Neuromuscular blockade with atracurium for ophthalmic surgery in horses-Effects on surgical and anesthetic characteristics and recovery quality.

OBJECTIVE: To study the surgical, anesthetic and recovery qualities of horses receiving either a neuromuscular blocking agent (atracurium) or intravenous lidocaine (treatment groups A and L, respectively). ANIMALS STUDIED: A total of thirty horses presented for ocular surgery were used in this study. PROCEDURE: Horses were randomly assigned to receive either atracurium (group A) or a lidocaine constant rate infusion (group L). Surgical quality was graded on a scale from 1 (excellent)-5 (poor). While anesthetized, the heart rate, oxygen saturation and mean arterial blood pressure, and end-expiratory carbon dioxide and desflurane concentration were monitored and recorded every 5 minutes. Recovery was scored on a scale from 10 (best)-115 (worst). RESULTS: Horses in treatment group A needed significantly less desflurane then horses in treatment group L (p = 0.04). Horses in treatment group A had a significantly better surgery score of 1 (1-2) (median and range) then horses in treatment group L (2.5; 1-5) (p = 0.02). The quality of recovery was significantly better in horses in treatment group A compared with treatment group L, and horses needed significantly less time to reach the standing position. CONCLUSIONS: Atracurium and lidocaine CRI are safe methods of anesthesia for equine patients undergoing ocular surgery. Horses receiving atracurium needed less desflurane and had better surgery and recovery scores than horses receiving a lidocaine constant rate infusion.

Cisatracurium Continuous Infusion Versus No Neuromuscular Blockade for Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation.

The benefit of continuous infusion neuromuscular blockade concurrently with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome who are receiving mechanical ventilation remains unclear. Adult patients with severe acute respiratory distress syndrome requiring VV ECMO were analyzed in 2 groups: continuous infusion neuromuscular blockade with cisatracurium vs no neuromuscular blockade. Similar mechanical ventilation strategies were used. The primary end point was duration of VV ECMO. This single-center, retrospective observational cohort included a total of 47 patients, 28 of whom received continuous infusion cisatracurium and 19 patients who did not receive neuromuscular blockade. There was no difference in the duration of VV ECMO in patients who received cisatracurium, 226.5 hours (interquartile range, 119-362.3) vs 187.0 hours (interquartile range, 108-374) in the group who did not receive a paralytic (P = .64). There were no differences in secondary outcomes of days in the hospital, days free of organ dysfunction, ECMO survival, or discharged alive. Among patients with severe ARDS who were managed with VV ECMO, patients who received continuous infusion cisatracurium had no difference in the duration of VV ECMO compared to the nonparalytic comparator group.

Lidocaine combined with magnesium sulfate preserved hemodynamic stability during general anesthesia without prolonging neuromuscular blockade: a randomized, double-blind, controlled trial.

BACKGROUND: Lidocaine and magnesium sulfate have become increasingly utilized in general anesthesia. The present study evaluated the effects of these drugs, isolated or combined, on hemodynamic parameters as well as on the cisatracurium-induced neuromuscular blockade (NMB). METHODS: At a university hospital, 64 patients, ASA physical status I and II, undergoing elective surgery with similar pain stimuli were randomly assigned to four groups. Patients received a bolus of lidocaine and magnesium sulfate before the tracheal intubation and a continuous infusion during the operation as follows: 3 mg.kg- 1 and 3 mg.kg- 1.h- 1 (lidocaine - L group), 40 mg.kg- 1 and 20 mg.kg- 1.h- 1 (magnesium - M group), equal doses of both drugs (magnesium plus lidocaine - ML group), and an equivalent volume of isotonic solution (control - C group). Hemodynamic parameters and neuromuscular blockade features were continuously monitored until spontaneous recovery of the train of four (TOF) ratio (TOFR > 0.9). RESULTS: The magnesium sulfate significantly prolonged all NMB recovery features, without changing the speed of onset of cisatracurium. The addition of lidocaine to Magnesium Sulfate did not influence the cisatracurium neuromuscular blockade. A similar finding was observed when this drug was used alone, with a significantly smaller fluctuation of mean arterial pressure (MAP) and heart rate (HR) measures during anesthesia induction and maintenance. Interestingly, the percentage of patients who achieved a TOFR of 90% without reaching T1-95% was higher in the M and ML groups. Than in the C and L groups. There were no adverse events reported in this study. CONCLUSION: Intravenous lidocaine plays a significant role in the hemodynamic stability of patients under general anesthesia without exerting any additional impact on the NMB, even combined with magnesium sulfate. Aside from prolonging all NMB recovery characteristics without altering the onset speed, magnesium sulfate enhances the TOF recovery rate without T1 recovery. Our findings may aid clinical decisions involving the use of these drugs by encouraging their association in multimodal anesthesia or other therapeutic purposes. TRIAL REGISTRATION: NCT02483611 (registration date: 06-29-2015).

Neurodevelopmental Outcomes after Premedication with Atropine/Propofol vs Atropine/Atracurium/Sufentanil for Neonatal Intubation: 2-Year Follow-Up of a Randomized Clinical Trial.

This study followed 173 newborn infants in the PREmedication Trial for Tracheal Intubation of the NEOnate multicenter, double-blind, randomized controlled trial of atropine-propofol vs atropine-atracurium-sufentanil for premedication before nonemergency intubation. At 2 years of corrected age, there was no significant difference between the groups in death or risk of neurodevelopmental delay assessed with the Ages and Stages Questionnaire. Trial registration Clinicaltrials.gov: NCT01490580.

Effects of Sugammadex Plus Rocuronium vs Neostigmine Plus Cisatracurium During Renal Transplantation on Graft Function: A Retrospective, Case-Control Study.

BACKGROUND: Rocuronium can be used in patients with severe renal failure (creatinine clearance <30 mL/min), but the duration of muscle relaxation is longer and results in an increased risk of postoperative residual neuromuscular block. Rocuronium can be antagonized by sugammadex, but the elimination of the complex they make (rocuronium-sugammadex complex) varies according to the renal function. Two case reports/series have reported the use of rocuronium-sugammadex complex during renal transplantation. A recently published retrospective study showed no differences in postoperative creatinine levels in patients receiving kidney transplantation. This retrospective case-control study aims to investigate the effects of rocuronium-sugammadex, used during renal transplantation, on transplanted kidney function. METHODS: We analyzed 113 medical records of patients undergoing kidney transplantation from January 2015 to December 2018. Forty-seven medical records were excluded because they did not report the administration of one of the following drugs during the transplantation: rocuronium, sugammadex, cisatracurium, neostigmine. The demographics of patients and donors were collected along with the following data: blood urea and creatinine, serum and urinary electrolytes, and diuresis. Marginal, single, or double kidney transplantations; Karpinski scores; and histologic evaluations of transplanted kidney were collected. RESULTS: We included data from 66 medical reports from January 2015 to December 2018. Blood creatinine levels at 6, 12, and 24 hours were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (creatinine 6 hours P = .05, creatinine 12 hours P = .038, creatinine 24 hours P = .049). Blood urea levels for 24 hours after transplantation were significantly lower in the rocuronium + sugammadex group than in the cisatracurium + neostigmine group (urea 0 hours P = .025, urea 6 hours P = .011, urea 12 hours P = .03, urea 24 hours P = .011). We found no statistically significant differences in blood sodium, blood potassium, blood calcium, diuresis, urinary sodium, or urinary potassium levels before and after transplantation. CONCLUSIONS: In this retrospective case-control study, the use of rocuronium and sugammadex during renal transplant surgery did not affect relevant kidney recovery outcomes in the first week after transplantation.

Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation.

BACKGROUND: Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters. METHODS: From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2 <150 mm Hg) in a cardiothoracic intensive care unit. The primary outcome was the cumulative atracurium dose (mg/kg/h). Secondary outcomes included respiratory parameters during the neuromuscular blockade. RESULTS: A total of 38 patients in the clinical + TOF (C + TOF) group and 39 patients in the clinical (C) group were included in an intention-to-treat (ITT) analysis. The cumulative atracurium dose was higher in the C + TOF group (1.06 [0.75-1.30] vs 0.65 [0.60-0.89] mg/kg/h in the C group; P < .001) compared to C group, as well as the atracurium daily dose (C + TOF - C group mean difference = 0.256 mg/kg/h [95% confidence interval {CI}, 0.099-0.416], P = .026). Driving pressures during neuromuscular blocking agent (NMBA) administration did not differ between groups (P = .653). Intensive care unit (ICU) mortality was 22% in the C group and 27% in the C + TOF group (P = .786). Days on ventilation were 17 (8-26) in the C group and 16 (10-35) in the C + TOF group. CONCLUSIONS: In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.

Study of Rocuronium-Sugammadex as an Alternative to Succinylcholine-Cisatracurium in Microlaryngeal Surgery.

Microlaryngeal surgery (ML) is a short procedure that requires a deep neuromuscular blockade to provide optimum surgical conditions. Succinylcholine is a relaxant widely used but involves numerous complications. One valid alternative is rocuronium, with a specific antagonist, sugammadex. The primary objective was to assess the surgical conditions in ML according to the relaxant. The secondary objectives were to assess intubation conditions and intraoperative and immediate postoperative adverse events. STUDY DESIGN: Prospective randomized study. METHODS: This was a prospective study of patients scheduled for ML randomized into two groups according to relaxant. Neuromuscular blockade was recorded after administration and during ML surgery. Surgical conditions were assessed using the ML Rating Scale, intubation conditions, remifentanil doses, intraoperative complications, surgery time, emergence time, and complications in the postanesthesia care unit. RESULTS: Two hundred five patients were included (rocuronium = 103, succinylcholine = 102). Train-of-four values were higher for rocuronium, though the otorhinolaryngology surgical conditions were significantly better in that group (rocuronium = 5.54 ± 1.39 points; succinylcholine = 9.13 ± 1.99 points). Intubation conditions were similar in both groups. Remifentanil doses were higher for succinylcholine (P < .001) (rocuronium = 0.102 ± 0.05 µg/kg/min; succinylcholine = 0.201 ± 0.05 µg/kg/min). There were no differences in the duration of surgery, but the time to awakening was significantly longer for succinylcholine (rocuronium = 3.82 ± 1.38 minutes, succinylcholine = 9.18 ± 2.04 minutes, P < .001). CONCLUSIONS: Rocuronium provides better surgical conditions and allows for the use of lower doses of remifentanil as compared to succinylcholine and cisatracurium in ML. This makes it possible to decrease the time to awakening and the complications associated with high doses of remifentanil. LEVEL OF EVIDENCE: 1b Laryngoscope, 131:E212-E218, 2021.

Seizure activity following atracurium continuous rate infusion in three mechanically ventilated juvenile dogs.

OBJECTIVE: To describe patient recovery in dogs that had undergone mechanical ventilation (MV) and received atracurium as a continuous rate infusion (CRI). CASE SERIES SUMMARY: Three dogs were treated with atracurium CRI while mechanically ventilated and were successfully weaned. All were pediatric patients (2-3 months old) ventilated due to respiratory fatigue and hypoxemia. All dogs experienced seizure activity in the initial 24 h following extubation and were treated with various anticonvulsant protocols; no patients experienced documented seizures after 48 h of discontinuation from MV. NEW OR UNIQUE INFORMATION PROVIDED: All three successfully weaned dogs that had received an atracurium CRI experienced new onset seizures in their recovery from MV. Atracurium use in long-term MV has not been described previously, and seizures in dogs following atracurium administration has not been described in the clinical setting. Although causation cannot be proven in this case series, atracurium use should be carefully considered and be monitored appropriately when used for a prolonged duration.

Supine versus semi-Fowler's positions for tracheal extubation in abdominal surgery-a randomized clinical trial.

BACKGROUND: Tracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler's position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery. METHODS: We enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler's (n = 70) or supine (n = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU. RESULTS: In comparison with the supine position, the semi-Fowler's position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference. CONCLUSION: Tracheal extubation in the semi-Fowler's position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1900025566 . Registered on 1st September 2019.

Laparoscopic gynecological surgery in an adult woman with Becker muscular dystrophy performed with sevoflurane with cisatracurium anesthesia: A case report.

RATIONALE: Becker muscular dystrophy (BMD) and Duchenne muscular dystrophy (DMD) are progressive neuromuscular disorders caused by mutations in the dystrophin gene. The management of anesthesia in patients with BMD is complicated because they are highly sensitive to the conventional anesthetics such as volatile anesthetics and muscle relaxants. It is reported that anesthesia in patients with DMD is associated with several complications. However, a few case reports have been published on adult patients with BMD undergoing surgery with general anesthesia. Reports indicate that children with BMD may experience some serious complications with flurane-inhaled anesthesia. However, no study has yet shown that the use of flurane-induced anesthesia in adults with DMD carries high risks. PATIENT CONCERNS: We describe a 56-year-old woman with BMD who was scheduled for laparoscopic hysterectomy and bilateral adnexectomy under general anesthesia due to a mass in the uterus. The patient was diagnosed with BMD 20 years back and reported that during this period, she was able to walk slowly with help during her daily life. Additionally, she also had a history of hypertension since 4 years and type 2 diabetes mellitus since 2 years. DIAGNOSIS: The patient was postmenopausal and presented with abnormal uterine bleeding and elevated CA125. Abdominal ultrasonography revealed diffuse enlargement of the uterus and hypoechoic internal echoes. These findings were suggestive of diffuse adenomyosis with multiple uterine leiomyomas, which would have adverse effects later in her life. Therefore, the patient required surgery to address the symptoms and further confirm the diagnosis. The final diagnosis was confirmed by histopathological analysis. INTERVENTIONS: The patient was scheduled for laparoscopic hysterectomy and bilateral adnexectomy. Anesthesia was induced and maintained by a combination of intravenous and inhalation anesthetic agents, particularly cisatracurium besilate and inhaled. sevoflurane. OUTCOMES: The duration of anesthesia and postoperative period were uneventful. At the end of the operation, the patient had normal vital signs and was fully conscious. The patient was followed up for 8 months and no complications were noted during this period. LESSONS: The combination of sevoflurane and cisatracurium besilate is a safe and effective method for the anesthetic management of adult patients with BMD scheduled for laparoscopic gynecological surgery. On the other hand, it is important to be aware of even rare complications of procedures, so that necessary precautions can be undertaken. Further investigations are necessary to determine the safe dosage of volatile anesthetics specifically for this clinical scenario so that anesthesiologists can use this combination method more accurately and precisely.

Neuromuscular Blocking Agents and Rapid Sequence Induction for Laparoscopic Pyloromyotomy: Impact on Time to Extubation and Perioperative Complications.

INTRODUCTION: Infants with hypertrophic pyloric stenosis have gastric outlet obstruction, indicating a pyloromyotomy. To prevent aspiration, a rapid sequence induction (RSI) of anesthesia used to be preferred. However, due to concerns about the side-effects of this technique in infants, a modified RSI with gentle mask ventilation is nowadays mostly used. This research investigates if induction with succinylcholine (classic RSI), cisatracurium (modified RSI), or no neuromuscular blocking agent (NMBA) influences time until extubation and incidence of complications in infants undergoing laparoscopic pyloromyotomy. MATERIALS AND METHODS: A retrospective chart review was performed, observing infants undergoing laparoscopic pyloromyotomy in Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, from January 2007 until July 2015. Baseline preoperative data, anesthesia and operation details, time to extubation, and reported complications were gathered. Inclusion criteria were maintenance of anesthesia with sevoflurane and a registered extubation time. Exclusion criteria were the use of combinations of NMBAs, repyloromyotomy, and conversion to laparotomy. RESULTS: A total of 168 patients were included, of which 21 received succinylcholine, 107 cisatracurium, and 40 no NMBA. Mean duration of surgery was 29 minutes in all three groups; mean duration of anesthesia was 89, 82, and 77 minutes; mean time to extubation was 26, 25, and 23 minutes, respectively, without statistically significant difference. Complications were evenly distributed, no aspiration occurred. CONCLUSION: The use of succinylcholine, cisatracurium, or no NMBA at induction of anesthesia in infants undergoing laparoscopic pyloromyotomy had no statistically significant effect on time until extubation and complication rates. A modified RSI seems to be safe and effective in these cases.

A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography: A prospective observational study.

BACKGROUND: Neuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative. OBJECTIVE: The aim of our study was to compare NMB onset and recovery at both sites. DESIGN: Prospective observational study. SETTING: Operating rooms at the University Hospital of Poitiers, France. PATIENTS: Sixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia. INTERVENTION: After atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously. MAIN OUTCOME MEASURES: The time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF = 4, T4/T1 ratio = 0.75 and T4/T1 ratio more than 0.90. RESULTS: NMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4 ±â€Š1.5 versus 3.7 ±â€Š1.2 min at adductor pollicis (P = 0.0001). Recovery to TOF = 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF = 4. The full recovery of NMB (T4/T1 > 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ±â€Š9.9 versus 64.5 ±â€Š10.7 min at adductor pollicis (P < 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0 ±â€Š12.2 min at flexor hallucis brevis versus 54.0 ±â€Š12.4 min at adductor pollicis (P = 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients. CONCLUSION: Flexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02825121).

Compared efficacy and tolerance of the neuromuscular blockade induced by brand-name (Nimbex®) and generic (Cisatrex®) of cisatracurium in mechanically ventilated critically ill patients: a crossover double-blind randomized study.

INTRODUCTION: use of generic drugs is common. However, there is still concern among patients and physicians that brand name drugs are more efficient. The aim of the study was to compare efficacy and tolerance between two forms of cisatracurium: brand name versus generic name. METHODS: it´s a crossover, randomized, double-blind physiological trial. Patients admitted for hypoxemic acute respiratory failure with PaO2/FIO2 < 200mmHg despite optimized ventilation and sedation thus requiring non-depolarizing neuromuscular blocking agents (NMBAs), were enrolled. Patients received consecutively, in a random order, cisatracurium brand name (Nimbex®) and generic (Cisatrex®) over two-hour period separated by one-hour washout period. Neuromuscular function was monitored by a calibrated train-of-four (TOF) stimulation device. Paralysis time delay to reach TOF of 2/4, recovery kinetics and tolerance were monitored. The number needed to demonstrate a significant difference in time delays to reach a TOF of 2/4 between the two forms of cisatracurium was estimated at 22 patients. RESULTS: twenty-two patients were included. Eight (36.4%) had acute respiratory distress syndrome; 8(36.4%), acute exacerbation of chronic obstructive pulmonary disease and 3(13.6%), status asthmaticus. Median [IQR] SAPS II at admission, 28.5 [22, 41]. PaO2/FIO2, 121 [81, 156] mmHg. Paralysis time delays were respectively, 80 [50, 112] vs. 87 [65, 115] minutes, in Nimbex® group and Cisatrex® group; (p=0.579). Within the recovery period, the between two-studied drugs´ difference in TOF was at 0.25±0.96; p=0.64. There were no significant hemodynamic differences. CONCLUSION: the present study revealed no significant differences in efficacy nor in tolerance between cisatracurium brand name Nimbex® and generic name Cisatrex® in hypoxemic ventilated patients.

[Effect of intraoperative warming on muscle relaxation recovery of cisatracurium in patients undergoing gastrointestinal surgery].

Objective: To investigate the effect of intraoperative warming on the postoperative relaxation recovery of cisatracurium in patients undergoing gastrointestinal surgery. Methods: Sixty ASA Ⅰ-Ⅱ patients, aged 20 to 60, undergoing elective gastrointestinal surgery in Cancer Hospital Chinese Academy of Medical Sciences from October, 2016 to March, 2019 were selected and they were randomly divided into two groups (n=30), N group and H group by random number table. N group was non-heat preserving group, and H group was heat preserving group. Tracheal intubation was induced by general anesthesia with cisatracurium 0.15 mg/kg, and the nasopharyngeal temperature were continuously monitored and recorded. Cisatracurium were infused 1-3 µg·kg(-1)·min(-1) by venous pump during operation with T1 at 1%-10% and stopped infusion 30 minutes before the end of surgery. The time when T1 recovered from 25% to 75%(muscle relaxation recovery index), and the time of T1 recovered to 25% to TOF ratios (TOFR, the ratio of the fourth muscle twitch height to T1 in TOF) recovery to 90% (full recovery time), cumulative drug use and surgery time were recorded. Results: There was no significant difference between the two groups in the cumulative drug dosage and operation time (P>0.05).The body temperature N group (35.7±0.2) ℃ was significantly lower than the H group (36.2±0.1) ℃ (t=13.940, P<0.01). The recovery index of N group (16.5±1.8) min was significantlyhigher than H group (10.5±2.1) min (t=12.094, P<0.01) and complete recovery time in N group (26.9±4.1) min was obviously longer than those in H group (15.0±2.9) (t=13.082, P<0.01). Conclusions: Patients with open gastrointestinal surgery are prone to hypothermia during surgery and heat protection is helpful to muscle relaxation recovery of cisatracurium.

Paralytics, Sedation, and Steroids in Acute Respiratory Distress Syndrome.

In this article, we discuss the literature behind the use of paralytics, sedation, and steroids in acute respiratory distress syndrome. We explore the controversies and discuss the recommendations for the use of these agents.

Cisatracurium dosing in a patient with hyperthermia.

PURPOSE: A case report involving varying cisatracurium dosing requirements in a hyperthermic patient undergoing prone ventilation who subsequently received active cooling as part of targeted temperature management is presented. SUMMARY: Cisatracurium is known to be primarily metabolized via pH- and temperature-dependent Hofmann elimination. Previous reports in the literature described cases of decreased dosing requirements for both cisatracurium and its parent compound, atracurium, for patients in hypothermic states. While augmented atracurium dosing requirements in hyperthermic states have been reported, a literature search found no such reports concerning cisatracurium administration. In the case described here, a patient was initiated on cisatracurium for treatment of symptoms suggestive of acute respiratory distress syndrome (ARDS) and septic shock. An initial dosing requirement of 12 µg/kg/min (adjusted to a goal of 2-4 twitches per train-of-four monitoring) was needed to achieve adequate paralysis while the patient remained hyperthermic (a bladder temperature of 40.1°C). This cisatracurium infusion rate exceeded maximum reported and maximum institutional infusion rates (10 µg/kg/min). After initiation of cooling and lowering of the bladder temperature to 37.8°C, the cisatracurium rate requirement decreased to 5 µg/kg/min. CONCLUSION: A hyperthermic patient thought to have ARDS and septic shock required a high rate of cisatracurium infusion for adequate paralysis during mechanical ventilation. The cisatracurium did not appear to cause prolonged neuromuscular blockade.