Need For Muscle Relaxants Research Articles

Effect of classical laryngeal mask or I-gel use on otolaryngeal system in ambulatory inhalation general anesthesia: A prospective study.

To investigate the effects of supraglottic airway tools such as classical laryngeal mask (cLMA) and I-gel, which can be used without the need for muscle relaxation in the airway management of general anesthesia patients, on the otolaryngeal system. This prospective randomised study was conducted at Karadeniz Technical University Hospital, Faculty of Medicine, Trabzon, Turkey, during November 2020 to December 2021. Eighty-nine patients in the American Society of Anesthesiologists (ASA) grade I-II group, who would undergo elective surgery under general anesthesia, were randomized into two groups, namely Group cLMA and Group I-gel. cLMA and I-gel were used for airway management of the patients. After anesthesia induction, tympanometric measurements were taken at regular intervals for middle ear pressures of both ears. While air way pressures, SpO2 and EtCO2 values were within normal limits, there were no differences in terms of complications. In tympanometric measurements, middle ear pressure increase was statistically higher in the cLMA group than in the I-gel group (p <0.001). We think that I-gel may be a more advantageous supra glottic airway device in terms of otolaryngeal effecs and middle ear pressure in theair way management during short surgical procedures.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction.

Background:Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.Methods:To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.Results:Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).Conclusions:Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Intubating conditions following four different doses of propofol in children

Background: Day case surgery offers advantages to the patient, the family and the performing institution. Children are excellent candidates since they are generally healthy and often require brief surgical interventions. Day case surgery requires rapid emergence from anaesthesia, minimal delay in recovery and rapid readiness for discharge from the ward. The ideal anaesthetic agents should have rapid onset, short duration, minimal side effects and minimal residual effects. The pharmacodynamics and -kinetics of propofol and alfentanil are well suited for day case surgery and may obviate the need for muscle relaxants. The purpose of our study was to determine the optimal dosing schedules for intubation following propofol combined with alfentanil and sevoflurane anaesthesia while maintaining haemodynamic stability as these dosing schedules still warrant refinement. Methods: We conducted a randomised prospective blinded study in which fifty-nine children (aged 3–10 years) presenting for dental extractions were induced with sevoflurane (in 50% oxygen/nitrous oxide), then received propofol (0.5, 1, 1.5 or 2 mg/kg) and alfentanil (10 μg/kg) to aid intubation. For each dose of propofol, the ease of intubation (assessed by the Helbo-Hansen score) was correlated with blood pressure and pulse rate (prior, during and after intubation) to determine the optimal propofol dosage allowing adequate intubation conditions with the least haemodynamic effects. Results: Overall adequacy of intubating conditions improved significantly (p = 0.0079) as propofol dose increased. Similarly, decrease in vocal cord movement (p = 0.0341), incidence of coughing (p = 0.0379) and limb movement (p = 0.0165) was observed. Ease of laryngoscopy and jaw relaxation did not improve significantly (p = 0.1319 and 0.1971 respectively). Changes in systolic, diastolic and mean arterial pressure as propofol dose increased were not statistically significant. Conclusion: Propofol in a dose of 1.5 to 2 mg/kg (when used in conjunction with alfentanil 10 μg/kg, after sevoflurane induction) allowed adequate intubating conditions whilst maintaining cardiovascular stability. The decrease in blood pressure, although not statistically significant, may become clinically relevant in children with underlying cardiovascular disease. This drug combination seems to be a reasonable means for avoiding the need for muscle relaxation for children who require tracheal intubation for brief surgical procedures.

The prolonged sub-tenon block for long vitreoretinal surgery

The purpose of this study was to compare efficiency and safety of the prolonged Sub-Tenon block in comparison with IV 100 mg tramadol for long vitreoretinal surgery ander general anesthesia. 74 patients were undergoing microinvasive vitrectomy. For the prolonged Sub-Tenon block 1% solution of lidocaine at the speed of 2 ml/hour was used. The value of block of oculovisceral reflexes, HR and MAP, the need for muscle relaxants, time of awakening and time of removal of a laryngeal mask, postoperative pain and analgesia requirements, and postoperative nausea and vomiting were recorded. In prolonged Sub-Tenon block group there was more effective blocking of oculocardiac and oculovasomotor reflexes, a smaller average dose of muscle relaxants, shorter awakening time and removal of a laryngeal mask, and also lower pain syndrome in the first 24 hours after surgery. Postoperative nausea and vomiting also was in Sub-Tenon block group considerably less frequent than in tramadol group. Use of the prolonged Sub-Tenon block with the general anesthesia is an effective and safe technique for vitreoretinal surgery.

Analysis of the applied technique of intravenous anesthesia for in vitro fertilization in obese and patients with normal body mass index

Introduction/Objective. In this study, the effects of applied anesthetic techniques were investigated in a retrospective analysis of obese patients and those with normal body mass index undergoing in vitro fertilization, using bispectral index as an indicator of anesthetic depth. Methods. In total 116 patients with normal body mass index were allocated to group N. Another 116 patients with body mass index &gt; 30 kg/m2 were allocated to group O. Anesthetic protocol comprised midazolam for premedication, diclofenac for pre-emptive analgesia, propofol for induction and maintenance, alfentanil for analgesia, suxamethonium for muscle relaxation. We recorded and compared the monitored parameters using t-test and ?2 test. Results. Procedure duration and recovery time were significantly longer in O group (p &lt; 0.01). There is a statistically significant difference (p = 0.000181) in the number of patients requiring mechanical ventilation after induction of anesthesia. Propofol consumption was significantly higher (p &lt; 0.0001) in O group (2.7 ? 1.6 mg/kg) as compared to group N (2.1 ? 0.4 mg/kg). The incidence of postoperative nausea and vomiting was observed in six patients in N group (5.17%) and nine patients in O group (7.76%). Pain intensity was found higher in group O compared to group N (p &lt; 0.0001). Assessment of patients? sedation using verbal scale reported no statistically significant difference between N and O groups (p = 0.2548). Conclusion. Induction and maintenance of anesthesia in obese patients results in increased consumption of propofol and the need for muscle relaxation. The statements of the patients who underwent the procedure under intravenous propofol and alfentanil serve as the best recommendation for clinical practice.

Thoracic epidural anesthesia for severe myasthenia gravis patient undergoing laparoscopic cholesistectomy

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by different degrees of weakness and fatigue of skeletal muscles after physical exercise. It has an incidence of 2-10/100000 per year. The optimal anesthetic management of these patients is still controversial. A 69 year-old male patient with MG was scheduled for laparoscopic cholesistectomy due to gallbladder stone. Epidural puncture was performed by a 18G Tuohy needle inserted between 7th and 8th thoracic vertebrae. After the placement of epidural catheter, a combination of 40 mg bupivacaine, 100 mg prilocaine and 100 µg fentanil were applied slowly. Pneumoperitonium was applied with approximetly 12 mmHg CO2 for laparoscopic view. At the 10th minute of the surgery, a sudden deep bradicardia was observed. Following administration of one mg of atropine, heart rate of the patient turned to normal ranges within 30 seconds. In the postoperative period no respiratory or cardiac complications were detected and the patient was discharged from hospital after three days. Anesthetic management of MG patients should be individualized due to increased risk of intraoperative and postoperative complications. Their increased sensitivity to nondepolarizing muscle relaxants can lead to prolonged postoperative mechanical ventilation need. In adult patients, regional anaesthesia alone can be a good and safe method for myasthenic patients by eleminating the need for muscle relaxants and opioids in abdominal surgeries. In this case we prefer to insert a thoracic epidural catheter to control the level of blockage intraoperatively. Continuous epidural infusion allowed us to maintain postoperative analgesia without intravenous opioid agents.

Anesthetic management of a patient with multiple sclerosis - case report

Multiple sclerosis is a demyelinating disease of the brain and spinal cord, characterized by muscle weakness, cognitive dysfunction, memory loss, and personality disorders. Factors that promote disease exacerbation are stress, physical trauma, infection, surgery, hyperthermia. The objective is to describe the anesthetic management of a case referred to urological surgery. A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis, referred for endoscopic ureterolythotripsy. Balanced general anesthesia was chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respiratory difficulty presenting with chest wallrigidity, it was decided to discontinue the infusion of remifentanil. There was no other complication or exacerbation of disease postoperatively. The use of neuromuscular blockers (depolarizing and non-depolarizing) is a problem in these patients. As there was no need for muscle relaxation in this case, muscle relaxants were omitted. We conclude that the combination of propofol and sevoflurane was satisfactory, not resulting in hemodynamic instability or disease exacerbation.

Perioperative Analgesic Management of Newborn Bladder Exstrophy Repair Using a Directly Placed Tunneled Epidural Catheter with 0.1% Ropivacaine

Effective multimodal analgesia and sedation reduce the postoperative morbidity and mortality associated with newborn bladder exstrophy repair. Epidural analgesia is safe and effective for major surgery in neonates and infants, reducing the need for muscle relaxants, opioids, and ventilator support postoperatively. The risk of epidural catheter colonization typically dictates removal after 3 to 5 days. Tunneling the catheter subcutaneously reduces the risk of colonization, providing prolonged analgesia for patients requiring an extended immobilization to prevent compromise of the repair. In this report, we describe the postoperative analgesic management of an infant undergoing bladder exstrophy repair using a directly placed tunneled epidural catheter with ropivacaine 0.1% infusion. Because of the prolonged infusion, we also monitored plasma ropivacaine levels to preclude systemic toxicity from local anesthetic overdose.

Paravertebral Block Combined with Sedation for a Myasthenic Patient Undergoing Breast Augmentation.

Paravertebral block is a unilateral analgesic technique that can provide adequate surgical anesthesia and great advantages in many types of surgery with a low side-effect profile. In this case we present combination of bilateral thoracic paravertebral block under ultrasound guidance with sedation which provides complete anesthesia and postoperative analgesia in a myasthenic patient undergoing cosmetic breast surgery. In myasthenic patients paravertebral blocks may be a better option for breast surgery with avoiding the need for muscle relaxants and opioids and risk of respiratory failure in postoperative period.

LMA Extubation in Pediatric Patients: A Comparison of Inflated and Deflated LMA Cuff Methods

Background and Objectives: Extubating LMA (Laryngeal mask airway) can be performed either with inflated or deflated cuff . In this study the effects and complications of these two methods were compared in children . Materials and Methods: In a clinical trial, 180 patients under 11 years old with ASA I/II who were scheduled for elective surgeries for less than one hour with no need for muscle relaxation were randomly divided into two groups. In group D, LMAs were extubated after oral cavity suctioning and cuff deflation. In group I, LMAs were extubated without suctioning and deflating the cuffs. Results: In group I after removing the LMA, mean heart rate significantly increased, mean diastolic blood pressure significantly increased, and mean arterial blood saturation significantly decreased. In Group D, none of these changes occurred. Despite a higher incidence of complications in the group I, difference was not significant. Conclusions: LMA removal with inflated cuff increases hemodynamic changes and decreases the arterial blood saturation. Hence, when hemodynamic stability and saturation of arterial blood is particularly important for us, extubating the LMA with deflated cuff is recommended. Keywords: LMA; Complication; Inflated; Deflated

Pediatric Rigid Bronchoscopy for Foreign Body Removal

Pediatric Rigid Bronchoscopy for Foreign Body Removal

Pediatric Rigid Bronchoscopy for Foreign Body Removal

PhiliPPine Journal of otolaryngology-head and neck Surgery 39 Rigid bronchoscopy is a procedure that is performed in order to directly visualize the upper and lower airway and is carried out for either a diagnostic or therapeutic purpose. Suspected foreign body (FB) aspiration is the most common indication for performing this procedure in the pediatric age group at the Philippine Children’s Medical Center where a recent census (May 2008 to April 2009) showed that of 21 cases where rigid bronchoscopy was performed, 10 were for suspected FB aspiration. A review of 101 cases in the same institution showed that the average age of patients with FB aspiration was 2 years and the most common item aspirated was a peanut followed by the atis (sweetsop) seed and chicken bone chips. The most common inorganic foreign body was an earring and “whistle” (which broke off from a toy).1 It is more common in males probably because of their usually more active nature and is frequently found in the right mainstem bronchus where the FB more easily lodges being straighter, shorter and wider in diameter. FBs are life-threatening events in children that require early diagnosis and prompt successful management.2 A good history, physical examination and analysis of diagnostic tests are vital in every situation. In most cases, the child’s aspiration of the foreign object is a witnessed event 3 and this history of aspiration is the most sensitive diagnostic tool. The main symptoms include choking, prolonged cough and dyspnea. Abnormal physical examination findings are found in 67% to 80% of cases and include unilaterally decreased breath sounds, wheezing and stridor.2,4 Radiographic procedures may show abnormal findings in only about 68-86% of cases.4,5 The most useful radiographs requested are the chest posteroanterior (anteroposterior in infants and small children) and lateral views which may help localize the impaction site when the object aspirated is radiopaque.3 However, most inhaled FBs are radiolucent and their presence can be suspected by obtaining inspiration and expiration views to demonstrate unilateral hyperinflation. Other suggestive features include atelectasis, pneumothorax and pneumonia. These indirect radiologic features of FB inhalation are present in 76% of cases.2, Where inspiration and expiration views cannot be obtained, as in very young children, left and right decubitus views may be helpful. 6 Fluoroscopic studies may also be obtained along with the plain radiographs, however, specificity and sensitivity are not very high.4 Virtual bronchoscopy may also be used in patients with suspected FB aspiration. Virtual bronchoscopy which uses multislice computerized tomography (MDCT) with realistic 3-dimensional reconstruction may be helpful in detecting and localizing the FB prior Pediatric Rigid Bronchoscopy for Foreign Body Removal Maria Rina T. Reyes-Quintos, MD, MClinAud1,2

Role of muscle relaxants in pediatric anesthesia

Changes in practice and the development of new anesthetic drugs have influenced the use of muscle relaxants in children. This article reviews these developments, and defines the current role and factors affecting the choice of muscle relaxant drugs in pediatric anesthesia. The introduction of the laryngeal mask airway as a means of controlling the pediatric airway has reduced the need for muscle relaxants. In cases requiring tracheal intubation, however, a balanced anesthetic technique incorporating a nondepolarizing relaxant provides the best intubating conditions with the minimal potential for adverse effects. The introduction of newer less-toxic, shorter-acting anesthetic drugs has reduced the requirement for muscle relaxants during surgery. Moderate anesthesia with sevoflurane-remifentanil or propofol-remifentanil can keep patients immobile without producing hypotension and facilitate controlled ventilation once the effects of the intubating dose of a muscle relaxant have worn off. Recent developments in clinical practice have reduced or obviated the need for muscle relaxants in pediatric anesthesia. Muscle relaxants are still indicated for intubation and procedures requiring profound muscle relaxation, and to minimize the amounts of anesthetic drugs given to infants and sick children. Specific relaxants and doses can be chosen to suit the clinical circumstances.

A case of Churg–Strauss syndrome undergoing radical mastectomy under general anaesthesia and thoracic epidural analgesia

A case of Churg–Strauss syndrome undergoing radical mastectomy under general anaesthesia and thoracic epidural analgesia

In praise of the epidural space for analgesia in neonates

Epidural analgesia in neonates is now an accepted technique for intraoperative and postoperative pain management in major paediatric centres (1–3). However, its use still creates controversy and discussion. The potential benefits of the intervention must be weighed against the ability of an institution to perform and manage the technique safely. This review will concentrate on the advantages of epidural analgesia in neonates, making recommendations for safe practice, and outline the disadvantages of continuous intravenous morphine infusions. Advantages of epidural analgesia IntraoperativelyReduction of MAC for volatile agents Resulting in: • faster and clearer recovery • reduced side effects which may be associated with higher concentrations of volatile agents • reduced need for muscle relaxants (4) Reduction in postoperative ventilation Epidural analgesia has been shown to be especially suited for specific neonatal conditions such as oesophageal atresia (5), Nissens fundoplication (6) and repair of congenital diaphragmatic hernia (7), particularly in reducing the need for postoperative ventilation. Even if ventilation is required, this period is shorter and less problematic than if opioids are employed (8). The degree of muscle relaxation provided by epidural analgesia will facilitate the reduction of gastroschisis or exomphalos (9). Epidural analgesia can also provide excellent pain relief following thoracic surgery (10). Decrease in stress response The stress of surgery is known to result in compromise of the cardiovascular system, protein metabolism and the immune system, all of which may have significant detrimental effects on the high-risk neonate (11). Epidural analgesia has been demonstrated to reduce this stress response (12), whereas the use of morphine, with its immunosuppressive effect, would amplify this. Haemodynamic stability Epidural analgesia is associated with haemodynamic stability, whereas anaesthesia, with parenteral analgesics, often results in a rise in blood pressure compared. There is also some evidence that bleeding is reduced and operative times are shorter with regional anaesthesia (13). Postoperatively Epidural analgesia decreases, or indeed, removes the need to administer opioid analgesia, thereby reducing the incidence of postoperative respiratory complications. Not only is this safer for the child, it also allows the child to be nursed in ward areas, once adequate education of nursing staff has occurred (3). Gastric function rapidly returns to normal when epidural analgesia is used. This facilitates the re-establishment of feeding and earlier discharge (14). The lack of sedation associated with epidural analgesia enables the parents to be actively involved in the care of their child, thereby increasing parental satisfaction. Economics The use of epidural analgesia produces cost savings for hospitals: • faster discharge • reduced Intensive care stay • efficient use of ward nurses time Safety of regional analgesia in children The complication rate of epidural analgesia in neonates is low. However, there are a number of recommendations that should be followed: (a) the technique should be used only when clinically indicated, nerve blocks are safer than central techniques (15) (b) the technique should be restricted to experienced practitioners. minimising the number of attempts required to achieve successful catheter placement. (c) there should be no contraindications to the technique (d) if possible a caudal catheter technique is safer than a lumbar or thoracic approach (e) loss of resistance techniques using saline are safer than those employing air (f) safer epidural delivery systems should be used (g) utilisation of newer local anaesthetic solutions, i.e. Ropivacaine (3,16), and Chirocaine (h) adherence to the dose recommendations (17) (i) to use epidural infusions for less than 48 hours (18) (j) staff need to be thoroughly educated and assessed to enable them to effectively care for children receiving epidural analgesia Is it safe to use regional analgesia in neonates? There are no studies of complications of regional analgesia in neonates, information can only be derived from studies including older children. The studies by ADARPEF, both retrospective and prospective, demonstrated a low incidence of complications in children. The retrospective study (19) described five tragedies out of 10 000 patients following regional analgesia. The prospective study (15) described 23 incidents in 15 000 central blocks. This incidence is similar to that found in a US study of 15 000 caudal blocks. There is also evidence that bacterial colonisation of caudal or lumbar epidural catheters is not significant for up to 48 hours following the start of the infusion (20).

The Laryngeal Mask and High-Frequency Jet Ventilation for Resection of High Tracheal Stenosis

The Laryngeal Mask and High-Frequency Jet Ventilation for Resection of High Tracheal Stenosis

Third Anaesthesia and Critical Care Symposium

Third Anaesthesia and Critical Care Symposium

The laryngeal mask airway

The laryngeal mask airway (LMA) is a new concept in airway management. A miniature inflatable mask is positioned in the hypopharynx, forming a low-pressure seal around the laryngeal inlet. The mask is attached via a tube to the breathing circuit. It is inserted after induction of anesthesia without the need for muscle relaxants or laryngoscopy. The LMA can be used to facilitate both spontaneous and controlled ventilation in adults and children. The LMA has been used for a wide variety, of surgical procedures but is probably best suited to short procedures, especially if a light general anesthetic is used in combination with a regional technique. It may be particularly useful in outpatient anesthesia, as it avoids the need for intubation or muscle relaxants. It can be used as an alternative to mask anesthesia or when (in endotracheal tube would have been inserted to allow surgical access. It has been used successfully in cases of difficult or failed intubation, although its role here needs further appraisal. It does not protect against aspiration of stomach contents and should not be used when aspiration is a risk. Controversy exists regarding its use to facilitate positive-pressure ventilation (PPV) due to concern that gases under pressure may be forced into the stomach and predispose the patient to regurgitation. It may be more difficult to use in children. It is now widely used in the United Kingdom; however, it is not yet available for sale in the U.S. It has already had a major effect on practice in Britain and has the potential to do the same in the United States.

INTERMITTENT MANDATORY VENTILATION DURING ANAESTHESIA USING THE MANLEY SERVOVENT VENTILATOR

The lungs of 25 patients were ventilated with intermittent mandatory ventilation (IMV) during anaesthesia using the Manley Servovent Model MS. This ventilatory mode is especially suitable for prolonged operations in which there is no need for muscle relaxation. While incorporating the advantages of spontaneous and mechanical ventilation, it is superior to both in selected cases. The Manley Servovent Model MS ventilator is capable of delivering IMV without modification, using a single source of gas.