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The neuromuscular junction is a complex structure consisting of the muscle cell, the nerve terminal of a motor neuron and the synaptic cleft. It is the site of action for neuromuscular blocking drugs, which are a cornerstone of anaesthetic practice. These drugs can be divided into depolarizing and non-depolarizing drugs; the latter can be further subdivided into benzylisoquinolinium and aminosteroid compounds. Reversal agents are also discussed. The pharmacology of neuromuscular blocking drugs and reversal agents is discussed including mechanism of action, metabolism, factors influencing choice of drug as well as adverse effect profile. [ABSTRACT FROM AUTHOR]

• Postneuromuscular blockade sedation and analgesia differ for patients intubated with succinylcholine or rocuronium. • Intubation with rocuronium was associated with a longer time to administration of sedation. • Intubation with rocuronium was also associated with a decreased weight-adjusted dose of fentanyl. Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P <.001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation. [ABSTRACT FROM AUTHOR]

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BACKGROUND: Data are limited regarding current practice and outcomes for emergency department airway management in status asthmaticus. This paper describes the foremost methods and outcomes of airway management in patients in the emergency department who required intubation for status asthmaticus. METHODS: We analyzed all intubations with a primary indication of asthma over a 3-y period (January 1, 2016 to December 31, 2018) using the National Emergency Airway Registry (NEAR), a 25-center, prospective, observational registry of emergency department intubations. We report the incidence of intubations for asthma, methods and medications used, devices used, peri-intubation adverse events, and intubation success and failures using univariate descriptive statistics and cluster-adjusted incidence with 95% CI. RESULTS: A total of 19,071 encounters were recorded during the study period, with 14,517 patients intubated for medical indications. Of those, 173 (1.2%, 95% CI 0.9-1.6) were intubated for asthma. The first-attempt success rate was 90.8% (95% CI 81.9-95.5), and overall intubation success was 100%. Compared to the medical registry as a whole, patients with asthma were more likely to undergo rapid-sequence intubation (96.5% [95% CI 92.9-98.3] vs 80.8% [95% CI 75.1-82.5]), preoxygenation with bi-level positive airway pressure (BPAP) (62.9% [95% CI 49.6-74.6] vs 13.5% (95% CI 10.4-16.9]), and induction with ketamine (51.8% [95% CI 30.6-71.4] vs 11.6% [95% CI 7.6-16.8]). The adverse event rate in the patients with asthma was 12.14% (95% CI 8.1-17.9) compared to 11.93% (95% CI 9.79-14.12) in the medical registry. CONCLUSIONS: Status asthmaticus accounted for about 1% of emergent medical intubations. The majority of patients were intubated using rapid-sequence intubation after preoxygenation with BPAP and induction with ketamine, with the latter 2 practices being much more common for emergent intubations for status asthmaticus than for other medical indications. [ABSTRACT FROM AUTHOR]

This study evaluates the effect of pregabalin on fasciculation and myalgia after using succinylcholine. This randomized double-blind prospective study was conducted among 100 patients aged 20 to 60 years old. Pregabalin (300 mg) and placebo (in capsule form) were placed in similar containers. The results were analyzed by SPSS 23 software, and statistical analysis consisted of χ2 test and t test, and a P value less than.05 was considered significant. The mean pain score in the group receiving pregabalin was lower than the placebo group. According to the χ2 test, there was a significant difference between the two groups in the frequency of fasciculation (P =.003). Mean fasciculation severity in the pregabalin group was lower than placebo group. According to t test, there was a significant difference in the mean fasciculation severity between the two groups (P =.002). This study showed that 300 mg of pregabalin was effective in reducing postoperative fasciculation and myalgia in patients treated with succinylcholine. [ABSTRACT FROM AUTHOR]

Malignant hyperthermia (MH) is a rare pharmacogenic disorder of skeletal muscle calcium regulation, resulting from general anesthesia that can be fatal. Most cases are caused by administration of volatile anesthetics or depolarizing muscle relaxants. It has been generally reported that both of sevoflurane and succinylcholine can induce the delayed onset of MH. Here, we report a case of malignant hyperthermia in a four-year-old girl during anesthesia induction for unilateral congenital ptosis surgery, two minutes after sevoflurane and succinylcholine administration. The crisis was atypical but early recognized and managed by administration of dantrolene with symptomatic treatment. [ABSTRACT FROM AUTHOR]

The use of neuromuscular blocking agents (NMBAs) in acute care settings during intubation is vitally important. The NMBAs increase first pass success rates significantly while protecting patients from gastric aspiration, tracheal injury, and death. During emergent intubations, succinylcholine and rocuronium are commonly used, but each comes with specific risks and individualized interventions. First pass success can be increased by ensuring correct dosing for overweight patients and employing the use of video laryngoscope. For planned, nonemergent intubations with sustained paralysis, the chosen NMBA can be individualized to fit the patient's needs. This includes dosages based on upregulation or downregulation of acetylcholine as well as speed of administration to prevent histamine release. Nurses must provide specific care when managing the treatment in high-risk patient populations (coronary artery disease, hyperkalemia, renal failure, liver failure, and traumatic brain injuries) who may receive certain types of NMBAs. Finally, because of the wide range of adverse effects with these drugs, close assessments are essential to prevent complications. [ABSTRACT FROM AUTHOR]

Malignant hyperthermia is an uncommon, but potentially lethal condition that may be encountered during the perioperative period. There is wide variability in the manner in which malignant hyperthermia may manifest. For a patient to survive a malignant hyperthermia crisis, prompt recognition and treatment is of paramount importance. Perioperative nurses play a pivotal role in the successful management of malignant hyperthermia. The fictitious case study presented in this paper describes the identification, presentation, pathophysiology, and treatment of a general anesthesia patient with fulminant malignant hyperthermia. [ABSTRACT FROM AUTHOR]

The article presents a case study of a patient suffering from respiratory arrest following computed tomogrphy (CT) guided selective cervical nerve root injection. Topics discussed include CT guided cervical nerve root injection, and complications like spinal cord or brain infarction and death, vascular penetration with vessel injury or intravascular injection of local anaesthetic and steroid.

Resumo Justificativa e objetivos A ação epidural de agentes bloqueadores neuromusculares pode ser explicada à luz de suas características físico‐químicas e propriedades do espaço epidural. Na literatura existem poucos casos sobre a administração acidental em espaço epidural de agente neuromuscular que se manifesta principalmente com a instituição de bloqueio neuromuscular ou fasciculações. Relato de caso Relatamos um caso de administração acidental de succinilcolina como uma dose teste epidural em uma paciente submetida à laparotomia programada, sob anestesia combinada geral e peridural. Aproximadamente dois minutos após a injeção de succinilcolina, a paciente queixou‐se de falta de ar, enquanto fasciculações leves apareceram em seu tronco e rosto, tratadas com a instituição imediata de anestesia geral. Exceto pela duração relativamente longa do bloqueio neuromuscular em comparação com a administração intravenosa, sequelas neurológicas ou cardiovasculares ou outros sintomas de toxicidade local ou sistêmica não foram observados. Conclusões A administração oral de diazepam parece diminuir os efeitos adversos da administração epidural acidental de succinilcolina. A meticulosidade e discriminação dos rótulos das seringas, bem como os cuidados persistentes mantidos durante todos os procedimentos de anestesia, continuam a ser de importância crucial. Background and objectives Epidural action of neuromuscular blocking agents could be explained under the light of their physicochemical characteristics and epidural space properties. In the literature there are few cases of accidental neuromuscular agent's epidural administration, manifesting mainly with neuromuscular blockade institution or fasciculations. Case report We report a case of accidental succinylcholine administration as an epidural test dose, in a female patient undergoing scheduled laparotomy, under combined general and epidural anesthesia. Approximately 2 min after the succinylcholine injection the patient complained for shortness of breath, while mild fasciculations appeared in her trunk and face, managed by immediate general anesthesia institution. With the exception of a relatively longer duration of neuromuscular blockade compared with intravenous administration, no neurological or cardiovascular sequelae or other symptoms of local or systemic toxicity were observed. Conclusions Oral administration of diazepam seems to lessen the adverse effects from accidental epidural administration of succinylcholine. The meticulous and discriminative labeling of syringes, as well as keeping persistent cautions during all anesthesia procedures remains of crucial importance. [ABSTRACT FROM AUTHOR]

Resumo Justificativa A succinilcolina é comumente usada para atingir um bloqueio neuromuscular profundo, de início rápido e de curta duração. Objetivo Comparar a eficácia de pregabalina na prevenção de mialgia e fasciculação induzidas por succinilcolina. Desenho Estudo prospectivo, randômico, duplo‐cego e controlado por placebo. Materiais e métodos Pacientes de ambos os sexos submetidos a cirurgia eletiva de coluna foram aleatoriamente divididos em dois grupos. Os pacientes do Grupo P (pregabalina) receberam 150 mg de pregabalina oral uma hora antes da indução da anestesia e os pacientes do Grupo C (controle) receberam placebo. A anestesia foi induzida com fentanil (1,5 mcg/kg) e propofol (1,5‐2,0 mg/kg), seguidos de succinilcolina 1,5 mg/kg. A intensidade da fasciculação foi avaliada por um observador, cego para a alocação dos grupos, com uma escala de 4 pontos. Um observador cego registrou o grau pós‐operatório de mialgia após 24 horas de cirurgia. Para o alívio da dor no pós‐operatório, fentanil foi usado em sistema de analgesia controlada pelo paciente. Resultados Os dados demográficos de ambos os grupos eram comparáveis ( p > 0,05). A incidência de fasciculação muscular não foi significativa entre os dois grupos ( p = 0,707), enquanto mais pacientes do Grupo C apresentaram fasciculação de moderada a grave em relação ao Grupo P ( p = 0,028). A incidência e a gravidade da mialgia foram significativamente menores no grupo P ( p < 0,05). Conclusão Pregabalina (150 mg) previne mialgia e fasciculação induzidas por succinilcolina, além de diminur o consumo de fentanil em cirurgia eletiva de coluna. Background Succinylcholine is commonly used to achieve profound neuromuscular blockade of rapid onset and short duration. Objective The present study compared the efficacy of pregabalin for prevention of succinylcholine‐induced fasciculation and myalgia. Design Prospective, randomized, placebo controlled, double blinded study. Materials and methods Patients of both genders undergoing elective spine surgery were randomly assigned to two groups. Patients in Group P (pregabalin group) received 150 mg of pregabalin orally 1 h prior to induction of anesthesia with sips of water and patients in Group C (control group) received placebo. Anesthesia was induced with fentanyl 1.5 mcg/kg, propofol 1.5–2.0 mg/kg followed by succinylcholine 1.5 mg/kg. The intensity of fasciculations was assessed by an observer blinded to the group allotment of the patient on a 4‐point scale. A blinded observer recorded postoperative myalgia grade after 24 h of surgery. Patients were provided patient‐controlled analgesia with fentanyl for postoperative pain relief. Results Demographic data of both groups were comparable ( p > 0.05). The incidence of muscle fasciculation's was not significant between two groups ( p = 0.707), while more patients in group C had moderate to severe fasciculation's compared to group P ( p = 0.028). The incidence and severity of myalgia were significantly lower in group P ( p < 0.05). Conclusion Pregabalin 150 mg prevents succinylcholine‐induced fasciculations and myalgia and also decreases the fentanyl consumption in elective sine surgery. [ABSTRACT FROM AUTHOR]

Objectives: Butyrylcholinesterase (BChE), commonly known as pseudocholinesterase or non-neural cholinesterase, hydrolyzes neuromuscular blocker agents containing choline esters such as succinylcholine that is widely used in rapid sequence induction (RSI) for general anesthesia. The aim of this study is to compare plasma BChE levels and investigate the affects and relationship of succinylcholine on BChE levels in preeclamptic, gestational diabetic and healthy pregnants.Study Design: We designed a prospective, controlled, pilot single-center study. Thirty (n=30) pregnant women who were scheduled for cesarean section under general anesthesia (refusal of regional anesthesia) with RSI involved. Group 1 included ten (n=10) preeclamptic pregnancies, Group 2 included ten (n=10) gestational diabetic (GD) pregnancies and Group 3 included ten (n=10) healthy pregnancies.Main Outcome Measures: BChE levels of all patients were measured prior to the initiation of cesarean section. Train-of-four recovery of 90% (TOF T1) was used to monitor the degree of neuromuscular block beginning from the administration of succinylcholine.Results: No statistically significant difference was found between the groups comparing BChE levels and the duration between tracheal intubation and formation of TOF T1 (p>0.05).Conclusions: As similar results were gathered from normal and high-risk pregnancies (preeclamptic pregnancy or gestational diabetic pregnancy) who underwent cesarean section under general anesthesia, we believe that succinylcholine is still neuromuscular agent of choice in cesarean section. [ABSTRACT FROM AUTHOR]

Critical care units serve the vital function of patient rescue through life-saving and life-preserving treatments. When an older patient's life hangs in the balance, preserving life takes priority over potential serious adverse drug events. There may be a tendency to consider transfer out of the unit as a less serious event; therefore, less attention is given to medication assessment. Often thought of by nurses as an almost clerical level task, the professional nurse plays a key role in identifying potentially harmful medications or medication combinations. If older patients remain on medications considered to be potentially dangerous, then patients are at risk for adverse drug events. Once the emergent nature of critical care interventions has passed, it is important to judiciously appraise patient status and conduct a medication assessment to discontinue or change the medication regimen to safer alternatives for older adults. Nurses can be instrumental in further research, education, and awareness for practitioners, patients, and families regarding the role of medications for older adults. Beers Criteria are not intended to be a clinical mandate, rather a designated as a clinical guideline with a clinical recommendation to support a provider's clinical judgment. [ABSTRACT FROM AUTHOR]

The compound crossbow can be used to eject syringe-like dart loaded with poisonous solution. Succinylcholine (Sch) is a short-acting neuromuscular blocker medically used to achieve complete relaxation of muscle for a good intubation condition. Without the help of an artificial respirator, intramuscular injection of a large dose of Sch can paralyze the respiratory muscle and result in the receiver's death. In this paper, we present the homicide case of a young male killed by Sch from a syringe-like dart ejected by a compound crossbow. The subcutaneous and muscular hemorrhages observed around the entry were more severe than that caused by a medical injection. Additionally, other autopsy results showed the external appearance of a pinhole, general asphyxia signs and pathological findings which were not characteristic. The discovery of a syringe-like dart at the scene is the critical clue and reason for analyzing for Sch, which is commonly used to load syringe-like dart to paralyze and steal dog in the countryside of China. [ABSTRACT FROM AUTHOR]

The article examines the case of a 50-year-old male with hepatic impairment caused by human immunodeficiency virus that was determined to have pseudocholinesterase deficiency after undergoing laparoscopic cholecystectomy. His past medical history, current medications, and results of physical examination are detailed. The physiologic, pharmacologic, and pathologic factors that contribute to decreased pseudocholinesterase activity are discussed.

Succinylcholine revolutionized anaesthetic practice by providing intense neuromuscular blockade of very rapid onset and ultrashort duration, thereby greatly easing the maneuver of tracheal intubation. However the worth of succinylcholine is limited by the frequent occurrence of muscular side effects which manifest biochemically in the form of rise in serum creatine kinase (CK). The administration of small doses of nondepolarizing muscle relaxants before the administration of succinylcholine has been shown to decrease the incidence and severity of muscular side effects experienced by the patients. This study was aimed at evaluating the efficacy of technique in reducing the muscular side effects of succinylcholine, biochemically manifested as rise in CK. Sixty healthy adults were enrolled in the study who were scheduled for minor muscle cutting surgeries under general anaesthesia. They were assigned at random to two groups of thirty patients each. They randomly received succinylcholine for intubation and a precurarization dose of rocuronium followed by succinylcholine for intubation. Blood samples were drawn for estimation of serum creatinine kinase. There was a significantly raised CK in the succinylcholine group. In the precurarization group the rise in CK was prevented and the levels were significantly less as compared to the group which received succinylcholine alone. Present study concluded that precurarization with rocuronium was effective in reducing the succinylcholine-induced rise in creatinine kinase. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We aimed to compare the effect of remifentanil without muscle relaxant with succinylcholine for intubation in microlaryngoscopy. PATIENTS AND METHODS: Eighty patients were randomly divided into two groups: Group R (n=40) and S (n=40) received remifentanil 4 µg/kg intravenously or 1 µg/kg respectively. Anesthesia was induced with 2 mg/kg propofol in both groups. Intubation was performed after bolus administration of 10 ml saline as a placebo or 1 mg/kg of succinylcholine in Group R and S respectively. Remifentanil infusion was initiated at 0.025 µg/kg in each groups. RESULTS: Intubation conditions were similar in both groups. The mean arterial pressure (MAP) values at post-induction period were significantly lower in the Group S than in the Group R (p = 0.001). The requirement for ephedrine in Group R was found to be significantly lower than Group S (p = 0.023). Recovery times were significantly shorter (p = 0.001) and recovery scores were significantly higher (p = 0.021) in Group R. Time to patient could respond to commands was significantly longer in the Group S (p = 0.001). The surgeon's satisfaction score was significantly higher in Group R (p = 0.001). CONCLUSIONS: It was concluded that remifentanil without muscle relaxants provides similar intubating conditions as that provided by succinyl-choline, and remifentanil is superior to succinyl-choline with regard to haemodynamic stability and recovery duration. [ABSTRACT FROM AUTHOR]

Pseudocholinesterase (PCE) is a glycoprotein enzyme produced in the liver that hydrolyzes choline esters in the plasma. PCE deficiency may be inherited, acquired, or iatrogenic. In anesthesia management, PCE is important in the metabolism of succinylcholine, mivacurium, procaine, and cocaine. Succinylcholine is a depolarizing neuromuscular blocker used for muscle relaxation with an approximate half-life of less than a minute. Patients with PCE deficiency metabolize choline esters slower than patients with normal levels of PCE. In severe cases, paralysis may last 8 hours resulting in prolonged neuromuscular blockade and apnea. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 71-year-old Caucasian female with acute cholecystitis who was presented for laparoscopic cholecystectomy. It says that the patient had a history of small cell lung cancer, coronary artery disease, and ventricular tachycardia. It says that a 6.5 endotracheal tube (ETT) was placed in patient through direct laryngoscopy and was monitored in the post anesthesia care unit (PACU). It discusses the causes of prolonged muscle paralysis.

There are no definitive evidence based standards regarding use of succinylcholine (SCh) for anesthesia induction. However, there is a global trend toward eliminating SCh not only in elective, but also in emergency surgery in adults. The aim of the study was to survey the use of SCh in adult elective and emergency anesthesia practice in several European countries and the United States by questionnaire. One hundred and seventy anesthesiologists out of 201 possible, from six institutions in five countries (Croatia, Bosnia and Herzegovina, Hungary, United Kingdom, and the United States) anonymously completed the questionnaire about their use of SCh. The questionnaire was structured to assess the respondents': frequency of use of SCh in adult surgery (elective and emergency), reasons for use or rejection of SCh, positive and negative attributes of SCh, and observed side effects in their practice. Differences in use were tested using c 2-test when appropriate. There was a significant difference in the use of SCh between countries for elective surgery with the lower use in UK and Hungary (c 2=45.8, p<0.001). One hundred and seventeen (69%) use it regularly. In emergency surgery 165 (97%) anesthesiologists use it without any significant difference among countries (c 2=2.13, p<0.711). The top indications for SCh use were anticipated difficult intubation/ventilation (74%), caesarean section (54%), and obesity and/or hiatus hernia (49%). The top reasons against SCh use were adequate substitutes (87%), fear of arrhythmias (45%), and anaphylaxis (19%). The most desirable reported drug features were: rapid onset (88%), short duration (64%), and effective relaxation (61%). Forty-six per cent of the surveyed anesthesiologists stated they had never experienced a complication with its use. The most frequently reported side effects were myalgias (47%), bradycardias (42%), and prolonged blockade (39%). Allergic reactions were reported by 13%, and asystole by 12% of physicians. From our survey it is possible to conclude that succinylcholine is still regularly used, at least by surveyed anesthesiologists in Europe and USA, in adult anesthesia practice, especially in elective surgery for which it may be least suited. This reflects the discrepancies between the international guidelines for the use of SCh and the clinical practice of many anesthesiologists in different countries. The regional differences in SCh usage may be considered through anesthesia cultures and practice variations depending on country. [ABSTRACT FROM AUTHOR]

Purpose: The present visual and electromyographic study was designed to evaluate muscle fasciculations caused by succinylcholine in adults pretreated with either remifentanil 1.5 μg/kg or saline. Materials and Methods: The effect of remifentanil on succinylcholine-induced muscle fasciculations was studied using a double-blind method in 40 adults. After i.v. pretreatment with either remifentanil 1.5 μg/kg (remifentanil group, n = 20) or an equivalent volume of i.v. saline (saline group, n = 20), patients were anaesthetized with a 2.0 mg/kg of i.v. propofol followed by i.v. succinylcholine 1.0 mg/kg. Intensity and duration of muscle fasciculation following i.v. succinylcholine administration were recorded. Electromyography (EMG) was used to quantify the extent of muscle fasciculation following i.v. succinylcholine injection. Myalgia was evaluated 24 hours after induction time. Serum potassium levels were measured five minutes after i.v. succinylcholine administration and creatine kinase (CK) levels 24 hours after induction time. Results: Compared to saline treated controls, remifentanil decreased the intensity of muscle fasciculations caused by i.v. succinylcholine [fasciculation severity scores (grade 0 to 3) were 2/1/12/5 and 3/13/4/0 (patients numbers) in the saline group and the remifentanil group, respectively, p < 0.001]. The mean (SD) maximum amplitude of muscle action potential (MAP) by EMG was smaller in the remifentanil group [283.0 (74.4) μV] than in the saline group [1480.4 (161.3) μV] (p = 0.003). Postoperative serum CK levels were lower in the remifentanil group (p < 0.001). Postoperative myalgia was not different between the two groups. Conclusion: Remifentanil 1.5 μg/kg attenuated intensity of muscle fasciculations by succinylcholine. [ABSTRACT FROM AUTHOR]

Abstract: Although antiquated and long targeted for obsolescence, neostigmine and succinylcholine still serve the anesthesia community, decades after their inferior pharmacological profiles have been recognized. The need to quickly establish a good intubation condition with a relaxant that will recover rapidly is fundamental to safe anesthesia practice. So is the need to restore muscle power safely and quickly at the end of surgery, by reversing a residual neuromuscular block. Recent data have shown that sugammadex can safely and rapidly reverse profound neuromuscular block established by rocuronium and vecuronium. This allows for use of rocuronium to establish a good intubation condition, and use of sugammadex to terminate the neuromuscular block at will. The present article assesses the clinical implications of such therapeutic regimen, and provides an educated guess on how the clinical neuromuscular practice might change, if and when sugammadex becomesclinically available. [Copyright &y& Elsevier]

Summary: Malignant hyperthermia (MH) was first recognised as a potentially fatal pharmacogenetic disorder nearly 50 years ago. The abnormality has been localised to skeletal muscle, specifically the mechanisms regulating myoplasmic calcium ion homeostasis. The gene principally implicated is RYR1, which encodes the skeletal muscle sarcoplasmic reticulum calcium release channel, but the genetics of MH are relatively complex, with more than 100 mutations described in RYR1 and with a significant minority of cases not involving this gene. This review describes how the pathophysiology of MH relates to the clinical features, which follow a logical pattern. Reasons for the reaction reaching an untreatable stage are proposed, emphasising the importance of early diagnosis and aggressive treatment using the latest guidelines. Early intervention in suspected cases, and the lack of specificity of any single clinical feature for MH, necessitates laboratory confirmation of the diagnosis using muscle biopsy specimens. These relatively invasive tests can also be used to screen family members of known cases, although the limited introduction of DNA testing has obviated the need for some individuals to have a muscle biopsy. Patients at risk of developing MH can receive general anaesthesia and guidelines for this are described. [Copyright &y& Elsevier]

Malignant hyperthermia is a rare anesthetic-related disorder. We present a case with unusual presentation. A boy aged 3 years and 9 months who was scheduled for Hotz''s operation presented normally before the operation. Anesthesia was induced by atropine, thiopental and sevoflurane. Trachea intubation was facilitated by succinylcholine. Jaw stiffness was first noted although trachea was intubated without difficulty. The following tachycardia, hypercapnia and hyperthermia led to the diagnosis of malignant hyperthermia. Symptoms were relieved dramatically after the discontinuation of sevoflurane. Molecular genetic testing identified a novel ryanodine receptor (RYR1) mutation in exon 39, which confirmed malignant hyperthermia susceptibility in this patient. [Copyright &y& Elsevier]

The article reports that Electroconvulsive therapy (ECT) is a medical treatment that involves the electrical stimulation of the brain under general anesthesia with reference to reports from American Psychiatric Association. Topics include occasions in which a psychiatrist is unable to elicit a therapeutic seizure during a treatment session; and literature indicates that ketamine might be an alternative anesthetic agent in the treatment of ECT.

Malignant hyperthermia (MH) is a rare, inherited disorder of skeletal muscle. MH signs and symptoms are caused by an abnormal, diffuse release of calcium from the sarcoplasmic reticulum. Signs and symptoms include tachycardia, muscle rigidity, hyperthermia, increases in end-tidal carbon dioxide (CO2) and oxygen consumption, and metabolic and respiratory acidosis. Specific anesthetic triggers for MH currently used in the United States include the volatile agents desflurane, isoflurane and sevoflurane and the depolarizing muscle relaxant succinylcholine. According to a review by Rosenberg, et al, MH occurrence during anesthesia ranges from 1:5,000 to 1:50,000-100,000 anesthesias. [ABSTRACT FROM AUTHOR]

Abstract: Multidisciplinary communication is vital before and during general anaesthesia for obstetrics. A locally adapted World Health Organization Surgical Safety Checklist should be articulated before embarking upon every case. At induction of general anaesthesia, head-up tilt is recommended as routine, both for prevention of regurgitation and optimization of pre-oxygenation and airway management. Left-lateral tilt is important to avoid aorto-caval compression and maintain feto-placental perfusion. Gas monitoring lends objectivity to pre-oxygenation: the endpoint is an end-tidal fractional expired oxygen concentration approaching 90%. Thiopental remains the induction agent of choice. In pre-eclampsia, it is vital that the pressor response to intubation is obtunded to prevent intracerebral haemorrhage. The opioids alfentanil and remifentanil are suitable adjuncts. 0.75 minimum alveolar concentration end-tidal vapour concentration (plus 50% nitrous oxide) are required for a bispectral index of less than 60. A scarred uterus (for example after previous caesarean section) is a key predictor of intraoperative major haemorrhage. Grounds no longer exist for risking awareness with light anaesthetic regimens. Rocuronium is a licensed alternative to succinylcholine at caesarean section; sugammadex offers the facility to reverse even high-dose rocuronium blockade. Training opportunities in obstetric general anaesthesia (particularly elective cases) and simulation should be encouraged. [ABSTRACT FROM AUTHOR]

Summary: Succinylcholine is a commonly used depolarizing muscle relaxant in general endotracheal anesthesia. The degradation of succinylcholine is accomplished by the human serum based enzyme pseudocholinesterase. Availability of pseudocholinesterase within the human being can be deficient as a result of an inherited or acquired cause. This case report will describe a female patient who was diagnosed with an acquired pseudocholinesterase deficiency. [ABSTRACT FROM AUTHOR]