Neuromuscular Blockade Research Articles

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort.

Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population. Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome). Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients. ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Cerebral hemodynamics and optic nerve sheath diameter acquired via neurosonology in critical patients with severe coronavirus disease: experience of a national referral hospital in Peru

AimWe aimed to describe the neurosonological findings related to cerebral hemodynamics acquired using transcranial Doppler and to determine the frequency of elevated ICP by optic nerve sheath diameter (ONSD) measurement in patients with severe coronavirus disease (COVID-19) hospitalized in the intensive care unit of a national referral hospital in Peru.MethodsWe included a retrospective cohort of adult patients hospitalized with severe COVID-19 and acute respiratory failure within the first 7 days of mechanical ventilation under deep sedoanalgesia, with or without neuromuscular blockade who underwent ocular ultrasound and transcranial Doppler. We determine the frequency of elevated ICP by measuring the diameter of the optic nerve sheath, choosing as best cut-off value a diameter equal to or >5.8 mm. We also determine the frequency of sonographic patterns obtained by transcranial Doppler. Through insonation of the middle cerebral artery. Likewise, we evaluated the associations of clinical, mechanical ventilator, and arterial blood gas variables with ONSD ≥5.8 mm and pulsatility index (PI) ≥1.1. We also evaluated the associations of hemodynamic findings and ONSD with mortality the effect size was estimated using Poisson regression models with robust variance.ResultsThis study included 142 patients. The mean age was 51.39 ± 13.3 years, and 78.9% of patients were male. Vasopressors were used in 45.1% of patients, and mean arterial pressure was 81.87 ± 10.64 mmHg. The mean partial pressure of carbon dioxide (PaCO2) was elevated (54.08 ± 16.01 mmHg). Elevated intracranial pressure was seen in 83.1% of patients, as estimated based on ONSD ≥5.8 mm. A mortality rate of 16.2% was reported. In the multivariate analysis, age was associated with elevated ONSD (risk ratio [RR] = 1.07). PaCO2 was a protective factor (RR = 0.64) in the cases of PI ≥ 1.1. In the mortality analysis, the mean velocity was a risk factor for mortality (RR = 1.15).ConclusionsA high rate of intracranial hypertension was reported, with ONSD measurement being the most reliable method for estimation. The increase in ICP measured by ONSD in patients with severe COVID-19 on mechanical ventilation is not associated to hypercapnia or elevated intrathoracic pressures derived from protective mechanical ventilation.

Epidural, Inadvertent Subdural, and Combined Epidural–Subdural Anesthesia in Lumbar Spine Surgery: A Retrospective Analysis

This study aimed to categorize contrast media images associated with epidural, subdural, and combined epidural–subdural anesthesia in patients who had undergone fluoroscopy-guided epidural anesthesia using contrast media combined with monitored anesthesia care (MAC) targeted at deep sedation, incorporating capnography over 5 years. Additionally, a correlation was established between the anesthetic effects and radiographic findings according to the categorized imaging appearances. This study included 628 patients who underwent endoscopic, open, or fusion surgery under epidural anesthesia at Nanoori Hospital in Gangnam between March 2018 and September 2023. Fluoroscopy-guided epidural anesthesia using contrast media combined with MAC and capnography was used. The dataset included detailed radiographic imaging, nursing, and anesthesia records. Distinct patterns of anesthesia administration were observed, with 49%, 19.6%, and 31% of patients receiving epidural, subdural, and combined epidural–subdural anesthesia, respectively. The incidence and duration of motor block were significantly different among the three groups. Additionally, subdural anesthesia displayed a higher incidence of motor block and a prolonged motor deficit duration than epidural anesthesia. Fluoroscopic guidance using a contrast medium for epidural and subdural anesthesia ensures precise space identification and prevents serious anesthetic complications. Our findings suggest the potential to achieve stable anesthesia, particularly using subdural and combined epidural–subdural anesthesia.

Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants.

The European Society of Anesthesiology and Intensive Care recommends the use of neuromuscular blocking agents (NMBA) in adults, to facilitate tracheal intubation and reduce its associated complications. Children who undergo tracheal intubation may suffer some of the same complications, however, no consensus exists regarding the use of NMBA for tracheal intubation in the pediatric population. We will explore the existing evidence assessing the effects of avoidance versus the use of NMBA for the facilitation of tracheal intubation in children and infants. This protocol follows the preferred reporting items for systematic reviews and meta-analyses protocols recommendations. We will include all randomized controlled clinical trials assessing the effects of avoidance versus the use of NMBA for facilitation of tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy in pediatric participants (<18 years). Our primary outcome is incidence of difficult tracheal intubation. Secondary outcomes include incidence of serious adverse events, failed intubation, events of upper airway discomfort or injury, and difficult laryngoscopy. We will conduct a thorough database search to identify relevant trials, including CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, CINAHL, and trial registries. Two review authors will independently handle the screening of literature and data extraction. Each trial will be evaluated for major sources of bias with the "classic risk of bias tool" used in the Cochrane Collaboration tool from 2011. We will use Review manager (RevMan) or R with the meta package to perform the meta-analysis. We will perform a trial sequential analysis on the meta-analysis of our primary outcome, providing an estimate of statistical reliability. Two review authors will independently assess the quality of the body of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We will use GRADEpro software to conduct the GRADE assessments and to create "Summary of the findings" tables.

Using implementation science to decrease variation and high opioid administration in a surgical ICU.

High doses and prolonged duration of opioids are associated with tolerance, dependence, and increased mortality. Unfortunately, despite recent efforts to curb outpatient opioid prescribing because of the ongoing epidemic, utilization remains high in the intensive care setting, with intubated patients commonly receiving infusions with a potency much higher than doses required to achieve pain control. We attempted to use implementation science techniques to monitor and reduce excessive opioid prescribing in ventilated patients in our Surgical ICU. We conducted a prospective study investigating opioid administration in a closed SICU at an academic medical center over 18 months. Commonly accepted conversions were used to aggregate daily patient opioid use. Patients with a history of chronic opioid use and those being treated with an ICP monitor/drain, neuromuscular blocker, or ECMO were excluded. If the patient spent a portion of a day on a ventilator, that day's total was included in the "vent group." MMEs per patient were collected for each patient and assigned to the on-call intensivist. Intensivists were blinded to the data for the first seven months. They were then provided with academic detailing followed by audit & feedback over the subsequent 11 months, demonstrating how opioid utilization during their time in the SICU compared to the unit average and a blinded list of the other attendings. Student's T-tests were performed to compare opioid utilization before and after initiation of academic detailing and audit & feedback. Opioid utilization in patients on a ventilator decreased by 20.1% during the feedback period, including less variation among all intensivists and a 30.9% reduction by the highest prescribers. Implementation science approaches can effectively reduce variation in opioid prescribing, especially for high outliers in a SICU. These interventions may reduce the risks associated with prolonged use of high-dose opioids. Prospective pre-post-intervention, Level II.

Comparative characteristics of the effectiveness of spinal anesthesia based on bupivacaine in combination with different intrathecal doses of dexmedetomidine

Background. To increase the quality of a block, corresponding adjuvants are used intrathecally. However, currently, the interrelation between different doses of intrathecal dexmedetomidine as an adjuvant, differential analgesia, and the effectiveness of a spinal block is not adequately elucidated. The purpose: to conduct a comparative analysis on the effectiveness of motor (MB) and sensory block (SB), as well as to evaluate the clinical efficiency of analgesia during spinal anesthesia based on bupivacaine in combination with various intrathecal doses of dexmedetomidine. Materials and methods. The study included 150 patients with a mean age of 41.3 ± 8.2 years who underwent biportal endoscopic discectomy. Participants were divided into the following groups: group 1 (n = 30) — intrathecal administration of 2.5 ml bupivacaine combined with intrathecal administration of 2.5 µg dexmedetomidine; group 2 (n = 30) — intrathecal use of 2.5 ml bupivacaine with intrathecal administration of 5 µg dexmedetomidine; group 3 (n = 30) — intrathecal administration of 2.5 ml bupivacaine combined with intrathecal administration of 10 µg dexmedetomidine. In the groups, the sensory and motor status of patients and the level of analgesia were assessed. Results. The time of a SB onset was 22.78 ± 2.04 % higher in group 1 than in group 2 and 37.42 ± 2.75 % higher compared to group 3. The time of a MB onset in group 1 was 9.16 ± 1.32 % higher than in group 2 and 20.17 ± 2.36 % higher compared to group 3. In group 1, the time of a two-segment sensory regression was 21.38 ± 2.18 % lower than in group 2 and 36.40 ± 2.81 % lower than in group 3. The duration of a MB in group 3 was 18.23 ± 2.21 % higher compared to group 2 and 42.39 ± 3.05 % higher than in group 1. In group 3, the indicators of differential analgesia were 110.74 ± 4.53 % higher compared to group 2 and 202.39 ± 5.72 % higher than in group 1. Conclusions. Increasing the intrathecal dose of dexmedetomidine resulted in a reduction in the time of a sensory block onset, while the duration of a motor block increased. The indicators of analgesia duration also directly proportionally increased with the escalation of dexmedetomidine dosage.

Use of sugammadex in prevention of post-operative urinary retention in minimally invasive hernia surgery.

Post-operative urinary retention (POUR) is a known complication of hernia surgery. Minimally invasive inguinal hernia repair (IHR) is typically done under general anesthesia with neuromuscular blockade (NMB), which is commonly reversed with an anticholinesterase inhibitor paired with an anticholinergic agent. Sugammadex is a unique NMB reversal agent that does not have to be paired with an anticholinergic. We sought to explore the role of sugammadex in reducing the rate of POUR following these procedures. Data were collected retrospectively at a single institution between February 2016 and October 2019. We identified and studied patients who underwent minimally invasive IHR and received either sugammadex or neostigmine/glycopyrrolate for NMB reversal. The primary endpoint was POUR requiring bladder catheterization. Secondary endpoints included post-operative and 30-day readmissions. 274 patients were included in this study (143 received neostigmine and glycopyrrolate, 131 sugammadex). The sugammadex patients were on average 5years older than the neostigmine/ glycopyrrolate patients (63.2 vs 58.2, p = 0.003), and received less median intravenous fluids (IVF) (900ml vs 1000ml; p = 0.015). There was a significant difference in the rate of POUR between the sugammadex and neostigmine/glycopyrrolate patients (0.0% vs 8.4%, p ≤ 0.001). The difference remained significant after controlling for age and IVF. The odds of POUR for those who received neostigmine/glycopyrrolate were 25 × higher than the odds of those who received sugammadex. The results of this study reflect the protective role of sugammadex against POUR in minimally invasive IHR cases.

Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach.

Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results. We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.

Effective bolus dose of remimazolam for i-gel® insertion in nonparalyzed patients: a dose-finding study.

Remimazolam is a recently developed ultra-short-acting benzodiazepine used for anesthesia induction and maintenance. Nevertheless, the effective bolus dose of remimazolam for i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK) insertion without the use of neuromuscular blocking agents (NMBAs) has not been well established. This study included 25 adult patients scheduled for surgery under general anesthesia who were eligible for i-gel use. Anesthesia was induced with predetermined bolus doses of remimazolam, starting at 0.3mg·kg-1 for the first patient, without the use of NMBAs. All patients concurrently received remifentanil using target-controlled infusion (TCI) at a fixed effect-site concentration (Ce) of 3.0ng·mL-1. Insertion of the i-gel was attempted 90sec after remimazolam administration, and insertion conditions were assessed. Subsequent doses of remimazolam were decreased or increased by 0.05mg·kg-1, depending on the success or failure of i-gel insertion. The mean (standard deviation) 50% effective dose (ED50) of a remimazolam bolus for successful i-gel insertion as determined by the modified Dixon's up-and-down method was 0.100 (0.027)mg·kg-1. The ED50 and ED95 estimated by isotonic regression were 0.111 (83% confidence interval [CI], 0.096 to 0.131)mg·kg-1 and 0.182 (95% CI, 0.144 to 0.195)mg·kg-1, respectively. None of the patients required treatment for hypotension or bradycardia during anesthesia induction. Based on the ED95 of remimazolam bolus dose determined in our study, we recommend using 0.182mg·kg-1 of remimazolam in combination with remifentanil TCI at a Ce of 3.0ng·mL-1 for successful i-gel insertion without NMBAs in adult patients. This regimen seems effective with a low risk of hemodynamic instability during anesthesia induction. ClinicalTrials.gov ( NCT05298228 ); first submitted 6 March 2022.

Obstructive Sleep Apnea and Risk of Postoperative Complications after Non-Cardiac Surgery

Obstructive sleep apnea (OSA), a common sleep disorder, poses significant challenges in perioperative management due to its complexity and multifactorial nature. With a global prevalence of approximately 22.6%, OSA often remains undiagnosed, and increases the risk of cardiac and respiratory postoperative complications. Preoperative screening has become essential in many institutions to identify patients at increased risk, and experts recommend proceeding with surgery in the absence of severe symptoms, albeit with heightened postoperative monitoring. Anesthetic and sedative agents exacerbate upper airway collapsibility and depress central respiratory activity, complicating intraoperative management, especially with neuromuscular blockade use. Additionally, OSA patients are particularly prone to opioid-induced respiratory depression, given their increased sensitivity to opioids and heightened pain perception. Thus, regional anesthesia and multimodal analgesia are strongly advocated to reduce perioperative complication risks. Postoperative care for OSA patients necessitates vigilant monitoring and tailored management strategies, such as supplemental oxygen and Positive Airway Pressure therapy, to minimize cardiorespiratory complications. Health care institutions are increasingly focusing on enhanced monitoring and resource allocation for patient safety. However, the rising prevalence of OSA, heterogeneity in disease severity, and lack of evidence for the efficacy of costly perioperative measures pose challenges. The development of effective screening and monitoring algorithms, alongside reliable risk predictors, is crucial for identifying OSA patients needing extended postoperative care. This review emphasizes a multidimensional approach in managing OSA patients throughout the perioperative period, aiming to optimize patient outcomes and minimize adverse outcomes.

Pericapsular Nervous Group Block versus Suprainguinal Fascia Iliaca Block Using the Same Injection Volume in Primary HIP Arthroplasty Prospective Observational Study

Objectives. To determine the pericapsular nerve group (PENG) block’s postoperative analgesic efficacy and safety compared to the suprainguinal fascia iliaca (SFI) block in patients undergoing primary hip arthroplasty using the same injectate volume. Material and Methods. Between January 2021 and March 2022, American Society of Anesthesiologists Physical Status (ASA-PS) classification I–III patients scheduled for hip arthroplasty were included in this study. After standard monitoring and subarachnoid anesthesia, an ultrasound-guided PENG or SFI block with 20 ml of 0.25% levobupivacaine was performed for postoperative analgesia. All patients were assessed with a numerical rating scale (NRS) at presurgery, upon arrival at the postanesthesia care unit (PACU), and in the postoperative period at 2, 4, 12, and 24 hours. The need for analgesic rescue and adverse effects was also assessed. Results. A total of 130 patients were included in the study (62 PENG block and 68 SFI block). Both blocks were equally effective in managing postoperative pain without any statistically significant differences except at 12 h (p=0.023), where the deviation found was not clinically relevant. The median total morphine consumption was 0 mg [0–2] in the PENG block group and 0 mg [0–2] in the SFI block group. A more significant motor block was found in the first 6 hours in the SFI block group (p=0.001). There was no significant difference in the ease of performing PENG (79%) or SFI (85%) blocks. No major complications were recorded in both groups, and patient satisfaction was high (83.9% for the PENG block group vs. 91.2% for the SFI block group). Discussion. Both blocks have been demonstrated to be effective for postoperative analgesia in hip arthroplasty and should be integrated as a multimodal analgesic strategy. The lesser degree of motor block recorded in the first hours with the PENG block makes it the most suitable option for early recovery. Both techniques were easy and safe to perform.

The effect of common paralytic agents used for fluorescence imaging on redox tone and ATP levels in Caenorhabditis elegans.

One aspect of Caenorhabditis elegans that makes it a highly valuable model organism is the ease of use of in vivo genetic reporters, facilitated by its transparent cuticle and highly tractable genetics. Despite the rapid advancement of these technologies, worms must be paralyzed for most imaging applications, and few investigations have characterized the impacts of common chemical anesthetic methods on the parameters measured, in particular biochemical measurements such as cellular energetics and redox tone. Using two dynamic reporters, QUEEN-2m for relative ATP levels and reduction-oxidation sensitive GFP (roGFP) for redox tone, we assess the impact of commonly used chemical paralytics. We report that no chemical anesthetic is entirely effective at doses required for full paralysis without altering redox tone or ATP levels, and that anesthetic use alters the detected outcome of rotenone exposure on relative ATP levels and redox tone. We also assess the use of cold shock, commonly used in combination with physical restraint methods, and find that cold shock does not alter either ATP levels or redox tone. In addition to informing which paralytics are most appropriate for research in these topics, we highlight the need for tailoring the use of anesthetics to different endpoints and experimental questions. Further, we reinforce the need for developing less disruptive paralytic methods for optimal imaging of dynamic in vivo reporters.

Ensemble-Based Virtual Screening Led to the Discovery of Novel Lead Molecules as Potential NMBAs

Neuromuscular blocking agents (NMBAs) are routinely used during anesthesia to relax skeletal muscle. Nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels; NMBAs can induce muscle paralysis by preventing the neurotransmitter acetylcholine (ACh) from binding to nAChRs situated on the postsynaptic membranes. Despite widespread efforts, it is still a great challenge to find new NMBAs since the introduction of cisatracurium in 1995. In this work, an effective ensemble-based virtual screening method, including molecular property filters, 3D pharmacophore model, and molecular docking, was applied to discover potential NMBAs from the ZINC15 database. The results showed that screened hit compounds had better docking scores than the reference compound d-tubocurarine. In order to further investigate the binding modes between the hit compounds and nAChRs at simulated physiological conditions, the molecular dynamics simulation was performed. Deep analysis of the simulation results revealed that ZINC257459695 can stably bind to nAChRs’ active sites and interact with the key residue Asp165. The binding free energies were also calculated for the obtained hits using the MM/GBSA method. In silico ADMET calculations were performed to assess the pharmacokinetic properties of hit compounds in the human body. Overall, the identified ZINC257459695 may be a promising lead compound for developing new NMBAs as an adjunct to general anesthesia, necessitating further investigations.

Randomised control trial comparing postoperative analgesia between nalbuphine and fentanyl as an adjuvant with intrathecal levobupivacaine for lower abdominal gynaecological surgeries

Background Effective post-operative pain management is crucial for patient comfort and recovery following lower abdominal gynaecological surgeries. This study protocol outlines a randomised control trial designed to compare the efficacy and safety of two intrathecal adjuvants, nalbuphine and fentanyl, in conjunction with hyperbaric levobupivacaine for postoperative analgesia. Methods The study will be conducted at the Department of Anaesthesiology, Jawaharlal Nehru Medical College, DMIMS (DU), and affiliated institutions. Sixty eligible patients aged 35-75 years undergoing lower abdominal gynaecological surgeries under subarachnoid block will be randomly assigned to one of two groups. Group A will receive nalbuphine with levobupivacaine, while Group B will receive fentanyl with levobupivacaine. Patients will be monitored for the duration of post-operative analgesia, onset of sensory and motor block, hemodynamic effects, and side effects. Outcomes The primary outcome is the comparison of post-operative analgesia duration between nalbuphine and fentanyl. Secondary outcomes include assessing sensory and motor block onset, hemodynamic changes, ephedrine usage, and side effects. Aim To evaluate the efficacy and safety of intrathecal nalbuphine and fentanyl as adjuvants with hyperbaric levobupivacaine for postoperative analgesia in lower abdominal gynaecological surgeries.

Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome

BackgroundIn acute respiratory distress syndrome (ARDS), respiratory drive often differs among patients with similar clinical characteristics. Readily observable factors like acid–base state, oxygenation, mechanics, and sedation depth do not fully explain drive heterogeneity. This study evaluated the relationship of systemic inflammation and vascular permeability markers with respiratory drive and clinical outcomes in ARDS.MethodsARDS patients enrolled in the multicenter EPVent-2 trial with requisite data and plasma biomarkers were included. Neuromuscular blockade recipients were excluded. Respiratory drive was measured as PES0.1, the change in esophageal pressure during the first 0.1 s of inspiratory effort. Plasma angiopoietin-2, interleukin-6, and interleukin-8 were measured concomitantly, and 60-day clinical outcomes evaluated.Results54.8% of 124 included patients had detectable respiratory drive (PES0.1 range of 0–5.1 cm H2O). Angiopoietin-2 and interleukin-8, but not interleukin-6, were associated with respiratory drive independently of acid–base, oxygenation, respiratory mechanics, and sedation depth. Sedation depth was not significantly associated with PES0.1 in an unadjusted model, or after adjusting for mechanics and chemoreceptor input. However, upon adding angiopoietin-2, interleukin-6, or interleukin-8 to models, lighter sedation was significantly associated with higher PES0.1. Risk of death was less with moderate drive (PES0.1 of 0.5–2.9 cm H2O) compared to either lower drive (hazard ratio 1.58, 95% CI 0.82–3.05) or higher drive (2.63, 95% CI 1.21–5.70) (p = 0.049).ConclusionsAmong patients with ARDS, systemic inflammatory and vascular permeability markers were independently associated with higher respiratory drive. The heterogeneous response of respiratory drive to varying sedation depth may be explained in part by differences in inflammation and vascular permeability.

Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial

BackgroundGeneral anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatients. This study aimed to investigate the effect of transitioning from propofol to remimazolam with flumazenil reversal administered toward the end of surgery during propofol-based total intravenous anesthesia (TIVA) on recovery.MethodsAdults with mental disabilities scheduled to undergo dental treatment were randomly assigned to receive either propofol-based TIVA (Group P) or propofol-remimazolam-based TIVA with flumazenil reversal (Group PR). Propofol was replaced with remimazolam 1 h before the end of surgery in Group PR; moreover, 0.5 mg of flumazenil was administered after the neuromuscular blockade reversal agent. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). The secondary outcomes included time to eye-opening, time to extubation, occurrence of PONV, and quality of recovery.ResultsFifty-four patients were included in this study. The duration of stay in the PACU in Group PR was significantly shorter than that in Group P (mean difference, 8.7 min; confidence interval [95% CI], 3.3–14.2; P = 0.002). Group PR exhibited a shorter time to eye opening (mean difference, 5.4 min; 95% CI, 3.3–8.1; P < 0.001) and time to extubation (mean difference, 5.5 min; 95% CI, 3.6–7.9; P < 0.001) than Group P. Neither group required the administration of rescue analgesics, and the incidence of PONV was not reported.ConclusionsTransitioning from propofol to remimazolam 1 h before the end of surgery followed by flumazenil reversal reduced the duration of stay in the PACU and the time to eye opening and extubation without affecting the incidence of PONV and quality of recovery.Trial registration numberClinical Research Information Service (KCT0007794), Clinical trial first registration date: 12/10/2022.

[Evaluation of monitoring and reversal habits of neuromuscular blockade by anesthesiologists in Hungary].

[Evaluation of monitoring and reversal habits of neuromuscular blockade by anesthesiologists in Hungary].

Comparison of the effect of intraoperative dexmedetomidine versus ketamine on postoperative analgesia in fracture femur patients operated under subarachnoid block – A prospective randomized double-blind controlled trial

Abstract Background and Aims: Intravenous sedation during spinal anesthesia has the advantages of increased duration of spinal anesthesia and better postoperative pain control. The aim of this study was to compare the effect of intravenous bolus and infusion of dexmedetomidine versus ketamine given intraoperative on the postoperative analgesia in fracture femur patients operated under subarachnoid block. Material and Methods: In this prospective randomized double-blind controlled study, 75 patients aged 18–65 years posted for elective surgery were selected and randomly divided into three groups to receive ketamine (group K), dexmedetomidine (group D), and saline (control group C). Postoperative pain was evaluated using the numerical rating scale (NRS). The duration of analgesia and the amount of analgesic consumption were also recorded. Student’s t-test and Chi-square test were used to compare the two groups, and one-way ANOVA with posthoc analysis was performed for comparison of the three groups. Results: Patients in the ketamine group had better postoperative analgesia as assessed by decreased pain (on the NRS scale) and decreased need for postoperative rescue analgesics (P &lt; 0.001). The duration of sensory block and motor block was prolonged in group K as compared to the other two groups (P &lt; 0.001). Conclusion: Intraoperative use of intravenous ketamine was superior to dexmedetomidine for postoperative analgesia in fracture femur patients operated under subarachnoid block.

Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment caesarean section: a randomised controlled study.

Opioids are commonly added to local anaesthetic for subarachnoid block for caesarean section due to their synergistic effects. The physiochemical characteristics of opioids suggest premixing with hyperbaric bupivacaine may limit their distribution within the CSF. We studied the effect of a separate injection with a combination of bupivacaine, morphine and fentanyl on block characteristics, haemodynamic changes, postoperative pain and patient satisfaction. Following ethical approval and informed consent, a prospective double-blinded randomised controlled trial was performed in a university hospital. A total of 126 patients undergoing caesarean section were randomised to two groups. In group M, the premixed group, patients received 12mg of hyperbaric bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine injected as a single mixture. In group S, the separate injection group, patients received the same drugs in separate injections. Measurements included haemodynamics, block distribution, intra- and postoperative pain, as well as patient satisfaction. Patients in both groups had similar block height, time to maximum sensory block, time to block regression and motor block. However, haemodynamics were different between the groups. The proportion of systolic hypotension episodes was greater in group S [159/1320 (12.05%)] than group M [113/1452 (7.78%)], with P = 0.0002. Moreover, a greater amount of ephedrine was administered in group S than group M, with values 12.09 (8.1) and 9.09 (8.5) mg respectively (P = 0.001). Additionally, postoperative pain, as measured by the Visual Analogue Scale (VAS), was greater in group M, with a VAS of 4.6 (1.7), vs. group S, which recorded a VAS of 3.8 (2.0) (P = 0.017). Sequential injection of intrathecal opioids and hyperbaric bupivacaine resulted in greater early haemodynamic instability and slightly better postoperative analgesia without any difference in block height or patient satisfaction. NCT04403724.

The role of mivacurium in contemporary anesthesiology: a narrative review

Background: Mivacurium is the shortest-acting non-depolarizing neuromuscular blocking agent (NMBA) with a rapid onset of action that is mainly used for short procedures. Despite the fact that mivacurium has a very favorable average 6-minute recovery index after its infusion in comparison to the approximately 15–30 minutes for atracurium, mivacurium is still not really popular among practicing anesthesiologists. Many new studies showing the potential further benefits of implementing mivacurium into daily practice are still being published. Aim of the Study: This study aimed to focus on spreading the common knowledge about the detailed pharmacokinetic and pharmacodynamic properties of mivacurium as a medication that has yet to be used widely by practicing anesthesiologists. Material and methods: The literature review was conducted using the common sources of original articles such as PubMed and Google Scholar from 1975 to September 2022. Results: Based on the literature review, we observed that Mivacurium at a dosage of 6μg produces a lower impact on hemodynamics, shorter intubation and extubation times, faster postoperative recovery, absence of the accumulation of neuromuscular blockade, higher safety, and no significant increase in allergic related adverse events in comparison with other NMBAs.Conclusions: Mivacurium is a muscle relaxant medication that is particularly suited for short-lasting surgical procedures. However, it is important to remember that existing mutations in the butyrylcholinesterase enzyme (BChE) may prolong the effect of the neuromuscular blockade due to significantly reducing plasma cholinesterase activity. Therefore, it is advised to stay cautious during its use as more research needs to be done to be able to thoroughly assess the potential advantages and disadvantages of mivacurium introduction in particular patients