Ricardo Vieira Carlos

Rocuronium and sugammadex in a 3 days old neonate for draining an ovarian cyst. Neuromuscular management and review of the literature

A case is reported in which a 3-days old neonate with a giant ovarian cyst was scheduled for surgery. The patient received a dose of sugammadex to reverse a rocuronium-induced neuromuscular block. A fast and efficient recovery from neuromuscular block was achieved within 90s. No adverse events or other safety concerns were observed. Furthermore, a review of the literature on the use of sugammadex in neonates was performed.

Variação da pressão sistólica como método diagnóstico da hipovolemia durante anestesia para cirurgia cardíaca

JUSTIFICATIVA E OBJETIVOS: A estimativa acurada do volume intravascular efetivo e de grande importância em pacientes submetidos a procedimentos cirurgicos de grande porte. A avaliacao da volemia, baseada na variacao da pressao sistolica (VPS), (diferenca entre os valores sistolicos maximos e minimos durante um ciclo respiratorio controlado mecanicamente) e sua variavel delta down (dDown) tem se mostrado um indicador sensivel da pre-carga, quando cotejados com parâmetros hemodinâmicos convencionais. Como a VPS nao e um parâmetro utilizado rotineiramente para avaliacao da volemia, este trabalho teve como objetivo introduzir a tecnica da medida da VPS e verificar sua validade em pacientes submetidos a anestesia para cirurgia cardiaca. METODO: A partir de programa de computador especialmente desenvolvido, transmitiu-se em tempo real a variacao da pressao arterial a partir do monitor da sala cirurgica para microcomputador conectado em rede. Apos a adaptacao deste sistema, foram estudadas as variacoes da pressao sistolica em nove pacientes submetidos a revascularizacao do miocardio. As variaveis foram registradas em dois momentos, utilizando-se a expansao volemica como indicador: M0 (antes da expansao volemica) e M1 (apos a expansao volemica). Tambem foram estudados alguns parâmetros hemodinâmicos convencionais, confrontados com a variacao da pressao sistolica. RESULTADOS: Os principais resultados deste estudo mostram que a VPS, em seu componente dDown, e a que apresenta maior consistencia de variacao apos a expansao volemica com amido.Os demais parâmetros hemodinâmicos estudados, embora apontem para nitida melhora cardiovascular apos a expansao, possuem alta variabilidade entre os pacientes e mesmo quanto a resposta ao expansor. CONCLUSOES: Os resultados obtidos mostram que a VPS se comporta como um sensivel indicador da volemia, em pacientes sob ventilacao mecânica, quando correlacionada as variacoes da pressao venosa central, pressao capilar pulmonar e indice sistolico.BACKGROUND AND OBJECTIVES An accurate predictor of effective intravascular volume is of paramount importance for patients submitted to major surgical procedures. A new method to evaluate intravascular volume based on systolic blood pressure variations (SPV), (difference between the maximum and minimum systolic values during controlled respiratory cycle) and its variable delta down (dDown) has shown to be a sensitive indicator of ventricular preload. As SPV is not routinely used in clinical practice our purpose was to evaluate the accuracy of this parameter in evaluating volume status of patients submitted to cardiac surgery. METHODS As from specially developed software, blood pressure variation was transmitted in real time from operating room monitor to a network-connected computer. After the adaptation of this system, nine patients submitted to cardiac surgery were evaluated. Variables were recorded in two moments: T0 (before volume replacement) and TP (after volume replacement). At the same time, conventional hemodynamic parameters were also studied and compared to systolic pressure variation. RESULTS Primary study results have shown that SPV (systolic pressure variation), in its dDown component, presents the best variation consistency after volume replacement with starch. Remaining hemodynamic parameters evaluated, although pointing to clear cardiovascular improvement after replacement, are highly variable among the patients and even on expanders response. CONCLUSIONS Results have shown that SPV is a sensitive method to evaluate intravascular volume status in patients under mechanical ventilation, when correlated to central venous pressure, pulmonary capillary wedge pressure and systolic index variations.

Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco

Heart transplantation is a frequent procedure in the treatment of end-stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose-dependent life-threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequelae and discuss the reversal of neuromuscular block in this patient population.

New Drug Developments for Neuromuscular Blockade and Reversal: Gantacurium, CW002, CW011, and Calabadion

Purpose of ReviewThe purpose of this chapter is to provide a brief review of the literature on the recent developments in neuromuscular blockade and reversal agents.Recent FindingsNovel drug development resulted in pharmacological advancements in neuromuscular management and led to a new series of compounds, chlorofumarates, such as gantacurium, CW002, and CW011. These drugs have a fast onset and rapid to intermediate duration of action and can be rapidly reversed by l-cysteine adduction without side effects that are commonly observed with anticholinesterase reversal drugs. Another new advancement is the development of a new class of reversal drugs, the calabadions. These drugs are able to reverse both steroidal and non-steroidal non-depolarizing neuromuscular blocking drugs rapidly.SummaryRecent advancements in neuromuscular blocking agents and reversal drugs have shown promise in improving safety of management of neuromuscular blockade. Preclinical and clinical studies are discussed. However, to date these new drugs are not yet available for clinical use.

Systolic pressure variation as diagnostic method for hypovolemia during anesthesia for cardiac surgery

JUSTIFICATIVA E OBJETIVOS: A estimativa acurada do volume intravascular efetivo e de grande importância em pacientes submetidos a procedimentos cirurgicos de grande porte. A avaliacao da volemia, baseada na variacao da pressao sistolica (VPS), (diferenca entre os valores sistolicos maximos e minimos durante um ciclo respiratorio controlado mecanicamente) e sua variavel delta down (dDown) tem se mostrado um indicador sensivel da pre-carga, quando cotejados com parâmetros hemodinâmicos convencionais. Como a VPS nao e um parâmetro utilizado rotineiramente para avaliacao da volemia, este trabalho teve como objetivo introduzir a tecnica da medida da VPS e verificar sua validade em pacientes submetidos a anestesia para cirurgia cardiaca. METODO: A partir de programa de computador especialmente desenvolvido, transmitiu-se em tempo real a variacao da pressao arterial a partir do monitor da sala cirurgica para microcomputador conectado em rede. Apos a adaptacao deste sistema, foram estudadas as variacoes da pressao sistolica em nove pacientes submetidos a revascularizacao do miocardio. As variaveis foram registradas em dois momentos, utilizando-se a expansao volemica como indicador: M0 (antes da expansao volemica) e M1 (apos a expansao volemica). Tambem foram estudados alguns parâmetros hemodinâmicos convencionais, confrontados com a variacao da pressao sistolica. RESULTADOS: Os principais resultados deste estudo mostram que a VPS, em seu componente dDown, e a que apresenta maior consistencia de variacao apos a expansao volemica com amido.Os demais parâmetros hemodinâmicos estudados, embora apontem para nitida melhora cardiovascular apos a expansao, possuem alta variabilidade entre os pacientes e mesmo quanto a resposta ao expansor. CONCLUSOES: Os resultados obtidos mostram que a VPS se comporta como um sensivel indicador da volemia, em pacientes sob ventilacao mecânica, quando correlacionada as variacoes da pressao venosa central, pressao capilar pulmonar e indice sistolico.BACKGROUND AND OBJECTIVES An accurate predictor of effective intravascular volume is of paramount importance for patients submitted to major surgical procedures. A new method to evaluate intravascular volume based on systolic blood pressure variations (SPV), (difference between the maximum and minimum systolic values during controlled respiratory cycle) and its variable delta down (dDown) has shown to be a sensitive indicator of ventricular preload. As SPV is not routinely used in clinical practice our purpose was to evaluate the accuracy of this parameter in evaluating volume status of patients submitted to cardiac surgery. METHODS As from specially developed software, blood pressure variation was transmitted in real time from operating room monitor to a network-connected computer. After the adaptation of this system, nine patients submitted to cardiac surgery were evaluated. Variables were recorded in two moments: T0 (before volume replacement) and TP (after volume replacement). At the same time, conventional hemodynamic parameters were also studied and compared to systolic pressure variation. RESULTS Primary study results have shown that SPV (systolic pressure variation), in its dDown component, presents the best variation consistency after volume replacement with starch. Remaining hemodynamic parameters evaluated, although pointing to clear cardiovascular improvement after replacement, are highly variable among the patients and even on expanders response. CONCLUSIONS Results have shown that SPV is a sensitive method to evaluate intravascular volume status in patients under mechanical ventilation, when correlated to central venous pressure, pulmonary capillary wedge pressure and systolic index variations.

Train-of-four recovery precedes twitch recovery during reversal with sugammadex in pediatric patients: A retrospective analysis

After reversal of a rocuronium‐induced neuromuscular blockade with sugammadex, the recovery of train‐of‐four ratio to 0.9 is faster than recovery of first twitch of the train‐of‐four to 90% in adults. These findings after reversal of neuromuscular blockade with sugammadex have not yet been investigated in pediatric patients.

Será que ainda existe uma indicação para o uso de succinilcolina em cesariana? A resposta é não

n a recent trail by Stourac et al., it was discussed whether ocuronium and sugammadex confer benefit in time to traheal intubation and other Neuromuscular Blockade (NMB) utcomes compared with succinylcholine, rocuronium, and eostigmine in women undergoing general anesthesia for esarean delivery.1 The authors’ conclusion was that rocuroium for rapid sequence induction is noninferior regarding he time needed for intubation. Furthermore, there was ore frequent absence of resistance during laryngoscopy nd less myalgia compared with the use of succinylcholine. ell, nothing new so far, but still there is a discussion hether we should use succinylcholine or rocuronium in esarean section undergoing general anesthesia. Benumof et al. predicted, based on calculations, healthy 70 kg adult patient after a succinycholine .0 mg.kg−1 induced apnea, the SatO2 will start to decrease o less than 90% after approximately 8 min. However, the hysiology compared with healthy patients is changed during regnancy.2 As pregnancy progresses, oxygen consumption ontinues to increase, and cardiac output increases to a esser extent, resulting in a reduced mixed venous oxyen content and increased arteriovenous oxygen difference. fter mid gestation, pregnant women in the supine posiion frequently have a PaO2 less than 100 mmHg (13.3 kPa).3 his occurs because the Functional Residual Capacity (FRC) ay be less than closing capacity, resulting in closure of mall airways during normal tidal volume ventilation. As consequence of these physiological changes, obstetrics atients have shorter apnoea time compared to nonbstetric patients. In addition, the risk of difficult intubation s 5--10 times greater in term pregnancy.1 Therefore, airway anagement in obstetric patients is challenging. Succinylcholine has so many side effects that they can e classified according to mechanism of action as: depoarisation of the endplate and muscle; agonistic actions t other nicotinic sites; muscarinic effects; abnormal equence induction of anaesthesia, a faster onset of oxygen esaturation is observed during the subsequent apnea ompared with rocuronium.4 The authors postulated that his rapid onset of desaturation may be attributed to the igher fasciculation score and fasciculation duration in this roup. These two factors may be responsible for causing an ncrease in oxygen consumption. In this manner, avoiding asciculation, replacing succinylcholine by rocuronium, s a way that can improve the safety margin (through onger apnoea time) during airway management in pregnant atients. Reducing the dose of succinylcholine in order to avoid hese effects is not a good alternative. Naguib et al. studied reduction of the dose of succinylcholine from 1.0 mg.kg−1 o 0.56 mg.kg−1 in healthy normal weight patients.5 This tudy showed that oxygen saturation decreased <90% in 65% s. 85% of the patients in the 0.56 mg.kg−1 and 1.0 mg.kg−1 uccinylcholine group, respectively. Although there was a eduction in desaturation with the lower dose of succinylholine, still a high percentage of patients showed a critical xygen desaturation, putting these patients at risk in case f a difficult intubating situation.5 Therefore, we strongly believe that the use of the comination of rocuronium and sugammadex means an increase n the safety and quality of care to these obstetric patients. owever, the additional cost of sugammadex might be a arrier for institutions to replace succinylcholine for rocuroium, but in our opinion the use of succinylcholine in esarean sections might not longer be indicated.

The effect of prior tetanic stimulation on train-of-four monitoring in paediatric patients: A randomised open-label controlled trial.

BACKGROUND In clinical research, neuromuscular monitoring must present a stable response for a period of 2 to 5 min before administration of a neuromuscular blocking agent. The time required to reach this stable response may be shortened by applying a 5-s tetanic stimulus. OBJECTIVES The aim of this study was to test whether tetanic stimulation interferes with onset and recovery times after a single dose of rocuronium 0.6 mg kg−1 followed by spontaneous recovery. DESIGN A randomised, open-label, controlled trial. SETTING A single-centre trial, study period from January 2014 to July 2015. PATIENTS Fifty children aged 2 to 11 years scheduled for elective paediatric surgery. INTERVENTION Patients were randomly allocated to receive either tetanic stimulation (group T) or not (group C) before calibration of the neuromuscular monitor. MAIN OUTCOME MEASURES Onset and recovery times. Initial and final T1 height, time to obtain initial T1 height stability and monitor settings were also analysed. RESULTS There was no significant difference in mean onset time [(C: 57.5 (± 16.9) vs. T: 58.3 (± 31.2) s; P = 0.917]. Mean times to normalised train-of-four (TOF) ratios of 0.7, 0.8 and 0.9 were significantly shorter in the tetanic stimulation group [C: 40.1 (±7.9) vs. T: 34.8 (±10) min; P = 0.047, C: 43.8 (±9.4) vs. T: 37.4 (±11) min; P = 0.045 and C: 49.9 (±12.2) vs. T: 41.7 (±13.1) min; P = 0.026, respectively]. The mean time required for T1 height stabilisation was similar in the two groups [C: 195.0 (± 203.0) vs. T: 116.0 (± 81.6) s; P = 0.093], but the initial and final T1 height values were significantly lower in the tetanic stimulation group (C: 98.0 vs. T: 82.7%; P < 0.001 and C: 95.3 vs. T: 69.3%; P < 0.001, respectively). CONCLUSION Tetanic stimulation shortened the mean times to normalised TOF ratios of 0.7, 0.8 and 0.9, but there was no difference in the mean onset time or the mean time required for T1 height stabilisation after a single dose of rocuronium 0.6 mg kg−1 followed by spontaneous recovery in children aged 2 to 11 years. TRIAL REGISTRATION Clinicaltrials.gov. identifier: NCT02498678.

Why should we invest in objective neuromuscular monitoring anyway

With great interest we read the editorial by Dr. Pino related to the problem of residual neuromuscular blockade. Recent published articles accumulate results showing the global aspect of this problem. As a result of residual neuromuscular blockade, there is increased respiratory morbidity and mortality and concomitant higher expenses for the health system. As an example of the relevance of this topic, Dr. Eikermann used the term initially described by the American virologist Dr. J.R. Paul, ‘‘the universality of hidden disease’’ in the context of residual neuromuscular blockade. ‘‘The hidden universality of residual neuromuscular blockade’’ means that the number of clinically apparent cases are far outnumbered by those in which blockade produces no apparent signs or symptoms. However, we disagree with the following statement made by Dr. Pino: ‘‘In the absence of accurate TOF monitoring, clinical assessment of the patient’s response to mechanical ventilation may prove a reliable surrogate’’. Despite the great technological evolution of mechanical ventilators, they are not able to detect residual neuromuscular blockade and not able to evaluate the muscle strength of the pharynx. Moreover, there are no changes in respiratory variables, including tidal volume, until the train of four (TOF) ratio decreases to <0.6. This implies that when TOF is in the range of 0.6–0.9 these respiratory variables seems to be normal, but still a residual neuromuscular block exists. Accordingly, evaluation of the muscle strength of the pharynx through assessment of respiratory variables will not be reliable enough, as this muscle group is primarily responsible for maintaining the patency of the upper airway, and has also proven to be the most sensitive to neuromuscular blockers. In addition, to date, no clinical test is able to detect residual neuromuscular blockade efficiently. Therefore, the best way to uncover this ‘‘hidden universality of residual neuromuscular block’’ is through the routine use of neuromuscular monitoring equipment, which should be available and used for every patient in whom neuromuscular blocking drugs are used. Moreover, neuromuscular management which includes the use of an adequate neuromuscular blocking drug, objective neuromuscular monitoring and proper reversal of neuromuscular blockade should be in the guidelines of anesthesia societies. Only by investment in continuous education will training and awareness of residual neuromuscular blockade contribute to a reduction in morbidity and mortality related to residual neuromuscular blockade and improved patient outcomes.

Variación de la presión sistólica como método diagnóstico de la hipovolemia durante anestesia para cirugía cardiaca

JUSTIFICATIVA E OBJETIVOS: A estimativa acurada do volume intravascular efetivo e de grande importância em pacientes submetidos a procedimentos cirurgicos de grande porte. A avaliacao da volemia, baseada na variacao da pressao sistolica (VPS), (diferenca entre os valores sistolicos maximos e minimos durante um ciclo respiratorio controlado mecanicamente) e sua variavel delta down (dDown) tem se mostrado um indicador sensivel da pre-carga, quando cotejados com parâmetros hemodinâmicos convencionais. Como a VPS nao e um parâmetro utilizado rotineiramente para avaliacao da volemia, este trabalho teve como objetivo introduzir a tecnica da medida da VPS e verificar sua validade em pacientes submetidos a anestesia para cirurgia cardiaca. METODO: A partir de programa de computador especialmente desenvolvido, transmitiu-se em tempo real a variacao da pressao arterial a partir do monitor da sala cirurgica para microcomputador conectado em rede. Apos a adaptacao deste sistema, foram estudadas as variacoes da pressao sistolica em nove pacientes submetidos a revascularizacao do miocardio. As variaveis foram registradas em dois momentos, utilizando-se a expansao volemica como indicador: M0 (antes da expansao volemica) e M1 (apos a expansao volemica). Tambem foram estudados alguns parâmetros hemodinâmicos convencionais, confrontados com a variacao da pressao sistolica. RESULTADOS: Os principais resultados deste estudo mostram que a VPS, em seu componente dDown, e a que apresenta maior consistencia de variacao apos a expansao volemica com amido.Os demais parâmetros hemodinâmicos estudados, embora apontem para nitida melhora cardiovascular apos a expansao, possuem alta variabilidade entre os pacientes e mesmo quanto a resposta ao expansor. CONCLUSOES: Os resultados obtidos mostram que a VPS se comporta como um sensivel indicador da volemia, em pacientes sob ventilacao mecânica, quando correlacionada as variacoes da pressao venosa central, pressao capilar pulmonar e indice sistolico.BACKGROUND AND OBJECTIVES An accurate predictor of effective intravascular volume is of paramount importance for patients submitted to major surgical procedures. A new method to evaluate intravascular volume based on systolic blood pressure variations (SPV), (difference between the maximum and minimum systolic values during controlled respiratory cycle) and its variable delta down (dDown) has shown to be a sensitive indicator of ventricular preload. As SPV is not routinely used in clinical practice our purpose was to evaluate the accuracy of this parameter in evaluating volume status of patients submitted to cardiac surgery. METHODS As from specially developed software, blood pressure variation was transmitted in real time from operating room monitor to a network-connected computer. After the adaptation of this system, nine patients submitted to cardiac surgery were evaluated. Variables were recorded in two moments: T0 (before volume replacement) and TP (after volume replacement). At the same time, conventional hemodynamic parameters were also studied and compared to systolic pressure variation. RESULTS Primary study results have shown that SPV (systolic pressure variation), in its dDown component, presents the best variation consistency after volume replacement with starch. Remaining hemodynamic parameters evaluated, although pointing to clear cardiovascular improvement after replacement, are highly variable among the patients and even on expanders response. CONCLUSIONS Results have shown that SPV is a sensitive method to evaluate intravascular volume status in patients under mechanical ventilation, when correlated to central venous pressure, pulmonary capillary wedge pressure and systolic index variations.