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The article focuses on the usage of sugammadex in emergency departments (EDs) within a large regional health system. Topics include the demographic and clinical characteristics of patients receiving sugammadex, the primary indications for its use (especially for neurological examination post-intubation), and the variation in administration practices between academic and community hospitals.

Introduction: we sought to explore the efficacy of ketamine in a patient on extracorporeal membrane oxygenation (ECMO) receiving ketamine for sedation by investigating the utility of plasma ketamine concentrations. Case report: retrospective chart review of one critically ill patient on ECMO Discussion: This was a descriptive review of serial plasma ketamine concentrations in an ECMO patient. Although no reference plasma concentrations exist in ECMO patients, ketamine levels appeared to be lower than those seen in surgical patients not on ECMO. Conclusion: At this point, no reference plasma concentrations exist for ketamine in ECMO patients, further research may help understand the effects of ECMO on ketamine disposition and that lower ketamine concentrations may be used for effective analgesia or sedation. [ABSTRACT FROM AUTHOR]

Aim: Endotracheal intubation, a critical procedure in anaesthesia, can induce significant hemodynamic fluctuations, posing risks, especially to patients with cardiovascular concerns. This study compares the effects of dexmedetomidine and fentanyl, two agents commonly used to mitigate these responses, on endotracheal intubation conditions and associated hemodynamic changes. Material and Method: Conducted at tertiary care training and research hospital, this study involved 60 patients aged 40-60, all classified American Society of Anesthesiologists (ASA) I-II, undergoing elective upper and lower extremity surgeries. Excluding patients with contraindicating conditions, the subjects were divided into two groups to receive either dexmedetomidine or fentanyl, along with propofol and vecuronium, for induction. Hemodynamic parameters were continuously monitored, and intubation conditions were assessed using the Cooper scoring system. Results: The study found that both dexmedetomidine and fentanyl effectively stabilised hemodynamic parameters during intubation. However, the fentanyl group displayed significantly higher total scores on the Cooper intubation conditions scale, indicating more favourable conditions for endotracheal intubation in terms of ease and patient comfort. Conclusion: While both dexmedetomidine and fentanyl are effective in maintaining hemodynamic stability during endotracheal intubation, fentanyl demonstrates a slight advantage in optimising intubation conditions. This distinction offers valuable insight for anesthesiologists in tailoring anaesthetic strategies and balancing patient safety with procedural efficiency in surgical settings. [ABSTRACT FROM AUTHOR]

Objective. Neuromuscular blocking agents (NMBAs) are part of the three elements of general anaesthesia (sedation, analgesia, and muscle relaxation), which can relax muscles and facilitate intubation and surgery. It has been reported that cancer cells are prone to invasion or metastasis during surgery, but various anaesthetics are currently used in cancer resection, particularly NMBA, and the effects on cancer cell behavior are poorly understood. Guidelines for the correct application of NMBA in cancer surgery have not been reported; therefore, the aim of this paper is to explore the relationship between NMBA and cancer. Methods. Two investigators independently searched PubMed, Embase, the Cochrane Library, Web of Science, and CBM for articles of NMBA and cancer. Results. The available evidence suggests that cisatracurium may be more appropriate for use in anaesthesia for cancer surgery, while rocuronium deserves further attention, particularly for breast and gastric cancer surgery, and vecuronium is suitable for breast cancer and non-small-cell lung cancer, while it is used with caution in gastric cancer. Also, the relationship between NMBA (mivacurium, succinylcholine, gantacurium, and decamethonium bromide) and cancer is unclear and deserves further study. Conclusion. The effect of different NMBAs on cancer cells varies, and the effect of some NMBAs on cancer cells is unclear, and most of the current findings are only from in vitro studies, which need to be validated by further clinical studies in the future to better guide the clinical application of NMBAs. [ABSTRACT FROM AUTHOR]

Objective: Our study aimed to evaluate two modified nasogastric tube (NGT) insertion techniques in intubated patients compared to the conventional method in respect of first attempt success rate, time taken for insertion, and complications. Methods: In this prospective interventional study, patients with orotracheal intubation requiring NGT insertion were randomly allocated into three groups by SNOS Group A (control group- standard sniffing position, n = 40), Group B (additional flexion of the neck, n = 40), Group C (standard sniffing position with lateral neck pressure, n = 40). The number of attempts for successful NGT insertion, time for insertion, and complications were compared. Results: Modified positions showed a high first-attempt success rate in Group B (55%) and Group C (85%) as compared to conventional Group A (32.50%) (P < 0.001). On intergroup analysis of modified groups (B and C), Group C was superior to Group B in 1st attempt success rate with a significant P value of 0.003. Conclusion: In intubated patients, NGT insertion in standard sniffing position with lateral neck pressure has the highest first attempt success rate followed by additional flexion of neck position. Both the modified positions are better positions for NGT insertion in intubated patients. [ABSTRACT FROM AUTHOR]

Parry--Romberg syndrome (PRS) is a rare disorder characterised by progressive hemifacial atrophy, along with various neurological and ophthalmological manifestations. Patients with PRS may undergo reconstructive procedures such as fat grafting to address the facial contour deformities. Anaesthesiologists may face significant challenges due to the asymmetric craniofacial structures and the potential presence of neurological deficits, including hemiparesis. We report a case of an 18-year-old male with left-sided hemifacial atrophy and PRS with wasting of one side of the lobe of the thyroid gland who underwent fat grafting under general anaesthesia. The challenges faced during the anaesthetic management of this patient are airway management, positioning and monitoring of neurological deficits. PRS has been reported to coexist with other autoimmune diseases, including thyroid disorders. However, thyroid involvement in PRS is rare. This case used ultrasound to evaluate the airway and assess PRS impact. This case highlights the importance of ultrasound airway, which can serve as an effective tool for identifying associated conditions (like thyroid atrophy) in patients with PRS and can assist in the diagnosis and management of this rare and complex disease. [ABSTRACT FROM AUTHOR]

Purpose There is a lack of information on the compatibility of remimazolam with opioid analgesics, muscle relaxants, and other sedatives. This study aimed to evaluate the physical compatibility of remimazolam with these drug classes. Methods Remimazolam was combined with 1 or 2 target drugs (remifentanil, fentanyl, rocuronium, vecuronium, dexmedetomidine, and midazolam). Ten physical compatibility tests were conducted, including four 3-drug compatibility tests. Remimazolam was dissolved in 0.9% sodium chloride injection to a final concentration of 5 mg/mL. Other medications were diluted in 0.9% sodium chloride injection to obtain clinically relevant concentrations. Compatibility tests were conducted with 3 test solutions, wherein remimazolam and the target drugs were compounded at equal volume ratios (1:1 or 1:1:1). Visual appearance was assessed and testing of Tyndall effect, turbidity, and pH was performed immediately after mixing and then again 1 hour and 4 hours after mixing. Appearance and turbidity were evaluated by comparison with the control solution of each target drug diluted with 0.9% sodium chloride injection to the same concentration as the test solution. Results All drugs tested were determined to be compatible with remimazolam. The drug combination with the highest change of turbidity was remimazolam and vecuronium (a mean increase of 0.16 NTU relative to the remimazolam control solution), 4 hours after mixing. The combination with the highest pH was remimazolam, fentanyl, and vecuronium (mean [SD], 3.76 [0.01]), 4 hours after mixing. The combination of remimazolam and fentanyl showed a larger change in pH at 4 hours after mixing (a mean increase of 2.6%) than immediately after mixing. Conclusion Remifentanil, fentanyl, rocuronium, vecuronium, dexmedetomidine, and midazolam are physically compatible with remimazolam during simulated Y-site administration. [ABSTRACT FROM AUTHOR]

Central diabetes insipidus (DI) is a known complication associated with pituitary surgeries occurring in postoperative period. However, development of DI following aneurysmal subarachnoid hemorrhage (SAH) is rarely reported. We describe here a case of intraoperative DI in a patient undergoing aneurysmal clipping surgery that posed a challenge for both diagnosis and management. Intraoperative development of central DI was attributed to the evolving ischemic injury to the hypothalamus at the time of rebleeding that was not apparent in the preoperative scan. DI resolved postoperatively after 18 hours of medical management. A careful observation of preoperative scans and vigilant monitoring may help in early diagnosis and management of such complication in the perioperative period. [ABSTRACT FROM AUTHOR]

Aim. The aim of this study was to evaluate the effects of preoperative administration of tizanidine on the maintenance dose duration of the nondepolarizing muscle relaxant, i.e. vecuronium bromide. Material and Methods. This prospective clinical study was conducted in 30 adult male patients scheduled for elective inguinal hernia surgery. Patients were categorised into two randomised groups based on the premedication use. Group 1 included patients (n = 15) who received oral diazepam (Diazem) in the evening prior to the surgery, as well as meperidine (Dolantin) 1 mg/kg-1 (max. 50 mg) i.m. with 50 ml water by mouth 1 hour before the procedure. Group 2 comprised patients (n = 15) who were given oral tizanidine 4 mg in the evening before the surgery, as well as oral tizanidine 4 mg with 50 ml water 1 hour prior to the operation. The following parameters were recorded in both groups: pre-operative and perioperative diastolic arterial blood pressure, systolic arterial blood pressure, mean arterial blood pressure, heart rate, respiratory rate, pre-operative vecuronium bromide maintenance doses, procedure time and postoperative score according to the Ramsay scale in 1st, 2nd and 3rd hour. Results. No significant difference was observed between the two groups with regard to the pre-operative and perioperative haemodynamic variables and the respiratory rate (P > 0.05), although it was found that vecuronium maintenance dose duration was significantly higher in the tizanidine premedicated group (P = 0.015). In addition, the operative time (P = 0.128) and the postoperative patients’ Ramsay scores did not differ statistically between the two groups (P > 0.05). Conclusions. The prolonged duration of vecuronium maintenance dose, the increased nondepolarizing block time, as well as haemodynamic stability preservation in patients undergoing inguinal hernia surgery following preoperative oral administration of tizanidine support the view that tizanidine can be used as an effective and safe myotonolytic premedication agent.

Aim. The aim of this study was to evaluate the effects of preoperative administration of tizanidine on the maintenance dose duration of the nondepolarizing muscle relaxant, i.e. vecuronium bromide. Material and Methods. This prospective clinical study was conducted in 30 adult male patients scheduled for elective inguinal hernia surgery. Patients were categorised into two randomised groups based on the premedication use. Group 1 included patients (n = 15) who received oral diazepam (Diazem) in the evening prior to the surgery, as well as meperidine (Dolantin) 1 mg/kg-1 (max. 50 mg) i.m. with 50 ml water by mouth 1 hour before the procedure. Group 2 comprised patients (n = 15) who were given oral tizanidine 4 mg in the evening before the surgery, as well as oral tizanidine 4 mg with 50 ml water 1 hour prior to the operation. The following parameters were recorded in both groups: pre-operative and perioperative diastolic arterial blood pressure, systolic arterial blood pressure, mean arterial blood pressure, heart rate, respiratory rate, pre-operative vecuronium bromide maintenance doses, procedure time and postoperative score according to the Ramsay scale in 1st, 2nd and 3rd hour. Results. No significant difference was observed between the two groups with regard to the pre-operative and perioperative haemodynamic variables and the respiratory rate (P > 0.05), although it was found that vecuronium maintenance dose duration was significantly higher in the tizanidine premedicated group (P = 0.015). In addition, the operative time (P = 0.128) and the postoperative patients' Ramsay scores did not differ statistically between the two groups (P > 0.05). Conclusions. The prolonged duration of vecuronium maintenance dose, the increased nondepolarizing block time, as well as haemodynamic stability preservation in patients undergoing inguinal hernia surgery following preoperative oral administration of tizanidine support the view that tizanidine can be used as an effective and safe myotonolytic premedication agent. [ABSTRACT FROM AUTHOR]

Superselective anesthesia functional evaluation (SAFE) is an adjunct to the Wada test. It is performed to rule out unintentional positioning of the tip of the embolization catheter proximal to the origin of a normal artery supplying eloquent region of spinal cord. We report a case of a 36-year-old male with cervical intramedullary spinal cord arteriovenous malformation (SCAVM) at C3 level. In this patient, we monitored motor-evoked potentials (MEPs) of bilateral upper and lower limbs along with diaphragm. Electrodes for compound muscle action potential of diaphragm were placed under fluoroscopy guidance. Through this case, we want to emphasize that intraprocedural diaphragmatic MEPs enhance the safety margin during endovascular embolization of cervical intramedullary SCAVMs. Placement of electrodes under fluoroscopy guidance ensures proper positioning into the diaphragm muscle. [ABSTRACT FROM AUTHOR]

Background: Sugammadex (Bridion) was approved by the US Food and Drug Administration (FDA) in December 2015 for the reversal of neuromuscular block (NMB) induced by rocuronium and vecuronium bromide in adults undergoing surgery and approved for use in both adults and children in the European Union in 2008. Sugammadex use in children has been reported in the United States, but to what extent is not clear. Aims: The aim was to describe the utilization pattern of NMB agents and factors associated with the use of reversal agents (neostigmine and sugammadex) in US children. Methods: Cross-sectional study of children with exposure to NMB agents between 2015 and 2017 in the Cerner Health Facts® database, which is an electronic health record (EHR) database across 600 facilities in the United States. Logistic regression estimated factors associated with the use of sugammadex vs neostigmine. Results: A total of 27 094 pediatric clinical encounters were exposed to neuromuscular blocking agents (NMBAs), in which 21 845 were exposed to rocuronium (76%), vecuronium (18%), or both (6%). Among children with exposure to rocuronium and vecuronium, the use of sugammadex was 1.7% in 2016 and 7.6% in 2017. The multivariable logistic model suggested that children who were older (age 12-17 years vs 0-1 year; odds ratio [OR] 1.96; 95% confidence interval [CI], 1.36-2.83), Hispanic or Latino ethnicity and other ethnicities (vs non-Hispanic or Latino; OR 2.03 and 1.56; 95% CI, 1.55-2.67 and 1.15-2.13, respectively), in teaching facilities (OR 1.26; 95% CI, 1.00-1.59), or admitted through emergency departments (OR 1.65; 95% CI, 1.06-2.58) were independently more likely to receive sugammadex than neostigmine after controlling for other covariates. Conclusions: In Cerner Health Facts database 2015 to 2017, among children, rocuronium was more commonly used than vecuronium, and sugammadex use was observed since 2016. Sugammadex and neostigmine users varied by demographic, clinical, and site-level characteristics. [ABSTRACT FROM AUTHOR]

Background: Residual neuromuscular block at the end of surgery may compromise the patient's safety. The risk of airway complications can be minimized through monitoring of neuromuscular function and reversal of neuromuscular block if needed. Effective reversal can be achieved with selective relaxant binding agents, however, sugammadex is the only clinically approved drug in this group. We investigated the concentration–response properties of a novel selective relaxant binding agent, carboxymethyl-γ-cyclodextrin for the reversal of neuromuscular block. We evaluated the hypothesis that it is equally potent for reversing neuromuscular block as sugammadex. Methods: Phrenic nerve – hemidiaphragm tissue preparations were isolated from male Wistar rats and suspended in a tissue holder allowing electrical stimulation of the nerve and monitoring of muscle contraction force. Concentration–response relationships were constructed for the neuromuscular blocking agents rocuronium, pipecuronium, and vecuronium. The half-effective concentrations of sugammadex and carboxymethyl-γ-cyclodextrin for reversal of neuromuscular block were determined. Results: The half effective concentrations (95% confidence interval, CI) were 7.50 (6.93–8.12) μM for rocuronium, 1.38 (1.33–1.42) μM for pipecuronium, and 3.69 (3.59–3.80) μM for vecuronium. The half effective concentrations (95% CI) of carboxymethyl-γ-cyclodextrin and sugammadex were 35.89 (32.67–39.41) μM and 3.67 (3.43–3.92) μM, respectively, for the reversal of rocuronium-induced block; 10.14 (9.61–10.70) μM and 0.67 (0.62–0.74) μM, respectively, for the reversal of pipecuronium-induced block; and 376.1 (341.9–413.8) μM and 1.45 (1.35–1.56) μM, respectively, for the reversal of vecuronium-induced block. Conclusions: Carboxymethyl-γ-cyclodextrin is an effective, but less potent agent for reversal of neuromuscular block than sugammadex. [ABSTRACT FROM AUTHOR]

Background: This randomized, double-blind trial evaluated sugammadex-mediated recovery time from rocuronium- or vecuronium-induced moderate (M-) or deep (D-) neuromuscular block in morbidly obese adults dosed by actual (ABW) or ideal body weight (IBW). Methods: Adults with BMI ≥40 kg/m2 were randomized to 1 of 5 groups: M-neuromuscular block, sugammadex 2 mg/kg ABW; M-neuromuscular block, sugammadex 2 mg/kg IBW; M-neuromuscular block, neostigmine 5 mg, and glycopyrrolate 1 mg; D-neuromuscular block, sugammadex 4 mg/kg ABW; or D-neuromuscular block, sugammadex 4 mg/kg IBW. Supramaximal train of four (TOF) stimulation of the ulnar nerve (TOF-watch SX®) monitored recovery. Primary endpoint was time to TOF ratio ≥ 0.9 for ABW and IBW groups pooled across neuromuscular blocking agent (NMBA)/blocking depth, analyzed by log-rank test stratified for agent and depth. Prespecified safety outcomes included treatment-emergent bradycardia, tachycardia, and other arrhythmias, and adjudicated hypersensitivity and anaphylaxis. Results: Of 207 patients randomized, 188 received treatment (28% male, BMI 47 ± 5.1 kg/m2, age 48 ± 13 years). Recovery was 1.5 min faster with ABW vs IBW dosing. The sugammadex 2 mg/kg groups recovered 9-fold faster [time 0.11-fold, 95% CI 0.08 to 0.14] than the neostigmine group. ABW (5.3%) and IBW (2.7%) groups had similar incidences of recovery time > 10 min (95% CI of difference: − 4.8 to 11.0%); 84% for neostigmine group. Re-curarization occurred in one patient each in the 2 mg/kg IBW and neostigmine groups. Prespecified safety outcomes occurred with similar incidences. Conclusions: ABW-based sugammadex dosing yields faster reversal without re-curarization, supporting ABW-based sugammadex dosing in the morbidly obese, irrespective of the depth of neuromuscular block or NMBA used. Trial registration: Registered on November 17, 2017, at ClinicalTrials.gov under number NCT03346070. [ABSTRACT FROM AUTHOR]

In this article the author talks about the use of anticholinesterases to reverse residual neuromuscular block which is efficacious only if recovery is already established, and it was originally advised that at least the second twitch (T2) of train-of-four response should be detectable before neostigmine is administered. It mentions the ideal reversal agent which could be given at any time after administration of a neuromuscular blocking agent (NMBA), and should have no muscarinic side-effects.

Pediatric airway management is a huge challenge for anaesthetists, and airway-related complications should be actively addressed and focused on. [ABSTRACT FROM AUTHOR]

Background and Aims: Previous studies suggest that administration of vecuronium based on total body weight rather than ideal body weight (IBW) in obesity results in overdosing with prolonged recovery times. We hypothesised that larger doses of neostigmine could result in faster recovery in obese patients administered vecuronium based on total body weight. Methods: Forty-five obese American Society of Anesthesiologists' II patients undergoing elective surgery under general anaesthesia were randomised into 3 groups to receive neostigmine 30, 40 and 50 μg/kg. Following induction, patients were paralysed with vecuronium 0.1 mg/kg based on total body weight. Reversal was achieved with neostigmine based on the patient's group, and time to train-of-four (TOF) ratios of 0.5, 0.7 and 0.9 measured. The primary outcome variable was time to achieve TOF ratio >0.9. Results: Neostigmine 50 μg/kg achieved faster recovery to TOF 0.7 than neostigmine 30 and 40 μg/kg. There was no significant difference in recovery times to TOF 0.7 in patients receiving either 30 or 40 μg/kg of neostigmine. However, neostigmine 40 μg/kg attained TOF ratio 0.9 faster than 30 μg/kg. We did not note a significant difference between the 40 and 50 μg/kg dose with regard to recovery of TOF to 0.9. Conclusion: Facilitated recovery from neuromuscular blockade to TOF of 0.7 was faster with neostigmine 50 μg/kg compared to 40 or 30 μg/kg. Recovery to TOF ratio of 0.9 was not significantly different with 40 or 50 μg/kg doses although such time was faster as compared to 30 μg/kg dose.

Background: Sugammadex reverses the neuromuscular blockade induced by rocuronium and vecuronium and is approved by the U.S. Food and Drug Administration for use in patients aged over 2 years. There is, however, a paucity of data regarding its dosing profile in infants and children younger than 2 years., Aims: The aim of this study was to assess the risk of recurarization, or re-paralysis, in children under 2 years of age to increase awareness on the importance of appropriate neuromuscular blocked monitoring and reversal., Methods: All patients aged ≤24 months who underwent an operative procedure at a tertiary medical center between January 1, 2018, and December 31, 2021, and received both rocuronium for neuromuscular blockade and sugammadex for neuromuscular blockade reversal, were identified in the electronic medical record. Patients were excluded from analysis if they (1) received vecuronium, cisatracurium, atracurium, or succinylcholine for neuromuscular blockade, (2) received neostigmine for reversal, or (3) underwent more than one operation within 24 h. We performed a survival analysis of sugammadex redose using a Cox proportional hazards model., Results: We reviewed 2923 records. Sugammadex was redosed in 123 (4.2%) cases. The median [IQR] time to redose was 7 [4-17] min, and the median [IQR] amount of redose administered was 2.74 [1.96-3.99] mg/kg. Increasing patient age (p < .01) and weight (p < .01) were associated with reduced hazard rate of sugammadex redose. For a patient of median weight, increasing age from 3 to 13 months was associated with a 53% risk reduction (HR: 0.47; 95% CI: 0.24-0.91). For a patient of median age, increasing weight from 4.7 to 9.2 kg was associated with 41% risk reduction (HR: 0.59; 95% CI: 0.32-1.07). We failed to detect any other associations., Conclusions: In this single-center, retrospective cohort study of pediatric surgery patients, there was an association between the hazard of sugammadex redose with both increased age and weight., (© 2023 John Wiley & Sons Ltd.)

This study was undertaken to determine the most hemodynamically stable method to low-flow anesthesia (LFA) between 10-minute administration of high fresh gas flow, 0.8 equilibration ratio (Fe/Fi), and state entropy (SE) between 40 and 60, a marker for adequate depth of anesthesia. Change from high fresh gas flow to LFA was done in 3 groups of 30 patients each: group T (time): 10 minutes; group R (ratio): Fe/Fi = 0.8, and group SE: SE = 40 to 50. A decrease in mean blood pressure or heart rate was treated with ephedrine or atropine, with study termination at more than 2 boluses of either. In group SE, no patient required ephedrine or atropine. The requirement for ephedrine was statistically higher in groups R and T than group SE. Atropine requirement was statistically higher in group R vs groups T and SE. In group R, the mean (SD) time to LFA was 43.9 (20.37) minutes, and in group SE was 151.9 (74.4) seconds. Hypotension or bradycardia did not occur when LFA was started at SE of 40 to 50 after anesthesia induction compared with LFA at 10 minutes, which caused hypotension, and Fe/Fi of 0.8, which caused hypotension and bradycardia. [ABSTRACT FROM AUTHOR]

Background: Myocardial protection in Tetralogy of Fallot patients undergoing intracardiac repair is suboptimal due to hypertrophied right ventricle. Hypertrophied myocardium is more susceptible to poor myocardial preservation because of inadequate capillary density as compared to the myocytes. There is a capillary to myocyte ratio mismatch. But del Nido Cardioplegia owing to its less viscosity is able to get more evenly distributed under hypothermic cardiopulmonary bypass as opposed to blood Cardioplegia. We hypothesized that the del Nido Cardioplegia technique, would be beneficial in myocardial protection because of its composition and method of delivery, leading into better early and late clinical outcomes in patients undergoing Tetralogy of Fallot repair as compared to blood cardioplegia reconstituted using St Thomas Cardioplegia solution. The objective of the study was to identify a better technique of myocardial preservation in Tetralogy of Fallot patient. Methods: In total, 56 Tetralogy of Fallot patients undergoing intracardiac repair under mild hypothermic cardiopulmonary bypass were randomly allocated to receive antegrade Cardioplegia with either standard blood Cardioplegia (Group I) or del Nido Cardioplegia (Group II). Preoperative as well as postoperative data including echocardiographic parameters for right ventricle functions, creatine kinase MB level, inotropic requirement, mechanical ventilation duration, intensive care unit stay and hospital mortality were evaluated. Results: Inotropic score in the first 24 hours postoperatively was significantly lower in Group II compared to Group I (13.4 ± 7.2 vs. 21.2 ± 9.6, p = 0.003). Creatine kinase MB level (ng/mL) was comparable between the groups. Echocardiographic parameters for right ventricle functions were also comparable between the groups during early as well as after 3 to 6 months postoperatively. Conclusion: Del Nido Cardioplegia is equally efficacious in providing myocardial protection during intracardiac repair under mild hypothermic cardiopulmonary bypass in Tetralogy of Fallot patients as compared to blood Cardioplegia solution with the added benefit of reducing inotropic requirement in first 24 hours postoperative period. [ABSTRACT FROM AUTHOR]

Background: Nondepolarising muscle relaxants (NDMRs) provide optimal conditions for tracheal intubation and improve surgical conditions. Several clinical conditions, diseases and pharmacological interactions have been suggested to cause resistance towards NDMRs that may translate into difficult intubation or inadequate operating conditions during surgery.Objective: The aim of this study was to evaluate the current evidence of patient groups with resistance towards NDMRs. A prolonged onset time was defined as a difference that exceeded 25% compared with controls.Design: A systematic review of randomised controlled trials and cohort studies.Data Sources: A comprehensive search was performed in 2016 in PubMed and EMBASE.Eligibility Criteria: Patients with conditions or diseases, or patients taking medication, which lead to resistance towards current NDMRs (rocuronium, vecuronium, cisatracurium, atracurium, mivacurium and pancuronium). Included outcomes were onset time defined as the time between administration of NDMR to maximal (90, 95 or 100%) depression of baseline twitch height of the first twitch in a train-of-four.Results: Twenty-five studies were included. Strong evidence supports a prolonged onset time of rocuronium in patients with thermal injury and Duchenne muscular dystrophy. Moderate evidence supports a prolonged onset time of NDMRs during hypothermia and in patients with infection, oculopharyngeal muscular dystrophy, liver cirrhosis treated with ulinastatin, when remifentanil is administered prior to administration of an NDMR, in fasting patients being rehydrated intravenously prior to administration of NDMR, in children with end-stage renal failure and in patients with atrial or ventricular septal defects.Conclusion: A prolonged onset time should be suspected in patients with thermal injury and Duchenne's muscular dystrophy. Further, evidence supports a prolonged onset time in patients with infection, oculopharyngeal muscular dystrophy, congenital heart defects, kidney failure, liver cirrhosis treated with ulinastatin along with remifentanil or intravenous fluids administered prior to NDMR. [ABSTRACT FROM AUTHOR]

Background and Aims: Obese patients are more vulnerable to residual neuromuscular block (NMB) and its associated complications in the post-operative period. This study was carried out to compare neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients, objectively using neuromuscular (NM) monitoring. Methods: Twenty female patients each belonging to normal weight, overweight and obese, based on body mass index, requiring general anaesthesia were recruited for this prospective cross sectional study. NMB was induced with vecuronium (0.1 mg/kg) dose based on patient′s real body weight (RBW) and monitored using acceleromyographic train of four (TOF). All patients received neostigmine 40 μg/kg and glycopyrrolate 10 μg/kg at 25% of spontaneous recovery of first twitch height (T1) of TOF (DUR 25%) and were allowed to recover to TOF ratio of 0.9. Statistical analysis was done using analysis of variance test. Results: Recovery of TOF ratio to 0.5 was comparable in all three groups. Recovery of TOF ratio to 0.7 was delayed in obese (9.82 ± 3.21 min) compared with normal weight group (7.50 ± 2.52 min). Recovery of TOF to 0.9 was significantly delayed in both overweight (12.18 ± 4.29 min) and obese patients (13.78 ± 4.30 min). DUR 25% was significantly longer in overweight (mean, standard deviation [range]; 30.10 [19-40 min]) and obese (28.8 [12-45 min]) compared with normal weight patients (22.75 [16-30 min]). Conclusion: In overweight and obese patients, when vecuronium induction dose is based on RBW, neostigmine induced recovery of NMB is delayed in late phases (TOF 0.7-0.9), which may result in vulnerability for associated complications of incomplete recovery. Ensuring safe recovery thus requires objective NM monitoring.

The mechanism of action of sugammadex in reversing neuromuscular blockers (NMBs) was theoretically studied by extensive molecular modeling (molecular docking, molecular dynamic and molecular mechanics-quantum mechanics). The NMBs-sugammadex inclusion complex was established by an enthalpy-driven process, which stabilized by hydrophobic interaction, hydrogen bonding and electrostatic interaction between NMBs and sugammadex. Furthermore, the binding energy of NMBs-sugammadex indicated that vecuronium (∆ E  = −25.29 kJ mol −1 ) had lower binding affinity to sugammadex than rocuronium (∆ E  = −34.61 kJ mol −1 ), thus the former one would be more difficult to be reversed which was consist with the phenotype of clinical trials. Molecular electrostatic potential, natural bond orbital and frontier molecular orbitals were also utilized to give explanation for the discrepancy of interaction strength between rocuronium-sugammadex and vecuronium-sugammadex inclusion complexes. In summary, the molecular modeling study made it possible to explain the different reversal efficiency of NMBs by sugammadex, which could be used to predict the drug-receptor interactions during the design phase of novel compounds development and also provide great opportunity to design novel γ-cyclodextrin-based muscle relaxant antagonists. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the effect and safety of 5-hydroxytryptamine (5-HT) receptor antagonist in alleviating the pain of patients under general anesthesia induced by rocuronium injection and preemptive analgesia. Methods. Meta-analysis was conducted with RevMan 5.1 software by electronically retrieving the databases of PubMed, Embase, the Cochrane Library, WanFang Data, and CNKI and collecting the published random control tests (RCTs) where 5-hydroxytryptamine receptor antagonist was used to alleviate the pain/limb shrinkage reaction associated with rocuronium injection. Results. Seven RTCs, including 556 patients, were included. The results of meta-analysis showed the following. (1) Compared to the control group, 5-HT receptor antagonist could prevent the total pain/limb shrinkage reaction associated with rocuronium injection [RR=0.62, 95% CI (0.54, 0.71), P<0.00001] and reduce the incidence rate of mild and moderate pain/limb shrinkage reaction associated with rocuronium injection [RR=0.46, 95% CI (0.33, 0.63), P<0.00001; RR=0.18, 95% CI (0.11, 0.31), P<0.000 01]. (2) Compared to the lidocaine group, the incidence rate was higher in preventing the pain/limb shrinkage reaction associated with rocuronium injection by 5-HT receptor antagonist, which was statistically significant [RR=1.33, 95% CI (1.05, 1.68), P=0.02]. Conclusion. 5-hydroxytryptamine receptor antagonist may be effective in preventing the pain/limb shrinkage reaction associated with rocuronium injection. [ABSTRACT FROM AUTHOR]

The neuroimmunoregulation of inflammation has been well characterized. Entamoeba histolytica provokes an inflammatory response in the host in which macrophages and neutrophils are the first line of defense. The aim of this study was to analyze the effect of the 220 kDa lectin of Entamoeba histolytica on stimulation of human macrophages and neutrophils, especially the secretion of cytokines and the relation of these to neurotransmitters. Human cells were interacted with L220, epinephrine, nicotine, esmolol and vecuronium bromide. The concentrations of IL-1β, IFN-γ, TNF-α and IL-10 were determined by ELISA at, 4 h of interaction. L220 has a cytokine stimulating function of macrophages and neutrophils for secretion of IL-1β, and IL-10 only by macrophages, which was modulated by the effect of vecuronium on cholinergic receptors in this immune cells. [ABSTRACT FROM AUTHOR]