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RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research. [ABSTRACT FROM AUTHOR]

Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality.Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given.Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities.Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used. [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 (MH) is a life-threatening hypermetabolic state that can occur following induction with depolarizing neuromuscular blockade and volatile anesthesia gases. Because succinylcholine is a common choice for prehospital and emergency department inductions, it is important for staff to be able to recognize and effectively treat an MH crisis. This case study highlights a 20-year-old male trauma patient who presented to a Level I trauma center and was intubated for declining mental status. He developed suspected MH following his anesthetic induction with succinylcholine. The following outlines the case, clinical identification of MH, and treatment. [ABSTRACT FROM AUTHOR]

Background: The development of liver failure is a major problem in critically ill patients. The hepatotoxicity of many drugs, as one important reason for liver failure, is poorly screened for in human models. Rocuronium and succinylcholine are neuromuscular blocking agents used for tracheal intubation and for rapid-sequence induction.Objective: We used an in-vitro test with a permanent cell line and compared rocuronium and succinylcholine for hepatotoxicity.Design: In-vitro study.Setting: A basic science laboratory, University Hospital Rostock, Germany.Material/(patients): The basic test compound is the permanent human liver cell line HepG2/C3A. In a standardised microtitre plate assay the toxicity of different concentrations of rocuronium, succinylcholine and plasma control was tested.Interventions: After two incubation periods of 3 days, the viability of cells (XTT test, lactate dehydrogenase release and trypan blue staining), micro-albumin synthesis and the cytochrome 1A2 activity (metabolism of ethoxyresorufin) were measured.Main Outcome Measures: Differences between rocuronium and succinylcholine were assessed using the Kruskal-Wallis one-way test and two-tailed Mann-Whitney U test.Results: Rocuronium, but not succinylcholine, led to a significant dose-dependent decrease of viability, albumin synthesis and cytochrome 1A2 activity of test cells.Conclusion: An in-vitro test with a cell line showed hepatotoxicity of rocuronium that was dose-dependent. Further studies are needed to investigate the underlying mechanisms of the effects of rocuronium on hepatic cellular integrity.Trial Registration: Not suitable. [ABSTRACT FROM AUTHOR]

This study aimed to prospectively evaluate mortality, among other outcomes, following RSI with rocuronium compared to succinylcholine for patients presenting to the emergency department (ED) with acute TBI. The study population consists of adult patients presenting to the ED of a Level 1 Trauma Center with acute TBI who underwent RSI with either succinylcholine or rocuronium. B Introduction: b Acute traumatic brain injury (TBI) often requires rapid sequence intubation (RSI) to protect patients' airways. [Extracted from the article]

Objectives: Severe postictal confusion (sPIC) is an important but poorly investigated adverse effect of electroconvulsive therapy (ECT). In this retrospective study, prevalence of sPIC and potential risk factors were explored., Methods: Medical charts of 295 ECT patients (mean ± SD age, 57 ± 15 years; male, 36%) were scrutinized for occurrence of sPIC, as well as demographic, clinical, and treatment characteristics. Patients showing sPIC were compared with patients who did not, using univariate statistics. Multivariate analyses with a split-sample validation procedure were used to assess whether predictive models could be developed using independent data sets., Results: O 295 patients, 74 (25.1%) showed sPIC. All patients showing sPIC needed extra medication, 9% (n = 7) required physically restraints, and 5% (n = 4) had to be secluded. Univariate analyses showed several trends: patients with sPIC were more often males (P = 0.05), had more often history of cerebrovascular incident (P = 0.02), did not use concomitant selective serotonin reuptake inhibitors (P = 0.01), received higher median dosage of succinylcholine (P = 0.02), and received pretreatment with flumazenil more often (P = 0.07), but these associations did not remain significant after correction for multiple comparisons. Multiple logistic regression analysis did not result in a model that could predict sPIC in the holdout data set., Conclusions: In this retrospective naturalistic study in 295 ECT patients, the prevalence of sPIC appeared to be 25%. Patients showing sPIC were characterized by male sex, history of cerebrovascular incident, use of higher-dose succinylcholine, and pretreatment with flumazenil. However, multivariate analysis revealed no significant model to predict sPIC in independent data., Competing Interests: The authors have no conflicts of interest or financial disclosures to report., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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]

Background: Pharmacogenomics, which offers a potential means by which to inform prescribing and avoid adverse drug reactions, has gained increasing consideration in other medical settings but has not been broadly evaluated during perioperative care., Methods: The Implementation of Pharmacogenomic Decision Support in Surgery (ImPreSS) Trial is a prospective, single-center study consisting of a prerandomization pilot and a subsequent randomized phase. We describe findings from the pilot period. Patients planning elective surgeries were genotyped with pharmacogenomic results, and decision support was made available to anesthesia providers in advance of surgery. Pharmacogenomic result access and prescribing records were analyzed. Surveys (Likert-scale) were administered to providers to understand utilization barriers., Results: Of eligible anesthesiology providers, 166 of 211 (79%) enrolled. A total of 71 patients underwent genotyping and surgery (median, 62 years; 55% female; average American Society of Anesthesiologists (ASA) score, 2.6; 58 inpatients and 13 ambulatories). No patients required postoperative intensive care or pain consultations. At least 1 provider accessed pharmacogenomic results before or during 41 of 71 surgeries (58%). Faculty were more likely to access results (78%) compared to house staff (41%; P = .003) and midlevel practitioners (15%) ( P < .0001). Notably, all administered intraoperative medications had favorable genomic results with the exception of succinylcholine administration to 1 patient with genomically increased risk for prolonged apnea (without adverse outcome). Considering composite prescribing in preoperative, recovery, throughout hospitalization, and at discharge, each patient was prescribed a median of 35 (range 15-83) total medications, 7 (range 1-22) of which had annotated pharmacogenomic results. Of 2371 prescribing events, 5 genomically high-risk medications were administered (all tramadol or omeprazole; with 2 of 5 pharmacogenomic results accessed), and 100 genomically cautionary mediations were administered (hydralazine, oxycodone, and pantoprazole; 61% rate of accessing results). Providers reported that although results were generally easy to access and understand, the most common reason for not considering results was because remembering to access pharmacogenomic information was not yet a part of their normal clinical workflow., Conclusions: Our pilot data for result access rates suggest interest in pharmacogenomics by anesthesia providers, even if opportunities to alter prescribing in response to high-risk genotypes were infrequent. This pilot phase has also uncovered unique considerations for implementing pharmacogenomic information in the perioperative care setting, and new strategies including adding the involvement of surgery teams, targeting patients likely to need intensive care and dedicated pain care, and embedding pharmacists within rounding models will be incorporated in the follow-on randomized phase to increase engagement and likelihood of affecting prescribing decisions and clinical outcomes., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

The objective of this study was to compare FAIS rates for rocuronium and succinylcholine when used for RSI in the emergency department (ED). B Introduction: b Succinylcholine and rocuronium are commonly used paralytics for rapid sequence intubation (RSI). No difference was observed in FAIS between patients receiving rocuronium (median dose: 1.22 mg/kg, IQR 1.04-1.55) or succinylcholine (median dose: 1.43 mg/kg, IQR 1.25-1.67) (361 (80.6%) vs. 150 (82.0%), p=0.69). [Extracted from the article]

A personal narrative is presented which explores the author's experience of examining succinylcholine-induced hyperkalemia in burn patients.

Butyrylcholinesterase (BChE) hydrolyses the neuromuscular blocking agents, succinylcholine and mivacurium used during general anaesthesia. Hereditary low BChE activity may result in an extensively prolonged duration of action of these drugs, especially in patients who are homozygous for the atypical or silent variants. We present three novel mutations in the butyrylcholinesterase gene (BCHE) identified in three families in which a member had experienced severely prolonged duration of action of succinylcholine.As the phenotypes of the three probands could not be established with certainty using conventional biochemical tests, DNA samples were collected from two of the probands and four relatives. Genotypes were determined using complete nucleotide sequencing.Three novel mutations were identified: BCHE∗FS126, BCHE∗I3E4-14C and BCHE∗328D. The proband in family 1 was genotyped as BCHE∗115D∗I3E4-14C/BCHE∗FS126, whereas the proband in family 3 was compound heterozygous for BCHE∗328D and BCHE∗142M. In both patients, BChE activity was below detection limit, and they experienced an extensively prolonged duration of action of succinylcholine. The proband in family 2 was not sequenced, but a relative was heterozygous for BCHE∗FS126. BCHE∗I3E4-14C was in linkage with a known silent variant.Two novel variants of BCHE are silencing the enzyme function. BCHE∗FS126 results in a truncated protein lacking the active site and is therefore inactive. The second variant is BCHE∗328D, also resulting in an inactive protein, as this change in amino acid is radical and furthermore situated in the gorge harbouring the active site. These variants result in extensively prolonged duration of action of succinylcholine. [ABSTRACT FROM AUTHOR]

People with genetic variants of butyrylcholinesterase (EC 3.1.1.8, BChE) can have hours of prolonged apnea after a normal dose of succinylcholine or mivacurium.Plasma samples from 226 people in the Vysya community in Coimbatore, India were tested for BChE activity.Nine unrelated individuals had no detectable activity. DNA sequencing revealed a novel mutation in exon 2 of the BCHE gene, responsible for the silent phenotype of human serum BChE. All silent BChE samples were homozygous for a point mutation at codon 307 (CTT→CCT), resulting in substitution of leucine 307 by proline. Western blot analysis with a monoclonal antibody showed no BChE protein in plasma. Silent BChE plasma samples had no organophosphate-reactive BChE, as measured with FP-biotin. Expression of recombinant Leu307Pro BChE in cell culture confirmed that this mutant is expressed at very low levels. The proline substitution most likely destabilizes the BChE structure and causes the protein to be misfolded and rapidly degraded.This is the first report of a molecularly defined BChE mutation in the Indian population. The frequency of homozygous silent BChE in the Vysya community is 1 in 24, a value 4000-fold higher than the frequency of homozygous silent BChE in European and American populations. [ABSTRACT FROM AUTHOR]

Background and objective: To survey French anaesthetic practice regarding acid aspiration prophylaxis and compare it with an earlier survey. Methods : A confidential questionnaire was sent to all 800 maternity units in France to assess three major topics: (a) drugs used for pharmacological prophylaxis; (b) regional anaesthesia for labour and Caesarean section and (c) techniques used for general anaesthesia and endotracheal intubation. Results: Two-hundred-and-two units responded. Pharmacological prophylaxis was regularly used for labouring women in 78% of the responding units in 1998 (compared with 63% in 1988, P < 0.05). Antacid drug use before Caesarean section had increased from 75% in 1988 to 97% in 1998 (P < 0.05). General anaesthesia was used for Caesarean section by less than 2% of responding units (vs. 21% in 1988, P < 0.05). In contrast, there was little change in the use of endotracheal intubation for instrumental delivery (53% vs. 50%) or manual removal of the placenta (15% vs. 16%) between 1988 and 1998. The use of cricoid pressure increased significantly during the 10 yr period (50% vs. 88%, P < 0.05) and the technique was correctly described by 80% of the responding units (vs. 50%, P < 0.05). Similarly, the use of succinylcholine increased significantly from 25% (1988) to 47% (1998) (P < 0.05). Conclusions: There was a significant overall improvement of French practice regarding acid aspiration prophylaxis in obstetrics. However, the complete prophylaxis strategy is still not used in every patient emphasizing the need for continuing medical education. [ABSTRACT FROM AUTHOR]

Background: Neuromuscular blockade (NMB) is a critical part of many surgical procedures. Data on practice patterns of NMB agents (NMBAs) and NMB reversal in recent years in the US ambulatory surgical care setting are limited., Methods: This retrospective analysis of US adult outpatients was conducted using the Premier Healthcare Database. We describe anesthesia practice trends in NMB management and assess the association of patient, procedural, and site characteristics with NMB reversal approach using multivariable logistic regression., Results: Approximately 5.2 million outpatient surgical encounters involving NMB and 4.6 million involving rocuronium or vecuronium between January 2014 and June 2019 were included. Following the introduction of sugammadex to US clinical practice (~2016), there was an increased use of rocuronium or vecuronium and a decrease in succinylcholine alone. Before 2016, NMB was pharmacologically reversed with neostigmine in approximately two-thirds of outpatient encounters. Over time, active reversal increased; by 2019, 42.3% and 36.0% of encounters were reversed by neostigmine and sugammadex, respectively, with 21.7% undergoing spontaneous recovery. Choice of NMBA (rocuronium or vecuronium alone), time since 2016, obesity, peripheral vascular disease, and procedures on the digestive, ocular, and female genital systems (vs musculoskeletal procedures) were independently and positively associated with pharmacologic reversal (versus spontaneous reversal). Conversely, advanced age; Western geography; and cardiovascular, endocrine, hemic/lymphatic, respiratory, and ear, nose, and throat procedures were independently and negatively associated with pharmacologic reversal of NMB.Among pharmacologic reversals, time since 2016 was positively and independently associated with sugammadex compared with neostigmine (odds ratios [ORs], ranged from 1.8 in 2017 to 3.2, P < .0001 in 2019). Those administered rocuronium or vecuronium without succinylcholine, with increased age and history of certain comorbidities, and those undergoing ocular or respiratory procedures (compared with musculoskeletal) were positively associated with reversal with sugammadex and endocrine procedure negatively and independently associated with reversal with sugammadex. There was variability in the association of several factors with NMB reversal choices by geographic region, particularly in patients' race, ethnicity, and size of affiliated hospital., Conclusions: Overall, active pharmacological reversal of NMB increased in US adult outpatients following the introduction of sugammadex, although there remains significant practice variability. The multifactorial relationship between patient-, procedural-, and environmental-level characteristics and NMB management is rapidly evolving. Additional research on how these anesthesia practice patterns may be impacted by the shift to the ambulatory care setting and how they may impact patient outcomes and health disparities is warranted., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: The administration of postintubation sedation (PIS) is an essential component of postintubation care. Recent studies in the adult emergency medicine literature have highlighted both delays in time to administration of PIS and subtherapeutic dosing of sedative agents in the emergency department. We aimed to investigate the administration of PIS in the pediatric population as this has not been adequately reviewed to date., Objectives: The aim of this study was to determine the percentage of pediatric emergency department patients who received PIS within an adequate time frame. We also investigated the relationship between this primary outcome and the rapid sequence intubation (RSI) agents used, the reason for intubation, and individual patient characteristics., Methods: This was a retrospective cohort analysis of all pediatric patients who underwent RSI at a tertiary care pediatric emergency department from July 2007 to January 2016. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-RSI sedative administration that was shorter than the duration of action of the RSI sedative agent used. Logistic regression was performed to identify predictors of adequate sedation., Results: A total of 240 patients were included in the analysis. Of these, 28% (95% confidence interval, 22.7%-34.1%) met the primary outcome of sedation within an adequate time frame; 72.8% (95% confidence interval, 66.8%-78.1%) of patients received some form of PIS during their emergency department stay. Patients receiving long-acting paralytic agents were much less likely to receive PIS with an odds ratio (OR) of 0.16 for meeting the primary outcome (P < 0.001, adjusted OR [AOR] = 0.13, P < 0.001). Children with higher systolic blood pressure were more likely to receive appropriate PIS with an OR of 1.02 for every mm Hg increase in systolic blood pressure (P = 0.006, AOR = 1.02, P = 0.021). Finally, patients who were ultimately admitted to the pediatric intensive care unit (vs the operating room, transfer, or neonatal intensive care unit) were less likely to receive PIS as evidenced by an OR of 0.37 (P = 0.009, AOR = 0.27, P = 0.004)., Conclusions: Most pediatric patients do not receive PIS within an adequate time frame. Patients who receive long-acting paralytic agents are much less likely to be adequately sedated after RSI compared with those receiving succinylcholine., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Prolonged neuromuscular blockade from succinylcholine after neostigmine administration has been reported in patients with frank renal failure. We present a case of prolonged neuromuscular blockade from succinylcholine administration, given 2 hours after neostigmine reversal of neuromuscular blockade in a patient with chronic renal insufficiency. This case shows that patients with chronic renal insufficiency, like patients with renal failure, are at risk for prolonged succinylcholine blockade if they have recently received anticholinesterase reversal of neuromuscular blockade. Administration of succinylcholine for facilitation of urgent endotracheal intubation may be required soon after reversal of nondepolarizing muscle relaxants, particularly in patients who return to the operating room for emergency care. [ABSTRACT FROM AUTHOR]

B Learning Objectives: b Moderate to severe traumatic brain injury (TBI) patients often require rapid sequence intubation (RSI) using a sedative and neuromuscular blocking agent (NMBA) to facilitate placement of an endotracheal tube. This study was conducted to evaluate differences in outcomes, including mortality, associated with the use of succinylcholine versus rocuronium for RSI in TBI patients. B Methods: b This was a retrospective cohort of patients >= 18 years old admitted to an academic, level 1 trauma center after TBI from January 2014 to December 2017 who received succinylcholine or rocuronium for RSI within 24 hours of admission. [Extracted from the article]

Organophosphorus (OP) pesticides are commonly used in agricultural fields to control pests in India. However, exposure to it can cause poisoning in humans and animals, or it can be taken intentionally as poison to commit suicide. We present a case of a 35-year-old suicidal man who developed prolonged apnea for almost 4 hours on day 13 of OP poisoning after brief general anesthesia induced by propofol and 1 mg/kg of suxamethonium, during the first session of the third cycle of modified electroconvulsive therapy, despite all due precautions. Such prolonged apnea secondary to complex interactions has been reported very rarely in literature. This case therefore, highlights the importance of careful evaluation and monitoring while giving anesthesia to OP-poisoning patients.

SummaryThe choice of hypnotics and opioids for rapid-sequence induction, and the use of premedication, is influenced by the choice of the muscle relaxant. Anaesthetic agents have a major influence on the quality of intubation when rapid-sequence induction is achieved without a muscle relaxant. Premedication is important, along with a high dose of propofol (2.5 mg kg-1 or more) and a short-acting opioid such as alfentanil (30–40 µg kg-1) or remifentanil (up to 4 µg kg-1). It has also been demonstrated that i.v. lidocaine can improve intubating conditions. When a muscle relaxant is used, the choice of the anaesthetic agents depends on the onset of action of the relaxant. With a rapid-acting compound such as rocuronium at a dose of 0.6 mg kg-1, the hypnotic agents need to be supplemented with only a small dose of opioids, e.g. alfentanil 10–20 µg kg-1. When succinylcholine, rocuronium 1.0 mg kg-1 or rapacuronium 1.5 mg kg-1 are used, excellent intubating conditions may be obtained by relatively smaller doses of hypnotic agents even without opioids; however, haemodynamic and intraocular pressure changes are better controlled when small doses of opioids are administered. [ABSTRACT FROM AUTHOR]

SummaryMuscle relaxants are given as part of a rapid-sequence induction to facilitate tracheal intubation. Among all the muscle relaxants available, succinylcholine is the only one with a fast (≅1 min) onset and a fast recovery. Therefore it is still the most frequently used muscle relaxant for rapid-sequence induction despite its well-known side-effects. The short duration of action of succinylcholine is, however, no substitute for aggressive airway management in the case of an unexpectedly difficult intubation in order to prevent life-threatening hypoxia. A preoperative assessment of the airway is mandatory in any patient and may indicate the need for using intubation techniques without a muscle relaxant. Rocuronium in large doses (i.e. ≥1 mg kg-1) is an alternative to succinylcholine in a classical rapid-sequence setting under relatively light anaesthesia. With respect to rapid tracheal intubation, the timing and priming principles offer little advantage over the use of rocuronium in doses of 0.6 mg kg-1 in combination with an appropriate induction technique (i.e. including an opioid) or over the use of larger doses of rocuronium (≥1.0 mg kg-1) under relatively light anaesthesia, and may even be potentially harmful. In contrast to rocuronium, the use of rapacuronium in a rapid-sequence setting has been associated with dose-dependent respiratory side-effects that limit its usefulness in doses higher than 1.5 mg kg-1 for this indication. [ABSTRACT FROM AUTHOR]

SummaryIt has been estimated that more than 60% of all paediatric surgery is performed on a day case basis. The benefits of this type of surgery in children include reduced costs, avoidance of the stress of hospitalization and less disruption to family life. The growth of day surgery in children has been facilitated by the development of non-depolarizing neuromuscular blocking agents characterized by short and intermediate duration of action and fewer side-effects. The more rapid onset and shorter duration of action of non-depolarizing neuromuscular blocking agents in children should facilitate the use of these agents in place of succinylcholine for day case procedures. [ABSTRACT FROM AUTHOR]

SummaryNeuromuscular blocking agents are used as adjuvants in day case anaesthesia to facilitate tracheal intubation and/or surgery. Although the majority of day case procedures are performed without the use of neuromuscular blocking agents, there are procedures, such as laparoscopic surgery, microsurgery, open eye surgery, some ear, nose and throat procedures and some paediatric procedures, which may require neuromuscular blockade. The characteristics of an ideal neuromuscular blocking agent for day case surgery are a short onset, a short clinical duration and a short recovery time, with or without reversal. It should also lack histamine release, provide haemodynamic stability, and be competitively priced. This paper reviews the neuromuscular blocking agents currently available and used, such as succinylcholine and mivacurium, low doses of an intermediate-acting neuromuscular block, such as rocuronium and the recently introduced rapacuronium. Their advantages and disadvantages are described and discussed, with special reference to the needs of day case surgery. Rapacuronium offers certain benefits compared with the currently available neuromuscular blocking agents for day care anaesthesia. [ABSTRACT FROM AUTHOR]

Background: We aimed to compare the effects of succinylcholine and rocuronium-sugammadex on development of myalgia and headache after electroconvulsive therapy (ECT)., Methods: Forty-five patients undergoing ECT were enrolled in the study. Anesthesia induction was provided with propofol 1 mg/kg intravenously (IV) + succinylcholine 1 mg/kg IV in group S (n = 24) and propofol 1 mg/kg IV + rocuronium 0.3 mg/kg IV in group R (n = 21). Sugammadex 4 mg/kg IV was administered to group R after the motor seizure. The first 3 ECT sessions were evaluated on the basis of time to onset of spontaneous respiration following the induction, time to eye-opening response to verbal stimuli, and visual analog scale (VAS) scores for myalgia and headache at hours 2, 6, 12, and 24 following the ECT for all patients., Results: The times to onset of spontaneous respiration and eye-opening response to verbal stimuli were significantly shorter in all the 3 sessions in group R compared with group S (P < 0.002). Myalgia VAS scores at hours 2, 6, and 12 and the headache VAS scores at hours 2 and 6 were significantly higher in group S versus group R (P < 0,015)., Conclusions: We concluded that the rates of myalgia and headache after ECT were significantly lower in group R than in group S, and also the awakening time (spontaneous respiration and opening the eyes in response to verbal stimuli) was significantly shorter in group R compared with group S.

Aspiration is a significant cause of anesthetic morbidity, occurring most commonly during the induction of anesthesia. For patients with a high likelihood of aspiration, rapid sequence intubation (RSI) techniques may minimize this risk by reducing the time between the loss of protective airway reflexes and the placement of a cuffed endotracheal tube. Although RSI frequently involves the administration of a neuromuscular-blocking agent (NMBA) such as succinylcholine or rocuronium, there are times when the administration of an NMBA is contraindicated or undesirable. We present an 11-year-old boy who presented with vomiting, papilledema, and a history concerning for an undiagnosed neuromuscular disorder. Deep sedation or anesthesia was required during an emergent lumbar puncture to evaluate his symptoms. Rapid sequence intubation was successfully performed with propofol and remifentanil without the use of an NMBA. We highlight the anesthetic considerations in such a clinical scenario and review the literature regarding the combination of remifentanil and propofol for RSI.

This report addresses the dilemma of continuing lithium prophylaxis and antidepressant therapy in view of cardiovascular adverse effects under electroconvulsive therapy (ECT) in patients with a long history of recurrent affective disorders. A severely depressed 48-year-old woman who had been treated with lithium for 18 years developed a ventricular tachycardia during ECT. Possible interaction with succinylcholine was taken into account, and rocuronium was used as an alternative muscle relaxant. Electroconvulsive therapy was continued without adverse effects after reduction of lithium and withdrawal from duloxetine. Systemic studies on cardiac adverse effects of serotonin and norepinephrine reuptake inhibitors and serotonin and norepinephrine reuptake inhibitor-lithium combinations during ECT are needed.

The presence of rhythmic electroencephalographic artifacts may at times be confused with actual brain-related activity even before electroconvulsive therapy. Here, we present a case of rapid persistent blinking due to tardive dyskinesia, causing rhythmic deltalike artifacts on the electroencephalographic monitor.

Background: Electroconvulsive therapy (ECT) induces increase of QT dispersion (QTD) and the rate-corrected QTD (QTcD), which are associated with increased risk of ventricular arrhythmias and cardiovascular mortality. The effects of electrical stimulus during ECT on QTD and QTcD in elderly patients are of considerable interest., Objective: The purpose of this study was to clarify the differential effects of electrical stimulus caused by ECT on interbeat interval, QT interval, the rate-corrected QT (QTc) interval, QTD, and the QTcD under propofol anesthesia between younger and elderly patients with major depression., Methods: Twenty younger psychiatric patients (aged 30-40 years) and 20 elderly patients (aged 65-75 years) scheduled for ECT were studied under propofol anesthesia. A 12-lead electrocardiogram was monitored to measure parameters. Muscle paralysis was achieved by administering 1-mg/kg succinylcholine intravenously, and the efficacy of ECT was determined by the tourniquet technique., Results: The mean arterial pressure in the elderly was significantly higher than that of the younger patients from immediately to 2 minutes after electrical stimulus. The interbeat interval in the elderly was significantly lower than that of the younger patients from immediately to 1 minute after electrical stimulus. There was no statistically significant difference in the QT interval between the groups. The baseline value of QTc interval was higher than the normal limits, and the QTc interval in the elderly was significantly lower than that of the younger patients from immediately to 1 minute after electrical stimulus. The baseline value of QTD was higher than the normal limits, and the QTD in the elderly was significantly higher than that of the younger patients from immediately to 7 minutes after electrical stimulus. The baseline value of QTcD was higher than the normal limits, and the QTcD in the elderly was significantly higher than that of the younger patients from immediately to 7 minutes after electrical stimulus., Conclusions: The QTc interval, QTD, and QTcD may be higher than the normal limits before anesthesia in patients with major depression. The QTD and QTcD in the elderly, which are associated with increased risks of ventricular arrhythmias, are higher than those of the younger patients after electrical stimulus during ECT. Electrical stimulus may induce further increased risks of cardiac events in elderly patients.

Background: Prolonged QTc intervals have been associated with increased cardiac morbidity and mortality. We investigated whether pretreatment prolongation of the QTc interval was associated with increased cardiac-related events (CREs) in electroconvulsive therapy (ECT) treatment of psychiatric disorders., Methods: The charts of 1437 ECT patients were reviewed for the presence of baseline QTc prolongation. Broadly defined CREs during the course of treatment were abstracted from patient charts., Results: Presence of baseline QTc prolongation was not independent of increased risk of CREs during ECT., Implications: Careful consideration should be given to patients who have QTc prolongation on an electrocardiogram and are undergoing ECT treatment, but this should not definitively exclude patients from receiving ECT treatment.

Background: Malignant hyperthermia (MH) is a potentially lethal hypermetabolic syndrome. Volatile anesthetics and/or succinylcholine lead to an increase of the intracellular calcium concentration resulting in activation of various intracellular processes. A production of carbon dioxide, and later lactate, are early signs of increased cellular energy consumption. On a cellular level, magnesium acts as a physiological calcium inhibitor resulting in less-intense calcium liberation from the sarcoplasmic reticulum. In this study, we examined the effects of IV magnesium administration on the clinical course of an MH crisis., Methods: Sixteen Pietrain pigs (10 MH-susceptible [MHS] and 6 MH-nonsusceptible [MHN]) were anesthetized without an MH trigger substance. Invasive hemodynamic monitoring was established before 4 mg/kg succinylcholine was administered. Four of the MHS pigs received 10 mg/kg magnesium sulfate 10 minutes later. Hemodynamic changes (heart rate, mean arterial blood pressure, and oxygen saturation as measured by pulse oximetry) were continuously monitored. Venous and arterial blood gases (pH, Pco(2), Po(2), base excess, and lactate) were taken at 15-minute intervals. The H test and U test were used with P < 0.05 for significant differences among the groups., Results: No differences among the groups were seen for weight, hemodynamic, and metabolic variables before administration of succinylcholine. In all MHS animals, succinylcholine led to a marked decrease of mean arterial blood pressure and increase of heart rate. Animals in both MHS groups developed combined metabolic and respiratory acidosis. Succinylcholine had no effect on animals in the MHN group. Hemodynamic and metabolic values were not different between the 2 MHS groups but were between groups MHS and MHN., Conclusion: Succinylcholine led to a hemodynamic and metabolic reaction in only MHS pigs. Treatment with magnesium did not influence the clinical course. The intervention had no beneficial effect in the acute phase of an MH crisis., (© 2011 International Anesthesia Research Society)

Purpose of Review: The regimen of thiopental, succinylcholine (SCh) and unsupplemented nitrous oxide/oxygen for Caesarean section was first introduced 50 years ago. This review examines which elements have endured, what has changed, and how practice might alter in the very near future., Recent Findings: Sugammadex, a cyclodextrin, is capable of rapid reversal of profound rocuronium neuromuscular blockade., Summary: It is now feasible that SCh might be replaced with a high-dose rocuronium-sugammadex combination.

Background: Thiopentone has a protective effect as far as succinylcholine-induced myalgias are concerned; however, a few studies were done in the efficacy of thiopentone on fasciculation induced by succinylcholine. The purpose of this study was to determine the effects of thiopentone on onset, duration, and severity of fasciculation caused by succinylcholine injection., Methods: Three hundred patients, in American Society of Anesthesiologists Physical Status Classification I and II, undergoing elective ocular surgery at Farabi Eye Hospital in 2003 were considered and divided into 2 groups who received intravenous succinylcholine immediately and 30 seconds after thiopentone injection, respectively. After premedication and induction of anesthesia, the severity and duration of fasciculations caused by succinylcholine were compared between the 2 groups., Results: In the group using succinylcholine immediately after thiopentone injection, the onset of fasciculation was earlier (P = 0.0006), and duration of fasciculation was shorter (P = 0.0002) than the other group. In addition, moderate to severe fasciculation was found more in the group using succinylcholine 30 seconds after thiopentone injection (P = 0.038)., Conclusions: Pretreatment with thiopentone immediately before succinylcholine administration can decrease the duration and severity of fasciculation more than thiopentone injection 30 seconds before succinylcholine administration.

Purpose of Review: After myorelaxants, myalgia and residual curarization may complicate recovery. Local anaesthesia and minimally invasive airway management make myorelaxants disputable in many outpatient procedures; nevertheless, neuromuscular blockade may be necessary to facilitate intubation or maintain muscle relaxation. Agent selection criteria are discussed., Recent Findings: Reduced hospital time is not associated with central neuraxial or peripheral nerve block. To reduce the risk for residual block, neuromuscular monitoring is mandatory. Use of reversal agents should not be restricted, although studies have shown higher incidence of postoperative nausea and vomiting following their use. Higher succinylcholine dosage is followed by lower incidence of myalgia. The relationship between fasciculation and myalgia is unclear. Sodium channel blockers or nonsteroidal antiinflammatory drugs may prevent myalgia. Sugammadex functions as a chelating agent., Summary: Ear-nose-throat, open eye surgery and laparoscopy may demand myoresolution. Regional and minimally invasive anaesthesia are alternative solutions. Central and peripheral nerve blocks are associated with increased induction time, reduced pain scores, and decreased need for analgesics. Central neuraxial block, however, is associated with prolonged outpatient unit stay. Bad intubating conditions may cause pharyngo-laryngeal complications: the decision to avoid myorelaxants for tracheal intubation appears illogical. Incidence of postoperative residual curarization remains very high. Sugammadex offers new perspectives.

Electroconvulsive therapy (ECT) is a highly effective treatment for severe depression. However, its use is associated with significant posttreatment cognitive impairment. Magnetic seizure therapy (MST) was developed as an alternative therapy that could reduce postseizure side effects through the induction of more "focal" seizure activity. Using an open-parallel study design, we compared 20 case-matched patients undergoing a series of either ECT or MST procedures with respect to their anesthetic, muscle relaxant, and cardiovascular drug requirements, effects on cardiovascular and electroencephalographic bispectral index (BIS) values, and early recovery times. We found that MST was associated with a reduced time to orientation (4 +/- 1 versus 18 +/- 5 min; P < 0.01) compared with ECT. To minimize residual muscle paralysis after MST, a reduction in the succinylcholine dosage (38 +/- 17 versus 97 +/- 2 mg; P < 0.01) was required. The BIS values were higher before, and lower immediately after, the stimulus was applied in the MST (versus ECT) group. The Hamilton depression rating scale score was significantly reduced from the baseline value in both treatment groups; however, the posttreatment score was lower after the series of ECT treatments (6 +/- 6 versus 14 +/- 10; P < 0.05). We conclude that MST was associated with a decreased requirement for muscle relaxants, reduced variability in the BIS values after seizure induction, and a more rapid recovery of cognitive function compared with ECT. Further studies are required to evaluate the antidepressant efficacy of MST versus ECT when they are administered at comparable levels of cerebral stimulation.