Neuromuscular Blockade Research Articles

Association of Intravenous Neostigmine and Anticholinergics or Sugammadex with Postoperative Delirium: A Retrospective Cohort Study.

Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine. We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery. Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium (P = .637) or postoperative early delirium (P = .904). Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.

Unraveling the molecular dynamics of sugammadex-rocuronium complexation: A blueprint for cyclodextrin drug design

Sugammadex, marketed as Bridion™, is an approved cyclodextrin (CD) based drug for the reversal of neuromuscular blockade in adults undergoing surgery. Sugammadex forms an inclusion complex with the neuromuscular blocking agent (NMBA) rocuronium, allowing rapid reversal of muscle paralysis. In silico methods have been developed for studying CD inclusion complexes, aimed at accurately predicting their structural, energetic, dynamic, and kinetic properties, as well as binding constants. Here, a computational study aimed at characterizing the sugammadex-rocuronium system from the perspective of docking calculations, free molecular dynamics (MD) simulations, and biased metadynamics simulations with potential of mean force (PMF) calculations is presented. The aim is to provide detailed information about this system, as well as to use it as a model system for validation of the methods. This method predicts results in line with experimental evidence for both the optimal structure and the quantitative value for the binding constant. Interestingly, there is a less profound preference for the orientation than might be assumed based on electrostatic interactions, suggesting that both orientations may exist in solution. These results show that this technology can efficiently analyze CD inclusion complexes and could be used to facilitate the development and optimization of novel applications for CDs.

Skeletal muscle relaxants as adjunctive pain control following cardiothoracic surgery: a systematic review protocol

IntroductionMultimodal pain control following cardiothoracic surgery remains a focus in international guidelines. We hypothesise that non-depolarising skeletal muscle relaxants can prove to be a useful adjunct for this population.Methods/analysisThis systematic...

Rapid Critical Care Training for Nurses Deployed to Intensive Care Units During the COVID-19 Surge.

During the first COVID-19 pandemic wave, non-intensive care unit (non-ICU) nurses were deployed to temporary ICUs to provide critical care for the patient surge. A rapid critical care training program was designed to prepare them to care for patients in either temporary or permanent ICUs. To evaluate the effectiveness of this training program in preparing non-ICU nurses to provide critical care for COVID-19 patients in temporary ICUs. A survey was used to evaluate the impact of rapid critical care training on nurses' critical care skills and compare the experiences of nurses deployed to temporary versus permanent ICUs. Data were analyzed with χ2 and Spearman ρ tests with α = .05. Compared with nurses in other locations, nurses deployed to temporary ICUs were less likely to report improved capability in managing mechanical ventilation; infusions of sedative, vasoactive, and paralytic agents; and continuous renal replacement therapy. Nurses in temporary ICUs also reported being less prepared to care for critically ill patients (all P < .05). The rapid training program provided basic critical care knowledge for nurses in temporary ICUs, but experiences differed significantly between those deployed to temporary versus permanent ICUs. Although participants believed they provided safe care, nurses with no critical care experience cannot be expected to learn comprehensive critical care from expedited instruction; more formal clinical support is needed for nurses in temporary ICUs. Rapid critical care training can meet emergency needs for nurses capable of providing critical care.

Antishivering effect of intrathecal versus intravenous tramadol in patients undergoing urethroscopic lithotripsy under spinal anesthesia

Background: Shivering is the most common complication seen in the perioperative period in patients undergoing urological surgeries under spinal anesthesia. Intravenous tramadol is used for the treatment of shivering. Aims and Objectives: In this study, we wanted to assess the prophylactic effect of tramadol, intrathecal (IT) versus intravenous with the control group, in decreasing the incidence of shivering. Materials and Methods: Fifty-four eligible patients posted for urethroscopic lithotripsy (URSL) were randomly allocated into three equal groups – Group C: Received 2.5 mL 0.5% bupivacaine heavy + 0.5 mL normal saline intrathecally and 5 mL of normal saline intravenously, Group V: Received 2.5 mL of 0.5% bupivacaine heavy+0.5 mL normal saline intrathecally and 25 mg tramadol in 5 mL of normal saline intravenously, and Group T: Received 2.5 mL of 0.5% bupivacaine heavy + 25 mg (0.5 mL) of tramadol intrathecally and 5 mL of normal saline intravenously. The incidence and severity of shivering were noted. Onset of sensory and motor block, duration of post-operative analgesia, core body temperature, and adverse effects such as nausea, vomiting, and hypotension were noted. Results: The incidence of intraoperative shivering was significantly lower in Group T versus C (P=0.014) but comparable among Group I versus C (P=0.502) and Group T versus I (P=0.06). The duration of analgesia was significantly higher in Group T compared to Groups I and C (P&lt;0.001). The additional tramadol requirement was significantly lower in Group T versus I and in Group T versus C but comparable among Group I versus C. Conclusion: The addition of 25 mg tramadol to IT 0.5% bupivacaine heavy is effective in preventing intraoperative shivering in patients undergoing urological surgeries like URSL.

A Review of Muscular Dystrophies.

Muscular dystrophy encompasses a group of genetic conditions with progressive muscle damage and weakness. Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are X-linked recessive disorders that affect the production of the protein dystrophin. Emery-Dreifuss muscular dystrophy (EDMD) is typically an X-linked-recessive disorder involving the gene that codes for emerin. Facioscapulohumeral muscular dystrophy and oculopharyngeal muscular dystrophy (OPMD) are both autosomal dominant disorders. Although commonly mistaken as a condition in which patients are susceptible to malignant hyperthermia with volatile inhalational anesthetics, muscular dystrophy is more closely associated with rhabdomyolysis. Providers developing an anesthetic plan for dental patients with muscular dystrophy must take into consideration the patient's baseline cardiac and pulmonary function as well as the potential for abnormalities. Nondepolarizing neuromuscular blocker use is safe but likely to result in prolonged skeletal muscle relaxation. Succinylcholine and volatile anesthetics are generally contraindicated due to the risks of rhabdomyolysis and hyperkalemia with subsequent ventricular fibrillation, cardiac arrest, and death if left untreated. In-depth understanding of the more commonly encountered forms of muscular dystrophy is vital to providing safe and effective ambulatory anesthesia care for patients undergoing dental treatment outside the traditional hospital operating room setting.

Sublethal neurotoxicity of saxitoxin in early zebrafish development: Impact on sensorimotor function and neurotransmission systems

Saxitoxin (STX) represents a marine toxin of significant concern due to its deleterious implications for aquatic ecosystems and public food safety. As a potent paralytic agent, the role of STX in obstructing voltage-gated sodium channels (VGSCs) is well-characterized. Yet, the mechanistic details underlying its low-dose toxicity remain largely enigmatic. In the current study, zebrafish embryos and larvae were subjected to subchronic exposure of graded STX concentrations (0, 1, 10, and 100 μg/L) until the 7th day post-fertilization. A tactile stimulus-based assay was employed to evaluate potential behavioral perturbations resulting from STX exposure. Both behavioral and transcription level analyses unveiled a compromised tactile response, which was found to be associated with a notable upregulation in the mRNA of two distinct VGSC isoforms, specifically the scn8aa/ab and scn1Laa/ab transcripts, even at the minimal STX dose. Notably, exposure to this lowest STX concentration also resulted in alterations in the transcriptional patterns of pivotal genes for cholinergic and GABAergic pathways, including ache and gabra1. Furthermore, STX induced a marked decrease in the levels of the neurotransmitter GABA. Our findings underscore that prolonged low-dose STX exposure during early development can significantly compromise the tactile response behavior in zebrafish. This study reveals that chronic low-dose STX exposure of developing zebrafish alters neurotransmission pathways that converge on altered tactile behavior.

Novel triple injection technique - Avante garde for costoclavicular block. A Case series

Costoclavicular block has garnered the attention of regional anesthesia enthusiasts because the cords are snuggly packed and consistently arranged in a particular pattern around the first part of the axillary artery. The single injection technique has been widely used conventionally, but the effect is unpredictable. The effect is unpredictable because of the septum that compartmentalizes cords in upper and lower compartments. We propose a triple injection technique targeting the individual cords separately. Onset time of sensory block from 16 min to 7 min. The average time for a complete motor block was 9.6 min. The chances of the median nerve sparing, as has been reported in some cases in previous studies, are almost nil by this technique–the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately, covering the lateral root of the median nerve. The costoclavicular block has already carved a niche as an excellent choice for surgeries of the upper limb involving the elbow or below the elbow. The use of the triple injection technique makes the block effect more predictable and reliable.

Comparison of three different doses of cis-atracurium under isoflurane anesthesia

Aims: In this study; we compared the effects of three different doses of cis-atracurium, a nondepolarizing muscle relaxant agent, on neuromuscular blockade duration, endotracheal intubation quality and hemodynamic parameters under isoflurane anaesthesia.&#x0D; Methods: A total of 60 patients (ASA I-II) were included in the study. Patients were premedicated with 10 mg diazepam intramuscularly 45 minutes before the operation. After the patients were transferred to the operating room, they were monitored noninvasively for heart rate and arterial blood pressure. Train of Four (TOF)-GUARD acceleration monitor was used for neuromuscular evaluation. All patients were administered 1 mg/kg fentanyl and 2 mg/kg propofol at induction, and anaesthesia maintenance was provided with 1.5% isoflurane+50% N2O+50% O2. The patients were divided into three groups according to the dose of cisatracurium administered: 0.15 mg/kg was administered to Group 1, 0.20 mg/kg was administered to Group 2, and 0.40 mg/kg cis-atracurium was administered to Group 3. Endotracheal intubation was performed at 120 seconds, and the block time of 99-100% (effect onset time) was recorded.&#x0D; Result: Although the endotracheal intubation quality was evaluated as excellent and/or good in all three groups, the intubation quality of Group 3 was statistically higher than the other two groups (p

Effect of Different Doses of Sugammadex on Recovery and Hemodynamic Parameters in Reversing Neuromuscular Blockade in Patients Undergoing Electroconvulsive Therapy.

This retrospective observational study aimed to investigate the effect of different doses of sugammadex used in reversing neuromuscular blockade in electroconvulsive therapy (ECT) procedures on patient recovery and hemodynamic measurements. Anesthesia induction was performed using propofol (1 mg/kg) and rocuronium (0.4 mg/kg). Patients were classified into group 2 (2 mg/kg) and group 3 (3 mg/kg) according to the dose of sugammadex used to reverse neuromuscular blockade. The patient's spontaneous breathing time, eye-opening time, time to comply with voluntary commands, time to reach Modified Aldrete score (MAS) 9, complications, and hemodynamic data were analyzed. In total, 314 ECT sessions were performed on 46 patients. The average age of the patients was 38.3±12.6 years, and 56.6% (n=26) were male. While the average number of ECTs applied to the patients was 6.8±2.8, the average seizure duration was 28.2±12.7 seconds. The most common diagnosis (32.7%) in patients who underwent ECT was bipolar disorder. The average time to recovery of spontaneous breathing, eyeopening time, time to comply with voluntary commands, and time to reach MAS 9 were found to be significantly lower in group 3 (p<0.001, p<0.001, p<0.001, and p=0.002, respectively). Tooth damage was observed in 0.3% (n=1) and tongue abrasion in 0.6% (n=2) of the cases. Hemodynamic measurements were similar between groups (p>0.05). Sugammadex used at a dose of 3 mg/kg in ECT procedures significantly reduces recovery times compared with 2 mg/kg. However, both doses can be safely and cost-effectively used to reverse the neuromuscular blockade provided by 0.4 mg/kg rocuronium.

Comparison of the analgesic effects of different bupivacaine concentrations in continuous femoral block after total knee arthroplasty surgery

Aim: In regional anesthesia practice, anesthesists’ goal must be to use the lowest effective concentration of local anesthetics to provide sufficient pain relief while minimizing side effects and complications. This study was designed to compare the analgesic efficacy of two different concentrations of bupivacaine (0.125% and 0.1%) in continuous femoral block for postoperative analgesia.Method: In this study, fifty patients were enrolled, all of whom underwent femoral nerve block catheterization. The block procedure involved the administration of 30ml of bupivacaine solution at a concentration of 0.25%. Following a thirty-minute interval post-block application, patients underwent knee surgery under general anesthesia. During the closure of subcutaneous tissues, an additional 10ml of bupivacaine solution was injected through the catheter. Two groups were formed based on the concentration of the solution administered: Group(0.125%) received bupivacaine at a concentration of 0.125%, while Group(0.1%) received it at a concentration of 0.1%. Subsequently, upon arrival at the postoperative care unit, infusion through the catheter commenced at a rate of 10ml/h-1, maintaining the same concentrations for both groups. In addition to the nerve block, all patients were provided with intravenous Patient Controlled Analgesia (PCA) devices containing morphine for pain management. Throughout the postoperative period, sensory and motor block levels, Numerical Rating Scale (NRS) values for static and dynamic pain assessment, total morphine consumption, morphine demand, as well as any observed side effects and complications, were meticulously recorded for analysis.Results: Postoperatively the NRSstatic values at 24th and 48th hours and NRSdynamic values at the 24th hour were higher in Group(0.1%) and it was statistically significant(p&lt;0,007). And at 48th hour, morphine consumption was significantly higher in Group(0.1%) (p&lt;0,05).Conclusions: In our study, all patients across both experimental groups initially experienced satisfactory analgesia. However, within the 24-hour postoperative period, Group(0.1%) exhibited a decline in the quality of analgesia, necessitating increased utilization of rescue analgesics. This escalation in rescue analgesic use was associated with a higher incidence of adverse effects and reduced patient comfort levels within this group. Consequently, our findings indicate that the 0.125% concentration of bupivacaine yielded superior efficacy compared to the 0.1% concentration in the context of continuous femoral block administration.

Barriers, Facilitators, and Trends in Prone Positioning for ARDS

BackgroundProne positioning is a historically underutilized evidence-based practice for acute respiratory distress syndrome (ARDS). Despite increased prone positioning during the COVID-19 pandemic, some patients may remain at risk of non-use. Research QuestionWhat is the current evidence-based gap for prone positioning in ARDS, how is use changing over time, and what are patient level barriers and facilitators to prone positioning. Study Design and MethodsThis retrospective cohort included invasively ventilated adults with ARDS and who met prone positioning criteria from six hospitals. The rate of prone positioning among eligible patients was summarized January 2018 to December 2021. Segmented Poisson regression was used to describe temporal trends. Logistic regression was used to identify patient level barriers and facilitators to prone positioning. Results799 patients fulfilled criteria for prone positioning; mean age 57 years, 125 (15.6%) COVID-19, intensive care stay 19.5 days and mortality 50.1%. Prone positioning was used in 297/799 (37.2%) patients. Prone positioning was increasing pre-pandemic with relative rate (RR) 1.12 per quarter (95% Confidence Interval [CI] 1.03 – 1.22). Prone positioning increased during the pandemic vs. pre-pandemic (RR 1.62, 95%CI 1.02 – 2.61), but not for patients with non-respiratory diagnoses (RR 0.74, 95%CI 0.22 – 2.52). Barriers to prone positioning included vasopressor use (odds ratio [OR] for withholding prone 1.15 per 0.1 mcg/kg/min norepinephrine equivalent, 95%CI 1.06 – 1.26), age (OR 1.12 per 5 years, 95%CI 1.03 – 1.22), and being post-operative (OR 2.41, 95%CI 1.00 – 5.81). Facilitators included having COVID-19 (OR for withholding prone 0.10, 95%CI 0.04 – 0.24) or another respiratory illness (OR 0.42, 95%CI 0.23 – 0.79), and receiving neuromuscular blockade (OR 0.22, 95%CI 0.13 – 0.38). Interpretation:Despite increased prone positioning during the COVID-19 pandemic an evidence-based gap persists, especially for patients with non-respiratory causes of ARDS. There are multiple barriers and facilitators to target to increase prone positioning.

Trapping and reversing neuromuscular blocking agent by anionic pillar[5]arenes: Understanding the structure-affinity-reversal effects

Selective relaxant binding agents (SRBA) have great potential in clinical surgeries for the precise reversal of neuromuscular blockades. Understanding the relationship between the structure-affinity-reversal effects of SRBA and neuromuscular blockade is crucial for the design of new SRBAs, which has rarely been explored. Seven anionic pillar[5]arenes (AP5As) with different aliphatic chains and anionic groups at both edges were designed. Their binding affinities to the neuromuscular blocking agent decamonium bromide (DMBr) were investigated using 1H NMR, isothermal titration calorimetry (ITC), and theoretical calculations. The results indicate that the capture of DMBr by AP5As is primarily driven by electrostatic interactions, ion-dipole interactions and C-H‧‧‧π interactions. The optimal size matching between the carboxylate AP5As and DMBr was ∼0.80. The binding affinity increased with an increase in the charge quantity of AP5As. Further animal experiments indicated that the reversal efficiency increased with increasing binding affinity for carboxylate or phosphonate AP5As. However, phosphonate AP5As exhibited lower reversal efficiencies than carboxylate AP5As, despite having stronger affinities with DMBr. By understanding the structure-affinity-reversal relationships, this study provides valuable insights into the design of innovative SRBAs for reversing neuromuscular blockade.

Effects of Ketamine and Tramadol As Adjuvants to Bupivacaine in Spinal Anesthesia for Unilateral Open Ovarian Cystectomy: A Randomized Controlled Trial.

Spinal anesthesia offers numerous advantages and desirable features. However, it is associated with various side effects related to local anesthetic agents used. Reducing the dose of local anesthetic in spinal anesthesia can help minimize side effects but may lead to a diminished analgesic effect or failure of anesthesia. Therefore, adding an adjuvant may enhance the benefits while mitigating side effects. This study aimed to evaluate the effects of ketamine and tramadol as adjuvants to bupivacaine on the duration of spinal analgesia. The objectives were to compare the three groups and prove their analgesic effects, safety, and superiority.The primary outcomes werethe duration of spinal analgesia, as well as the onset and duration of both sensory and motor blocks. Secondary outcomes included the heart rate, mean arterial pressure, and the incidence of undesired effects such as nausea, vomiting, sedation, shivering, and postoperative headache. In this double-blind randomized controlled trial, 120 female patients undergoing elective open unilateral ovarian cystectomy under spinal anesthesia were studied. The inclusion criteria included patients aged 16-45 years with a physical status classified as American Societyof Anesthesiologists (ASA) class I and II. Patients were randomly allocated into three groups: group B (n=40) received only bupivacaine, group BK (n=40) received bupivacaine mixed with preservative-free ketamine, and group BT (n=40) received bupivacaine mixed with preservative-free tramadol. The mean duration of spinal analgesia, measured in minutes, showed significant differences (P < 0.001) between group BK (165 ± 4) and group B (170 ± 5). There was also a significant difference between group BT (313 ± 8) and group B (170 ± 5) (P < 0.001). Additionally, significant differences were observed between group BK (165 ± 4) and group BT (313 ± 8) (P < 0.001). The administration of 25 mg of ketamine and 25 mg of tramadol as adjuvants to bupivacaine in spinal anesthesia significantly affected the postoperative duration of analgesia. Tramadol prolonged the duration of spinal anesthesia, while ketamine shortened it. The use of both adjuvants did not result in undesired effects.

Sugammadex shortens operation time and improves operation turnover efficacy in video-assisted thoracoscopic surgery.

This study compared sugammadex and neostigmine as agents for routine neuromuscular blockade reversal in video-assisted thoracoscopic surgery (VATS) to determine the optimal choice that achieves a shorter operation time and improved turnover efficiency while enhancing postoperative outcomes and ensuring patient safety during thoracic surgery. This prospective study, conducted from July 2022 to March 2023, compared the effect of sugammadex and neostigmine on operation time and turnover efficiency in VATS, involving 60 participants randomly assigned to either group, with the primary objective of identifying the optimal anesthesia reversal choice for improved outcomes and patient safety during thoracic surgery. In the study, the sugammadex group showed a significantly shorter total operation room occupancy time (130 ± 7 vs 157 ± 7 minutes; p = 0.009) than the neostigmine group. Patients in the neostigmine group had higher mean pulse rates when leaving the operation room (85 ± 3 vs 73 ± 3 beats/min; p = 0.002) and 120 minutes later in the postanesthesia care unit (76 ± 2 vs 68 ± 2; p = 0.016). This study's findings suggest that sugammadex may enhance total operating room occupancy time, operation turnover efficacy, and respiratory recovery outcomes in VATS, potentially improving patient care and anesthesia management.

Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act.

Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.

Gastrointestinal changes in critical patients with covid-19 receiving enteral nutritional, neuromuscular blockers and/or vasoactive drugs

Objective: The aim of this study was to evaluate the frequency of gastrointestinal alterations (GIA) and possible associated risk factors in critically ill patients with COVID-19 receiving enteral nutrition (EN) concomitantly with vasoactive drug (VAD) and/or neuromuscular blockers (NMB). Methods: Retrospective cohort study, performed in intensive care units (ICU), with individuals over 18 years of age with COVID-19 who received concomitant exclusive EN with at least one VAD and/or one NMB in ≥ 1 day. GIA were: presence of ≥ 1 of the following changes: diarrhea (≥ 3 liquid stools/day), gastric residual volume (GRV), paralysis of the lower gastrointestinal tract (GIT) (absent evacuation for ≥ 3 consecutive days), emesis and gastrointestinal bleeding. A mixed logistic regression was used to assess the association of drugs with GIA and a multivariate logistic regression to assess potential confounders. Results: We evaluated 78 individuals and 774 days of hospitalization. All of them received EN within 48h and 70.5% died. The most frequent GIA were: lower GIT paralysis, 75 patients in 362 days; GRV, 18 patients at 34 days and diarrhea, 13 patients at 22 days. Norepinephrine was associated with GRV (p=0.003) and fentanyl (mcg/min) with the presence of GIA (p=0.029). Conclusions: The NMB showed no relationship with the assessed GIA, as for the VAD we suggest the assessment of norepinephrine as a possible risk factor for GRV.

Median Effective Dose of Ropivacaine for Prophylactic Cervical Cerclage in Chinese Women: A Dose-Finding Study

(Reg Anesth Pain Med. 2023;48:168–172. doi: 10.1136/rapm-2022-104242) Complications in pregnancy leading to preterm labor or miscarriage can occur for a variety of reasons. One reason that represents a significant public health burden is cervical incompetence or insufficiency. Current treatment guidelines focus on cervical cerclage as an effective treatment to prevent or arrest the effects of cervical insufficiency. Performing this procedure requires surgery, and therefore different anesthetic methods can be used to minimize pain and adverse outcomes for the patients, namely general or neuraxial anesthesia. One local anesthetic used for spinal neuraxial blocks in obstetrics is ropivacaine, but research has not explored its effect when used for cervical cerclage. This study from China was designed to find the median effective dose of intrathecal ropivacaine for cervical cerclage placement in 50% of patients (ED50). Secondary to this, the effective dose of intrathecal ropivacaine in 95% of patients (ED95) was also calculated. Other outcome measures included the duration of the sensory and motor blocks.

Peripheral nerve blocks of wrist and finger flexors can increase hand opening in chronic hemiparetic stroke.

Hand opening is reduced by abnormal wrist and finger flexor activity in many individuals with stroke. This flexor activity also limits hand opening produced by functional electrical stimulation (FES) of finger and wrist extensor muscles. Recent advances in electrical nerve block technologies have the potential to mitigate this abnormal flexor behavior, but the actual impact of nerve block on hand opening in stroke has not yet been investigated. In this study, we applied the local anesthetic ropivacaine to the median and ulnar nerve to induce a complete motor block in 9 individuals with stroke and observed the impact of this block on hand opening as measured by hand pentagonal area. Volitional hand opening and FES-driven hand opening were measured, both while the arm was fully supported on a haptic table (Unloaded) and while lifting against gravity (Loaded). Linear mixed effect regression (LMER) modeling was used to determine the effect of Block. The ropivacaine block allowed increased hand opening, both volitional and FES-driven, and for both unloaded and loaded conditions. Notably, only the FES-driven and Loaded condition's improvement in hand opening with the block was statistically significant. Hand opening in the FES and Loaded condition improved following nerve block by nearly 20%. Our results suggest that many individuals with stroke would see improved hand-opening with wrist and finger flexor activity curtailed by nerve block, especially when FES is used to drive the typically paretic finger and wrist extensor muscles. Such a nerve block (potentially produced by aforementioned emerging electrical nerve block technologies) could thus significantly address prior observed shortcomings of FES interventions for individuals with stroke.

Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases.

The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.