Acute Myopathy Associated with Combined use of Corticosteroids and Neuromuscular Blocking Agents

1996 ◽  
Vol 30 (12) ◽  
pp. 1437-1445 ◽  
Author(s):  
Janet R Fischer ◽  
Rebecca K Baer
Keyword(s):  
English Language ◽  
Case Reports ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Mechanically Ventilated ◽  
Medline Search ◽  
Blocking Agents ◽  
Systemic Corticosteroids ◽  
Combined Use

OBJECTIVE: To review the occurrence and pathophysiology of myopathy associated with combined use of neuromuscular blocking agents (NMBAs) and systemic corticosteroids. DATA SOURCES: A MEDLINE search (1985 to July 1995, English language) yielded case reports and clinical studies involving myopathy or weakness associated with the use of NMBAs and/or corticosteroids. References cited in those articles were reviewed. DATA SYNTHESIS: Prolonged muscle weakness has been reported in intubated patients in the intensive care unit (ICU) who were receiving NMBAs and/or corticosteroids. Many cases involved the use of both agents in individuals with no underlying risk factors. The term “blocking agent—corticosteroid myopathy” (BACM) has been used to describe this myopathy when it develops following combined use of these agents. Features common to BACM include prolonged weakness, elevated creatine kinase concentrations, myopathic features on electromyography, normal nerve conduction and sensation, and reduced deep tendon reflexes. Muscle biopsy results vary, but tend to show type 1 and/or 2 fiber atrophy without inflammation. Some recently reported cases revealed thick myosin myofilament loss, which is consistent with findings in denervated rat muscle after exposure to corticosteroids. Two small prospective studies reported that 36–50% of mechanically ventilated patients receiving either one or both drugs developed prolonged weakness. CONCLUSIONS: NMBAs and corticosteroids alone have both been reported to cause myopathy in patients in the ICU. When coadministered, these agents appear to confer an even greater risk of myopathy; the exact pathology is not understood. Concomitant use of NMBAs and corticosteroids should be avoided if possible. Guidelines for cautious use and careful monitoring are suggested when combined use is deemed necessary.

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.

scholarly journals Use of Sedatives and Neuromuscular-Blocking Agents in Mechanically Ventilated Patients with COVID-19 ARDS

2021 ◽  
Vol 9 (11) ◽  
pp. 2393
Author(s):  
Amédée Ego ◽  
Lorenzo Peluso ◽  
Julie Gorham ◽  
Alberto Diosdado ◽  
Giovanni Restuccia ◽  
...  
Keyword(s):  
Distress Syndrome ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Inclusion Criteria ◽  
Mechanically Ventilated ◽  
Blocking Agents ◽  
Observational Cohort ◽  
Sedative Drugs ◽  
Retrospective Observational Cohort Study

Objectives: To assess differences in the use of analgesics, sedatives and neuromuscular-blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) due to COVID-19 or other conditions. Methods: Retrospective observational cohort study, single-center tertiary Intensive Care Unit. COVID-19 patients with ARDS (March–May 2020) and non-COVID ARDS patients (2017–2020) on mechanical ventilation and receiving sedation for at least 48 h. Results: A total of 39 patients met the inclusion criteria in each group, with similar demographics at baseline. COVID-19 patients had a longer duration of MV (median 22 (IQRs 16–29) vs. 9 (6–18) days; p < 0.01), of sedatives administration (18 (11–22) vs. 5 (4–9) days; p < 0.01) and NMBA therapy (12 (9–16) vs. 3 (2–7) days; p < 0.01). During the first 7 days of sedation, compared to non-COVID patients, COVID patients received more frequently a combination of multiple sedative drugs (76.9% vs. 28.2%; p < 0.01) and a higher NMBA regimen (cisatracurium: 3.0 (2.1–3.7) vs. 1.3 (0.9–1.9) mg/kg/day; p < 0.01). Conclusions: The duration and consumption of sedatives and NMBA was significantly increased in patients with COVID-19 related ARDS than in non-COVID ARDS. Different sedation strategies and protocols might be needed in COVID-19 patients with ARDS, with potential implications on long-term complications and drugs availability.

scholarly journals Efek Pemberian Magnesium Sulfat 45 Mg/kgBB terhadap Kualitas Tindakan Intubasi Endotrakeal Tanpa Obat Pelumpuh Otot dan Perubahan Respons Hemodinamik

2019 ◽  
Vol 7 (1) ◽  
pp. 48-57
Author(s):  
Fatima Fatima ◽  
Erwin Pradian ◽  
Dedi Fitri Yadi
Keyword(s):  
Endotracheal Intubation ◽  
Surgical Procedures ◽  
Magnesium Sulphate ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent ◽  
Neuromuscular Blocking Agents ◽  
Chi Square ◽  
Blocking Agents

Intubasi endotrakeal merupakan tindakan berisiko tinggi yang menghasilkan stimulasi adrenergik. Intubasi endotrakeal menggunakan obat pelumpuh otot sebagai standar baku dapat menimbulkan efek samping berupa reaksi anafilaksis dan rekurisasi pascabedah. Intubasi endotrakeal tanpa obat pelumpuh otot ditujukan untuk prosedur pembedahan yang singkat, membutuhkan identifikasi saraf, dan terdapat kontraindikasi pemberian obat pelumpuh otot. Tujuan penelitian ini mengkaji pemberian magnesium sulfat 45 mg/kgBB terhadap kualitas intubasi dan respons hemodinamik pada tindakan intubasi endotrakeal tanpa obat pelumpuh otot. Penelitian ini merupakan penelitian eksperimental secara acak buta ganda yang dilakukan secara prospektif terhadap 42 subjek penelitian yang menjalani prosedur pembedahan dengan anestesi umum di Rumah Sakit Umum Pusat Dr. Hasan Sadikin, Bandung pada bulan April–Juli 2018. Pada penelitian ini, data numerik diuji dengan uji t tidak berpasangan, sedangkan data kategorik diuji dengan uji chi-square dan Mann Whitney. Hasil penelitian menunjukkan kualitas intubasi endotrakeal tanpa obat pelumpuh otot lebih baik dengan disertai penurunan respons hemodinamik pada kelompok yang diberikan magnesium sulfat 45 mg/kgBB dibanding dengan kelompok kontrol (p<0,05). Simpulan, pemberian magnesium sulfat 45 mg/kgBB meningkatkan kualitas tindakan intubasi endotrakeal tanpa obat pelumpuh otot yang dinilai menggunakan skor Copenhagen dan menurunkan respons hemodinamik pada tindakan intubasi endotrakeal tanpa obat pelumpuhotot.Effect of 45 mg/kgBW Magnesium Sulphate on Quality of Endotracheal Intubation without Neuromuscular Blocking Agents and Change in Hemodynamic ResponsesEndotracheal intubation is a high-risk procedure that can stimulate adrenergic response. Neuromuscular blocking agent is used to facilitate endotracheal intubation but it has undesirable effects such as anaphylactic reaction and postoperative recurarization. This technique is indicated for short surgical procedures, requires nerve identification, and is contraindicated for neuromuscular blocking agent. The purpose of this study was to review the effect of 45 mg/kgBW magnesium sulphate to the quality of intubation and hemodynamic responses in endotracheal intubation without neuromuscular blocking agent. This was a prospective double blind experimental study conducted on 42 research subjects  underwent surgical procedures under general anesthesia in Dr. Hasan Sadikin General Hospital, Bandung in the period of April–July 2018. In this study, numerical data were tested by unpaired t test. Categorical data were tested by chi-square and Mann Whitney tests. The results showed that the quality of endotracheal intubation without neuromuscular blocking agent improved with minimum hemodynamic changes in the group receiving 45 mg/kgBW magnesium sulphate (p<0.05). It is concluded that 45 mg/kgBW magnesium sulphate improves intubating quality assessed using Copenhagen score and decreases hemodynamic responses to endotracheal intubation without neuromuscular blocking agents.

Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications

2015 ◽  
Vol 122 (6) ◽  
pp. 1201-1213 ◽  
Author(s):  
Duncan J. McLean ◽  
Daniel Diaz-Gil ◽  
Hassan N. Farhan ◽  
Karim S. Ladha ◽  
Tobias Kurth ◽  
...  
Keyword(s):  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Respiratory Complications ◽  
Blocking Agents ◽  
Increased Risk ◽  
Postoperative Respiratory Complications ◽  
High Doses ◽  
Post Hoc ◽  
Dose Dependent

Abstract Background: Duration of action increases with repeated administration of neuromuscular-blocking agents, and intraoperative use of high doses of neuromuscular-blocking agent may affect respiratory safety. Methods: In a hospital-based registry study on 48,499 patients who received intermediate-acting neuromuscular-blocking agents, the authors tested the primary hypothesis that neuromuscular-blocking agents are dose dependently associated with the risk of postoperative respiratory complications. In the secondary analysis, the authors evaluated the association between neostigmine dose given for reversal of neuromuscular-blocking agents and respiratory complications. Post hoc, the authors evaluated the effects of appropriate neostigmine reversal (neostigmine ≤60 μg/kg after recovery of train-of-four count of 2) on respiratory complications. The authors controlled for patient-, anesthesia-, and surgical complexity–related risk factors. Results: High doses of neuromuscular-blocking agents were associated with an increased risk of postoperative respiratory complications (n = 644) compared with low doses (n = 205) (odds ratio [OR], 1.28; 95% CI, 1.04 to 1.57). Neostigmine was associated with a dose-dependent increase in the risk of postoperative respiratory complications (OR, 1.51; 95% CI, 1.25 to 1.83). Post hoc analysis revealed that appropriate neostigmine reversal eliminated the dose-dependent association between neuromuscular-blocking agents and respiratory complications (for neuromuscular-blocking agent effects with appropriate reversal: OR, 0.98; 95% CI, 0.63 to 1.52). Conclusions: The use of neuromuscular-blocking agents was dose dependently associated with increased risk of postoperative respiratory complications. Neostigmine reversal was also associated with a dose-dependent increase in the risk of respiratory complications. However, the exploratory data analysis suggests that the proper use of neostigmine guided by neuromuscular transmission monitoring results can help eliminate postoperative respiratory complications associated with the use of neuromuscular-blocking agents.

scholarly journals Neuromuscular blockers and their reversal: have we finally found the on-off switches?

2021 ◽  
Vol 13 (1) ◽  
Author(s):  
Shagun Bhatia Shah ◽  
R. Chawla ◽  
A. Pahade ◽  
Ashraf EL-Molla
Keyword(s):  
Side Effects ◽  
English Language ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
General Anesthetics ◽  
Reversal Agent ◽  
Duration Of Action ◽  
Medline Search ◽  
Comprehensive Search ◽  
Novel Drug

Abstract Background A nondepolarizing neuromuscular blocking agent (NMBA) with a succinylcholine-like quick onset and offset has been the holy grail of the science of neuromuscular blockade. Although this drug is still elusive, the advent of promising new drug combinations like rocuronium–sugammadex and gantacurium–l-cysteine may achieve the same end result. The type of NMBA; the type, timing, and dose of their reversal drugs; the means of monitoring NMB; and the site of monitoring are potentially on the verge of a paradigm shift. Main text A comprehensive search using PubMed and Google Scholar and Medline search was made by using keywords gantacurium, l-cysteine, calabadion, and newer neuromuscular blocking agents for peer-reviewed English language manuscripts published before December 2019. Out of the 97 articles screened, 16 were found to be eligible (original articles) and included in this review. Conclusion Quantitative, objective neuromuscular monitoring should be included in the minimum monitoring standards. Gantacurium is a new promising nondepolarizing NMBA with desirable succinylcholine-like onset and duration of action without its side effects. A broad-spectrum reversal agent (calabadion) can be used for both depolarizing and nondepolarizing NMB as well as general anesthetics (etomidate and ketamine). A novel drug (WP [6]) can block the side effects of succinylcholine; all are staring at us from the horizon.

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