Resistance to Neuromuscular Blockade by Rocuronium in Surgical Patients with Spastic Cerebral Palsy

: Individuals with spastic cerebral palsy (CP) often exhibit altered sensitivities to neuromuscular blocking agents (NMBAs) used for surgical intubation. We assessed usage of the NMBA rocuronium in patients with spastic CP and evaluated potential modifiers of dosing including gross motor function classification system (GMFCS) level, birthweight, gestational age, and the use of anticonvulsant therapy. In a case-control study, surgical patients with spastic CP (n = 64) or with idiopathic or non-neuromuscular conditions (n = 73) were enrolled after informed consent/assent. Patient data, GMFCS level, anticonvulsant use, and rocuronium dosing for intubation and post-intubation neuromuscular blockade were obtained from medical records. Findings reveal participants with CP required more rocuronium per body weight for intubation than controls (1.00 ± 0.08 versus 0.64 ± 0.03 mg/kg; p < 0.0001). Dosing increased with GMFCS level (Spearman’s rho = 0.323; p = 0.005), and participants with moderate to severe disability (GMFCS III-V) had elevated rocuronium with (1.21 ± 0.13 mg/kg) or without (0.86 ± 0.09 mg/kg) concurrent anticonvulsant therapy. Children born full-term or with birthweight >2.5 kg in the CP cohort required more rocuronium than preterm and low birthweight counterparts. Individuals with CP exhibited highly varied and significant resistance to neuromuscular blockade with rocuronium that was related to GMFCS and gestational age and weight at birth.

Suggestion For a New Classification of Postoperative Neurological Complications (CPNC) in Neurosurgery

To design a classification concentrating on the art and severity of functional restriction that could include all possible postoperative neurological disturbances and prove its validity to be comparable and easily used in neurosurgery. A seven grade classification was proposed commencing from grade "0" for no neurological disturbances to grade "6" for coma/vegetative state/demise: grade “1”, any remittent neurological disturbances with full improvement spontaneously or as a result of any temporary drug therapy or re-surgery, a single epileptic seizure without the need for anticonvulsant therapy; grade “2”, lasting neurological disturbances resulting in no functional restrictions, no epileptic seizures needing for long-term anticonvulsant therapy; grade “3”, lasting neurological disturbances resulting in slight functional restrictions, rare epileptic seizures despite of anticonvulsant therapy, slight aphasia; grade “4”, lasting neurological disturbances resulting in moderate functional restrictions and partial need of outside help, average frequency of epileptic seizures despite anticonvulsant therapy, moderate aphasia; and grade “5”, lasting neurological disturbances resulting in severe functional restriction and complete need of outside help, high frequency of epileptic seizures despite of anticonvulsant therapy, severe aphasia. The study included a total of 1681 operations at 1530 patients. The postoperative neurological disturbances occurred in 7.7% (n=119) of patients. All postoperative neurological disturbances could be easily classified according to the CPNC. The ranking system was proportional to the length of hospital stay. The CPNC is useful and easily applicable to assess the rates of postoperative neurological disturbances. It can be a comparable instrument in the quality management of neurosurgery.

Manejo da pressão arterial e terapia anticonvulsivante na pré-eclâmpsia grave

Analisar a produção científica dos últimos 10 anos sobre o manejo da pressão arterial e da terapia anticonvulsivante na Pré-Eclâmpsia Grave. Revisão integrativa da literatura realizada nas bases de dados: Bancos de Dados em Enfermagem, Literatura Latino-americana e do Caribe em Ciências da Saúde, Medical Literature Analysis and Retrieval System Online e Biblioteca Virtual em Saúde. Foram analisados 3 artigos sobre o manejo da pressão arterial, 14 sobre terapia anticonvulsivante (analisados nas subcategorias: experiências de países no uso do sulfato de magnésio para o tratamento da Pré-Eclâmpsia e Prescrição e Posologia do sulfato de magnésio) e 1 sobre ambos os assuntos, totalizando 18 artigos. Verificou-se lacunas no tratamento da Pré-eclâmpsia grave a fim de reduzir os altos índices de morbimortalidade. Enfatiza-se a realização de estudos sobre esta temática, interligados com a capacitação profissional, recursos e infraestrutura adequada para assistência a essas mulheres.Descritores: Pré-eclâmpsia, Hipertensão Induzida pela Gravidez, Tratamento de Emergência. Management of blood pressure and anticonvulsive therapy in serious pre-eclampsyAbstract: To analyze the scientific production of the last 10 years on the management of blood pressure and anticonvulsant therapy in severe pre-eclampsia. Integrative literature review carried out in the databases: Nursing Databases, Latin American and Caribbean Literature in Health Sciences, Medical Literature Analysis and Retrieval System Online and Virtual Health Library. Three articles were analyzed on the blood pressure management, 14 on anticonvulsant therapy (analyzed in the subcategories: experiences of countries in the use of magnesium sulfate for the treatment of Preeclampsia and Prescription and Dosage of magnesium sulfate) and 1 on both subjects, totaling 18 articles. There were gaps in the treatment of severe pre-eclampsia in order to reduce the high rates of morbidity and mortality. It is emphasized that studies on this theme are carried out, interconnected with professional training, resources and adequate infrastructure to assist these women.Descriptors: Pre-Eclampsia, Pregnancy-Induced Hypertension, Emergency Treatment. Manejo de la presión arterial y terapia anticonvulsiva en pre-eclampsia graveResumen: Analizar la producción científica de los últimos 10 años sobre el manejo de la presión arterial y el tratamiento anticonvulsivo en la preeclampsia grave. Revisión integral de la literatura realizada en las bases de datos de enfermería, literatura latinoamericana y caribeña en ciencias de la salud, sistema de análisis y recuperación de literatura médica en línea y biblioteca virtual de salud. Se analizaron tres artículos sobre manejo de la presión arterial, 14 en terapia anticonvulsiva (analizadas en las subcategorías: experiencias de países en el uso de sulfato de magnesio para el tratamiento de preeclampsia y prescripción y dosificación de sulfato de magnesio) y 1 en ambos sujetos, totalizando 18 artículos. Hubo lagunas en el tratamiento de la preeclampsia severa para reducir las altas tasas de morbilidad y mortalidad. Se enfatiza que se realizan estudios sobre este tema, interconectados con capacitación profesional, recursos e infraestructura adecuada para ayudar a estas mujeres.Descriptores: Preeclampsia, Hipertensióninducida por Elembarazo, Tratamiento de Emergencia.

NCOG-25. EFFICACY OF ANTICONVULSANT THERAPY IN GLIOMA PATIENTS

Gliomas account for 30% of primary brain tumors and can frequently present with seizures. There are few guidelines for usage of anticonvulsant therapy in glioma patients. Some clinicians utilize anticonvulsant therapy in all glioma patients as a means of prophylaxis, whereas other clinicians prescribe anticonvulsant therapy only in patients that experience seizures. In this single-institution retrospective cohort study, we evaluate the effect of commonly prescribed anticonvulsant levetiracetam on incidence of post-operative seizures and overall survival in primary glioma patients. 436 patients met the inclusion criteria for this study. 35% of patients presented with a pre-operative seizure and 63% of patients received pre-operative Levetiracetam. The incidence of a seizure within 1 year of tumor resection was 31%. On multivariate logistic regression analysis of patient pre-operative clinical and imaging characteristics, it was found that only a pre-operative seizure (p = 0.02) significantly increased the odds of a post-operative seizure within 1 year of tumor resection. Neither pre-operative levetiracetam (p = 0.31), intra-operative levetiracetam (p = 0.59), or post-operative levetiracetam (p = 0.75) significantly reduced the odds of a post-operative seizure. Using a cox proportional hazards model, pre-operative levetiracetam (p = 0.11), intra-operative levetiracetam (p = 0.34), and post-operative levetiracetam (p = 0.88) do not significantly affect overall survival. Our findings reveal that glioma patients are often prescribed anticonvulsant medication regardless of whether they have had a pre-operative seizure. Most patients also receive anti-convulsant medication in the peri-operative and post-operative setting regardless of whether they have had pre-operative or immediate post-operative seizures. Use of pre-operative or intra-operative levetiracetam as a prophylactic measure does not impact the incidence of post-operative seizures. Furthermore, anti-convulsant therapies do not demonstrate a survival benefit in our study. These results provide a rationale for re-evaluating the use of anti-convulsant medications in glioma patients that do not have seizure symptoms.