Prolonged neuromuscular blockade by non-depolarizing neuromuscular blocking agents

Myotonic dystrophy type 1 is a rare neuromuscular disease that represents a challenge to anaesthetic management. Most of the literature does not recommend the usage of neuromuscular blocking agents, if general anaesthesia is needed in these patients. Depolarising neuromuscular blocking agents like suxamethonium are contraindicated, and there might be an increased sensitivity to non-depolarising agents like rocuronium with greater risk of postoperative residual neuromuscular blockade and consequent respiratory failure. Reversing neuromuscular blockade is also problematic as neostigmine can induce myotonic crisis, impairing normal ventilation. We discuss the use of sugammadex for neuromuscular blockade reversal, from a clinical case of a patient with myotonic dystrophy type 1 for laparoscopic cholecystectomy. The patient had a general anaesthesia with neuromuscular blockade with rocuronium. After the surgical procedure, neuromuscular blockade was safely reversed with sugammadex, guided by neuromuscular monitoring without any perioperative complications.

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Myopathy in Status Asthmaticus: Relation to Neuromuscular Blockade and Corticosteroid Administration

Journal of Intensive Care Medicine ◽

10.1177/088506669300800305 ◽

1993 ◽

Vol 8 (3) ◽

pp. 144-152 ◽

Cited By ~ 15

Author(s):

Janet M. Shapiro ◽

Rany Condos ◽

Randolph P. Cole

Keyword(s):

Mechanical Ventilation ◽

Creatine Kinase ◽

Neuromuscular Blockade ◽

Muscle Weakness ◽

Status Asthmaticus ◽

Rare Complication ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Corticosteroid Administration ◽

Blocking Agents

Myopathy is a rare complication that arises during management of status asthmaticus that may be related to administration of corticosteroids and neuromuscular blocking agents. We present 4 patients with myopathy and a review of the 31 previously reported patients in the literature. All patients received corticosteroids, and 33 of the 35 patients received neuromuscular blocking agents. Muscle weakness was often diffuse and, in several patients, involved the muscles of respiration. Creatine kinase values ranged from normal to markedly elevated. Diagnosis was obtained by electromyogram and muscle biopsy in most patients. Resolution of the muscle weakness occurred over a period of days to months. Patients in whom myopathy developed required mechanical ventilation for longer periods than patients intubated for status asthmaticus without myopathy.

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COST-EFFECTIVENESS ANALYSIS INVOLVING NEUROMUSCULAR BLOCKING AGENTS FOR SUSTAINED NEUROMUSCULAR BLOCKADE IN THE ICU

Critical Care Medicine ◽

10.1097/00003246-199912001-00367 ◽

1999 ◽

Vol 27 (Supplement) ◽

pp. A131

Author(s):

William T McGee

Keyword(s):

Cost Effectiveness ◽

Neuromuscular Blockade ◽

Cost Effectiveness Analysis ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Blocking Agents ◽

Effectiveness Analysis

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Residual Neuromuscular Blockade Affects Postoperative Pulmonary Function

Anesthesiology ◽

10.1097/aln.0b013e3182715b80 ◽

2012 ◽

Vol 117 (6) ◽

pp. 1234-1244 ◽

Cited By ~ 46

Author(s):

Gopalaiah Venkatesh Kumar ◽

Anita Pramod Nair ◽

Hanuman Srinivasa Murthy ◽

Koppa Ramegowda Jalaja ◽

Karnate Ramachandra ◽

...

Keyword(s):

Neuromuscular Blockade ◽

Peak Expiratory Flow ◽

Postoperative Period ◽

Forced Vital Capacity ◽

Vital Capacity ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Blocking Agents ◽

Train Of Four ◽

Expiratory Flow

Abstract Background Residual neuromuscular blockade (RNMB) is known to be associated with respiratory complications in the postoperative period after muscle relaxant usage. The authors hypothesized that RNMB causes reductions in pulmonary function test (PFT) parameters in the immediate postoperative period. Methods An open-label prospective randomized cohort study was conducted comparing reductions in PFT parameters due to RNMB among different neuromuscular blocking agents. One hundred and fifty patients were randomized to receive vecuronium, atracurium, or rocuronium. After reversal of neuromuscular blockade and extubation, train-of-four ratio was measured every 5 min until the train-of-four ratio of 0.9 or greater was attained. PFTs were performed preoperatively and postoperatively when the patients were willing and fit. The train-of-four ratio, measured at PFT, was used to classify patients into “RNMB absent” and “RNMB present.” RNMB was defined as a train-of-four ratio less than 0.9. Results Thirty-nine patients had RNMB at the time of performing PFT. There was no statistically significant difference in the postoperative reductions in PFT parameters in patients with RNMB among different neuromuscular blocking agents. Patients were regrouped as RNMB absent and RNMB present, irrespective of neuromuscular blocking agents. Postoperative PFT values for the RNMB-absent and RNMB-present groups were 62% and 49% of baseline forced vital capacity and 47% and 38% of baseline peak expiratory flow of the baseline, respectively. Postoperative forced vital capacity and peak expiratory flow values of RNMB-present patients were lower by 13% and 9% in absolute terms (P < 0.008) and 21% and 19% in relative terms, respectively, compared with RNMB-absent patients. Conclusion RNMB results in reductions in forced vital capacity and peak expiratory flow in the immediate postoperative period indicating impaired respiratory muscle function.

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Sugammadex: A neuromuscular blockade agent encapsulator

The Southwest Respiratory and Critical Care Chronicles ◽

10.12746/swrccc.v5i20.407 ◽

2017 ◽

Vol 5 (20) ◽

pp. 44 ◽

Cited By ~ 2

Author(s):

Victoria Yepes Hurtado

Keyword(s):

Neuromuscular Blockade ◽

Current Literature ◽

Neuromuscular Blocking ◽

Muscle Relaxants ◽

Neuromuscular Blocking Agents ◽

New Class ◽

Blocking Agents

Sugammadex sodium, a modified γ-cyclodextrin, represents a new class of drugs effectiveat reversing non-depolarizing muscle relaxants rocuronium and vecuronium. The cylindrical,basket-like structure encapsulates neuromuscular blocking agents which results in rapidreversal of paralysis within three minutes. The current literature was reviewed to analyze theclinical implications and considerations with its administration.

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Generalized Paralysis in the Intensive Care Unit: Emphasis on the Complications of Neuromuscular Blocking Agents and Corticosteroids

Journal of Intensive Care Medicine ◽

10.1177/088506669601100404 ◽

1996 ◽

Vol 11 (4) ◽

pp. 219-231 ◽

Cited By ~ 7

Author(s):

Kenneth C. Gorson ◽

Allan H. Ropper

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Motor Units ◽

Critical Illness Polyneuropathy ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Icu Patients ◽

Blocking Agents ◽

Neuromuscular Blockers ◽

Prolonged Neuromuscular Blockade

Generalized weakness in intensive care unit (ICU) patients is increasingly recognized as a frequent complication and a common cause of prolonged ventilator dependency. Intravenous corticosteroids and neuromuscular blocking agents, sepsis, and multiorgan failure have been strongly implicated in the ICU paralysis syndromes, but the pathophysiology of these disorders is poorly understood. The combination of neuromuscular blocking agents and corticosteroids may induce three distinct syndromes of generalized weakness in ICU patients: acute myopathy, prolonged neuromuscular blockade, and critical illness polyneuropathy. More than one syndrome may occur simultaneously, and the distinctions may be difficult in a particular patient, but a specific diagnosis usually can be established after careful clinical, electrodi-agnostic, and histological evaluation. Acute myopathy with generalized weakness, preserved eye movements, elevated creatine kinase levels, and myopathic motor units on electromyography (EMG) have developed in asthmatics requiring neuromuscular blockers and steroids. Muscle biopsy has shown distinctive changes, with fiber atrophy, scattered necrosis, and thick (myosin) filament depletion on ultrastructural studies. Patients who have had a prolonged ICU stay or sepsis with failure to wean from the ventilator, distal weakness, and areflexia probably have critical illness polyneuropathy. EMG in these patients has demonstrated reduced or absent motor and sensory potentials with neurogenic motor units. Prolonged neuromuscular blockade most commonly has occurred in patients with renal failure who received prolonged infusions of neuromuscular blockers. Severe flaccid, areflexic paralysis with normal sensation, facial weakness, and ophthalmoparesis persists for days or weeks after the neuromuscular blockers have been discontinued. Repetitive nerve stimulation has shown a decrement of the compound muscle action potential, and it establishes a disorder of neuromuscular transmission in most patients. We critically examine the clinical, electrophysiological, and pathological features of each of these syndromes, and we summarize current understanding of the pathophysiology of these disorders and the relationship to neuromuscular blocking agents and corticosteroids.

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Effect of intravenous infusion of rocuronium on emergence from propofol anesthesia in rats

10.21203/rs.2.23130/v1 ◽

2020 ◽

Author(s):

Kaoru Suzuki ◽

Hiroshi Sunaga ◽

Kentaro Yamakawa ◽

Yoshifumi Suga ◽

Ichiro Kondo ◽

...

Keyword(s):

Continuous Infusion ◽

Neuromuscular Blockade ◽

Normal Saline ◽

Case Reports ◽

Complete Recovery ◽

Cerebrovascular Diseases ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Sprague Dawley ◽

Blocking Agents

Abstract Background: Central nervous system effects of neuromuscular blocking agents have been indicated in some case reports. We investigated whether intravenous (IV) infusion of rocuronium affects emergence from propofol anesthesia in rats. Methods: We used Sprague Dawley rats. Propofol infusion was initiated with a bolus of 15 mg/kg and continued at a rate of 40 mg/kg/h. For the rocuronium group (n = 18), rocuronium was administered as an initial IV bolus of 5 mg/kg followed by continuous infusion at a rate of 250, 500, or 1000 μg/kg/min along with propofol infusion. Infusion was continued for 60 min, and sugammadex (32 mg/kg) was injected at the end of infusion. In a separate group of rats (n = 12), normal saline was administered along with propofol infusion. After continuous infusion for 60 min, normal saline or sugammadex (32 mg/kg) was injected. The time to emergence from propofol anesthesia was evaluated. To ascertain possible factors affecting emergence, the neuromuscular blocking, circulatory, and respiratory properties of IV rocuronium infusion at 1000 μg/kg/min were assessed (n = 18). Results: The time to emergence from propofol anesthesia was 239 ± 94 s after simultaneous infusion of normal saline without rocuronium and was 346 ± 78, 518 ± 134, and 638 ± 219 s after IV infusion of rocuronium at 250, 500, and 1000 μg/kg/min, respectively. The simultaneous IV infusion of rocuronium dose-dependently increased the time to emergence (ρ = 0.624; p = 0.006). Sugammadex alone did not delay emergence (280 ± 60 s; p = 0.39). Neuromuscular blockade induced by rocuronium at 1000 μg/kg/min was completely antagonized at 99 ± 21 s by sugammadex (32 mg/kg). Mean arterial pressure, heart rate, partial pressures of oxygen and carbon dioxide, and pH were not affected by rocuronium infusion. Conclusions: Our results show that IV infusion of rocuronium delays the emergence from propofol anesthesia in rats, despite the complete recovery from neuromuscular blockade by sugammadex. The use of neuromuscular blocking agents in neonates or patients with cerebrovascular diseases, whose blood-brain barrier might be immature or disrupted, should be carefully considered.

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