The effect of succinylcholine on malignant hyperthermia events in susceptible swine.

BACKGROUND: While the impact of volatile anaesthetics to induce malignant hyperthermia (MH) is abundantly clear, the role of succinylcholine still remains controversial. To evaluate the influence of succinylcholine on porcine MH events, the authors investigated the hemodynamic and metabolic responses in MH susceptible (MHS) and non-susceptible (MHN) swine following either succinylcholine or halothane application alone or a combination of both substances. METHODS: With approval of the local animal care committee 27 MHS and 30 MHN pigs were anaesthetized and mechanically ventilated. Fiberoptic probes for continuous PCO2 measurement were inserted into the femoral vein and the triceps muscle. Group A received succinylcholine 4 mg/kg, group B incremental doses of halothane (0.5, 1.0 vol%) and group C succinylcholine and halothane simultaneously. Vital signs were recorded continuously. RESULTS: Prior to drug application measured values did not differ between MHS and MHN. While MHN pigs did not show relevant alterations, succinylcholine, halothane and the combination of both lead to significant hemodynamic and metabolic changes in MHS swine. CONCLUSIONS: Hemodynamic and metabolic alterations following succinylcholine were similar to halothane in MHS pigs. The combination of both pharmacological agents potentiated the observed effects. According to these results succinylcholine acted as an independent and supportive factor during onset of an MH episode.

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

BACKGROUND: To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. MATERIAL/METHODS: Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. RESULTS: Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. CONCLUSIONS: This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.

Drug use inefficiency: a hidden source of wasted health care dollars.

UNLABELLED: A potential area for departmental savings is to minimize inefficient use of pharmaceuticals. We recorded drug waste data for multiple drugs for a fiscal year and surveyed providers' knowledge of departmental drug waste. Six large-cost or large-volume use drugs were chosen for study: thiopental, succinylcholine, rocuronium, atracurium, midazolam, and propofol. Amounts administered to patients were collected for one year by using a computerized anesthesia record keeper. Total drug distributed was the number of vials restocked by pharmacy for the year. An efficiency index, the percent administered to patients, was calculated for each drug. Drug administration to 25,481 patients was analyzed. Drug use efficiency indices were: atracurium 29%; thiopental, 31%; succinylcholine, 33%; propofol, 49%; midazolam, 53%; rocuronium, 61%. The total cost of unadministered study drugs was $165,667, 26% of the expenditure for all drugs. Most dollars wasted were for propofol, $80,863, and thiopental, $32,839. The reason most cited for drug waste was the disposal of full, or partially full, syringes. Drug wastage represents a significant portion of the entire anesthesia drug budget. Waste reduction strategies should allow a portion of the "avoidable" waste to be reduced. IMPLICATIONS: Unadministered drug amounts were measured for six study drugs over one fiscal year and found to be significant; the cost of unadministered drugs totaled $165,667. The reason most cited for waste was disposal of full, or partially full, syringes.

An assessment of preoxygenation techniques using the pulse oximeter.

The effect of preoxygenation with varying inspired oxygen concentration on the arterial oxygen saturation during induction of anaesthesia and intubation was studied using the pulse oximeter. Sixty-five healthy, young adults, (American Society of Anaesthesiologists Class I) undergoing elective surgery were randomly divided into three groups. Group I patients were not preoxygenated. Groups II and III patients were preoxygenated with 50% oxygen and nitrous oxide and 100% oxygen respectively for one minute. All were then induced with thiopentone, paralysed with suxamethonium and orally intubated. During intubation, severe arterial desaturation occurred in those patients who were not preoxygenated (lowest saturation was 81.7 +/- 7.8% occurring 87 +/- 24.5 seconds after suxamethonium injection). This was significantly lower than the other two groups (p < 0.001). No patient had clinical signs of hypoxaemia. Patients who were preoxygenated with either 50% oxygen and nitrous oxide or 100% oxygen showed similar and clinically insignificant desaturation during this period. One minute after intubation and manual ventilation with 100% oxygen, the saturations of all patients returned to preinduction levels.

Thiopentone and suxamethonium crash induction. An assessment of the potential hazards.

A technique of 'crash induction' using thiopentone and suxamethonium with cricoid pressure was studied in 100 unselected patients at risk from vomiting or regurgitation. No episode of regurgitation occurred. There was difficulty with intubation due to poor relaxation in 7 patients and, in 61 cases, it was believed that there was some evidence of a potential hazard from raised intra-abdominal pressure other than due to fasciculation. Systolic blood pressure rose more than 20% in 19 patients, and fell more than 20% in 9 patients.