scholarly journals A Case of Brainstem Anesthesia after Retrobulbar Block for Globe Rupture Repair

2021 ◽  
Vol 2021 ◽  
pp. 1-4
Author(s):  
Tavish Nanda ◽  
Lisa Ross ◽  
Gregory Kerr
Keyword(s):  
Postoperative Pain Management ◽  
Anesthesia Machine ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Postanesthesia Care Unit ◽  
Steady Increase ◽  
Mixed Formulations ◽  
Retrobulbar Block ◽  
Globe Rupture ◽  
Contralateral Eye

Purpose. To present a rare case of brainstem anesthesia from retrobulbar block and discuss evidence-based methods for reducing the incidence of this complication. Case. A 72-year-old female, was given a retrobulbar block of 5 mL of bupivacaine 0.5% for postoperative pain management, after a globe rupture repair under general anesthesia. Prior to injection, the patient was breathing spontaneously via the anesthesia machine circuit and had not received any additional narcotics/muscle relaxants for 2.5 hr (with full recovery of neuromuscular blocking agent after anesthetic reversal). Over 7 min, however, there was a steady increase in ETCO2 and the patient became apneic, consistent with brainstem anesthesia. She remained intubated and was transported to the postanesthesia care unit for prolonged monitoring, with eventual extubation. Discussion. Brainstem anesthesia is an important complication to recognize as it can lead to apnea and death. The judicious use of anesthetic volume, shorter needle tips, and mixed formulations can help reduce the chance of brainstem anesthesia. Observation of the contralateral eye 5–10 minutes after injection for pupillary dilation, and prior to surgical draping, can help identify early CNS involvement.

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

2021 ◽  
Author(s):  
Glenn S. Murphy ◽  
Sorin J. Brull
Keyword(s):  
Neuromuscular Block ◽  
Meta Analysis ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Monitoring ◽  
Postanesthesia Care Unit ◽  
Clinical Practices ◽  
Residual Neuromuscular Blockade ◽  
Quantitative Monitoring ◽  
Residual Neuromuscular Block

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

scholarly journals Preclinical Pharmacology in the Rhesus Monkey of CW 1759-50, a New Ultra-short Acting Nondepolarizing Neuromuscular Blocking Agent, Degraded and Antagonized by L-Cysteine

2018 ◽  
Vol 129 (5) ◽  
pp. 970-988 ◽  
Author(s):  
John J. Savarese ◽  
Hiroshi Sunaga ◽  
Jeff D. McGilvra ◽  
Matthew R. Belmont ◽  
Matthew T. Murrell ◽  
...  
Keyword(s):  
Heart Rate ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Neuromuscular Blockade ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent ◽  
Duration Of Action ◽  
Short Acting ◽  
Circulatory Effects

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Structure–activity studies were performed to identify a new neuromuscular blocking agent retaining the ultra-short acting characteristics of gantacurium, including degradation and reversal by l-cysteine, but lacking its histaminoid properties in man. CW 1759-50 has emerged from this program. Methods Adduction of CW 1759-50 with l-cysteine was studied by high-performance liquid chromatography and mass spectrometry. Institutional Animal Care and Use Committee–approved comparisons of CW 1759-50 to gantacurium were performed in rhesus monkeys. ED95 for neuromuscular blockade was established. Spontaneous recovery was compared to reversal by l-cysteine in paired studies of boluses or infusions. In addition, changes in mean arterial pressure and heart rate after very large doses of 15 to 60 × ED95 were compared. Results The half-time of adduction of l-cysteine to CW 1759-50 in vitro was 2.3 min. The ED95 of CW 1759-50 was 0.069 ± 0.02 mg/kg; ED95 of gantacurium was 0.081 ± 0.05 mg/kg (P = 0.006). Duration of action (recovery to 95% twitch height after 98 to 99% blockade) was as follows: CW 1759-50, 8.2 ± 1.5 min; and gantacurium, 7.4 ± 1.9 min; (n = 8 and 9, P = 0.355). Administration of l-cysteine (30 mg/kg) shortened recovery (i.e., induced reversal) from CW 1759-50 after boluses or infusions (P always less than 0.0001). Recovery intervals (5 to 95% twitch) ranged from 6.1 to 6.7 min (and did not differ significantly) after boluses of 0.10 to 0.50 mg/kg, as well as control infusions (P = 0.426 by analysis of variance). Dose ratios comparing changes of 30% in mean arterial pressure or heart rate to ED95 for neuromuscular blockade (ED 30% Δ [mean arterial pressure or heart rate]/ED95) were higher for CW 1759-50 than for gantacurium. Conclusions CW 1759-50, similar to gantacurium, is an ultra-short acting neuromuscular blocking agent, antagonized by l-cysteine, in the monkey. The circulatory effects, however, are much reduced in comparison with gantacurium, suggesting a trial in humans.

The Interaction Between Suxamethonium and the Succeeding Non-Depolarizing Neuromuscular Blocking Agent

1991 ◽  
Vol 35 (1) ◽  
pp. 8
Author(s):  
J. SWEN ◽  
H. W. J. ROOT ◽  
A. BENCINI ◽  
J. M. KET ◽  
J. HERMANS ◽  
...  
Keyword(s):  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent

SECTION ON CRITICAL CARE 1996 ANNUAL MEETING PROGRAM

PEDIATRICS ◽  
1996 ◽  
Vol 98 (3) ◽  
pp. 541-550
Keyword(s):  
Heart Surgery ◽  
Venous Pressure ◽  
Blocking Agent ◽  
Congenital Heart Surgery ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent ◽  
Hemodynamic Effects ◽  
Open Label ◽  
Maximal Increase ◽  
Hemodynamic Status

Background: Some neuromuscular blocking agents have previously been shown to have clinically significant hemodynamic effects. These agents should obviously be avoided in patients whose hemodynamic status might be considered compromised. Rocuronium bromide (ROC) is a new steroidal non-depolarizing neuromuscular blocking agent recently approved for use by the FDA. The hemodynamic effects associated with its use in critically ill pediatric patients have not been reported. Methods: In a nonrandomized open-label study 10 infants and children (ages 1 mth to 68 mths, mean 14 mths; weight 2.9-16 kg, mean 6.3 kg) were given two doses of ROC (0.6 mg/kg followed by 0.9 mg/kg) as a neuromuscular blocking agent after congenital heart surgery, once their hemodynamic status was thought to be stable (mean 20 hours after admission). All patients were sedated with morphine, fentanyl, midazolam or a combination of fentanyl and midazolam. Hemodynamic parameters including heart rate (HR), blood pressure (BP), central venous pressure, left atrial pressure and pulmonary artery pressure were recorded when possible just prior to injection and at one minute, five minutes and ten minutes. Any apparent adverse effects were also noted. Results: ROC produced small, transient increases in HR and BP at both 0.6 and 0.9 mg/kg doses. For both doses, the peak increase in BP was noted at one minute, with BP returning to baseline by five minutes. The maximal mean increase in BP for either group at any time period was 6%. The maximal increase in mean BP in any patient was 22%. Peak HR response was noted at five minutes in both groups and HR did not return to baseline by 10 minutes.

Preclinical Pharmacology of CW002

2016 ◽  
Vol 125 (4) ◽  
pp. 732-743 ◽  
Author(s):  
Hiroshi Sunaga ◽  
John J. Savarese ◽  
Jeff D. McGilvra ◽  
Paul M. Heerdt ◽  
Matthew R. Belmont ◽  
...  
Keyword(s):  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Safety And Efficacy ◽  
Circulatory Effects ◽  
Autonomic Changes ◽  
Train Of Four

Abstract Background CW002, a novel nondepolarizing neuromuscular blocking agent of intermediate duration, is degraded in vitro by l-cysteine; CW002-induced neuromuscular blockade (NMB) is antagonized in vivo by exogenous l-cysteine.1 Further, Institutional Animal Care and Use Committee–approved studies of safety and efficacy in eight anesthetized monkeys and six cats are described. Methods Mean arterial pressure, heart rate, twitch, and train-of-four were recorded; estimated dose producing 95% twitch inhibition (ED95) for NMB and twitch recovery intervals from 5 to 95% of baseline were derived. Antagonism of 99 to 100% block in monkeys by l-cysteine (50 mg/kg) was tested after bolus doses of approximately 3.75 to 20 × ED95 and after infusions. Vagal and sympathetic autonomic responses were recorded in cats. Dose ratios for [circulatory (ED20) or autonomic (ED50) changes/ED95 (NMB)] were calculated. Results ED95s of CW002 in monkeys and cats were 0.040 and 0.035 mg/kg; l-cysteine readily antagonized block in monkeys: 5 to 95% twitch recovery intervals were shortened to 1.8 to 3.6 min after 3.75 to 10 × ED95 or infusions versus 11.5 to 13.5 min during spontaneous recovery. ED for 20% decrease of mean arterial pressure (n = 27) was 1.06 mg/kg in monkeys; ED for 20% increase of HR (n = 27) was 2.16 mg/kg. ED50s for vagal and sympathetic inhibition in cats were 0.59 and >>0.80 mg/kg (n = 14 and 15). Dose ratios for [circulatory or autonomic changes/ED95 (NMB)] were all more than 15 × ED95. Conclusions The data further verify the neuromuscular blocking properties of CW002, including rapid reversal by l-cysteine of 100% NMB under several circumstances. A notable lack of autonomic or circulatory effects provided added proof of safety and efficacy.

Cardiovascular responses to insulin in the absence of hypoglycemia

1962 ◽  
Vol 202 (2) ◽  
pp. 249-252 ◽  
Author(s):  
Santiago A. Pereda ◽  
John W. Eckstein ◽  
François M. Abboud
Keyword(s):  
Pressor Response ◽  
Direct Action ◽  
Cardiovascular Responses ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Right Atrial ◽  
Systemic Vein ◽  
Anesthetized Dogs ◽  
Adrenergic Blocking ◽  
The Brain

Cardiovascular responses to intravenous administration of insulin were studied in lightly anesthetized dogs treated with a neuromuscular blocking agent. An early transient pressor response was observed. This abrupt increase in arterial pressure appeared 2–9 min after insulin was given. It was accompanied by increases in cardiac output and right atrial pressure. It occurred in the presence of hyperglycemia and in the absence of hypoglycemia. It was not altered by glucagon but it could be antagonized by ganglionic and adrenergic blocking drugs and by pentobarbital. The response could be produced when insulin was given in the carotid artery in doses that caused no effect when injected in a systemic vein. The experiments suggest that insulin may have a direct action on the brain.

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