A systematic review and meta-analysis of the use of succinylcholine to facilitate tracheal intubation in neonates

Use of succinylcholine in neonates is surrounded by many controversies. The need to review this topic stems from the fact that though there is an abundance of information, but there are divergent views regarding its use in neonates. We have analyzed the incidence of intubation attempts, bradycardia, and hemodynamic changes in clinical settings.The authors conducted a meta-analysis and systematic literature search to ascertain the risks and benefits of using succinylcholine in neonatal intubation by conducting a review in the online databases of PubMed, Cochrane, Scopus, Embase, Elsevier, and Google scholar. The combination of keywords used for the search included “Succinylcholine,” “succinylcholine” AND “neonates,” “neonates” AND “difficult airway,” “neuromuscular blockers” AND “neonates,” and “non-depolarizing neuromuscular blockers” AND “neonates”. The severe adverse reactions associated with use of succinylcholine include bradycardia, asystole, hyperkalemia, and apnea. The number of attempts required for intubation was significantly lower in the patients receiving succinylcholine as compared to those who did not receive succinylcholine. Evidence suggests that conscious awake intubation leads to adverse physiological responses in neonates. The main recommended indications for using succinylcholine include emergency intubation in laryngospasm, full stomach, difficult airway, absent intravenous access, and controlled endotracheal intubation in the neonatal intensive care unit. Hence, the use of succinylcholine can be rationally accepted after considerations of the pre-operative clinical status of the neonate and risk-benefit ratio with more research further to build up strong evidence for the most appropriate agents for use in neonatal patients.

Trends in the use of sedatives, opioids, and neuromuscular blockers in critically ill patients during the COVID-19 pandemic v1

Trends in the use of sedatives, opioids, and neuromuscular blockers in critically ill patients during the COVID-19 pandemic Introduction: The coronavirus disease 2019 (COVID-19) pandemic has increased the use of drugs administered for mechanical ventilation, leading to shortages in some countries. The objective was to identify trends in the consumption of sedatives, hypnotics, neuromuscular blockers, and opioids used for anesthetic induction and deep sedation in hospitals in Colombia. Method: This was a descriptive, longitudinal, and retrospective study with monthly follow-up of dispensations of sedatives, hypnotics, opioids, and neuromuscular blockers in 20 clinics and hospitals from January to November 2020. The frequencies of use of each drug and variations in the institutions and intensive care units (ICUs) were identified. Results: A total of 1,252,576 units of the analyzed drugs were delivered to 79,094 treated patients, 55.0% of whom were women (n=43,521). The drugs with the greatest increase in consumption were rocuronium (1.058% variation in March-November) and propofol (511%). The final consumption of midazolam and vecuronium decreased.Among dispensations made only in ICUs, 920,170 units were delivered (73.5% of the drugs dispensed during the study), and the most often dispensed drugs were fentanyl (n=251,519; 27.3% of the drugs used in the ICU) and midazolam (5mg/5mL) solution (n=188,568; 20.5%). Specifically in the ICU, the drugs with the greatest increase in use were rocuronium (19.709%), propofol (2.622%), and ketamine (2.591%). Conclusion: Rapid changes in the use of drugs were evident, which demonstrates the need for closer cooperation among treating physicians, service providers, pharmaceutical managers, and state institutions to maintain a sufficient and timely supply of critical drugs in this type of contingency.

Postoperative Nausea and Vomiting Implications in Neostigmine versus Sugammadex

Purpose/Background: Postoperative nausea and vomiting (PONV) is a frequent complaint in the postoperative period, which can delay discharge, result in readmission, and increase cost for patients and facilities. Inducing paralysis is common in anesthesia, as is utilizing the drugs neostigmine and sugammadex as reversal agents for non-depolarizing neuromuscular blockers. Many studies are available that compare these two drugs to determine if neostigmine increases the risk of PONV over sugammadex. Sugammadex has a more favorable pharmacologic profile and may improve patient outcomes by reducing PONV. Methods: This review included screening a total of 39 studies and peer-reviewed articles that looked at patients undergoing general anesthesia who received non-depolarizing neuromuscular blockers requiring either neostigmine or sugammadex for reversal, along with their respective PONV rates. 8 articles were included, while 31 articles were removed based on our exclusion criteria. These were published between 2014 and 2020 exclusively. The key words used were “neostigmine”, “sugammadex”, “PONV”, along with combinations “paralytic reversal agents and PONV”. This search was performed on the scholarly database MEDLINE. The data items were PONV rates in neostigmine group, PONV rates in sugammadex group, incidence of postoperative analgesic consumption in neostigmine group, and incidence of postoperative analgesic consumption in sugammadex group. Results: Despite numerical differences being noted in the incidence of PONV with sugammadex over reversal with neostigmine, there did not appear to be any statistically significant data in the multiple peer-reviewed trials included in our review, for not one of the 8 studies concluded that there was a higher incidence of PONV in one drug or the other of an y clinical relevance. Although the side-effect profile tended to be better in the sugammadex group than neostigmine in areas other than PONV, there was not sufficient evidence to conclude that one drug was superior to the other in causing a direct reduction of PONV. Implications for Nursing Practice: There were variable but slight differences noted between both drug groups in PONV rates, but it remained that none of the studies determined it was statically significant or clinically conclusive. This review did, however, note other advantages to sugammadex over neostigmine, including its pharmacologic profile of more efficiently reversing non-depolarizing neuromuscular blocking drugs and its more favorable pharmacokinetics. This lack of statistically significant evidence found within these studies consequentially does not support pharmacologic decision-making of one drug in favor of the other for reducing PONV; therefore, PONV alone is not a sufficient rationale for a provider to justify using one reversal over another at the current time until further research proves otherwise.

Uniportal surgical biopsy, without orotraqueal intubation, without thoracic drainage in intersticial pulmonary disease: initial results

ABSTRACT Objective: interstitial lung disease comprises a group of lung diseases with wide pathophysiological varieties. This paper aims to report the video thoracoscopic surgical biopsy in patients with interstitial lung disease through a single minimal chest incision, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers. Methods: this study is a series of 14 cases evaluated retrospectively, descriptively, where patients underwent a pulmonary surgical biopsy from January 2019 to January 2020. The patients included in the study had diffuse interstitial lung disease without a defined etiological diagnosis. Results: none of the patients had transoperative complications, there was no need for chest drainage in the postoperative period, and the patients pain, assessed using the verbal scale, had a mode of 2 (minimum value of 1 and maximum of 4) in the post immediate surgery and 1 (minimum value of 1 and maximum of 3) at the time of hospital discharge. The length of hospital stay was up to 24 hours, with 12 patients being discharged on the same day of hospitalization. Conclusion: therefore, it is concluded in this series of cases that the performance of uniportal video-assisted thoracoscopic surgery procedures to perform lung biopsies, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers, bring benefits to the patient without compromising his safety. Further larger studies are necessary to confirm the safety and efficiency of this method.

Bloqueantes neuromusculares y síndrome de distrés respiratorio: Artículo Original: National Heart, Lung and Blood Institute PETAL Clinical trials network. Early neuromuscular blockade in the acute respiratory distress syndrome. New England Journal of Medicine 2019; 380(21): 1997-2008.

El uso precoz de bloqueantes neuromusculares (BNM) en el síndrome de distrés respiratorio del adulto (SDRA) moderado-severo se había asociado a una disminución de la mortalidad en el ensayo ACURASYS en 2010. El recientemente publicado estudio ROSE (Reevaluation of Systemic Early Neuromuscular Blockade) pone en evidencia esta práctica. ABSTRACT Neuromuscular blockers and respiratory distress syndrome. Early use of neuromuscular blockers agents (NMBAs) in moderate-severe adult respiratory distress syndrome (ARDS) has previously been associated with a mortality decrease in the ACURASYS trial in 2010. However, the recently published ROSE study (Reevaluation of Systemic Early Neuromuscular Blockade) points out the disagreement with this practice.