Subparalyzing Doses of Rocuronium Reduce Muscular Endurance without Detectable Effect on Single Twitch Height in Awake Subjects.

PURPOSE: To test the hypothesis that a low-dose rocuronium acts mainly by means of reducing muscular endurance rather than by reducing momentary force. METHODS: In a randomized placebo-controlled double-blinded study, eight healthy volunteers were studied in two sets of experiments. In the first set, the subjects made a sustained maximum effort with the dominant hand for 80 seconds while squeezing an electronic handgrip dynamometer at three minutes after intravenous administration of placebo, 0.04 or 0.08 mg/kg rocuronium. Handgrip force at initiation of testing (maximum handgrip force) and after 60 seconds was evaluated. In the second set, the ulnar nerve of the subjects was electrically stimulated every tenth second for at least 10 and a maximum of 30 minutes following the administration of placebo and 0.08 mg/kg rocuronium. Single twitch height of the adductor pollicis muscle was recorded. RESULTS: There was no significant difference in the effect on maximum handgrip force at time 0 between the three different doses of rocuronium. As compared with placebo, handgrip force after 0.08 mg/kg rocuronium was reduced to approximately a third at 60 seconds (214 N (120-278) vs. 69 (30-166); p=0.008), whereas only a slight reduction was seen after 0.04 mg/kg (187 (124-256); p=0.016). Based on these results, the sustained handgrip force after 0.2 mg/kg at 60 seconds was calculated to be 1.27% (95% CI [0.40, 4.03]) of the maximum force of placebo. No effect on single twitch height after 0.08 mg/kg rocuronium at four minutes after drug administration could be detected. CONCLUSIONS: Subparalyzing doses of rocuronium show a distinct effect on muscular endurance as opposed to momentary force. The findings support the hypothesis that low doses of rocuronium act mainly by reducing muscular endurance, thereby facilitating, for example, tracheal intubation.

Endovascular treatment of vein of Galen aneurysmal malformation using rapid ventricular pacing: A case report.

The treatment of choice of vein of Galen aneurysmal malformation (VGAM) involves endovascular procedures that can be difficult to perform in high-flow fistulas. We describe the use of rapid ventricular pacing (RVP), a well-known cardiologic technique, to safely treat a high-flow fistula in an infant with VGAM.

Improving Survival and Neurologic Function for Younger Age Groups After Out-of-Hospital Cardiac Arrest in Sweden: A 20-Year Comparison.

OBJECTIVE: To describe changes in the epidemiology of out-of-hospital cardiac arrest in Sweden with the emphasis on the younger age groups. DESIGN: Prospective observational study. SETTING: Sweden. PATIENTS: Patients were recruited from the Swedish Registry of Cardiopulmonary Resuscitation from 1990 to 2012. Only non-crew-witnessed cases were included. INTERVENTION: Cardiopulmonary resuscitation. MEASUREMENT AND MAIN RESULTS: The endpoint was 30-day survival. Cerebral function among survivors was estimated according to the cerebral performance category scores. In all, 50,879 patients in the survey had an out-of-hospital cardiac arrest, of which 1,321 (2.6%) were 21 years old or younger and 1,543 (3.0%) were 22-35 years old. On the basis of results from 2011 and 2012, we estimated that there are 4.9 cases per 100,000 person-years in the age group 0-21 years. The highest survival was found in the 13- to 21-year age group (12.6%). Among patients 21 years old or younger, the following were associated with an increased chance of survival: increasing age, male gender, witnessed out-of-hospital cardiac arrest, ventricular fibrillation, and a short emergency medical service response time. Among patients 21 years old or younger , there was an increase in survival from 6.2% in 1992-1998 to 14.0% in 2007-2012. Among 30-day survivors, 91% had a cerebral performance category score of 1 or 2 (good cerebral performance or moderate cerebral disability) at hospital discharge. CONCLUSIONS: In Sweden, among patients 21 years old or younger, five out-of-hospital cardiac arrests per 100,000 person-years occur and survival in this patient group has more than doubled during the past two decades. The majority of survivors have good or relatively good cerebral function.

Characteristics of cardiac arrest and resuscitation by age group: an analysis from the Swedish Cardiac Arrest Registry.

AIM: The objective of this study was to describe patients who experienced an out-of-hospital cardiac arrest (OHCA) by age group. METHODS: All patients who suffered from an OHCA between 1990 and 2005 and are included in the Swedish Cardiac Arrest Registry (n = 40,503) were classified into the following age groups: neonates, younger than 1 year; young children, between 1 and 4 years; older children, between 5 and 12 years; adolescents, between 13 and 17 years; young adults, between 18 and 35 years; adults not retired, between 36 and 64 years; adults retired, between 65 and 79 years; and older adults, 80 years or older. RESULTS: Ventricular fibrillation was lowest in young children (3%) and highest in adults (35%). Survival to 1 month was lowest in neonates (2.6%) and highest in older children (7.8%). Children (<18 years), young adults (18-35 years), and adults (>35 years) survived to 1 month 24.5%, 21.2%, and 13.6% of cases, respectively (P = .0003 for trend) when found in a shockable rhythm. The corresponding figures for nonshockable rhythms were 3.8%, 3.2%, and 1.6%, respectively (P < .0001 for trend). CONCLUSIONS: There is a large variability in characteristics and outcome among patients in various age groups who experienced an OHCA. Among the large age groups, there was a successive decline in survival with increasing age in shockable and nonshockable rhythms.

Heart transplantation across the antibodies against HLA and ABO.

We have intentionally performed heart transplantation in a 5-year-old child, despite the most unfavourable risk factors for patient survival; the presence of high level of antibodies against donor's human leucocyte antigen (HLA) class I/II and blood group antigens. Pretransplant treatment by mycophenolate mofetil, prednisolone, tacrolimus, intravenous immunoglobulin, rituximab, protein-A immunoadsorption (IA) and plasma exchange reduced antibody titres against the donor's lymphocytes from 128 to 16 and against the donor's blood group antigen from 256 to 0. The patient was urgently transplanted with a heart from an ABO incompatible donor (A(1) to O). A standard triple-drug immunosuppressive protocol was used. No hyperacute rejection was seen. Antibodies against the donor's HLA antigens remained at a low level despite three acute rejections. Rising anti-A(1) blood group antibodies preceded the second rejection and were reduced by two blood group-specific IAs and remained at a low level. The patient is doing well despite the persistence of donor-reactive antibodies.