Rocuronium pharmacodynamic models for published five pharmacokinetic models: age and sex are covariates in pharmacodynamic models

Abstract

Purpose

Equilibration rate constant is necessary to calculate effect-site concentration, which is useful to control drug effect. We developed pharmacodynamic models for published five compartmental pharmacokinetic models published by Wierda, Szenohradszky, Cooper, Alvarez-Gomez, and McCoy.

Methods

We used 3848 train-of-four ratios from 15 male and nine female patients (21–76 years; 44–93 kg body weight; 148–181 cm height; and 17.3–29.8 kg/m² body mass index) as pharmacodynamic measures, which were collected at the start of 0.6 mg/kg rocuronium administration until the end of the surgery. Effect compartment was assumed to be connected to central compartment of the pharmacokinetic model with equilibration rate constant (k_e0). Sigmoid E_max model was fitted to describe the relationship between train-of-four ratio and effect-site concentration. Age, sex, and body mass index were assessed as possible covariates of the following model parameters: k_e0, effect-site concentration for half of maximum effect, and the steepness of the effect-site concentration versus effect relationship.

Results

The duration of neuromuscular monitoring was 69 (37–129) [median (range)] min. All pharmacodynamic models included age and three included sex as significant covariates. K_e0 values ranged between 0.0820 and 0.247 depending on the pharmacokinetic model. The time-courses of the effect-site concentration were similar among the pharmacodynamic models for Wierda, Cooper, and Alvarez-Gomez pharmacokinetic models, which were lower than that for the Szenohradszky pharmacokinetic model.

Conclusion

Each pharmacodynamic model with the corresponding pharmacokinetic model can be described the time course of rocuronium effect appropriately. The required effect-site concentration of rocuronium for a pharmacodynamic effect was depending on the applied models.

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Smith–Lemli–Opitz syndrome presenting as acute adrenal crisis in a child: a case report

Smith–Lemli–Opitz syndrome is a rare autosomal recessive disorder of cholesterol biosynthesis which is characterized by multiple congenital malformations and global developmental delay. Here we report the case...

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Shadow over abdomen

Description  

Male neonate was born by normal vaginal delivery at 38 weeks. He was antenatally diagnosed to have dextrocardia, congenitally corrected transposition of great arteries, moderate ventricular septal defect and pulmonary atresia. He was born in good condition and cried at birth. However, he was noted to have saturation of 65%–70% in air and started on continuous positive airway pressure and transferred to neonatal intensive care unit for further monitoring. Postnatal echocardiography confirmed the diagnosis, and he was started on prostaglandin E1 (PGE1) at 5 nanogram/kg/min.

On day 3 of life, he underwent a cardiac gated CT angiography (CTA) for further understanding of anatomy and confirmation of diagnosis. In view of need for PGE1 until transfer to tertiary cardiac surgical centre, a peripherally inserted central venous catheter was inserted in the following 12 hours. He underwent an abdominal X-ray to check long line position (figure 1).

...

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Unexpected cause for eyelid swelling and ptosis: rigid gas permeable contact lens migration following a 28-year-old trauma

A patient presented with left upper eyelid swelling and ptosis. The MRI reported a cyst with proteinaceous content. On surgical excision of the cyst, a rigid gas permeable (RGP) contact lens was found. The RGP lens was encapsulated within the upper eyelid soft tissue. It was later revealed that the patient experienced childhood trauma while wearing RGP contact lenses 28 years previously. The patient assumed that the RGP lens fell out and was lost; however, it can be inferred that the lens migrated into the eyelid and resided there asymptomatically for 28 years.

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Kikuchi-Fujimoto disease: a rare cause of cervical lymphadenopathy and fever

A 28-year-old Pakistani man with previously treated latent tuberculosis (TB) presented with a 3-month history of productive cough, fever, drenching night sweats, anorexia, sore throat and tender left cervical lymphadenopathy. Extensive biochemical and microbiological tests, and imaging studies were all inconclusive. Lymph node biopsy revealed the diagnosis of Kikuchi-Fujimoto disease (KFD). He had persistent fever and anorexia during admission despite supportive measures which resolved quickly on starting prednisolone. He remained well after being weaned off steroids on 18 weeks' follow-up. KFD is a rare, self-limiting disease which can mimic several serious conditions such as TB and lymphoma. Prompt diagnosis with lymph node biopsy is paramount in addressing diagnostic uncertainty and avoids starting potentially toxic treatment on these patients.

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Bitter experience with liquorice sweetening agent resulting in apparent mineralocorticoid excess with periodic paralysis

Chronic liquorice ingestion is a rare cause of secondary hypertension and hypokalaemia with periodic paralysis. We report the case of a middle-aged Indian man who presented with hypertension and hypokalaemic alkalosis with recurrent bouts of periodic paralysis. Biochemical investigations revealed suppressed plasma renin and aldosterone concentrations with normal cortisol concentration. A detailed history revealed that he was addicted for the last 5 years to a form of chewing tobacco mixed with herbal preparations as a sweetening agent which on analysis revealed active principles of glycyrrhizin using the thin liquid chromatography method. The hypokalaemia resolved and hypertension control improved significantly after discontinuing liquorice consumption, and the patient was asymptomatic at 1-year follow-up. Long-term liquorice ingestion should be kept in mind as a reversible cause of hypokalaemic periodic paralysis, with a meticulous history and biochemical evaluation helping in identifying this recognisable and curable medical disorder.

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Johanson-Blizzard syndrome with associated urogenital anomalies

We present a case of a child with pancreatic insufficiency and facial defects typical of Johanson-Blizzard syndrome (JBS), along with the more facultative anomalies of the JBS, such as those of the urogenital system including persistent urogenital sinus, urethral duplication and dysplastic kidneys. Fetal ultrasound in a 21-year-old G1P1 woman revealed ambiguous genitalia. Examination at birth revealed a phallic structure with urethral meatus, non-palpable gonads, two orifices in close proximity in the perineum, with the anterior being a common urogenital channel and the posterior, the rectum. A voiding cystourethrogram/genitogram showed bilateral high-grade vesicoureteral reflux and a common urogenital sinus extending 1.5 cm before dividing into three channels: the native urethra, an accessory urethra directed anteriorly towards the clitoris and a septate vagina with uterus didelphys. JBS was suspected by clinical presentation and confirmed by UBR1 molecular testing (46,XX). At 16 months of age, she underwent feminising genitoplasty and posterior sagittal anorectoplasty.

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Post-traumatic bony impingement into vagina: a rare cause of urethrovaginal fistula

A 22-year-old woman met with road traffic accident 6 months back following which she underwent exploratory laparotomy with intraperitoneal bladder rupture repair. She presented with urethrovaginal fistula due to a fragment of fractured pubic bone impinging into the anterior vaginal wall. The findings were confirmed on CT scan and cystoscopy. The patient was managed with removal of the bony spicule and transvaginal repair of urethrovaginal fistula with Martius fat pad interposition.

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Mediastinal lipoblastoma: a rare entity discovered on physical exam

Description 

A 3-year-old male with no significant medical or surgical history presents to his paediatrician for annual examination. On auscultation, he was noted to have diminished left-sided breath sounds and heart sounds displaced to the right. The patient had no complaints of pain, difficulty swallowing, shortness of breath or dyspnoea on exertion. An initial chest X-ray was performed which demonstrated complete opacification of the left hemithorax with mediastinal shift towards the right. This was followed by a radiation dose reduced CT of the chest with intravenous contrast, which demonstrated a 7.8x7.4x13.3 cm fat density mass filling the majority of the left lung and extending to the pleura and mediastinum (figure 1A). The patient was optimised for the operating room and underwent a left lateral thoracotomy. Intraoperatively, the mass was identified and noted to have fusion to the pericardium and pleura in its superior margin with all other...

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Cross-leg free flap for limb salvage in the setting of radiation

Limb salvage in an irradiated patient with limited recipient vessels leaves few options for reconstruction. Cross-leg free flaps have been used to reconstruct defects that would otherwise lead to amputation in patients with no ipsilateral recipient vessels. We present the first documented case of a cross-leg free flap for limb salvage in a radiated bed after infection and tumour resection.

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Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study

Background and Objectives The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space. We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. Methods Twenty-six fresh cadavers were dissected bilaterally. The number, location, and course of the pectoral nerves were recorded. Distances to surface landmarks (sternum, clavicle, and costae) and ultrasound landmarks (thoracoacromial artery [TAA] and pectoralis minor muscle [Pm]) were recorded. Results The lateral pectoral nerve and the TAA entered together into the IP space 8.9 cm (range, 8.0–12.0 cm) lateral to the midsternal line. The medial pectoral nerve (MPN) had between 1 and 4 branches that pierced the Pm, and 69% had additional branches lateral to the Pm. The muscle-piercing MPN branches were located 3.8 cm (range, 0.4–8.1 cm) and the lateral MPN branches 5.4 cm (range, 3.0–8.4 cm) from the lateral pectoral nerve. The IP course was 2.6 cm (range, 0.7–6.5 cm). All specimens were asymmetrical in location or number of MPN branches. Conclusions The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA. Accepted for publication April 4, 2018. Address correspondence to: Lena F. Carstensen, MD, Department of Breast Surgery, Sydvestjysk Sygehus, 6700 Esbjerg, Denmark (e-mail: lena.carstensen@dadlnet.dk). The authors declare no conflict of interest. Preliminary results were presented at the poster session, Oncoplastic & Reconstructive Breast Surgery (ORBS) International Scientific Meeting, Nottingham, September 2015. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Efficacy and safety of dexmedetomidine in peripheral nerve blocks: A meta-analysis and trial sequential analysis

BACKGROUND The duration of analgesia provided by nerve blocks is limited if local anaesthetics are administered alone. Therefore, several additives, including dexmedetomidine (DEX), have been investigated in order to prolong postoperative analgesia following single-shot regional anaesthesia. OBJECTIVES The aim of this meta-analysis was to assess the efficacy and safety of the addition of perineural DEX to local anaesthetics compared with local anaesthetics alone or local anaesthetics combined with systemic administration of DEX. DESIGN A systematic review of randomised controlled trials (RCT) with meta-analysis, trial sequential analysis and assessment of the quality of evidence by the GRADE approach. DATA SOURCES The databases MEDLINE, CENTRAL and EMBASE (to May 2017) were systematically searched. ELIGIBILITY CRITERIA All prospective RCTs investigating the efficacy and safety of perineural DEX combined with local anaesthetics compared with local anaesthetics alone or local anaesthetics in combination with systemic DEX in peripheral nerve blocks of adults undergoing surgery were included. RESULTS A total of 46 RCTs (3149 patients) were included. Patients receiving perineural DEX combined with local anaesthetics had a longer duration of analgesia than local anaesthetics alone [mean difference 4.87 h; 95% confidence interval (95% CI) 4.02 to 5.73; P 

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Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study

BACKGROUND When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg−1) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg−1) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = −2.2 (95% bootstrap CI −2.9 to 1.6), Bonferroni adjusted P 

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Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: A prospective observational study

OBJECTIVES Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN A prospective observational noninterventional study. METHODS After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ± SD (range) and GAA as median (interquartile range). RESULTS Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ± 120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm2 in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences −0.54, 95% confidence interval −1.00 to −0.07, P 

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Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis

BACKGROUND Circulating cardiac troponin levels are powerful predictors of prognosis in many clinical settings, but their association with outcomes after noncardiac surgery is unclear. OBJECTIVES The aim of this systematic review was to summarise current evidence on the association of pre-operative troponin elevation with postoperative major adverse cardiac events (MACE) and mortality in patients undergoing noncardiac surgery. DESIGN Systematic review of observational studies with meta-analysis. DATA SOURCES PubMed, EMBASE and Science Citation Index Expanded (ISI Web of Science) from their inception to 1 October 2017. ELIGIBILITY CRITERIA Observational studies reporting the associations between pre-operative troponin levels and MACE and all-cause mortality after noncardiac surgeries were included. RESULTS Ten studies met the eligibility criteria. The entire body of evidence addressing the research question was based on a total of 10 371 patients: 4.7 to 68.3% (median 23.8%) of patients had elevated troponin levels before surgery. Elevated pre-operative troponin was significantly associated with short-term MACE (seven studies, 5180 patients: odds ratio (OR) 6.92, 95% confidence interval (CI) 3.85 to 12.42), short-term mortality (five studies, 6103 patients: OR 4.23, 95% CI 2.27 to 7.89) and long-term mortality (two studies, 760 patients: OR 2.51, 95% CI 1.47 to 4.29). The associations remained significant when only multivariate-adjusted results were analysed. Overall, the reviewers' certainty about the summary estimates of the associations was very low. CONCLUSION Current evidence suggests that pre-operative high troponin levels are significantly associated with adverse cardiac events and mortality after noncardiac surgery. TRIAL REGISTRATION This systematic review was registered in the International Prospective Register of Systematic Reviews (Centre for Reviews and Dissemination 42017077837). Correspondence to Bing-Cheng Zhao, MD, Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou 510080, China E-mail: zhaobch@mail2.sysu.edu.cn Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Postanesthesia care by remote monitoring of vital signs in surgical wards

Purpose of review This narrative review summarizes recent insights into the role of remote monitoring of vital signs in the postoperative period in surgical wards. Recent findings Despite recent improvements in the safety of anesthesia and surgical procedures, postoperative complication rates are still unacceptably high. This is partly attributable to the intermittent provision of personal care to patients by nurses and ward physicians. Continuous remote monitoring of vital functions in the early postoperative period may reduce these complication rates. There are several medical-grade remote monitoring platforms available that integrate a biosensor signal with electronic patient records, enabling automated prediction or notification of patient deterioration. Most available platforms have technical limitations with respect to the accuracy of respiratory rate measurements. Of note, although the implementation of automated notifications of patient deterioration is associated with a reduced activation of acute response teams, the involvement of ward physicians in the early diagnosis and treatment of subtle changes in vital functions is increased. Summary Remote monitoring of vital signs in the surgical ward may contribute to prevention of severe complications and reduction in failure-to-rescue rates, although evidence for this association is still lacking. Anesthesiologists should contribute their knowledge and skills with respect to perioperative abnormalities in vital functions to improve patient safety during the postoperative period. Correspondence to Dr Christa Boer, Professor, Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands. Tel: +31 204443830; e-mail: c.boer@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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