Association between intraoperative non-depolarising neuromuscular blocking agent dose and 30-day readmission after abdominal surgery.

BACKGROUND: We hypothesised that intraoperative non-depolarising neuromuscular blocking agent (NMBA) dose is associated with 30-day hospital readmission. METHODS: Data from 13,122 adult patients who underwent abdominal surgery under general anaesthesia at a tertiary care hospital were analysed by multivariable regression, to examine the effects of intraoperatively administered NMBA dose on 30-day readmission (primary endpoint), hospital length of stay, and hospital costs. RESULTS: Clinicians used cisatracurium (mean dose [SD] 0.19 mg kg-1 [0.12]), rocuronium (0.83 mg kg-1 [0.53]) and vecuronium (0.14 mg kg-1 [0.07]). Intraoperative administration of NMBAs was dose-dependently associated with higher risk of 30-day hospital readmission (adjusted odds ratio 1.89 [95% Confidence Interval (CI) 1.26-2.84] for 5th quintile vs 1st quintile; P for trend: P<0.001), prolonged hospital length of stay (adjusted incidence rate ratio [aIRR] 1.20 [95% CI 1.11-1.29]; P for trend: P<0.001) and increased hospital costs (aIRR 1.18 [95% CI 1.13-1.24]; P for trend: P<0.001). Admission type (same-day vs inpatient surgery) significantly modified the risk (interaction term: aOR 1.31 [95% CI 1.05-1.63], P=0.02), and the adjusted odds of readmission in patients undergoing ambulatory surgical procedures who received high-dose NMBAs vs low-dose NMBAs amounted to 2.61 [95% CI 1.11-6.17], P for trend: P<0.001. Total intraoperative neostigmine dose increased the risk of 30-day readmission (aOR 1.04 [1.0-1.08], P=0.048). CONCLUSIONS: In a retrospective analysis, high doses of NMBAs given during abdominal surgery was associated with an increased risk of 30-day readmission, particularly in patients undergoing ambulatory surgery.

Azathioprine fails to alter the dose-response curve of d-tubocurarine in rats.

Cyclic 3':5' adenosine monophosphate (cAMP) mediated facilitation of neuromuscular (NM) transmission was previously implicated in the mechanisms of the reversal of nondepolarizing NM relaxants by azathioprine (AZA). This interaction of d-tubocurarine (dTC) with AZA was re-examined in rats and correlated to changes in cAMP in the same muscle. Three groups of animals were studied: controls, low-dose AZA (5 mg/kg), and high-dose AZA (50 mg/kg). After AZA or saline administration, dose-response (DR) curves for inhibition of gastrocnemius twitch tension by dTC were constructed. Contralateral gastrocnemius muscle was sampled for cAMP levels. In another group of animals, the response to 5- and 50-mg/kg boluses of AZA was recorded during a steady-state twitch depression maintained with an infusion of dTC. No significant shift in the DR curve of dTC was observed following low- and high-dose AZA. During steady-state twitch depression, high-dose AZA, however, caused a transient reversal of twitch lasting 5-10 min. High-dose AZA caused a significant (P less than 0.006) elevation of cAMP levels (340 +/- 49 pmol/mg prot) compared to control (120 +/- 18) and low-dose (163 +/- 24) AZA groups. These studies, therefore, document transient reversal of twitch tension by 50 mg/kg doses of AZA during a steady-state dTC infusion. On the other hand, AZA administered prior to dTC in low (5 mg/kg) and high (50 mg/kg) doses failed to cause a significant shift in the dTC DR curve. A three-fold increase in skeletal muscle cAMP induced by high-dose AZA does not alter dTC DR curves.

Systemic lupus erythematosus in childhood: clinical manifestations and improved survival in fifty-five patients.

A retrospective review of 55 patients with systemic lupus erythematosus (SLE) (45 girls and 10 boys) under age 18 (median age of onset; 12.2 years) seen at the Children's Hospital Medical Center (Boston, Mass.) over the past 20 years was done. Clinical presentation was similar to previous series, but atypical presentation was common. Certain unusual presentations (such as isolated hematopoietic abnormalities) often occurred and delayed diagnosis for years in some cases. The frequency of ARA clinical classification of SLE was different in children as compared to adults. We observed depression of lymphocyte count in many patients and encountered elevations of hepatic enzyme levels in others. Of the 55 patients reviewed, 9 have died and 8 have been lost to follow-up. Of the rest, 21 have mild to moderate disease and 17 have inactive or minimally active SLE, after a median length of follow-up of 8.8 years. In severe cases, using either corticosteroids and/or cytotoxic agents, a favorable prognosis was obtained. Our cumulative 5- and 10-year survival of 92 and 85%, respectively, equals or exceeds that of previous reports of childhood SLE.