scholarly journals Acceleromyography for Use in Scientific and Clinical Practice

2008 ◽  
Vol 108 (6) ◽  
pp. 1117-1140 ◽  
Author(s):  
Casper Claudius ◽  
Jørgen Viby-Mogensen ◽  
David S. Warner ◽  
Mark A. Warner
Keyword(s):  
Clinical Practice ◽  
Upper Airway ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Good Evidence ◽  
Residual Paralysis ◽  
Response Curves ◽  
Value Recovery ◽  
Airway Function ◽  
Train Of Four

This systematic review describes the evidence on the use of acceleromyography for perioperative neuromuscular monitoring in clinical practice and research. The review documents that although acceleromyography is widely used in research, it cannot be used interchangeably with mechanomyography and electromyography for construction of dose-response curves or for recording different pharmacodynamic variables after injection of a neuromuscular blocking agent. Some studies indicate that it may be beneficial to use a preload to increase the precision of acceleromyography, and to "normalize" the train-of-four ratio to decrease the bias in relation to mechanomyography and electromyography. However, currently the evidence is insufficient to support the routine clinical use of preload and "normalization." In contrast, there is good evidence that acceleromyography improves detection of postoperative residual paralysis. A train-of-four ratio of 1.0 predicts with a high predictive value recovery of pulmonary and upper airway function from neuromuscular blockade.

Neuromuscular blockade and reversal

2017 ◽  
Author(s):  
Jennifer M. Hunter ◽  
Thomas Fuchs-Buder
Keyword(s):  
Neuromuscular Block ◽  
Neuromuscular Disorders ◽  
Upper Airway ◽  
Blocking Agent ◽  
Rapid Onset ◽  
Neuromuscular Blocking ◽  
Onset Of Action ◽  
Disease States ◽  
Train Of Four ◽  
Residual Block

Over the past 70 years since the introduction of d-tubocurarine, the search for an ideal neuromuscular blocking agent has led to the development of the depolarizing drug, succinylcholine (suxamethonium), with its rapid onset of action and plasma metabolism, and a series of non-depolarizing agents of which there are two groups: benzylisoquinoliniums (e.g. atracurium, cisatracurium and mivacurium) and aminosteroidal agents (e.g. pancuronium, vecuronium and rocuronium). The need to monitor neuromuscular block perioperatively to ensure the appropriate dose of any neuromuscular blocking drug is given has led to the development of several nerve stimulation techniques. Particularly useful clinically are the train-of-four twitch response, double-burst stimulation, and the post-tetanic count. Their benefits and limitations are considered in this chapter. The most suitable equipment to monitor neuromuscular block and the appropriate anatomical sites for stimulation are discussed. To prevent residual block with its pathophysiological consequences such as upper airway and pharyngeal dysfunction and potential respiratory failure at the end of surgery, antagonizing agents are used. These are of two types: anticholinesterases such as neostigmine and edrophonium, and the γ‎-cyclodextrin, sugammadex. The pharmacodynamics and pharmacokinetics of neuromuscular blocking drugs and their antagonists are altered by the extremes of age, obesity, and several disease states including renal and hepatic failure, neuromuscular disorders, and critical illness. The altered response to all these drugs in these pathologies, which is related to their metabolism and excretion, is considered in detail, together with their other side-effects including the particular disadvantages to the use of succinylcholine.

Preclinical Pharmacology of CW002

2016 ◽  
Vol 125 (4) ◽  
pp. 732-743 ◽  
Author(s):  
Hiroshi Sunaga ◽  
John J. Savarese ◽  
Jeff D. McGilvra ◽  
Paul M. Heerdt ◽  
Matthew R. Belmont ◽  
...  
Keyword(s):  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Safety And Efficacy ◽  
Circulatory Effects ◽  
Autonomic Changes ◽  
Train Of Four

Abstract Background CW002, a novel nondepolarizing neuromuscular blocking agent of intermediate duration, is degraded in vitro by l-cysteine; CW002-induced neuromuscular blockade (NMB) is antagonized in vivo by exogenous l-cysteine.1 Further, Institutional Animal Care and Use Committee–approved studies of safety and efficacy in eight anesthetized monkeys and six cats are described. Methods Mean arterial pressure, heart rate, twitch, and train-of-four were recorded; estimated dose producing 95% twitch inhibition (ED95) for NMB and twitch recovery intervals from 5 to 95% of baseline were derived. Antagonism of 99 to 100% block in monkeys by l-cysteine (50 mg/kg) was tested after bolus doses of approximately 3.75 to 20 × ED95 and after infusions. Vagal and sympathetic autonomic responses were recorded in cats. Dose ratios for [circulatory (ED20) or autonomic (ED50) changes/ED95 (NMB)] were calculated. Results ED95s of CW002 in monkeys and cats were 0.040 and 0.035 mg/kg; l-cysteine readily antagonized block in monkeys: 5 to 95% twitch recovery intervals were shortened to 1.8 to 3.6 min after 3.75 to 10 × ED95 or infusions versus 11.5 to 13.5 min during spontaneous recovery. ED for 20% decrease of mean arterial pressure (n = 27) was 1.06 mg/kg in monkeys; ED for 20% increase of HR (n = 27) was 2.16 mg/kg. ED50s for vagal and sympathetic inhibition in cats were 0.59 and >>0.80 mg/kg (n = 14 and 15). Dose ratios for [circulatory or autonomic changes/ED95 (NMB)] were all more than 15 × ED95. Conclusions The data further verify the neuromuscular blocking properties of CW002, including rapid reversal by l-cysteine of 100% NMB under several circumstances. A notable lack of autonomic or circulatory effects provided added proof of safety and efficacy.

scholarly journals Postoperative Neuromuscular Function

1986 ◽  
Vol 14 (1) ◽  
pp. 41-45 ◽  
Author(s):  
G. H. Beemer ◽  
P. Rozental
Keyword(s):  
Recovery Room ◽  
Neuromuscular Transmission ◽  
Blocking Agent ◽  
Neuromuscular Function ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent ◽  
Number Of Patients ◽  
Clinical Methods ◽  
Train Of Four ◽  
Bedside Tests

One hundred patients who received a competitive neuromuscular blocking agent during anaesthesia were randomly selected for evaluation of neuromuscular function immediately on their arrival in the recovery room. The anaesthetist was not aware that the patient would be evaluated in the recovery room. Neuromuscular function was assessed by a train-of-four (TOF) ratio, and in conscious and co-operative patients by a series of bedside tests of neuromuscular function. Twenty-one patients had a TOF ratio of less than 0.70 and seven patients a TOF ratio of less than 0.60. Bedside tests of neuromuscular function did not reliably detect this defect in neuromuscular transmission. It is concluded that a relatively large number of patients have a defect in neuromuscular transmission on their arrival in the recovery room, and suggested that this reflects the inadequacy of clinical methods used for the administration and antagonism of competitive neuromuscular blocking agents at this institution.

Increased Sensitivity to Depolarizing and Nondepolarizing Neuromuscular Blocking Agents in Young Rat Hemidiaphragms

2001 ◽  
Vol 95 (2) ◽  
pp. 478-484 ◽  
Author(s):  
L. Philippe Fortier ◽  
Richard Robitaille ◽  
François Donati
Keyword(s):  
Neuromuscular Junctions ◽  
Relative Sensitivity ◽  
Optimal Dose ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Response Curves ◽  
Potency Ratio ◽  
Blocking Agents ◽  
Increased Sensitivity

Background Newborn neuromuscular junctions are more sensitive to d-tubocurarine than more mature preparations. It is unclear whether the same modifications occur with newer nondepolarizing agents and depolarizing agent succinylcholine. The purpose of this study was to determine the relative sensitivity of newborn neuromuscular junctions to succinylcholine and five nondepolarizing agents. Methods The phrenic nerve-hemidiaphragm preparation from 60 rats was used, 30 aged 9-12 days (newborn) and 30 aged 27-33 days (adult). Five rats from each group were exposed to one of six neuromuscular blocking agents (d-tubocurarine, cisatracurium, atracurium, vecuronium, rocuronium, and succinylcholine). Indirectly elicited twitch tension was measured during control conditions in the absence of blocking agent, followed by four concentrations of one of the six agents. Concentration-response curves were constructed and the EC50 (concentration required to produce 50% depression of twitch tension) was obtained. Potency ratios (EC50adult/EC50newborn) were derived for each agent. Results Newborn preparations were significantly (P < 0.001) more sensitive than their adult counterparts for all six agents tested. For nondepolarizing agents, the potency ratio was in the 6-12 range. The EC50adult/EC50newborn were as follows, in decreasing potency order: d-tubocurarine, 1.68/0.23 microM; cisatracurium, 2.73/0.47 microM; vecuronium, 5.47/0.59 microM; rocuronium, 9.7/0.78 microM; and atracurium, 12.3/1.9 microM. Succinylcholine was three times as potent in newborn rats, with an EC50adult/EC50newborn of 21.3/7.3 microM. The ratio for succinylcholine was significantly less than for all nondepolarizing drugs (P < 0.02). Conclusion The newborn neuromuscular junction of the rat shows an increased sensitivity to all neuromuscular blocking agents tested, including succinylcholine. However, the potency ratio was greater for nondepolarizing than depolarizing drugs. The optimal dose of these agents for certain situations such as cesarean section and anesthesia in neonates should be reassessed.

The modes of action of gallamine

1981 ◽  
Vol 211 (1183) ◽  
pp. 181-203 ◽  
Keyword(s):  
Membrane Potential ◽  
Equilibrium Constant ◽  
Rate Constant ◽  
Blocking Agent ◽  
Dissociation Rate ◽  
Neuromuscular Blocking ◽  
Fluctuation Analysis ◽  
Muscle Fibres ◽  
Response Curves ◽  
Kinetic Measurements

The action of gallamine, a classical competitive neuromuscular blocking agent, has been examined on voltage-clamped endplates of frog skeletal muscle fibres. Gallamine produces a parallel shift of the equilibrium log (concentration)–response curves in concentrations of up to about 40 μM. At a membrane potential of —70 mV the Schild plot of the dose ratios so measured has a gradient of slightly less than the theoretical value, for a competitive antagonist, of unity. The apparent equilibrium constant for ‘competitive’ block is about 2 μM, and is approximately independent of the membrane potential. Fluctuation analysis of the endplate current shows two components in the presence of gallamine. The results can be fitted, over the range tested, by a mechanism that involves block of open ion channels by gallamine in a manner similar to that by procaine or quaternary local anaesthetic analogues. The rate constants for this action are strongly dependent on the membrane potential. At — 100 mV the association rate constant is about 4 x 10 7 M -1 s -1 , the dissociation rate constant is about 600 s -1 , and the equilibrium constant about 15 μM. Other kinetic measurements (voltage-jump relaxation, and nerve-evoked endplate currents) give results consistent with this conclusion, but apparently these results are valid over a range of conditions narrower than that for fluctuation analysis.

scholarly journals Calabadion

2013 ◽  
Vol 119 (2) ◽  
pp. 317-325 ◽  
Author(s):  
Ulrike Hoffmann ◽  
Martina Grosse-Sundrup ◽  
Katharina Eikermann-Haerter ◽  
Sebastina Zaremba ◽  
Cenk Ayata ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Arterial Blood Pressure ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Train Of Four ◽  
Complete Reversal ◽  
Blood Gas Parameters

Abstract Introduction: To evaluate whether calabadion 1, an acyclic member of the Cucurbit[n]uril family of molecular containers, reverses benzylisoquinoline and steroidal neuromuscular-blocking agent effects. Methods: A total of 60 rats were anesthetized, tracheotomized, and instrumented with IV and arterial catheters. Rocuronium (3.5 mg/kg) or cisatracurium (0.6 mg/kg) was administered and neuromuscular transmission quantified by acceleromyography. Calabadion 1 at 30, 60, and 90 mg/kg (for rocuronium) or 90, 120, and 150 mg/kg (for cisatracurium), or neostigmine/glycopyrrolate at 0.06/0.012 mg/kg were administered at maximum twitch depression, and renal calabadion 1 elimination was determined by using a 1H NMR assay. The authors also measured heart rate, arterial blood gas parameters, and arterial blood pressure. Results: After the administration of rocuronium, resumption of spontaneous breathing and recovery of train-of-four ratio to 0.9 were accelerated from 12.3 ± 1.1 and 16.2 ± 3.3 min with placebo to 4.6 ± 1.8 min with neostigmine/glycopyrrolate to 15 ± 8 and 84 ± 33 s with calabadion 1 (90 mg/kg), respectively. After the administration of cisatracurium, recovery of breathing and train-of-four ratio of 0.9 were accelerated from 8.7 ± 2.8 and 9.9 ± 1.7 min with placebo to 2.8 ± 0.8 and 7.6 ± 2.1 min with neostigmine/glycopyrrolate to 47 ± 13 and 87 ± 16 s with calabadion 1 (150 mg/kg), respectively. Calabadion 1 did not affect heart rate, mean arterial blood pressure, pH, carbon dioxide pressure, and oxygen tension. More than 90% of the IV administered calabadion 1 appeared in the urine within 1 h. Conclusion: Calabadion 1 is a new drug for rapid and complete reversal of the effects of steroidal and benzylisoquinoline neuromuscular-blocking agents.

Can Acceleromyography Detect Low Levels of Residual Paralysis?

2004 ◽  
Vol 100 (5) ◽  
pp. 1119-1124 ◽  
Author(s):  
Florent Capron ◽  
Francois Alla ◽  
Claire Hottier ◽  
Claude Meistelman ◽  
Thomas Fuchs-Buder
Keyword(s):  
Clinical Practice ◽  
Neuromuscular Block ◽  
Intraclass Correlation ◽  
Residual Paralysis ◽  
Predictive Values ◽  
Train Of Four ◽  
Group A ◽  
Low Levels ◽  
Group B ◽  
The Impact

Background The incidence of residual paralysis, i.e., a mechanomyographic train-of-four (TOF) ratio (T4/T1) less than 0.9, remains frequent. Routine acceleromyography has been proposed to detect residual paralysis in clinical practice. Although acceleromyographic data are easy to obtain, they differ from mechanomyographic data, with which they are not interchangeable. The current study aimed to determine (1) the acceleromyographic TOF ratio that detects residual paralysis with a 95% probability, and (2) the impact of calibration and normalization on this predictive acceleromyographic value. Methods In 60 patients, recovery from neuromuscular block was assessed simultaneously with mechanomyography and acceleromyography. To obtain calibrated acceleromyographic TOF ratios in group A, the implemented calibration modus 2 was activated in the TOF-Watch S; to obtain uncalibrated acceleromyographic TOF ratios in group B, the current was manually set at 50 mA (n = 30 for each). In addition, data in group B were normalized (i.e., dividing the final TOF ratio by the baseline value). The agreement between mechanomyography and acceleromyography was assessed by calculating the intraclass correlation coefficient. Negative predictive values were calculated for detecting residual paralysis from acceleromyographic TOFs of 0.9, 0.95, and 1.0. Results Group A : For a mechanomyographic TOF of 0.9 or greater, the corresponding acceleromyographic TOF was 0.95 (range, 0.86-1.0), and the negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 37% (95% CI, 20-56%), 70% (95% CI, 51-85%), and 97% (95% CI, 83-100%), respectively. Group B: Without normalization, an acceleromyographic TOF of 0.97 (range, 0.68-1.18) corresponded to a mechanomyographic TOF of 0.9 or greater, with negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 being 40% (95% CI, 23-59%), 60% (95% CI, 41-77%), and 77% (95% CI, 58-90%), respectively. After normalization, an acceleromyographic TOF of 0.89 (range, 0.63-1.06) corresponded to a mechanomyographic TOF of 0.9 or greater, and the negative predictive values of acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 89% (95% CI, 70-98%), 92% (95% CI, 75-99%), and 96% (95% CI, 80-100%), respectively. Conclusion To exclude residual paralysis reliably when using acceleromyography, TOF recovery to 1.0 is mandatory.

scholarly journals Comparison of Train of Four Measurements with Kinemyography NMT DATEX and Accelerography TOFscan

2021 ◽  
Vol 9 (2) ◽  
pp. 21
Author(s):  
Cyrus Motamed ◽  
Migena Demiri ◽  
Nora Colegrave
Keyword(s):  
Neuromuscular Blockade ◽  
Lower Limit ◽  
Elective Surgery ◽  
Orotracheal Intubation ◽  
Neuromuscular Blocking ◽  
Physical Status Classification ◽  
Train Of Four ◽  
Surgery First ◽  
American Society ◽  
American Society Of Anesthesiologists

Introduction: This study was designed to compare the Datex neuromuscular transmission (NMT) kinemyography (NMTK) device with the TOFscan (TS) accelerometer during the onset and recovery of neuromuscular blockade. Patients and methods: This prospective study included adult patients who were scheduled to undergo elective surgery with general anesthesia and orotracheal intubation. The TS accelerometer was randomly placed at the adductor pollicis on one hand, and the NMTK was placed on the opposite arm. Anesthesia was initiated with remifentanil target-controlled infusion (TCI) and 2.0–3.0 mg/kg of propofol. Thereafter, 0.5 mg/kg of atracurium or 0.6 mg/kg of rocuronium was injected. If needed, additional neuromuscular blocking agents were administered to facilitate surgery. First, we recorded the train of four (TOF) response at the onset of neuromuscular blockade to reach a TOF count of 0. Second, we recorded the TOF response at the recovery of neuromuscular blockade to obtain a T4/T1 90% by both TS and NMTK. Results: There were 32 patients, aged 38–83 years, with the American Society of Anesthesiologists (ASA) Physical Status Classification I–III included and analyzed. Surgery was abdominal, gynecologic, or head and neck. The Bland and Altman analysis for obtaining zero responses during the onset showed a bias (mean) of 2.7 s (delay) of TS in comparison to NMTK, with an upper/lower limit of agreement of [104; −109 s] and a bias of 36 s of TS in comparison to NMTK, with an upper/lower limit of agreement of [−21.8, −23.1 min] during recovery (T4/T1 > 90%). Conclusions: Under the conditions of the present study, the two devices are not interchangeable. Clinical decisions for deep neuromuscular blockade should be made cautiously, as both devices appear less accurate with significant variability.

Arteriovenous fistula cannulation in hemodialysis: A vascular access clinical practice guidelines narrative review

2021 ◽  
pp. 112972982110069
Author(s):  
Rui Pinto ◽  
Clemente Sousa ◽  
Anabela Salgueiro ◽  
Isabel Fernandes
Keyword(s):  
Clinical Practice ◽  
Arteriovenous Fistula ◽  
Vascular Access ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Good Evidence ◽  
Preparation Technique ◽  
Patient Centered ◽  
The Past ◽  
Centered Care

The cannulation of an arteriovenous fistula (AVF) by the hemodialysis (HD) nurse is challenging. Despite it being the focus of extensive research, it is still one of the majors causes of damage making it prone to failure. A considerable number of Clinical Practice Guidelines (CPGs) for the management of vascular access (VA) have been published worldwide over the past two decades. This review aimed to assess all information available in the selected CPG regarding AVF cannulation for HD providing a comprehensive analysis in order to interpret possible future cannulation approaches. A total of seven CPGs were described in a coding table separated in seven subthemes: Initiation of cannulation, preparation, technique, needle selection, surveillance, pain, and education. Our analysis outlines current CPGs for HD VA cannulation with lack of good evidence support for the majority of the recommendations, showing that, there is an urgent need for international collaboration and coordination to ensure relevant and high-quality evidence. Future CPGs must consider recommendations with better grading of evidence aiming patient-centered care and nurse decision models that can potentially represent better AVF cannulation outcomes.

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