restricted in this demographic. Etomidate and ketamine had equivalent safety and effectiveness as sedatives, whilst succinylcholine and rocuronium showed similar success rates as neuromuscular blocking drugs. The sniffing position outperformed the ramping position for laryngoscopy.

Simultaneous Modeling of In Vivo and In Vitro Effects of Nondepolarizing Neuromuscular Blocking Drugs

Simultaneous Modeling of In Vivo and In Vitro Effects of Nondepolarizing Neuromuscular Blocking Drugs

Tonabersat Significantly Reduces Disease Progression in an Experimental Mouse Model of Multiple Sclerosis.

Multiple sclerosis (MS) is a neurodegenerative disease marked by chronic neuroinflammation thought to be mediated by the inflammasome pathway. Connexin 43 (Cx43) hemichannels contribute to the activation of the inflammasome through the release of adenosine triphosphate (ATP) inflammasome activation signals. The objective of the study was to evaluate if the Cx43 hemichannel blocker, tonabersat, is effective in modulating the inflammatory response and reducing disability in the myelin oligodendrocyte glycoprotein 35-55-induced experimental autoimmune encephalomyelitis (MOG35-55 EAE) model of MS. Here, we show that the Cx43 hemichannel blocking drug, tonabersat, significantly reduced expression of neuroinflammatory markers for microglial activation (ionized calcium-binding adapter molecule 1 (Iba1)) and astrogliosis (glial fibrillary acidic protein (GFAP)) while preserving myelin basic protein (MBP) expression levels in the corpus callosum, motor cortex, and striatum regions of the brain in MOG35-55 EAE mice. Reduced NOD-like receptor protein 3 (NLRP3) inflammasome complex assembly and Caspase-1 activation confirmed the drug's mode of action. MOG35-55 EAE mice showed clinical signs of MS, but MOG35-55 EAE mice treated with tonabersat retained behavior closer to normal. These data suggest that clinical trial phase IIb-ready tonabersat may merit further investigation as a promising candidate for MS treatment.

Efficiency of face mask ventilation before and after neuromuscular blockade: A randomised, double-blind controlled study.

The traditional practice of administrating neuromuscular blocking drugs (NMBDs) after checking face mask ventilation is challenged repeatedly. This study compared the efficiency of face mask ventilation before and after administrating an NMBD in a patient with a normal airway. The secondary outcome measured was the grade of mask ventilation and tracheal intubating conditions. After ethical approval, patients (n = 120) in the age group of 18-65 years scheduled for elective surgery under general anaesthesia were randomly assigned into two groups. Group 1 received an NMBD before checking face mask ventilation. Group 2 received an NMBD after checking face mask ventilation. Lungs were ventilated for 180 s, during which expiratory tidal volume (Vte) was recorded as the primary outcome. Hans's grading for face mask ventilation was used to grade mask ventilation. The ease of intubation was assessed based on intubating conditions (ease of laryngoscopy, vocal cord movement, and limb movement). SPSS 20.0 software was used for statistical analysis. For a total of 180 seconds of mask ventilation, the mean (standard deviation) Vte measured after apnoea was significantly higher in Group 1 versus Group 2 [471.9 (63.3) vs 434.8 (77.0) mL/breath, P = 0.004]. The intubating condition was either excellent or good in all patients. The administration of NMBDs resulted in a larger mask Vte and shorter intubation time.

Case report: Invasive neuromonitoring in status epilepticus induced hypoxic ischemic brain injury

ObjectivesLiterature on invasive neuromonitoring and bilateral decompressive craniectomies (BDC) in patients with refractory status epilepticus (RSE)-mediated hypoxic-ischemic brain injury (HIBI) is limited. Neuromonitoring can guide decision making and treatment escalation.Methods and resultsWe report a case of a 17 years-old male who was admitted to our hospital’s intensive care unit for RSE. HIBI was detected on neuroimaging on this patient’s second day of admission after he developed central diabetes insipidus (DI). Invasive neuromonitoring revealed raised intracranial pressure (ICP) and brain hypoxia as measured by reduced brain tissue oxygen tension (PbtO2). Treatments were escalated in a tiered fashion, including administration of hyperosmolar agents, analgesics, sedatives, and a neuromuscular blocking drug. Eventually, BDC was performed as a salvage therapy as a means of controlling refractory ICP crisis in the setting of diffuse cerebral edema (DCE) following HIBI.DiscussionSE-mediated HIBI can result in refractory ICP crisis. Neuromonitoring can help identify secondary brain injury (SBI), guide treatment strategies, including surgical interventions, and may lead to better outcomes.

Bradycardic Arrest in a Child with Complex Congenital Heart Disease Due to Sugammadex Administration.

The neuromuscular blocking drugs rocuronium and vecuronium are often used during general anesthesia. These drugs temporarily paralyze the patient and thus both facilitate placement of an endotracheal tube and prevent any patient movement during surgery. Reversal of neuromuscular blockade is necessary at the end of surgery to avoid postoperative weakness and adverse respiratory events in the recovery room. Neostigmine, the traditional reversal agent, may not completely restore muscle strength. Sugammadex is a reversal agent that is more effective and quicker acting than neostigmine. In adults, sugammadex administration has rarely been associated with bradycardia and cardiac arrest. In healthy children, the bradycardia that occurs after sugammadex administration is benign and does not require intervention. There is 1 case report of a 10- to 15-second bradycardic arrest after sugammadex administration to a 10-year-old child with heart disease. The present case report describes an 8-month-old child with complex congenital heart disease who experienced a 10-minute bradycardic arrest after the administration of sugammadex. Pediatric anesthesiologists should be aware that sugammadex administration to children with heart disease may cause hemodynamically significant bradycardia.

Comparison of Onset of Action, Intubating Conditions, and Recovery Characteristics of Rocuronium and Cisatracurium In Patients Undergoing Abdominal Surgery under General Anesthesia: A Prospective Randomized Control Trial

Background: Neuromuscular blocking drugs (NMBD) have paved the way for the conduct of every known surgical procedure. However, the hunt for optimum NMD with appropriate intubating circumstances is continuous. Rocuronium and cisatracurium are amongst the newer NMBDs. We aim to compare the onset of action, intubating conditions, duration of action, and recovery features in a dose twice the ED95 in patients having abdominal surgery.&#x0D; Methods: A total 60 American Society of Anesthesiology (ASA) I and II adult patients were randomized equally into Group A and Group B. Group A received Inj. Rocuronium 0.6 mg/kg and Group B received Inj. Cisatracurium 0.10 mg/kg. We assessed the intubating conditions after ensuring jaw relaxation using both the clinical criteria and neuromuscular monitoring whereas onset time, duration of action and recovery time were assessed using neuromuscular monitoring only.&#x0D; Results: In Group A, a significant rapid onset of action of muscle relaxant was seen compared to Group B (2.4±0.30 mins versus 4.0±0.09 mins, p= 0.00). 93% patients had excellent intubating conditions in Group A compared to 73% patients in Group B (p= 0.038). The duration of action in Group A was 36.73±1.05 mins and in Group B was 47.40 ±1.33mins (p=0.00). Similarly, early mean duration of recovery was found in Group A-45.30±1.29mins versus Group B -57.77±1.19 mins, p= 0.00).&#x0D; Conclusion: Rocuronium provides rapid onset of action with excellent intubating conditions, and shorter duration of action with an early recovery time compared to cisatracurium.

Response of the GE Entropy™ monitor to neuromuscular block in awake volunteers

BackgroundThe GE Entropy™ monitor analyses the frontal electroencephalogram (EEG) and generates two indices intended to represent the degree of anaesthetic drug effect on the brain. It is frequently used in the context of neuromuscular block. We have shown that a similar device, the Bispectral Index monitor (BIS), does not generate correct values in awake volunteers when neuromuscular blocking drugs are administered. MethodsWe replayed the EEGs recorded during awake paralysis from the original study to an Entropy monitor via a calibrated electronic playback system. Each EEG was replayed 30 times to evaluate the consistency of the Entropy output. ResultsBoth State Entropy and Response Entropy decreased during periods of neuromuscular block to values consistent with anaesthesia, despite there being no change in conscious state (State Entropy <60 in eight of nine rocuronium trials and nine of 10 suxamethonium trials). Entropy values did not return to pre-test levels until after the return of movement. Entropy did not generate exactly the same results when the same EEG was replayed multiple times, which is primarily because of a cyclical state within the Entropy system itself. ConclusionsThe GE Entropy™ monitor requires muscle activity to generate correct values in an awake subject. It could therefore be unreliable at detecting awareness in patients who have been given neuromuscular blocking drugs. In addition, Entropy does not generate the same result each time it is presented with the same EEG.