Pharmacotherapy optimization for rapid sequence intubation in the emergency department.

PURPOSE: Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY: There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH: The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION: In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION: A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS: The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS: The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Physical compatibility of remimazolam with opioid analgesics, sedatives, and muscle relaxants during simulated Y-site administration.

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.

Transcutaneous electric acupoint stimulation reduces rocuronium injection-related pain: a prospective randomized controlled study.

OBJECTIVE: Various approaches have been suggested to reduce the pain and discomfort associated with rocuronium injection. This randomized controlled trial aimed at exploring the effectiveness of transcutaneous electrical acupoint stimulation (TEAS), a non-invasive modality to reduce the pain associated with rocuronium injection. PATIENTS AND METHODS: 60 patients undergoing elective general anesthesia were recruited and randomly allocated to the TEAS or placebo TEAS (no electrical output) groups. TEAS consisted of 30 min of stimulation at a frequency of 2/100 Hz and an intensity of 6-9 mA on Hegu (LI4) and Neiguan (PC6) before anesthesia induction. A blinded observer evaluated the pain using a 4-point pain scale. RESULTS: The overall incidence of rocuronium injection-related pain was significantly lower in the TEAS group than that in the placebo TEAS group (40% and 86.7%, respectively). The incidence of no or mild pain was significantly higher in the TEAS group (100%, p<0,001) group than that in the placebo TEAS group (50%). CONCLUSIONS: Pretreatment with TEAS effectively reduced the frequency and severity of pain associated with rocuronium injection.

Plasma rocuronium concentration in cell salvage blood following cardiac surgery: a case series.

PURPOSE: The aim of the study was to evaluate the plasma rocuronium concentration in autologous blood transfusion obtained from the cell salvage (CS) system following cardiac surgery with cardiopulmonary bypass (CPB). METHODS: This prospective observational study was conducted in a university teaching hospital from July to November 2020. Patients undergoing general anesthesia for cardiac surgery with CPB were enrolled in the study. After separation from CPB, residual blood remaining in the extracorporeal system was collected as the control sample. The second sample (CS blood) was collected from the autologous blood transfusion obtained after completion of the CS system with Cell Saver® Elite®. Hematocrit values of both samples were also examined. RESULTS: Ten subjects (aged 57-86 years) were enrolled in this study. Plasma rocuronium concentrations (ng/ml) were significantly lower in the CS blood (94.0 ± 77.5) compared to the control (2950 ± 812.2) (p = 0.002). Hematocrit values (%) were significantly higher in the CS blood (75.2 ± 11.3) compared to the control (40.2 ± 10.2) (p = 0.002). CONCLUSION: Autologous blood transfusion obtained from CS system following cardiac surgery with CPB, only retained a small amount of plasma rocuronium concentration, therefore, the risk of autologous blood transfusion contributing to clinically relevant residual neuromuscular blockade postoperatively should be considered to be low. TRIAL REGISTRATION: This trial was registered in the University Hospital Medical Information Network under registration number UMIN000040877 (registration date; June 24, 2020).

[Simultaneous determination of three quaternary ammonium muscle relaxants in blood by high performance liquid chromatography-tandem mass spectrometry].

Vecuronium, rocuronium, and pancuronium are widely used as non-depolarizing muscle relaxants. There have been occasional cases of allergic reactions and even death when using such muscle relaxants. Rapid determination of the concentration of these muscle relaxants in blood can provide valuable information for early clinical diagnosis. As quaternary ammonium compounds, these muscle relaxants are highly polar. Hence, they cannot be retained effectively on reversed-phase chromatographic columns with conventional mobile phases. These quaternary ammonium muscle relaxants are mainly separated by ion-pair chromatography. Using an ion-pairing reagent can help improve the retention capabilities of quaternary ammonium muscle relaxants. Nevertheless, the sensitivity of MS detection is significantly decreased because of ionic inhibition caused by the ion-pairing reagent in the mobile phase. Furthermore, ion-pairing reagents can pollute the MS system. A method based on high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) was established for the simultaneous determination of the three quaternary ammonium muscle relaxants in blood. The blood samples were diluted and subjected to high-speed centrifugation. The supernatant was purified on a Bond Elut AL-N solid phase extraction column and then filtered through a 0.45 µm microporous membrane. The quaternary ammonium muscle relaxants were separated on a ZIC-cHILIC analytical column (50 mm×2.1 mm, 3.0 µm) with gradient elution. Acetonitrile and 0.1% formic acid aqueous solution were used as mobile phases. The separated compounds were analyzed by tandem MS with an electrospray ionization (ESI) source in positive and multiple reaction monitoring (MRM) modes. The matrix effects of vecuronium, rocuronium, and pancuronium in blood were 88.1% to 95.4%. The calibration curves for vecuronium, rocuronium, and pancuronium showed good linear relationships in each range, and all correlation coefficients (R2) were > 0.996. The limits of detection of vecuronium, rocuronium, and pancuronium were 0.2-0.8 ng/mL, with the corresponding limits of quantification being 0.5-2.0 ng/mL. The recoveries of vecuronium, rocuronium, and pancuronium were 92.8% to 110.6%, with relative standard deviations (RSDs) of 3.2%-9.4%. This method is sensitive, accurate, and easy to operate, and it can be used to rapidly determine vecuronium, rocuronium, and pancuronium in blood.

Efficacy of magnesium sulfate as an adjuvant to rocuronium in general anaesthesia: a meta-analysis.

OBJECTIVE: Magnesium sulfate is considered to be an effective adjuvant to rocuronium in general anaesthesia. We conducted a meta-analysis to clarify its efficacy. METHODS: We searched the PubMed, Embase, Web of Science, Cochrane Library, WanFang, Chinese Biomedical Literature, and China National Knowledge Infrastructure databases for randomized controlled trials (RCTs) of magnesium sulfate as an adjuvant to rocuronium from the start of the database establishment until May 2020. RESULTS: Eleven RCTs were analysed. The pooled meta-analysis showed that using magnesium sulfate as an adjuvant significantly shortened the onset time and prolonged the clinical duration of neuromuscular blockade by rocuronium compared with the control group without magnesium sulfate. However, there was no significant difference in recovery index of neuromuscular block between the magnesium and control groups. Furthermore, magnesium sulfate significantly increased the rates of excellent and clinically acceptable intubation conditions. CONCLUSION: Adding magnesium sulfate to rocuronium during general anaesthesia can alter the neuromuscular parameters, including shortening the anaesthesia-onset time and prolonging the clinical duration, without significantly increasing the recovery time. Pretreatment with magnesium sulfate may also improve intubation conditions during general anaesthesia.

Rapid Sequence Induction With a Standard Intubation Dose of Rocuronium After Magnesium Pretreatment Compared With Succinylcholine: A Randomized Clinical Trial.

BACKGROUND: Succinylcholine remains the muscle relaxant of choice for rapid sequence induction (RSI) but has many adverse effects. High-dose rocuronium bromide may be an alternative to succinylcholine for RSI but recovery times are nearly doubled compared with a standard intubating dose of rocuronium. Magnesium sulfate significantly shortens the onset time of a standard intubating dose of rocuronium. We set out to investigate whether intravenous (IV) pretreatment with MgSO4 followed by a standard intubating dose of rocuronium achieved superior intubation conditions compared with succinylcholine. METHODS: Adults were randomized to receive a 15-minute IV infusion of MgSO4 (60 mg·kg-1) immediately before RSI with propofol 2 mg·kg-1, sufentanil 0.2 µg·kg-1 and rocuronium 0.6 mg·kg-1, or a matching 15-minute IV infusion of saline immediately before an identical RSI, but with succinylcholine 1 mg·kg-1. Primary end point was the rate of excellent intubating conditions 60 seconds after administration of the neuromuscular blocking agent and compared between groups using multivariable log-binomial regression model. Secondary end points were blood pressure and heart rate before induction, before and after intubation, and adverse events up to 24 hours postoperatively. RESULTS: Among 280 randomized patients, intubating conditions could be analyzed in 259 (133 MgSO4-rocuronium and 126 saline-succinylcholine). The rate of excellent intubating conditions was 46% with MgSO4-rocuronium and 45% with saline-succinylcholine. The analysis adjusted for gender and center showed no superiority of MgSO4-rocuronium compared with saline-succinylcholine (relative risk [RR] 1.06, 95% confidence interval [CI], 0.81-1.39, P = .659). The rate of excellent intubating conditions was higher in women (54% [70 of 130]) compared with men (37% [48 of 129]; adjusted RR 1.42, 95% CI, 1.07-1.91, P = .017). No significant difference between groups was observed for systolic and diastolic blood pressures. Mean heart rate was significantly higher in the MgSO4-rocuronium group. The percentage of patients with at least 1 adverse event was lower with MgSO4-rocuronium (11%) compared with saline-succinylcholine (28%) (RR 0.38, 95% CI, 0.22-0.66, P < .001). With saline-succinylcholine, adverse events consisted mainly of postoperative muscle pain (n = 26 [19%]) and signs of histamine release (n = 13 [9%]). With MgSO4-rocuronium, few patients had pain on injection, nausea and vomiting, or skin rash during the MgSO4-infusion (n = 5 [4%]). CONCLUSIONS: IV pretreatment with MgSO4 followed by a standard intubating dose of rocuronium did not provide superior intubation conditions to succinylcholine but had fewer adverse effects.

The future of neuromuscular blocking agents.

PURPOSE OF REVIEW: The present review provides a summary of the literature on recent development of new neuromuscular blocking agents and presents clinically well established and new reversal agents. RECENT FINDINGS: Anesthesiologists are still waiting for the ideal neuromuscular blocking agent with a succinylcholine-like rapid onset and offset without side effects. Recent drug development led to a new series of neuromuscular compounds, called the chlorofumarates such as gantacurium, CW002, and CW011. These drugs have a promising pharmacodynamic profile; importantly, they can rapidly be reversed by L-cysteine adduction without relevant side effects. In addition, a new spectrum of reversal agents are currently examined in preclinical studies: adamgammadex sodium, a modified γ-cyclodextrin derivate that forms an inactive tight inclusion complex with rocuronium or vecuronium and calabadions, capable of reversing both benzylisoquinolines and steroidal neuromuscular blocking agents. SUMMARY: Although the recent advancements in neuromuscular research are very promising, to date, the presented drugs are currently not available for clinical use. Clinical studies will determine the role of these developments in anesthesia practice. Therefore, well established combinations such as rocuronium-sugammadex are popular in clinical practice to offer quick paralysis for intubation and to optimize surgical conditions, while providing a fast neuromuscular recovery at the end of surgery.

Anesthetic and surgical management of tracheostomy in a patient with COVID-19.

OBJECTIVE: The ongoing pandemic coronavirus disease-2019 (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare. Since COVID-19 spreads through contact and droplet infection routes, careful attention to infection control and surgical management is important to prevent cross-contamination of patients and medical staff. Tracheostomy is an effective method to treat severe respiratory dysfunction with prolonged respiratory management and should be performed as a high-risk procedure METHOD: The anesthetic and surgical considerations in this case involved difficult goals of the patient safety and the management of infection among health care workers. Our surgical procedure was developed based on the previous experiences of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). RESULTS: We described the management procedures for tracheostomy in a patient with COVID-19, including the anesthesia preparation, surgical procedures, required medical supplies (a N95 mask or powered air purifying respirator, goggles, face shield, cap, double gloves, and a water-resistant disposable gown), and appropriate consultation with an infection prevention team. CONCLUSION: Appropriate contact, airborne precautions, and sufficient use of muscle relaxants are essential for performing tracheostomy in a patient with COVID-19.

Incomplete recovery from rocuronium-induced muscle relaxation in patients with amyotrophic lateral sclerosis using sugammadex: A case report.

INTRODUCTION: Patients with motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), have higher sensitivity to nondepolarizing neuromuscular blocking agents (NMBAs) and are at higher risk for a residual block. For this reason, the use of NMBAs such as rocuronium has been limited owing to the delayed reversal of muscle relaxation. It was recently reported that rapid and effective reversal of muscle relaxation occurs when sugammadex, a muscle relaxant reversal drug, is administered to patients in ALS with rocuronium-induced muscle relaxation. However, in this paper, we report the incomplete recovery and recurarization of muscle relaxation after sugammadex administration in ALS patients, and delayed recovery of muscle relaxation after additional administration of sugammadex. PATIENT CONCERNS: A 71-year-old male patient with ALS received general anesthesia for laparoscopic nephroureterectomy. DIAGNOSIS: The patient was diagnosed with ALS 2 years earlier, and scheduled to undergo laparoscopic nephroureterectomy for ureteral cancer. INTERVENTION: We used sugammadex for the reversal of deep neuromuscular block. We measured a train-of-four (TOF) count of 4 and a TOF ratio of 54% at about 8 min after administration of 4 mg/kg sugammadex. However, then the TOF count decreased to 1 to 3 and tidal volume (TV) decreased to < 100 mL. Therefore, an additional 50 mg sugammadex was administered intravenously 12 min after the first dose of sugammadex was injected. OUTCOMES: The patient's vital signs were stable and his recovery from anesthesia was uneventful. Therefore, he was discharged to the intensive care unit. The patient had aspiration pneumonia symptoms owing to dysphagia on the third postoperative day, but after the symptoms improved he was transferred to the hospital for rehabilitation of dysphagia and dyspnea. CONCLUSION: It is critical to monitor whether muscle relaxation is sufficiently reversed when using sugammadex in ALS patients. Further research is needed to determine the appropriate dose of sugammadex for muscle relaxation reversal.

Effect of pretreatment with magnesium sulphate on the duration of intense and deep neuromuscular blockade with rocuronium: A randomised controlled trial.

BACKGROUND: Magnesium sulphate is an important adjuvant drug in multimodal anaesthesia. In combination with rocuronium it can enhance neuromuscular blockade (NMB). Limited data exist concerning the effect of magnesium sulphate on the duration of deep or intense NMB and the period of no response. OBJECTIVE(S): To determine the role of magnesium sulphate on the duration of rocuronium-induced deep and intense NMB, and the period of no response to nerve stimulation. DESIGN: A randomised controlled trial. SETTING: A public tertiary care hospital, Rio de Janeiro, Brazil, from February 2017 to March 2018. PATIENTS: All patients between 18 and 65 years of age scheduled to undergo elective otorhinolaryngological surgery, with a BMI between 18.5 and 24.9 kg m and an American Society of Anesthesiologists physical status classification of I or II. INTERVENTION(S): Before induction of anaesthesia 60 patients were pretreated with an intravenous infusion of either 100 ml 0.9% saline (saline group), or 60 mg kg magnesium sulphate (magnesium group). After loss of consciousness, a bolus of rocuronium (0.6 mg kg) was administered. Neuromuscular function was measured by TOF-Watch SX monitor. MAIN OUTCOME MEASURES: The primary and secondary outcomes were the duration of the period of no response to nerve stimulation and intense and deep NMB, respectively. An additional outcome was the NMB onset time. RESULTS: Median [IQR] durations of deep NMB were 20.3 [12.0 to 35.4] and 18.3 [11.2 to 26.3] min in the magnesium and saline groups, respectively (P = 0.18). Median durations of intense NMB were 21.7 [0.0 to 32.2] min and 0.0 [0.0 to 6.2] min (P = 0.001) in the magnesium and saline groups, respectively. Median durations of the period of no response were 40.8 [51.4 to 36.0] min and 28.0 [21.9 to 31.6] min (P = 0.0001) in the magnesium and saline groups, respectively. CONCLUSION: Magnesium sulphate increased both the duration of intense NMB and the period of no response. The duration of deep NMB was similar in the magnesium sulphate group and saline group. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02989272.

Rocuronium is more hepatotoxic than succinylcholine in vitro.

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.

[Update on muscle relaxation : What comes after succinylcholine, rocuronium and sugammadex?] / Update Muskelrelaxation : Was kommt nach Succinylcholin, Rocuronium und Sugammadex?

Due to the great advantages, it is not possible to imagine current practice in anesthesia without the adminstration of muscle relaxants. For a long time the administration of succinylcholine for rapid sequence induction (RSI) was considered to be the state of the art for patients at risk for aspiration. The favorable characteristics are, however, accompanied by many, sometimes severe side effects. Due to the development of non-depolarizing muscle relaxants, in particular rocuronium in combination with sugammadex, there is the possibility to achieve a profile of action similar to succinylcholine with low side effects. After the introduction of sugammadex onto the market, further substances were conceived, which enable a complete encapsulation of muscle relaxants. Calabadion is a very promising new substance for the antagonization of muscle relaxants, which can antagonize the action of steroid as well as benzylisoquinoline types. In the USA new muscle relaxants are currently being tested, which have a rapid onset and the effect can be reversed by L­cysteine. One of the most promising substances is gantacurium, which is currently being tested in the USA in phase III trials. It remains to be seen whether these muscle relaxants, which are not yet on the market and drugs for reversal of neuromuscular blockade have the potential to become a real alternative to the combination of rocuronium and sugammadex.

Pulmonary Phototherapy to Treat Carbon Monoxide Poisoning in Rats.

BACKGROUND: Carbon monoxide (CO) poisoning is a common cause of poison-related mortality. CO binds to hemoglobin in the blood to form carboxyhemoglobin (COHb), impairing oxygen delivery to peripheral tissues. Current treatment of CO-poisoned patients involves oxygen administration to rapidly remove CO and restore oxygen delivery. Light dissociates CO from COHb with high efficiency. Exposure of murine lungs to visible laser-generated light improved the CO elimination rate in vivo. The aims of this study were to apply pulmonary phototherapy to a larger animal model of CO poisoning, to test novel approaches to light delivery, and to examine the effect of chemiluminescence-generated light on the CO elimination rate. METHODS: Anesthetized and mechanically ventilated rats were poisoned with CO and subsequently treated with air or oxygen combined with or without pulmonary phototherapy delivered directly to the lungs of animals at thoracotomy, via intrapleural optical fibers or generated by a chemiluminescent reaction. RESULTS: Direct pulmonary phototherapy dissociated CO from COHb reducing COHb half-life by 38%. Early treatment with phototherapy in critically CO poisoned rats improved lactate clearance. Light delivered to the lungs of rats via intrapleural optical fibers increased the rate of CO elimination without requiring a thoracotomy, as demonstrated by a 16% reduction in COHb half-life. Light generated in the pleural spaces by a chemiluminescent reaction increased the rate of CO elimination in rats breathing oxygen, reducing the COHb half-life by 12%. CONCLUSIONS: Successful application of pulmonary phototherapy in larger animals and humans may represent a significant advance in the treatment of CO-poisoned patients.

Failed Vocalis Muscle Monitoring During Thyroid Surgery Resulting From Residual Muscle Relaxation.

Postoperative paralysis of the vocal cords resulting from intraoperative surgical injury of the recurrent laryngeal nerve is one of the most serious complications of elective thyroid surgery. The chance of injury is reduced by using intraoperative neuromonitoring (IONM). This educational report describes a case of IONM failure resulting from residual muscle relaxation that was restored by administration of sugammadex. It discusses possible pharmacology explanations and provides recommendations for how to prevent this situation in daily practice.

Electroconvulsive Therapy Considerations for Transgendered Patients.

As the transgender patient population continues to grow, health care providers will need to become aware of elements unique to the transgender community in order to provide the highest quality of care. Neuromuscular blockade with succinylcholine is routinely administered to patients undergoing electroconvulsive therapy (ECT). Decreased amounts or activity of pseudocholinesterase in serum can lead to prolonged duration of muscle paralysis. Causes of reduced action by pseudocholinesterase include genetically abnormal enzymes, reduced hepatic production, pregnancy, and various drug interactions. Estrogen supplementation taken by transitioning patients may affect the duration of neuromuscular blockade.This is a case of a 32-year-old male-to-female transgender patient with prolonged apnea following ECT treatment for severe, refractory depression. Further investigation revealed the patient was on estrogen therapy as a part of her transition and laboratory testing demonstrated reduced serum pseudocholinesterase activity. Further laboratory testing demonstrated reduced serum pseudocholinesterase activity. Succinylcholine dosing was titrated to an appropriate level to avoid prolonged apnea in subsequent ECT treatments. Physicians and other health care providers are faced with a unique population in the transgender community and must be aware of distinctive circumstances when providing care to this group. Of specific interest, many transitioning and transitioned patients can be on chronic estrogen supplementation. Neuromuscular blockade in those patients require attention from the anesthesiology care team as estrogen compounds may decrease pseudocholinesterase levels and lead to prolonged muscle paralysis from succinylcholine.

Intraoperative mandibular nerve block with peripheral nerve stimulator for temporomandibular joint ankylosis.

We describe the use of peripheral nerve stimulator for mandibular nerve block intraoperatively in a 4.5year old child with complete temporomandibular joint ankyloses. The block was not possible preoperatively, therefore, it was administered after release of ankyloses. The use of peripheral nerve stimulator increased the chances of a successful block. No intraoperative analgesics and muscle relaxants were required. Postoperative pain relief was excellent. Peripheral nerve stimulator is an easy way of for accurate needle tip placement for mandibular nerve block in patients with distorted anatomy.

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

BACKGROUND: Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. METHODS: We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. RESULTS: We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). CONCLUSIONS: We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.