Neuromuscular Blockade Research Articles

A real-world pharmacovigilance study of cardiac adverse events induced by sugammadex in the FDA adverse event reporting system

ABSTRACT Background Sugammadex is a novel agent that reverses neuromuscular blockade during general anesthesia. Recent case reports have raised concerns regarding potential cardiac adverse events (CAEs). However, no large-scale real-world studies have yet evaluated the potential link between sugammadex and CAEs. Research design and methods Data from the FDA Adverse Event Reporting System were obtained. The association between sugammadex and CAE was evaluated using reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and multi-item gamma Poisson shrinker methods. Serious outcomes resulting from sugammadex-related CAEs were assessed, and complications associated with CAEs were evaluated. Results Nineteen CAEs were identified and classified into two categories: cardiac arrhythmias and coronary artery disorders. The most frequent CAEs were bradycardia (n = 202), cardiac arrest (n = 119), tachycardia (n = 30), and Kounis syndrome (n = 22). Subgroup analysis based on age, sex, and weight revealed parallel findings. The CAEs most likely to result in serious consequences were pulseless electrical activity and cardiac arrest. The most common concurrent adverse effects with CAEs were hypotension (n = 51), anaphylactic reactions (n = 46), and anaphylactic shock (n = 23). Conclusion This study suggests a potential link between sugammadex and CAEs, highlighting the need for careful monitoring and personalized risk assessment, especially in patients with cardiovascular risk factors.

FORMULATION OPTIMIZATION AND CHARACTERIZATION OF NEWSTABLE READY TO USE (RTU) INJECTABLE FORMULATION OF ROCURONIUM BROMIDE

Commercially available injectable Rocuronium Bromide, a non-depolarizing neuromuscular blocker intended to store in a refrigerator at 2-8°C, requires an additional storage facility. The primary objectives of the present research were to design a stable, Ready to use (RTU) formulation of Rocuronium Bromide (RCB) Injection for Intravenous (IV) administration for storage at room temperature. Beta cyclodextrin (BCD) forms inclusion complexes with RCB. Edetate Disodium (EDTA) helps in achieving within the specification limit of Impurity C (Imp. C), a major metabolite of rocuronium bromide and Assay. Other excipients were selected to achieve a stable injectable formulation and cause less pain at the injection site. The formulation was optimized by Design of experiments (DoE) applying Central Composite Design (CCD) using Design Expert software and established design space where the formulation meets the desired acceptance criteria. The obtained optimized formulation can be terminally sterilized by moist heat and evaluated for thermal stability and robustness. The robustness of the formulation was established through Temperature excursion studies, pH sensitivity, and Oxygen sensitivity studies. Shelf life was estimated for 19 months when stored at 22°C which is an improvement to the currently available brands with 2-8°C storage. The formulation does not contain acetate buffer, which was identified as the root cause of the pain at the vascular site and may cause less vascular pain at the injection site. The current research work is encouraging in a positive way to achieve the objective of stable Rocuronium bromide injection at ambient conditions to enhance patient compliance.

Dental and anesthesiology problems in nicotine dependents (literature review)

Nowadays, smoking is one of the significant factors for the development of inflammatory periodontal diseases. The effect of nicotine on the microcirculation is manifested in the deterioration of the trophic level of the gums and a decrease in their resistance to infection. Atrophy of acinar parts of small salivary glands develops and other morphological changes characteristic of progressive sialadenitis occur. A change in the microflora of the oral cavity was found depending on the duration of smoking. Epithelial dysplasia, which covers the entire thickness of the epithelium, but does not affect the connective tissue, is called carcinoma. Worldwide, more than 300 million people use smokeless tobacco. Malignant changes at the site of precancerous diseases occur after a couple of years of using the product. In smokers, nicotine blocks H-cholinergic receptors and reduces sensitivity to local anesthetics. Nicotine promotes the production of the CYP2E1 enzyme, which is responsible for the metabolism of halogen anesthetics: halothane, enflurane, diethyl ether, trichlorethylene, chloroform, isoflurane and methoxyflurane. Chronic smokers show reduced pain tolerance. Before morphine loading, the assessment of pain threshold in nicotine-dependent individuals was significantly lower than in non-smokers. Smokers require higher doses of opiates and benzodiazepines than nonsmokers. Smoking reduces the potency of aminosteroid muscle relaxants, the required doses of vecuronium and rocuronium in smokers were 25 % higher than in patients leading a healthy lifestyle. Smokers also need more frequent doses to maintain neuromuscular block. Quitting smoking 4–6 weeks (ideally 8 weeks) before general anesthesia reduces the frequency of peri- and postoperative complications.

Dexamethasone as a perineural adjuvant to a ropivacaine popliteal sciatic nerve block for pediatric foot surgery: a randomized, double-blind, placebo-controlled trial

BackgroundThis study assessed the effect of perineural dexamethasone on block duration, opioid requirement, blood glucose levels, and stress response to surgery as measured by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte...

Effect of high-flow nasal and buccal oxygenation on safe apnea time in children with open mouth: A randomized controlled trial.

High-flow nasal oxygenation is reported to prolong duration of apnea while maintaining adequate oxygen saturation with the mouth closed. Also, buccal oxygenation is known to have similar effects in obese adults. We compared the effect of these two methods on prolongation of acceptable apnea time in pediatric patients with their mouth open. Thirty-eight patients, aged 0-10 years were randomly allocated to either the high-flow nasal oxygenation group (n = 17) or the buccal oxygenation group (n = 21). After induction of anesthesia including neuromuscular blockade, manual ventilation was initiated until the expiratory oxygen concentration reached 90%. Subsequently, ventilation was paused, and the patient's head was extended, and mouth was opened. The HFNO group received 2 L·min-1·kg-1 of oxygen, and the BO group received 0.5 L·min-1·kg-1 of oxygen. We set a target apnea time according to previous literature. When the apnea time reached the target, we defined the case as "success" in prolongation of safe apnea time and resumed ventilation. When the pulse oximetry decreased to 92% before the target apnea time, it was recorded as "failure" and rescue ventilation was given. The success rate of safe apnea prolongation was 100% in the high-flow nasal oxygenation group compared to 76% in the buccal oxygenation group (p = .04). Oxygen reserve index, end-tidal or transcutaneous carbon dioxide partial pressure, and pulse oximetry did not differ between groups. High-flow nasal oxygenation is effective in maintaining appropriate arterial oxygen saturation during apnea even in children with their mouth open and is superior to buccal oxygenation. Buccal oxygenation may be a good alternative when high-flow nasal oxygenation is not available.

Mobility Levels of Critically Ill Adult Patients and Extubation Success: A Cohort Study.

Background: The reduced mobility in critically ill patients is still a reality in many intensive care units. This study aims to investigate if mobility level is associated with extubation outcome in adult patients.Methods: Prospective cohort study which comprised adults who had undergone initial invasive mechanical ventilation for more than 24 hours and were independently mobile before hospitalization. Patient progress was monitored from ICU admission to discharge. Data were collected daily from medical records and multidisciplinary teams, considering variables such as age, sex, BMI, SAPS III score, type of ICU admission, comorbidities, sedation, usage of vasoactive drugs, neuromuscular blockers, duration of mechanical ventilation, and ICU mobility scale (IMS). The primary outcome was the success of extubation.Results: IMS values did not directly associate with extubation outcome. Older patients demonstrated a reduced tendency for high IMS values, as did those on prolonged usage of vasoactive drugs or mechanical ventilation. Patients with higher IMS values achieved successful extubation earlier, suggesting a link between mobility and faster extubation success.Conclusion: The level of mobility assessed 24 hours after extubation was not associated with extubation success. The following characteristics were associated with a lower propensity to present high IMS: older age, greater number of days of use of vasoactive drugs and mechanical ventilation. Patients with higher levels of mobility had a successful extubation event earlier in the ICU. Studies that assess mobility on a continuous basis would be more precise in identifying this association.

Evaluation and Prevention of Perioperative Respiratory Failure.

Respiratory failure is a common perioperative complication. The risk of respiratory failure can be reduced with effective preoperative evaluation, preventative measures, and knowledge of evidence-based management techniques. Effective preoperative screening methods include ARISCAT scoring, OSA screening, and the LAS VEGAS score (including the ASA physical status score). Evaluation by the six-minute walk test and a routine pulmonary physical exam has been shown to be effective at predicting postoperative pulmonary complications, whereas evidence on the predictive power of pulmonary function tests and chest radiography has been inconclusive. Preoperative smoking cessation and lung expansion maneuvers have been shown to decrease the risk of pulmonary complications postoperatively. Intraoperative management techniques that decrease the pulmonary complication risk include neuromuscular blockade reversal with sugammadex, limiting surgical times to less than 3 h when possible, lung-protective ventilation techniques, and multimodal analgesia to decrease opioid usage. In the immediate postoperative period, providers should be prepared to quickly treat bronchospasm, hypoventilation, and upper airway obstruction. For post-surgical patients who remain in the hospital, the risk of pulmonary complications can be decreased with lung expansion techniques, adequate analgesia, automated continuous postoperative ward monitoring, non-invasive ventilatory support, and early mobilization. This article was written to analyze the available literature on this topic in order to learn and practice the prevention of perioperative respiratory failure when caring for patients on a daily basis.

Prilocaine vs bupivacaine in spinal anesthesia for urologic endoscopy: clinical trials & historical overview

Introduction. In the evolving landscape of anesthetic practices for short-duration urologic procedures, the quest for an anesthetic agent that balances efficacy with minimal side effects remains a significant clinical challenge.The objective was to compare the efficacy and safety of 2% hyperbaric prilocaine and 0.5% hyperbaric bupivacaine in spinal anesthesia.Materials and methods. A comparative analysis was performed in terms of onset and duration of sensory and motor block, incidence of side effects (hypotension and bradycardia), and overall patient outcomes in urologic endoscopy. The research sample was divided into two groups, each consisting of 20 patients. In one case, spinal anesthesia was performed using 2% hyperbaric prilocaine (40 mg) + fentanyl 25 mcg, in the other – 0.5% hyperbaric bupivacaine (10 mg) + fentanyl 25 mcg.Results. Prilocaine offers a faster onset of sensory and motor block and a shorter duration of sensory block compared to bupivacaine. Prilocaine also showed a quicker recovery of full motor function and had a significantly lower incidence of side effects such as hypotension and bradycardia.Conclusion. These results suggest that 2% hyperbaric prilocaine could be an alternative to 0.5% hyperbaric bupivacaine in spinal anesthesia for urologic endoscopy, especially in procedures requiring quick recovery. The promising results of prilocaine in such short-duration surgeries can also prompt a reevaluation of anesthesia protocols across various surgical interventions and lead to enhanced patient outcomes, emphasizing safety, comfort, and efficacy of surgical care.

The effect of the application of adductor and Infiltration of local anesthetic between the popliteal artery and capsule of the knee (IPACK) block to patients on postoperative recovery and sleep quality following total knee arthroplasty: a randomized, controlled study

Aim: The adductor canal block (ACB) and IPACK (Infiltration of local anesthetic between the popliteal artery and capsule of the knee) block are motor protective blocks that provide effective analgesia and allow early ambulation. The aim of this study was to investigate the effect on postoperative recovery and sleep quality of patients applied with ACB and IPACK for total knee arthroplasty (TKA). Material and Method: This prospective, double-blinded, randomized, controlled study included 80 patients who underwent unilateral TKA under spinal anesthesia. The patients were separated as those applied with ACB+IPACK (Group ACB+IPACK, n=40) and a control group (Group C, n=40). The primary outcome was the postoperative first-day quality of recovery scale (QoR-15). Secondary outcomes were postoperative first and second-day Timed-Up-and-Go (TUG) test and range of motion (ROM), the total amount of rescue opioid drugs required, pain scales at different time points in the first 48 hours postoperatively, sleep evaluation on the postoperative and 6 following nights, and evaluation of sleep quality for 1 month using the Pittsburgh Sleep Quality Index (PSQI). Results: The QoR on postoperative days 1 and 7 were better in the ACB+ IPACK group than in the control group (p= 0.001, p= 0.002, respectively). On postoperative days 1 and 2, the TUG (p= 0.035, p= 0.019, respectively) and ROM (p=0.003, p=0.000) values were higher in the ACB+ IPCAK group. Postoperative opioid consumption was lower in the ACB+IPACK group (p= 0.012). The PSQI values at 1 month postoperatively were similar in both groups (p =0.095). Conclusion: The study results demonstrated that ACB+IPACK applied with ultrasound for TKA postoperative analgesia provided effective analgesia, higher QoR and physical performance, and reduced postoperative opioid consumption. However, there was no effect on postoperative sleep quality.

Intubating Laryngeal Mask Airway for Airway Management and Blind Tracheal Intubation Through It From 360° Around a Supine Patient: A Randomized Controlled Clinical Study in a Simulated Prehospital Emergency Scenario.

Introduction In emergency situations, airway management is often given priority over other treatment methods. The preferred technique for airway management of unconscious patients is endotracheal intubation, which has become the standard of care. Intubation of the trachea not only enables controlled ventilation even for extended periods and in any position but also allows for the removal of tracheal secretions. Supraglottic airways have several advantages over endotracheal intubation, including faster insertion,less need for neuromuscular blockade, and less hemodynamic instability. They can also be used as a bridge to intubation or as a rescue device when intubation fails or is contraindicated. The aim of this randomized controlled clinical study is to simulate a prehospital emergency/disaster scenario to evaluate and study the feasibility and effectiveness of the use of intubating laryngeal mask airway (ILMA) for onsite airway management from 360 degrees around the patient's head as in such situations, there may be limited or no access behind the head of the victim. Such a scenario can be extrapolated to disaster conditions where the victims may be trapped under the rubble following a building collapse /earthquake or are trapped in a vehicular road traffic/ train accident. It may take substantial time for extrication and evacuation of such patients to a hospital and hence it may be life-saving to provide prompt and early onsite airway management from wherever access is possible around the victim. We believe that the provision of a steel handle integrated with the airway tube may provide an opportunity for successful insertion of the device from 360 degrees around the patient merely by suitably changing the way the handle is gripped, so as to allow a single-handed smooth arc-like movement of the device for insertion, irrespective of the position of the rescuer relative to the patient's head. Objectives Our objective is to study the ease and time of insertion of ILMA, the number of attempts for successful ILMA insertion, and oropharyngeal leak pressure attained from unconventional positions in a supine patient. Materials and methods This prospective, randomized, observer-blinded controlled trial included 90 patients undergoing elective surgery under general anesthesia. Patients were randomized using a chit and box system for group allocation. Groups were as follows: Group 1 (n=30) - Investigator standing on the back of the head of the patient (0°); Group 2 (n=30) - Investigator standing on the left side facing the patient (120°); Group 3 (n=30) - Investigator standing on the right side facing the patient (240°). Then ease and time of insertion of ILMA, number of attempts for successful ILMA insertion and oropharyngeal leak pressure were noted, and intergroup comparison was done. Conclusion ILMA has proved to be an effective ventilatory device and a suitable conduit for intubation in patients lying in the supine position from a conventional standard position standing behind the head of the patient, as well as non-conventional position, facing the patient at 120° or 240° from the standard position.

Epidural Anesthesia Management for Unilateral Salpingo-Oophorectomy in Patients with Ovarian Mass : A Case Report

with sedation and mainly used in elderly patients or those with medical problems, including those who had ovarian mass. Epidural administration of amide local anesthetics in combination with opioids is widely used for pain relief because of the dose minimizing and side effects reducing benefits. Case: Patient was diagnosed with ovarian mass. The patient also had pleural effusion, ascites, and hypoalbuminemia. Epidural anesthesia used in this patient as a resource for perioperative and postoperative pain management. Discussion: Patient underwent unilateral salpingo-oophorectomy for her ovarian mass. Anesthetic doses were given carefully due to patient conditions with pleural effusion and ascites. Opioid and Neuromuscular Blocking Agents (NMBAs) effects were absolutely decreased due to hypoalbuminemia, but were overcome with Naloxone and Sugammadex. Epidural anesthesia used to stabilize the drugs and pain management for this patient. Conclusion: Epidural anesthesia is an excellent choice for unilateral salpingo-oophorectomy in patients with ovarian mass. It has been proven to provide excellent pain control after major surgeries and may be associated with a lower incidence of postoperative complications.

Effects of neuromuscular block reversal with neostigmine/glycopyrrolate versus sugammadex on bowel motility recovery after laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveTo compare the effects of neostigmine/glycopyrrolate (a traditional agent) and sugammadex on bowel motility recovery and the occurrence of digestive system complications after colorectal surgery. DesignProspective, randomized controlled trial. SettingA single tertiary center. Patients111 patients undergoing laparoscopic colorectal surgery. InterventionsPatients were randomized into two groups based on the block reversal agent: 1) a mixture of 50 μg.kg−1 of neostigmine and 10 μg.kg-1 of glycopyrrolate (neostigmine group) and 2) 2 mg.kg−1 of sugammadex (sugammadex group). MeasurementsThe primary outcome was the time from the surgery's completion to the first flatus.The time to the first postoperative defecation, incidences of postoperative nausea or vomiting, ileus, and dry mouth, as well as postoperative length of stay, were also assessed. Main resultsThe time to the first flatus was significantly shorter in the sugammadex group than in the neostigmine group (59 [42–79] h vs 69 [53–90] h, P = 0.027). The time to the first defecation and the incidences of postoperative nausea or vomiting and ileus did not differ between the groups, nor did the postoperative length of stay. However, the incidence of postoperative dry mouth was significantly lower in the sugammadex group than in the neostigmine group (7 patients [13%] vs 39 patients [71%], P < 0.001). ConclusionsThe time to the first flatus was shorter using 2 mg.kg−1 sugammadex to reverse the neuromuscular block for laparoscopic colorectal surgery compared to reversal with conventional neostigmine/glycopyrrolate.

A Comparative Study of Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia in Major Lower Limb Orthopedic Surgeries.

Background Neuraxial blockade includes epidural and spinal anesthesia (SA) that have gained wide acceptance for major lower limb orthopedic surgery. Both techniques are competent in rendering surgical anesthesia and pain relief, with specific advantages and disadvantages. SA has the merits of rapid onset and adequate anesthesia with a small volume of the drug but has significant hypotension and unpredictable duration. Epidural anesthesia allows for finer control over analgesia and the duration of anesthesia but requires more substantial volumes of drugs and is slower in onset. Combined spinal-epidural anesthesia (CSEA) combines the rapid commencement of action of SA with flexibility in epidural anesthesia, thus optimizing the management of the intraoperative and postoperative phases. This study aims to evaluate hemodynamic changes, compare the severity and duration of sensory and motor block, and track any problems related to CSEA and SA in major lower limb orthopedic procedures. Additionally, this study contrasts the hemodynamic, motor, and sensory changes in the two groups. Methodology A total of 30 individuals were randomized to one of two groups in this prospective comparative trial, which included 60 patients receiving major lower limb orthopedic surgery and meeting the American Society of Anesthesiologists physical status I-II criteria. Group A received CSEA, and Group B received SA. The degree and duration of sensory and motor blockade, hemodynamic changes, and complications were all recorded. A p-value of less than 0.05 was used to evaluate statistical significance using Student's t-test and chi-square test. Results The onset of sensory block in our study was earlier in Group B compared to Group A. In both groups, hemodynamic stability was maintained throughout the study. We recorded the onset/duration of sensory and motor block and hemodynamic changes and took mean values to find any significant difference. Postoperative complications and rescue analgesic requirements were monitored and managed and were a part of our study. Conclusions This study compared CSEA and SA regarding the severity and duration of sensory and motor block, hemodynamic stability, and associated complications in major lower limb orthopedic surgeries. The results shed light on the advantages and shortcomings of each anesthesia technique and, therefore, will help choose the correct method of anesthesia in a given surgery.

Nociception level index variations in ICU: curarized vs non-curarized patients — a pilot study

PurposePain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring.MethodsThis retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients.ResultsNOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent’s infusion, only NOL properly identified nociception. In the former group, EEG’s relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL.ConclusionNOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them.

Ultrasound guided supraclavicular block versus combined infraclavicular and Suprascapular block: A randomized controlled trial

The infraclavicular block (ICB) can avoid some of the side effects of the supraclavicular block (SCB) like hemi-diaphragmatic palsy. This study aimed to analyze the comparative efficacy of supraclavicular block versus combined infraclavicular block and suprascapular block.Patients undergoing upper limb surgery under general anaesthesia were randomized into group S (to receive supraclavicular brachial plexus block) and group I (to receive infraclavicular brachial plexus block and suprascapular nerve block). Onset times and the duration of both sensory and motor block was noted in both the groups. Postoperative pain as assessed by NRS score and total fentanyl requirement was noted for 24 hours. : The group S showed a significantly faster onset of both sensory (8.47±3.12) vs. 13.75±4.69; p&amp;#60;0.001) and motor blocks (15.56±5.32 vs. 24.17±5.67; p&amp;#60;0.001). The duration of sensory block was significantly greater in the group I, with no significant difference in the duration of motor block.We also noted hemi diaphragmatic paresis (27.8%) and paralysis (8.3%) only in the SCB group.For the patients undergoing upper limb surgeries, the use of ICB+SSB block as compared to the SCB block resulted in increased duration of sensory block; however, the fentanyl consumption was not significantly reduced.

Comparative study of different doses of intrathecal clonidine as an adjuvant to bupivacaine for lower limb surgeries: A prospective observational study

Clinical studies suggested that intrathecal clonidine as an adjuvant to hyperbaric bupivacaine prolongs sensory as well as the motor block of spinal anesthesia, decreases local anesthetic drug requirement, and provides postoperative analgesia.In the present study, we have examined the effects of two distinct clonidine dosages administered intrathecally as an adjuvant to hyperbaric bupivacaine in individuals undergoing elective lower limb operations, to find out the optimal dose among them. Two groups of thirty patients each posted for lower limb surgery were included in this study. Patients in Group A Received inj. bupivacaine (hyperbaric) 0.5% 3ml (15 mg) + inj. clonidine 0.2 ml (30 µg) + normal saline 0.1 ml intrathecally, in Group B patients received inj. bupivacaine (hyperbaric) 0.5% 3ml (15 mg) + inj.clonidine 0.3 ml (45 µg) intrathecally.Throughout spinal anesthesia; both groups were prospectively observed for various parameters.Compared to patients in group A, patients in group B experienced sensory and motor block for longer durations of time. As compared to group A patients, group B patients experienced increased hypotension, bradycardia, and dry mouth; however, overall adverse effects are mild and easily treated. In addition, we observed that group B patients experienced analgesia for a longer duration of time than did Group A patients. Addition of intrathecal clonidine to bupivacaine significantly hastens the onset of sensory and motor block, provides excellent surgical analgesia, prolongs the duration of superior quality postoperative analgesia and reduced postoperative analgesic requirements with relative hemodynamic stability.

A sensitive tobramycin electrochemical aptasensor based on multiple signal amplification cascades

The residue of tobramycin, a broad spectrum antibiotic commonly used in animal husbandry, has evitable impact on human health, which may cause kidney damage, respiratory paralysis, neuromuscular blockade and cross-allergy in humans. Sensitive monitoring of tobramycin in animal-derived food products is therefore of great importance. Herein, a new aptamer electrochemical biosensor for sensing tobramycin with high sensitivity is demonstrated via exonuclease III (Exo III) and metal ion-dependent DNAzyme recycling and hybridization chain reaction (HCR) signal amplification cascades. Tobramycin analyte binds aptamer-containing hairpin probe to switch its conformation to expose the toehold sequence, which triggers Exo III-based catalytic digestion of the secondary hairpin to release many DNAzyme strands. The substrate hairpins immobilized on the Au electrode (AuE) are then cyclically cleaved by the DNAzymes to form ssDNAs, which further initiate HCR formation of lots of long methylene blue (MB)-tagged dsDNA polymers on the AuE. Subsequently electro-oxidation of these MB labels thus exhibit highly enhanced currents for sensing tobramycin within the 5–1000 nM concentration range with an impressive detection limit of 3.51 nM. Furthermore, this strategy has high selectivity for detecting tobramycin in milk and shows promising potential for detect other antibiotics for food safety monitoring.

Parasacral ischial plane block for lower limb surgeries: A case series

The para-sacral ischial plane block (PIP block) is a novel fascial plane approach targeting the sacral plexus. This technique simplifies the process as direct visualization of the sacral plexus or sciatic nerve is unnecessary. This retrospective case series includes ten patients with American Society of Anesthesiologists (ASA) physical status II-IV, aged over 18 years, undergoing elective or emergency lower limb surgeries such as debridement and below-knee amputation between May 2023 and November 2023. The block was performed in ≤ 6 minutes for all patients. Onset of subjective analgesia was almost immediate in those presenting with pain. Sensory loss occurred within 9 to 12 minutes. Motor block in the sciatic nerve distribution did not reach Grade 2 in any patient. Hemodynamic stability was notably maintained in all high-risk cases. Intraoperative supplementation with ketamine was required for one patient. The PIP block is a quick, easy-to-perform technique that offers satisfactory surgical conditions and hemodynamic stability in high-risk patients undergoing lower limb surgeries. It also provides prolonged postoperative analgesia and early resumption of oral intake with minimal procedural discomfort.

Utilizing calcium gluconate with low dose neostigmine to enhance neuromuscular recovery from non-depolarizing blockade: A prospective randomized control study

Ionized calcium has a pivotal role to play in neuromuscular transmission. Co-administration of calcium gluconate may allow for tapering the dose of neostigmine used for neuromuscular reversal, thus minimizing adverse effects associated with it while also reducing the chances of residual neuromuscular blockade (NMB). This study aimed to assess the effectiveness of calcium gluconate upon co-administration with neostigmine in enhancing rate of neuromuscular recovery and reducing the incidence of postoperative residual curarization.: This parallel group, double-blind randomized controlled study was conducted on 60 patients undergoing surgery at a tertiary care center. Patients in Group CN received 5 mg kg of 10% calcium gluconate with neostigmine while Group N received 5 ml 0.9% saline with neostigmine for reversal of NMB. Time from neostigmine administration to achieving a TOF ratio of ≥0.9 was taken as the primary outcome. Additional neostigmine requirement and symptoms of residual neuromuscular blockade (RNMB) in the post-anesthesia care unit (PACU) were considered as secondary outcomes.A significant difference was found in the meantime taken to achieve TOF ratio ≥0.9 after giving reversal, taking 5.43 ±2.12 mins in Group CN and 8.49 ±4.72 mins in Group N (p = 0.001). Although in Group N, 13.33% patients showed signs of RNMB in PACU versus 3.33% patients in Group CN. This difference was not found to be clinically significant (p=0.081). The findings of our study suggest that the administration of exogenous calcium may improve neuromuscular transmission even in normocalcemic patients. In conclusion, co-administration of calcium gluconate with low dose neostigmine helps in reducing neuromuscular recovery time in the early period of NMB reversal without incurring any significant disadvantages of administering higher doses of neostigmine.

Analgesic efficacy of ultrasound-guided bilateral sphenopalatine ganglion block as a sole analgesic in fess surgeries and reconstructive nasal surgeries

: Severe postoperative pain is the most common complaint following Functional endoscopic sinus surgeries (FESS) and reconstructive nasal surgeries. Sensory, autonomic nerves supplying paranasal sinuses, nasal cavity, and palate relay in sphenopalatine ganglion. Bilateral Sphenopalatine ganglion block can be an effective regional anaesthetic technique for post-operative analgesia. We conducted a study with ultrasound-guided bilateral sphenopalatine ganglion block as the sole analgesic compared to Fentanyl in patients undergoing FESS &amp; reconstructive nasal surgeries performed under general anaesthesia. The primary objective of our study was to assess the analgesic effect, quality, and duration of analgesia of ultrasound guided bilateral sphenopalatine ganglion block as a sole analgesic. In addition, the secondary aim was to further evaluate the adverse effects.With Institutional ethical committee approval and written informed consent, we conducted this study with two groups of 30 patients each. The surgical procedure was performed under general anaesthesia. At the end of the surgery and before the reversal of neuromuscular blockade, bilateral sphenopalatine plexus block was performed under ultrasound guidance in interventional Group (A) with a mixture of 0.25% Ropivacaine, Dexamethasone 4mg 7.5ml each side, whereas the control Group (B) received fentanyl 2ug/kg intraoperatively. Visual analogue scale (VAS) scores were evaluated soon after extubating (0hrs) and up to 48 hrs postoperatively in all patients.There was no significant difference in VAS scores at 0hrs, 2hrs between both groups. Interventional group(A) had statistically significant lower scores (P &amp;#60;0.00) 4hrs onwards till 48hrs than in control group(B). No adverse events were noted with minimal postoperative analgesic requirement in group(A) (P &amp;#60;0.000).: We conclude, that ultrasound-guided bilateral sphenopalatine block is a safe and effective procedure that provides sustained and superior quality of analgesia when compared to fentanyl