Return Of Spontaneous Respiration Research Articles

Comparison of Response First Technique with Reversal First Technique for Quality of Extubation in Patients Undergoing Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial.

Early and smooth extubation following anesthesia is an important concern in patients undergoing transsphenoidal pituitary surgery to permit early neurological evaluation and prevent complications. The aim was to compare the RESPONSE FIRST and REVERSAL FIRST techniques for quality of extubation (QOE) in patients undergoing endoscopic transsphenoidal pituitary surgery. Fifty-six patients aged 18-60 years, with American Society of Anesthesiologists Physical Statuses I-II, and undergoing transsphenoidal surgery for pituitary tumors were randomized into either the RESPONSE FIRST group, in which neuromuscular reversal was given following the patient's response to oral commands, or the REVERSAL FIRST group, in which reversal of neuromuscular blockade (NMB) was given at the return of spontaneous respiration. QOE was the primary outcome. Hemodynamic response, jugular venous oxygen saturation (SjVO2), time to extubation, and awareness during emergence were assessed as secondary outcomes. The QOE in the RESPONSE FIRST group was significantly better than the REVERSAL FIRST group (mean (interquartile range (IQR)), 18 (17-19) vs 14 (12-14.75), P < 0.001). Heart rate (HR) and mean arterial pressure (MAP) were better in the RESPONSE FIRST group when compared to the REVERSAL FIRST group at the time of extubation, at 5 minutes, and 15 minutes following extubation (P < 0.05). SjVO2values were higher in the REVERSAL FIRST group as compared to the RESPONSE FIRST group during extubation and at 5 minutes after extubation (P < 0.01). There was no significant difference in the time to extubation between the groups (P = 0.73). The RESPONSE FIRST technique is associated with better QOE and preservation of systemic and cerebral hemodynamics during extubation in patients undergoing transsphenoidal pituitary surgery when compared to the REVERSAL FIRST technique.

Recovery process and determinants of adverse event occurrence in bronchoscopic procedures performed under general anaesthesia.

Regarding the fact that rigid bronchoscopy is generally performed under general anaesthesia and this patient subgroup is remarkably morbid, encountering procedure and/or anaesthesia related complications are highly likely. Here, we aimed to assess factors influencing recovery and detect possible determinants of adverse event occurrence during these operations performed in a tertiary referral centre. Eighty-one consecutive ASA I-IV patients were recruited for this investigation. In the operating theatre after induction of anaesthesia and advancement of the device, maintenance was provided with total intravenous anaesthesia. Neuromuscular blockage was invariably administered, and patients were ventilated manually. In addition to preoperative demographic and procedural characteristics, perioperative hemodynamic variables, recovery times and observed adverse events were noted. Basic demographic properties, ASA and Mallampati scores, and procedure specific variables as lesion localization, lesion and procedure type were comparable among groups assembled with reference to event occurrence. Patients who had experienced adverse event had higher heart rates. Recovery times were comparable between Event (-) and Event (+) groups. Relationship of recovery process were individually tested with all variables and only lesion type was detected to have an effect on respiration and extubation times. Among all parameters only procedural time seemed to be associated with adverse event occurrence (mins, 22.9 ± 11.9 vs 41.6 ± 28.8, P < .001). Recovery times related with return of spontaneous respiration were significantly lower in procedures performed for treatment of tumoral diseases in this study and procedure length was determined to be the ultimate factor which had an impact on adverse event occurrence.

Comparison of the effect of intravenous dexmedetomidine and lignocaine spray instilled into the endotracheal tube on extubation response in patients undergoing spine surgery

Abstract Background: In spine surgery rapid emergence and extubation with haemodynamic stability is crucial for early neurological examination. Here, we have studied the effect of α2 agonist – dexmedetomidine intravenous (IV) and lignocaine spray instilled into the endotracheal tube at the end of the procedure to attenuate the extubation responses. Methods: A total of 45 patients undergoing spine surgery were randomly allocated in three groups. After the return of spontaneous respiration, Group-D: Dexmedetomidine 0.3 mcg/kg IV, Group-L: 10% lignocaine spray 1.5 mg/kg through endotracheal route and Group-P: Normal saline IV given over 60 s. Haemodynamic responses (systolic blood pressure, diastolic blood pressure, mean arterial pressure [MAP], heart rate [HR] and SpO2) were recorded before and after administration of drugs and also duration of emergence, extubation, quality of extubation and post-operative sedation level were evaluated. Results: The increase in MAP and HR during extubation was significantly less in Group-D than Group-L and Group-P, 2 min after administration of the respective drugs (P &lt; 0.05). There were no significant differences in the grade of a cough after extubation and post-operative sedation level. Conclusion: Dexmedetomidine (0.3 mcg/kg) attenuates haemodynamic response better than lignocaine spray (1.5 mg/kg) during emergence and extubation. It also provides smooth extubation and easy recovery without any post-operative sedative effect.

Reversal of Vecuronium-induced Neuromuscular Blockade with Sugammadex in a Child with Moebius Syndrome after Accidental Extubation

Sugammadex chemically encapsulates rocuronium and vecuronium, thereby rapidly terminating the neuromuscular blockade induced by these agents. Although the experience with the use of sugammadex in children under 2 years of age is limited, it may be considered in specific clinical contexts. We present a case where spontaneous efficient respiratory effort was resumed after reversal of vecuroniuminduced neuromuscular blockade with sugammadex in a child. A 21-month-old boy with a history of Moebius syndrome and obstructive sleep apnea needing night time noninvasive ventilation support was scheduled for adenotonsillectomy and bilateral myringotomy. Tracheal intubation was anticipated to be difficult and so it was performed using a videolaryngoscope. In the postoperative period the child remained intubated in the intensive care unit sedated and with a continuous infusion of vecuronium. On day 3 accidental extubation occurred. As it was considered an urgent situation, flumazenil, naloxone and sugammadex 2 mg.kg-1 were administered with rapid return of spontaneous respiration and consciousness, obviating the need of unnecessary airway manipulation and the inherent risks.

A response to ‘The Glidescope® system: a clinical assessment of performance’

We read with interest the clinical assessment of the GlideScope® Video Intubation System by Drs Rai, Dering and Verghese [1]. Another possible application of this device is inspection of the vocal cords following thyroidectomy. Occasionally the surgeon may ask the anaesthetist to view the patient's vocal cords in an attempt to seek reassurance that the recurrent laryngeal nerve has not been damaged during dissection [2]. This manoeuvre is not always easy in the emerging patient and the fibreoptic laryngoscope has been used for this purpose [3, 4]. After the return of spontaneous respiration and extubation of the trachea, the patient is maintained at a suitable depth of anaesthesia so that the GlideScope® can be gently inserted into the patient's mouth. This allows the larynx to be displayed on a screen and both anaesthetist and surgeon can observe whether or not the vocal cords are moving normally.

Pharmacology of flumazenil.

Flumazenil, an imidazobenzodiazepine, is the first benzodiazepine antagonist available for clinical use. It is a specific competitive antagonist at benzodiazepine receptors, which are associated with receptors for gamma-aminobutyric acid, the most important inhibitory neurotransmitter in the central nervous system. Administered orally, it has a low bioavailability and the preferred route is intravenous. Its usual clinical role is to reverse the effects of benzodiazepine sedation; however, administered before, or with, other benzodiazepines, it modifies their effects, the extent of such modification depending on the dose, duration of effect and relative receptor affinity of the agonist. Flumazenil also reverses adverse physiological effects of benzodiazepines. Its indications include reversal of benzodiazepine-induced sedation, termination of benzodiazepine-induced anaesthesia, return of spontaneous respiration and consciousness in intensive care patients and the treatment of paradoxical reactions to benzodiazepines. Other potential indications include its use in hepatic encephalopathy, alcohol intoxication and coma; however, these claims still require substantiation. Following sedation reversed with flumazenil, minimal residual effects of the agonist can sometimes be detected using psychomotor tests and are due to the relatively short half-life of flumazenil, but are of no clinical consequence. There is concern that flumazenil could precipitate an acute withdrawal syndrome following long-term benzodiazepine administration; however, the available evidence suggests otherwise and that it could be useful in the treatment of benzodiazepine tolerance. The existence of flumazenil is important, with implications for future research and the development of minimally invasive therapy and day-case surgery. With increasing pressures on non-anaesthetically trained practitioners to perform sedation, flumazenil has important implications for safety.

Return of Spontaneous Respiration in an Infant Who Fulfilled Current Criteria to Determine Brain Death

It is generally assumed that the child's brain is more resistant to insults leading to death. Current guidelines for brain death, therefore, avoid application of these standards to young children.1 The determination of brain death in children, however, has become increasingly important, and different sets of new guidelines for children have been recently published.1-4 Especially, the recommendations of a special task force, consisting of representatives from neurologic organizations and the American Academy of Pediatrics, were published in five major journals.4 Those primary distinctions were three separate longer observation periods depending on the child's age and the necessity for two corroborating electroencephalograms (EEGs) or one EEG with a corroborating cerebral radionucleotide angiogram.

AN EVALUATION OF THE EFFECT OF METHOHEXITONE AND PROPANIDID ON BLOOD PRESSURE, PULSE RATE AND CARDIAC ARRHYTHMIA DURING ELECTROCONVULSIVE THERAPY

The effects of methohexitone and propanidid on the cardiovascular system of patients undergoing electroconvulsive therapy were evaluated on thirty-five patients. The anaesthetic and electroconvulsive therapy practice included intubation as a routine and pulmonary ventilation with 100 per cent oxygen between the administration of the shock and the onset of spontaneous respiration. The electrocardiogram was monitored continuously and the blood pressure and pulse rate were recorded at seven points in time during the procedure. In the evaluation only the first two treatment occasions were taken into consideration, methohexitone being used on one and propanidid on the other, the order for any given patient being determined at random. The effect of the order of the drugs was allowed for in the calculation of the results. Compared with propanidid, methohexitone was associated with higher systolic and diastolic blood pressures during the earlier stages and with lower pressures during the later stages. The higher blood pressures were in general associated with lower pulse rates and the lower pressures with slightly higher pulse rates. The return of spontaneous respiration was slower when propanidid rather than methohexitone was used. There was no reason to suspect a difference in the incidence of cardiac arrhythmia produced by the drugs.

SUXAMETHONIUM CHLORIDE IN INTRAOCULAR SURGERY

SUMMARY A series of 50 adult patients presenting for ophthalmic surgery was anaesthetized by a simple technique in which suxamethonium was used to facilitate endotracheal intubation. In the first 21 patients intraocular pressure was measured on the return of spontaneous respiration; a rise in pressure could not be demonstrated. When intraocular pressure was measured within 1 minute of the injection of suxamethonium, a rise in pressure was found in 20 of 29 patients. This rise was, however, transient and in all cases, including 10 patients with known glaucoma, the inferred intraocular pressure fell to or below the pre-operative level before the beginning of surgery.

Medical Aspects of Chemical Warfare

The action of nerve gas is to inhibit cholinesterase in the body and so to intensify the actions of existing acetylcholine. The primary cause of death is hypoxia, resulting from paralysis of both central and peripheral respiratory mechanisms. Atropine is therapeutic for certain of the autonomic and central nervous effects but has little if any effect against paralysis of the diaphragm and of accessory muscles of respiration. Therefore, the severe casualty will require artificial respiration until there is a return of spontaneous respiration. In the event of chemical warfare, nonmedical people will be responsible for rendering immediate treatment to the mass casualties that will result. The training of both civilian and military populations in treatment procedures is essential.