Use Of Neuromuscular Blockers Research Articles

Optimal Prone Position Duration in Patients With ARDS Due to COVID-19: The Omelette Pilot Trial.

Prone position (PP) has been widely used in the COVID-19 pandemic for ARDS management. However, the optimal length of a PP session is still controversial. This study aimed to evaluate the effects of prolonged versus standard PP duration in subjects with ARDS due to COVID-19. This was a single-center, randomized controlled, parallel, and open pilot trial including adult subjects diagnosed with severe ARDS due to COVID-19 receiving invasive mechanical ventilation that met criteria for PP between March-September 2021. Subjects were randomized to the intervention group of prolonged PP (48 h) versus the standard of care PP (∼16 h). The primary outcome variable for the trial was ventilator-free days (VFDs) to day 28. We enrolled 60 subjects. VFDs were not significantly different in the standard PP group (18 [interquartile range [IQR] 0-23] VFDs vs 7.5 [IQR 0-19.0] VFDs; difference, -10.5 (95% CI -3.5 to 19.0, P = .08). Prolonged PP was associated with longer time to successful extubation in survivors (13.00 [IQR 8.75-26.00] d vs 8.00 [IQR 5.00-10.25] d; difference, 5 [95% CI 0-15], P = .001). Prolonged PP was also significantly associated with longer ICU stay (18.5 [IQR 11.8-25.3] d vs 11.50 [IQR 7.75-25.00] d, P = .050) and extended administration of neuromuscular blockers (12.50 [IQR 5.75-20.00] d vs 5.0 [IQR 2.0-14.5] d, P = .005). Prolonged PP was associated with significant muscular impairment according to lower Medical Research Council values (59.6 [IQR 59.1-60.0] vs 56.5 [IQR 54.1-58.9], P = .02). Among subjects with severe ARDS due to COVID-19, there was no difference in 28-d VFDs between prolonged and standard PP strategy. However, prolonged PP was associated with a longer ICU stay, increased use of neuromuscular blockers, and greater muscular impairment. This suggests that prolonged PP is not superior to the current recommended standard of care.

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.

Delirium in patients with COVID-19 treated in the intensive care unit.

Coronavirus disease 2019 (COVID-19) can lead to acute organ dysfunction, and delirium is associated with long-term cognitive impairment and a prolonged hospital stay. This retrospective single-center study aimed to investigate the risk factors for delirium in patients with COVID-19 infection receiving treatment in an intensive care unit (ICU). A total of 111 patients aged >18 years with COVID-19 pneumonia who required oxygen therapy from February 2021 to April 2022 were included. Data on patient demographics, past medical history, disease severity, delirium, and treatment strategies during hospitalization were obtained from electronic health records. Patient characteristics and risk factors for delirium were analyzed. Old age (P < 0.001), hypertension (P < 0.001), disease severity (Sequential Organ Failure Assessment score) (P < 0.001), mechanical ventilator support (P < 0.001), neuromuscular blocker use (P < 0.001), and length of stay in the ICU (P < 0.001) showed statistically significant differences on the univariable analysis. Multivariable analysis with backward selection revealed that old age (odds ratio, 1.149; 95% confidence interval, 1.037-1.273; P = 0.008), hypertension (odds ratio, 8.651; 95% confidence interval, 1.322-56.163; P = 0.024), mechanical ventilator support (odds ratio, 226.215; 95% confidence interval, 15.780-3243.330; P < 0.001), and length of stay in the ICU (odds ratio, 30.295; 95% confidence interval, 2.539-361.406; P = 0.007) were significant risk factors for delirium. In conclusion, old age, ICU stay, hypertension, mechanical ventilator support, and neuromuscular blocker use were predictive factors for delirium in COVID-19 patients in the ICU. The study findings suggest the need for predicting the occurrence of delirium in advance and preventing and treating delirium.

Thigh ultrasound monitoring identifies muscle atrophy in mechanically ventilated pediatric patients.

Over the last decade, ultrasonography has taken on an increasingly important role in the daily management of critically patients and has recently been proposed as a means of measuring muscle volume and architecture. This study had two main aims: to monitor for the onset of muscle atrophy in mechanically ventilated pediatric patients during stays in a pediatric intensive care unit based on quadriceps femoris muscle thickness measurements and to study whether demographic and clinical variables have an impact on muscle loss in critically children. The study followed a prospective, observational, single-center design. The sample included all children admitted to our pediatric intensive care unit (PICU) who required mechanical ventilation for more than 48h. Two trained clinicians measured the thickness of the quadriceps using a 12-MHz linear ultrasound transducer within 24h of initiating invasive mechanical ventilation and again at 72h, 1week, and weekly thereafter until extubation. For the entire cohort, quadriceps femoris muscle thickness decreased by 4.67% on average (IQR = -13.4 to -0.59) between the first two assessments and 13% by the time of the final measurement (IQR = -24 to -0.5%) or 1.57%/day (p < 0.001). Approximately half of all the children (23/41; 56%) experienced muscle atrophy (defined a priori as a decrease in thickness of 10% or more). Bivariate analyses revealed that increasing age, being a child (vs. infant), cumulative energy and protein deficit, highest C-reactive protein value, exposure to neuromuscular blockers, and a longer stay in the PICU were all predictive of a greater decrease in thickness. In a multivariate model, exposure to neuromuscular blockers was linked with greater muscle loss. Conclusion: In mechanically ventilated children, point-of-care ultrasonography can identify skeletal muscle atrophy. Muscle atrophy of limbs is strongly associated with the use of neuromuscular blockers. Ultrasound-based monitoring of the quadriceps femoris is a clinically useful tool for assessing muscle mass that can provide information on nutritional status and guide rehabilitation. What is Known: • ICU-acquired muscle atrophy is common and has a deleterious effect on adult outcomes. The prevalence and severity of muscular atrophy in critically ill children, however, are poorly understood. • Point-of-care ultrasonography has been put forward as an accurate, reliable method for monitoring variations in muscle mass.. What is New: • The quadriceps femoris muscle tends to suffer an intense loss of thickness early on in most critically ill children. • Quadriceps femoris ultrasound monitoring is a helpful tool for measuring muscle thickness and could lead to the development of novel therapies for critically ill children.

Propensity of use of neuromuscular blocking agents among Indian anaesthesiologists: A questionnaire-based survey

This survey aimed to understand the use of neuromuscular blockers (NMBs) with respect to neuromuscular monitoring, reversal of residual neuromuscular block, and incidence of adverse events among Indian anaesthesiologists.A 40-item questionnaire was sent to 250 anaesthesiologists across India via email and their responses were statistically analysed.The response rate was 50%. To facilitate tracheal intubation, 81.0% respondents preferred cisatracurium, 72.2% preferred atracurium, 43.7% preferred vecuronium, 58.7% preferred rocuronium, and 70.6% preferred succinylcholine. Safety and recovery time are the most important criteria for an ideal NMB. About 84% respondents expressed concerns about the adverse effects of NMBs, especially recovery of neuromuscular function (31.1%) and hemodynamic effects (26.4%). The train-of-four (TOF) ratio for residual paralysis was not checked by 57% respondents. Reversal agents were used by &amp;#62;2/3 respondents; however, 86.5% used them after cisatracurium was used. Concerns about adverse effects of anticholinesterase/antimuscarinic agents were expressed by 63.4% respondents, while 85% expressed the need for availability of sugammadex in India. Almost two-thirds opined that conventional nerve stimulators and quantitative TOF monitors should be available in the operating room.The survey showed that safety and recovery time are the most important parameters in selecting an NMB. Cisatracurium was the most widely used NMB for tracheal intubation because of its safety, duration of action, less anaphylactic reactions, and fewer hemodynamic fluctuations. The use of TOF for monitoring was low. While reversal agents were used by &amp;#62;2/3 respondents, many respondents used them after cisatracurium was used as an NMB.

The effect of neuromuscular blockade reversal agents on postoperative pulmonary complications in patients undergoing femur fracture repair surgery: A retrospective observational study.

Femoral fracture repair surgery under general anesthesia is associated with postoperative pulmonary complications (PPCs). However, information on PPCs caused by residual neuromuscular blockade following perioperative use of neuromuscular blockers is limited. This study aimed to identify the differences in the incidence of PPCs according to the type of neuromuscular blockade reversal agent used in femoral fracture repair surgery, as well as the risk factors for PPCs. We retrospectively analyzed the electronic medical records of 604 patients aged >18 years who underwent general anesthesia for femoral fracture repair surgery at a single university hospital between March 2017 and March 2022. Patients in whom sugammadex or anticholinesterase was used to reverse the neuromuscular block were subjected to propensity score matching. Multivariate logistic regression analysis was performed to identify risk factors for PPCs. Among the 604 patients, 108 were matched in each group. The incidence rates of PPCs overall and in the anticholinesterase and sugammadex groups were 7.0%, 8.3%, and 5.6%, respectively, with no significant differences between the groups. Older age, higher American Society of Anesthesiologists physical status, and lower preoperative oxygen saturation were risk factors, whereas emergency surgery was a preventive factor. Our results demonstrated that the incidence of PPC did not differ significantly between sugammadex and anticholinesterase in patients undergoing femur fracture repair under general anesthesia. Identifying the risk factors and confirming complete recovery from neuromuscular blockade might be more important.

Clinical presentation, ICU management and outcome in severe COVID-19 disease – A prospective observational study

Aim: We conducted a prospective, observational study to describe the clinical characteristics, management, and outcomes of patients with moderate to severe coronavirus disease admitted to the Intensive Care Unit (ICU). Methods: The study was conducted from 1st July 2020 to 31st December 2020. The criteria for ICU admission included a positive Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) for the novel Coronavirus (SARS-CoV-2) and oxygen saturation of less than 90% with or without oxygen. Results: A total of 621 patients were included (median age, 59 years [interquartile range {IQR}, 48-68]; 75.8% were males. The common comorbidities were hypertension (323 [52%]), and diabetes mellitus. 96 (15.5%) patients underwent mechanical ventilation, 18 (2.9%) received renal replacement therapy, and 223 (36%) died. The median age in non-survivors was significantly higher [63 years (IQR 55-71)] vs. 57 years (IQR 46-66)] (p &lt; 0.001). Hypoxia (oxygen saturation (SpO2 &lt; 90%) and shortness of breath suggestive of impending respiratory failure were the most common symptoms necessitating ICU admission. A low absolute lymphocyte count (ALC), and high levels of inflammatory biomarkers which persisted for seven days after diagnosis were significantly associated with non-survival. Multivariate logistic regression analysis showed shortness of breath (SOB), hypoxia (SpO2 &lt; 90% on oxygen), use of neuromuscular blockers, and chronic kidney disease as independent risk factors associated with mortality as were the severity scores (APACHE and SOFA). Conclusion: This single-center case series provides clinical characteristics and outcomes of patients with confirmed COVID-19 disease admitted to the COVID ICU. These findings are important for guiding research and preparing for future pandemics.

LARYNGEAL MASK AIRWAY VERSUS ENDOTRACHEAL INTUBATION FOR ADENOIDECTOMY IN OUTPATIENT SURGERY - SINGLE CENTER EXPERIENCE.

Adenoidectomy with or without tonsillectomy remains one of the most routinely performed surgical procedures in children. The duration of the procedure is usually less than half an hour and is done in a day surgery setting. Airway management for adenoidectomy can be especially challenging as the airway is shared between the surgeon and the anesthesiologist. The gold standard for airway management is an endotracheal tube (ETT), even though there has been an increase in the use of laryngeal mask airway (LMA) over the past decade. This retrospective study investigated patient data collected over a 4-year period (2016 to 2020). Data included 210 cases in a day surgery setting. We analyzed the choice of airway device and use of neuromuscular blockers and analgesics for pain management. The use of LMA was noted in 67.62% while endotracheal intubation was performed in 32.38% of cases. LMA resulted in fewer respiratory complications compared to ETT (p=0.006). The need for neuromuscular blockers was also lower in the LMA group (p=0.01). There was no statistically significant difference in the intraoperative dose of opioid analgesia (p=0.09). Flexible LMA is a satisfactory alternative to endotracheal intubation for outpatient pediatric adenoidectomy.

Characteristics of postintubation dysphagia in ICU patients in the context of the COVID-19 outbreak: A report of 920 cases from a Brazilian reference center.

The purpose of this research was to identify risk factors that were independently related to the maintenance of a swallowing dysfunction in patients affected by critical COVID-19. We conducted a prospective observational cohort study of critical patients with COVID-19, who were admitted to a COVID-19 dedicated intensive care unit (ICU) and required prolonged orotracheal intubation (≥48 hours). Demographic and clinical data were collected at ICU admission and/or at hospital discharge or in-hospital death. Swallowing data was based on The Functional Oral Intake Scale (FOIS) and was collected at two distinct moments: initial swallowing assessment and at patient outcome. Patients were divided into two groups according to their FOIS level assigned on the last swallowing assessment: in-hospital resolved dysphagia-patients with FOIS levels 6 and 7; non-resolved dysphagia at hospital outcome-patients with FOIS levels 1 to 5. Nine hundred and twenty patients were included in our study. Results of the multivariate logistic regression model for the prediction of non-resolved dysphagia at hospital outcome in critical COVID-19 patients. indicated that increasing age (p = 0.002), severity at admission (p = 0.015), body mass index (p = 0.008), use of neuromuscular blockers (p = 0.028), presence of neurologic diseases (p = 0.038), presence of Diabetes Mellitus (p = 0.043) and lower FOIS levels on the initial swallowing assessment (p<0.001) were associated with higher chances of presenting dysphagia at hospital outcome. Critical patients with COVID-19 may experience post-acute COVID-19 dysphagia, indicating the need to prepare for the care/rehabilitation of these patients.

Intensive Care Unit- Acquired Weakness and Hospital Functional Mobility Outcomes Following Invasive Mechanical Ventilation in Patients with COVID-19: A Single-Centre Prospective Cohort Study.

Background: Acute physical function outcomes in ICU survivors of COVID-19 pneumonia has received little attention. Critically ill patients with COVID-19 infection who require invasive mechanical ventilation may undergo greater exposure to some risk factors for ICU-acquired weakness (ICUAW). Purpose: To determine incidence and factors associated with ICUAW at ICU discharge and gait dependence at hospital discharge in mechanically ventilated patients with COVID-19 pneumonia. Methods: Single-centre, prospective cohort study conducted at a tertiary hospital in Madrid, Spain. We evaluated ICUAW with the Medical Research Council Summary Score (MRC-SS). Gait dependence was assessed with the Functional Status Score for the ICU (FSS-ICU) walking subscale. Results: During the pandemic second wave, between 27 July and 15 December, 2020, 70 patients were enrolled. ICUAW incidence was 65.7% and 31.4% at ICU discharge and hospital discharge, respectively. Gait dependence at hospital discharge was observed in 66 (54.3%) patients, including 9 (37.5%) without weakness at ICU discharge. In univariate analysis, ICUAW was associated with the use of neuromuscular blockers (crude odds ratio [OR] 9.059; p = 0.01) and duration of mechanical ventilation (OR 1.201; p = 0.001), but not with the duration of neuromuscular blockade (OR 1.145, p = 0.052). There was no difference in corticosteroid use between patients with and without weakness. Associations with gait dependence were lower MRC-SS at ICU discharge (OR 0.943; p = 0.015), older age (OR 1.126; p = 0.001), greater Charlson Comorbidity Index (OR 1.606; p = 0.011), longer duration of mechanical ventilation (OR 1.128; p = 0.001) and longer duration of neuromuscular blockade (OR 1.150; p = 0.029). Conclusions: In critically ill COVID-19 patients, the incidence of ICUAW and acute gait dependence were high. Our study identifies factors influencing both outcomes. Future studies should investigate optimal COVID-19 ARDS management and impact of dyspnea on acute functional outcomes of COVID-19 ICU survivors.

Pathophysiology of intraabdominal hypertension and abdominal compartment syndrome and relevance to veterinary critical care.

Increased intraabdominal pressure, termed intraabdominal hypertension (IAH), is reported as an independent cause of morbidity and mortality in the human ICU but, until recently, has been rarely described in veterinary species outside of experimental models. Failure to identify severe IAH leads to organ dysfunction, termed abdominal compartment syndrome, and rapidly becomes fatal without therapeutic intervention. Although the veterinary community has been slow to address the concept of IAH and associated comorbidities, recent companion and large animal case series and experimental studies suggest IAH may also be common in veterinary species and correlates well with risk factors and grading systems already described in the human literature. Increasing abdominal pressures exert deleterious local effects through visceral ischemia and reperfusion injury as well as systemic effects on the cardiovascular, pulmonary, renal, and central nervous systems. Even mild grades of IAH increase systemic vascular resistance, impede venous return, increase pulmonary wedge pressure, and decrease pulmonary function. More severe grades cause azotemia, oliguria, decreased coronary blood flow, hypoxia, increased intracranial pressure, and death. Many of the common diseases in veterinary patients are associated with IAH, including gastric dilatation-volvulus, colon volvulus, closed pyometra, hemoperitoneum, ascites, uroperitoneum, and hydrops. Monitoring of the veterinary patient is difficult, but several experimental studies validate both the presence of IAH and the ability to monitor abdominal pressures in large and small animal species. Moreover, prompt recognition of IAH and subsequent treatment is feasible in the veterinary ICU. Increasing abdominal pressures exert deleterious local effects through visceral ischemia and reperfusion injury as well as systemic effects on the cardiovascular, pulmonary, renal, and central nervous systems. Increases in central venous pressure, systemic vascular resistance, pulmonary wedge pressure, and a decreased cardiac output by way of both decreased preload and increased afterload have been documented as a result of intraabdominal hypertension (IAH). Direct diagnosis of IAH is achieved by blind or ultrasound-guided abdominal needle puncture attached to a water manometer or direct pressure monitoring transducer. Transvesicular measurement of intraabdominal pressure (IAP) is relatively noninvasive, and many patients that would benefit from rapid diagnosis of IAH and abdominal compartment syndrome already have indwelling bladder catheters. Recommendations for interventions are based on the assigned grade of IAH (mild, moderate, severe). If IAH is strongly suspected or diagnosed, abdominal wall compliance may be improved through judicious use of neuromuscular blockers and sedation. Decompression, either minimally invasive or surgical, is absolutely recommended for IAPs consistently above 20mm Hg, especially in the presence of signs attributed to secondary organ dysfunction.

The Use of Neuromuscular Blockers to Prevent Shivering in the Setting of Postcardiac Arrest Targeted Temperature Management: A Narrative Review of an Off-Label Indication.

Targeted temperature management (TTM) has become a standard of care over the past two decades for the improvement in neurologic function and mortality in postcardiac arrest patients. There are various mechanisms by which hypothermia helps to improve these outcomes, one of which is by reducing oxygen requirements. Less established is the use of nondepolarizing neuromuscular blockers (NMBs) to prevent shivering during TTM. Shivering can be disadvantageous in this setting as it increases oxygen requirements, which TTM is actively trying to decrease, in an already oxygen-deprived system as well as generates heat making it difficult to maintain hypothermia. Whether NMBs can improve these outcomes is conflicting in the currently available literature and there lacks a consensus on their role in shivering management. The pharmacokinetic and pharmacodynamic responses of these agents may be altered in hypothermic patients, therefore, their standard of monitoring may be unreliable. The accurate dosing and administration of these agents also remain unclear, further complicated by the lack of a standard use protocol. Various studies have been conducted regarding the use of NMBs to prevent shivering in postcardiac arrest patients undergoing TTM; however, it remains an off-label indication requiring further investigation.

Lower Driving Pressure and Neuromuscular Blocker Use Are Associated With Decreased Mortality in Patients With COVID-19 ARDS.

The impact of mechanical ventilation parameters and management on outcomes of patients with coronavirus disease 2019 (COVID-19) ARDS is unclear. This multi-center observational study enrolled consecutive mechanically ventilated patients with COVID-19 ARDS admitted to one of 7 Korean ICUs between February 1, 2020-February 28, 2021. Patients who were age < 17 y or had missing ventilation parameters for the first 4 d of mechanical ventilation were excluded. Multivariate logistic regression was used to identify which strategies or ventilation parameters that were independently associated with ICU mortality. Overall, 129 subjects (males, 60%) with a median (interquartile range) age of 69 (62-78) y were included. Neuromuscular blocker (NMB) use and prone positioning were applied to 76% and 16% of subjects, respectively. The ICU mortality rate was 37%. In the multivariate analysis, higher dynamic driving pressure (ΔP) values during the first 4 d of mechanical ventilation were associated with increased mortality (adjusted odds ratio 1.16 [95% CI 1.00-1.33], P = .046). NMB use was associated with decreased mortality (adjusted odds ratio 0.27 [95% CI 0.09-0.81], P = .02). The median tidal volume values during the first 4 d of mechanical ventilation and the ICU mortality rate were significantly lower in the NMB group than in the no NMB group. However, subjects who received NMB for ≥ 6 d (vs < 6 d) had higher ICU mortality rate. In subjects with COVID-19 ARDS receiving mechanical ventilation, ΔP during the first 4 d of mechanical ventilation was independently associated with mortality. The short-term use of NMB facilitated lung-protective ventilation and was independently associated with decreased mortality.

Neuromuscular Blocker Use in Critically Ill Children: Assessing Mortality Risk by Propensity Score-Weighted Analysis.

We aim to describe the use of continuous infusion of neuromuscular blocking agents in mechanically ventilated critically ill children and to test its association with in-hospital mortality. Multicenter, registry-based, observational, two-cohort-comparison retrospective study using prospectively collected data from a web-based national registry. Seventeen PICUs in Italy. We included children less than 18 years who received mechanical ventilation and a neuromuscular blocking agent infusion from January 2010 to October 2017. A propensity score-weighted Cox regression analysis was used to assess the relationship between the use of neuromuscular blocking agents and in-hospital mortality. None. Of the 23,227 patients admitted to the PICUs during the study period, 3,823 patients were included. Patients who received a continuous infusion of neuromuscular blocking agent were more likely to be younger (p < 0.001), ex-premature (p < 0.001), and presenting with less chronic respiratory insufficiency requiring home mechanical ventilation (p < 0.001). Reasons for mechanical ventilation significantly differed between patients who received a continuous infusion of neuromuscular blocking agent and patients who did not receive a continuous infusion of neuromuscular blocking agent, with a higher frequency of respiratory and cardiac diagnosis among patients who received neuromuscular blocking agents compared with other diagnoses (all p < 0.001). The covariates were well balanced in the propensity-weighted cohort. The mortality rate significantly differed among the two cohorts (patients who received a continuous infusion of neuromuscular blocking agent 21% vs patients who did not receive a continuous infusion of neuromuscular blocking agent 11%; p < 0.001 by weighted logistic regression). Patients who received a continuous infusion of neuromuscular blocking agent experienced longer mechanical ventilation and PICU stay (both p < 0.001 by weighted logistic regression). A weighted Cox regression analysis found the use of neuromuscular blocking agents to be a significant predictor of in-hospital mortality both in the unadjusted analysis (hazard ratio, 1.7; 95% CI, 1.3-2.2) and in the adjusted one (hazard ratio, 1.6; 95% CI, 1.2-2.1). Thirteen percent of mechanically ventilated children in PICUs received neuromuscular blocking agents. When adjusting for selection bias with a propensity score approach, the use of neuromuscular blocking agent was found to be a significant predictor of in-hospital mortality.

Advances in the diagnosis and treatment of acute respiratory distress syndrome induced by pancreatitis

Acute pancreatitis (AP) is one of the common diseases of the digestive system mainly characterized by acute inflammation of the pancreas and acinar cell destruction, and it can often develop into severe acute pancreatitis (SAP). Acute respiratory distress syndrome (ARDS) is one of the most common and serious complications of SAP and a common cause of death in patients with SAP. In recent years, there have gained new understanding of the pathogenesis, diagnosis, and treatment of SAP-related ARDS, however, a variety of drugs that have been shown to prevent ARDS in SAP animal models have not improved the prognosis of SAP-related ARDS patients in clinical researches. At present, the treatment of SAP-related ARDS still follows the general treatment principles of ARDS, such as treatment of primary disease, lung protective ventilation strategy, prone position ventilation, early short-term use of neuromuscular blockers and extracorporeal membrane oxygenation (ECMO), and so on. However, the influence of high intra-abdominal pressure, intestinal function failure, abdominal incision, and drainage tube on the treatment measures should also be considered for patients with SAP-related ARDS. This article reviews the recent progress in diagnosis and treatment of SAP-related ARDS.

English

BACKGROUND The purpose of present study was to compare and evaluate both topical lignocaine and intravenous lignocaine for laryngeal mask airway (LMA) insertion prior to propofol. Main objective was to study the conditions for LMA insertion with respect to gagging, coughing, Laryngospasm and No. of attempts for LMA insertion and also study the hemodynamic parameters in both the groups (Heart rate, SBP,DBP, MAP, SpO2) METHODS This study included 60 patients of 30 in each group, ASA I &amp; II day care surgeries were performed in our hospital between 2019 and 2021. Patients were randomized into two groups. Group I received intravenous lignocaine 1.5 mg / kg over 30 seconds and group II received topical lignocaine 40 mg. Conditions of LMA insertion, gagging, laryngospasm, coughing were noted at the time of insertion, ECG, NIBP, SPO2 and ETCO2 were recorded according to scheduled times. RESULTS In conditions of LMA insertion, difference between both the groups was found to be significant, P &lt; 0.05 in groups with first minute rise in heart rate, fall in Systolic blood pressure, diastolic blood pressure, mean arterial pressure was significant. At two minutes and three minutes after the LMA insertion, HR, SBP, DBP, MAP all these parameters changed slightly but these changes were statistically not significant. CONCLUSIONS Prior to Propofol induction, compared to intravenous lignocaine, topical lignocaine 10 % aerosol provided excellent conditions for the insertion of LMA without the use of neuromuscular blockers. KEY WORDS IV Lignocaine, Topical Lignocaine, LMA

P0396 / #925: “EPIDEMIOLOGICAL CHARACTERISTICS OF THE PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME (PARDS) IN THE PEDIATRIC INTENSIVE CARE UNIT OF THE NATIONAL INSTITUTE OF PEDIATRICS IN MEXICO”

Aims & Objectives: Describe the epidemiological characteristics of the patients with diagnosis of PARDS in the PICU between 2013 and 2015. Methods: Observational, retrospective and descriptive study was carried out. Epidemiological and demographic characteristics of patients who entered the PICU between 2013 and 2015 with PARDS were studied. Descriptive analysis of the qualitative variables has made in SPSS V.21 program. Results: Information was collected from 42 patients; the comorbidities found were 59% malnutrition, 30% haemato-oncological, 19% chronic pulmonary, 9.5% immunodeficiency and 7.1% heart disease. Organic dysfunctions during the course of the disease were 83.3% cardiovascular, 47.6% hematological, 22% renal and 11.9% hepatic. Microbiological isolation was achieved in 23.8% of cases. 69% of patients received steroid treatment and 71% neuromuscular blockers to achieve ventilation goals. Overall mortality was 28%, complications were co- infections in 50% and pulmonary hemorrhage in 26%. Mean PEEP was 10 cmH2O, the average PaFiO2 was 99 and the median age of presentation was 14 months. Conclusions: Mortality is within the range reported in the literature, risk factors associated with poor outcome were malnutrition and pulmonary hemorrhage present in 91% of patients with fatal outcome. A sedation protocol must be developed in order to reduce the use of neuromuscular blockers and his deleterious effects.

Uniportal surgical biopsy, without orotraqueal intubation, without thoracic drainage in intersticial pulmonary disease: initial results.

interstitial lung disease comprises a group of lung diseases with wide pathophysiological varieties. This paper aims to report the video thoracoscopic surgical biopsy in patients with interstitial lung disease through a single minimal chest incision, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers. this study is a series of 14 cases evaluated retrospectively, descriptively, where patients underwent a pulmonary surgical biopsy from January 2019 to January 2020. The patients included in the study had diffuse interstitial lung disease without a defined etiological diagnosis. none of the patients had transoperative complications, there was no need for chest drainage in the postoperative period, and the patients pain, assessed using the verbal scale, had a mode of 2 (minimum value of 1 and maximum of 4) in the post immediate surgery and 1 (minimum value of 1 and maximum of 3) at the time of hospital discharge. The length of hospital stay was up to 24 hours, with 12 patients being discharged on the same day of hospitalization. therefore, it is concluded in this series of cases that the performance of uniportal video-assisted thoracoscopic surgery procedures to perform lung biopsies, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers, bring benefits to the patient without compromising his safety. Further larger studies are necessary to confirm the safety and efficiency of this method.

Residual neuromuscular blockade and late neuromuscular blockade at the post-anesthetic recovery unit: prospective cohort study

Introduction and objectivesThe use of neuromuscular blockers during surgery represented a landmark for anesthesiology. However, their use can prompt residual Neuromuscular Blockade (RNMB) and objective monitoring of neuromuscular function is crucial to warrant the recovery of muscle strength. The present study aimed to estimate the incidence of RNMB and late Neuromuscular Blockade (LNMB) at the Post-Anesthetic Recovery Unit (PACU). MethodThe study included 85 patients, 43 of which received cisatracurium and 42 of which, rocuronium. The depth of the Neuromuscular Blockade (NMB) was assessed by Train Of Four (TOF). NMB reversal was performed with the administration of neostigmine and atropine.RNMB was defined when a patient presented TOF below 90% at the PACU. ResultsRNMB at the PACU was diagnosed in 39.5% and 40.5% of the patients receiving cisatracurium and rocuronium, respectively (p = 1.0). LNMB at the PACU was found in 32.6% and 16.7% of the patients receiving cisatracurium and rocuronium, respectively (p = 0.131). ConclusionsThe incidence ofRNMB remains significant despite the use of intermediate-acting neuromuscular blockers and reversal agents. There was no statistically significant difference in the incidence of RNMB or LNMB in patients receiving cisatracurium or rocuronium. The use of objective NMB monitoring is effective for the diagnosis of RNMB, as well as for treatment management.

Effect of Perioperative Active Body Surface Warming Systems on Analgesic and Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Inadvertent perioperative hypothermia is a common complication of surgery, and active body surface warming (ABSW) systems are used to prevent adverse clinical outcomes. Prior data on certain outcomes are equivocal (ie, blood loss) or limited (ie, pain and opioid consumption). The objective of this study was to provide an updated review on the effect of ABSW on clinical outcomes and temperature maintenance. We conducted a systematic review of randomized controlled trials evaluating ABSW systems compared to nonactive warming controls in noncardiac surgeries. Outcomes studied included postoperative pain scores and opioid consumption (primary outcomes) and other perioperative clinical variables such as temperature changes, blood loss, and wound infection (secondary outcomes). We searched Ovid MEDLINE daily, Ovid MEDLINE, EMBASE, CINHAL, Cochrane CENTRAL, and Web of Science from inception to June 2019. Quality of evidence (QoE) was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Subgroup analysis sought to determine the effect of preoperative + intraoperative warming versus intraoperative warming alone. Metaregression evaluated the effect of year of publication, use of neuromuscular blockers, anesthesia, and surgery type on outcomes. Fifty-four articles (3976 patients) were included. Pooled results demonstrated that ABSW maintained normothermia compared to controls, during surgery (30 minutes postinduction [mean difference {MD}: 0.3°C, 95% confidence interval {CI}, 0.2-0.4, moderate QoE]), end of surgery (MD: 1.1°C, 95% CI, 0.9-1.3, high QoE), and up to 4 hours postoperatively (MD: 0.3°C, 95% CI, 0.2-0.5, high QoE). ABSW was not associated with difference in pain scores (<24 hours postoperatively, moderate to low QoE) or perioperative opioid consumption (very low QoE). ABSW increased patient satisfaction (MD: 2.2 points, 95% CI, 0.9-3.6, moderate QoE), reduced blood transfusions (odds ratio [OR] = 0.6, 95% CI, 0.4-1.0, moderate QoE), shivering (OR = 0.2, 95% CI, 0.1-0.4, high QoE), and wound infections (OR = 0.3, 95% CI, 0.2-0.7, high QoE). No significant differences were found for fluid administration (low QoE), blood loss (very low QoE), major adverse cardiovascular events (very low QoE), or mortality (very low QoE). Subgroup analysis and metaregression suggested increased temperature benefit with pre + intraoperative warming, use of neuromuscular blockers, and recent publication year. ABSW seemed to confer less temperature benefit in cesarean deliveries and neurosurgical/spinal cases compared to abdominal surgeries. ABSW is effective in maintaining physiological normothermia, decreasing wound infections, shivering, blood transfusions, and increasing patient satisfaction but does not appear to affect postoperative pain and opioid use.