Neuromuscular blockade management in patients with COVID-19

Chaves-Cardona Harold,Hernandez-Torres Vivian,Kiley Sean,Renew Johnathan 대한마취통증의학회 2021 Korean Journal of Anesthesiology Vol.74 No.4

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome (ARDS), and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.

The synergistic effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade

이지현,이수일,정찬종,이종환,이승철,최소론,오지나,배재영 대한마취통증의학회 2013 Korean Journal of Anesthesiology Vol.64 No.2

Background: Gentamicin reduces acetylcholine release and clindamycin causes end-plate ion channel blockade. Because of these reasons, two drugs show muscular relaxant effect and potentiate the action of nondepolarizing neuromuscular agents. This study was intended to evaluate the effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade and the interaction between these drugs. Methods: Male Sprague-Dawley rats' phrenic nerves and diaphragms were installed in a bath containing Krebs solution. They were divided into three study groups. The first group was pre-treated with 0.1 (n = 3), 0.2 (n = 4) or 0.5 (n = 3) mM gentamicin and the tension was measured as the concentration of rocuronium was increased. The second group was experimented by increasing gentamicin on 0.25 (n = 5), 0.5 (n = 6) or 1.0 (n = 6) mM clindamycin. The final group was pre-treated with various combinations of gentamicin and clindamycin. The drug concentration was gradually increased until single twitch tension decreased by around 80%. Effective concentration was calculated using a probit model and interaction indices derived the Loewe additivity. Results: The administration of gentamicin and the combination of gentamicin and clindamycin enhanced rocuronium-induced neuromuscular blockade. At 0.2 and 0.5 mM gentamicin, synergistic interactions with rocuronium were observed. Likewise, at 0.5 and 1.0 mM clindamycin, synergistic interactions with gentamicin appeared. When all three drugs were combined, in the tetanic fade, all the groups except for those administered with 0.01 mM gentamicin and 0.25 mM clindamycin showed synergistic interactions. Conclusions: This study demonstrate that gentamicin and clindamycin potentiated rocuronium induced neuromuscular blockade. Moreover, it was found that these drugs interacted synergistically.

At therapeutic concentration bupivacaine causes neuromuscular blockade and enhances rocuronium-induced blockade

이지현,이수일,이승철,최소론,이원지 대한마취통증의학회 2012 Korean Journal of Anesthesiology Vol.62 No.5

Background: Partially paralyzed patients may be placed in the risk of pharyngeal dysfunction. Bupivacaine acts as acetylcholine receptor ion channel blocker and may synergistically interact with rocuronium to augment NM blockade. Thus, this study aims to elucidate whether or not, at a therapeutic concentration, bupivacaine by itself may cause NM blockade and reduce an effective concentration of rocuronium. Methods: Twenty-two left phrenic nerve-hemidiaphragms (Male SD rats, 150-250 g) were hung in Krebs solution. Three consecutive ST, 0.1 Hz and one TT, 50 Hz for 1.9 s were obtained before drug application and at each new drug concentration. A concentration of bupivacaine in Krebs solution (n = 5) was cumulatively increased by way of 0.01, 0.1, 1, (1, 2, 3, 4, 5, 6, 7) × 10 μM. In a Krebs solution, pre-treated with bupivacaine 0 (n = 5), 0.1 (n = 5), 1.0 (n = 5), 10 (n = 2) μM, and then concentrations of rocuronium were cumulatively increased by way of 1, 3, 5, 7, 9, 12, 14, 16, 18, 20 μM. EC for each experiment were determined by a probit. The EC50’s of rocuronium were compared using a Student’s t-test with Bonferroni’s correction. Differences were considered significant when P < 0.05. Results: The potency of bupivacaine for normalized TF was 11.4 (± 1.1) μM. Below 30 μM of bupivacaine, the single twitch potentiation sustained despite the development of tetanic fade and partial inhibition of PTT. Bupivacaine significantly facilitated the NM blockade induced by rocuronium. Conclusions: Clinicians should be aware that bupivacaine by itself at its therapeutic concentration inhibit NM conduction and enhances rocuronium-induced muscle relaxation. Background: Partially paralyzed patients may be placed in the risk of pharyngeal dysfunction. Bupivacaine acts as acetylcholine receptor ion channel blocker and may synergistically interact with rocuronium to augment NM blockade. Thus, this study aims to elucidate whether or not, at a therapeutic concentration, bupivacaine by itself may cause NM blockade and reduce an effective concentration of rocuronium. Methods: Twenty-two left phrenic nerve-hemidiaphragms (Male SD rats, 150-250 g) were hung in Krebs solution. Three consecutive ST, 0.1 Hz and one TT, 50 Hz for 1.9 s were obtained before drug application and at each new drug concentration. A concentration of bupivacaine in Krebs solution (n = 5) was cumulatively increased by way of 0.01, 0.1, 1, (1, 2, 3, 4, 5, 6, 7) × 10 μM. In a Krebs solution, pre-treated with bupivacaine 0 (n = 5), 0.1 (n = 5), 1.0 (n = 5), 10 (n = 2) μM, and then concentrations of rocuronium were cumulatively increased by way of 1, 3, 5, 7, 9, 12, 14, 16, 18, 20 μM. EC for each experiment were determined by a probit. The EC50’s of rocuronium were compared using a Student’s t-test with Bonferroni’s correction. Differences were considered significant when P < 0.05. Results: The potency of bupivacaine for normalized TF was 11.4 (± 1.1) μM. Below 30 μM of bupivacaine, the single twitch potentiation sustained despite the development of tetanic fade and partial inhibition of PTT. Bupivacaine significantly facilitated the NM blockade induced by rocuronium. Conclusions: Clinicians should be aware that bupivacaine by itself at its therapeutic concentration inhibit NM conduction and enhances rocuronium-induced muscle relaxation.

The Neuromuscular Blockade of Atracurium Besylate after Administration of Succinylcholine in Rabbits

Suh, Jae Hyun,Park. Chong Min,Kwon, Ou Kyoung,Shim, Jae Yong,Park, Cheol Joo,Kim, Sung Nyeun CATHOLIC MEDICAL CENTER 1987 Bulletin of the Clinical Research Institute Vol.15 No.1

The purpose of this study is determine whether or not the prior use succinylcholine affects the neuromuscular blockade of atracurium in rabbits. "Train of four'" responses were recored from the common peroneal nerve-anterior tibial muscle preparation stimulated by supramaximal train of four impulses. Previous administration of succinylcholine shortened the onset time, prolonged the duration of neuromuscular blockade of atracurium. And potentiated the percentile depression of T_4 to corresponding T_1 and degree of fade of train of four responses during neuromuscular blockade. These results suggest that prior use of succinylcholine could shorten the onset time, prolong the duration, and potentiate the neuromuscular blocking action of atracurium.

The Effects of Atropine and Glycopyrrolate on the Recovery from Mivacurium-Induced Neuromuscular Blockade in the Rabbit

Kim, Changsung,Kwon, Oukyoung THE CATHOLIC UNIVERSITY OF KOREA 1997 Bulletin of The Catholic Research Institutes of Me Vol.25 No.-

The neuromuscular effects of atropine and glycopyrrolate on the recovery from Mivacurium-induced neuromuscular blockade were evaluated in rabbits. The results were as follows; There were no significant differences in recovery indices and post-tetanic potentiations between the antimuscarinic groups(atropine groups, glycopyrrolate groups) and the control group. Significant differences were found in tetanic fades between the antimuscarinic groups and the control group. These results showed that atropine and glycopyrrolate hastened the recovery from mivacurium induced neuromuscular blockade.

마그네슘 지속 투여 중인 HELLP 증후군을 동반한 산모의 전신 마취 중에 발생한 근이완제의 효과 연장

박진석 외 중앙대학교 의과대학 의과학연구소 2009 中央醫大誌 Vol.34 No.3/4

Hemolysis, elevated liver enzymes, and low platelet counts (HELLP) syndrome is a very serious obstetric complication. Magnesium is used to prevent seizure for preeclampsia and eclampsia. Magnesium interacts with neuromuscular blocking agent during general anesthesia and prolongs neuromuscular blockade. We report the case of anesthetic care for the patient with HELLP syndrome with magnesium continuous infusion. The neuromuscular blockade effect of vecuronium was prolonged for one hour.

Sugammadex: clinical development and practical use

Thomas Fuchs-Buder,Claude Meistelman,Julien Raft 대한마취통증의학회 2013 Korean Journal of Anesthesiology Vol.65 No.6

Sugammadex is belonging to a new class of drugs: the selective relaxant binding agents. Sugammadex can reverse residual paralysis by encapsulating free circulating non depolarizing muscle relaxants. The mains advantages of sugammadex when compared with conventional anticholinesterase agents are a much faster recovery time and the unique ability, for the first time, to reverse rapidly and efficiently deep levels of neuromuscular blockade. However it only works for reversal of rocuronium or vecuronium-induced neuromuscular blockade. When administered 3 min after rocuronium the use of a large dose (16 mg/kg) can even reverse rocuronium significantly faster than the spontaneous recovery after succinylcholine.

A short review of history and technical advances in quantitative neuromuscular monitoring devices

Wonjin Lee,Ki Tae Jung 조선대학교 의학연구원 2021 Medical Bilogical Science and Engineering Vol.4 No.2

Anesthetic procedures using a neuromuscular blocking drug (NMBD) always have a potential risk of residual neuromuscular block (RNMB) associated with serious respiratory complications despite the use of reversal agents. Due to the risk of RNMB, neuromuscular monitoring is a very important tool for assessing patient safety. Recently, the importance of quantitative neuromuscular monitoring has been highlighted because of the advent of sugammadex, which determines dosage based on the degree of NMB. Neuromuscular monitoring, which has been used clinically since the 1970s, is an appropriate method for assessing the level of neuromuscular blockade (NMB) after the use of a NMBD during anesthesia. Although the basic principles have not changed considerably, recent technical advances in neuromuscular monitoring devices can help anesthesiologists with convenient quantitative neuromuscular monitoring to accurately evaluate the levels of NMB, choose an appropriate NMBD, and avoid RNMB. The recently released electromyography-based devices provide more accurate values than acceleromyography (AMG). Although AMG has a problem with overestimation, modern AMG devices with new three-dimensional technology overcome this limitation. Anesthesiologists should increase their knowledge of neuromuscular mechanisms and monitoring, including how to use the latest device for proper neuromuscular monitoring and patient safety. In this review, we have explored the short history of neuromuscular monitoring devices and the latest trends in technology development.

Effect of pneumoperitoneum on the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic surgery

김홍순,이동철,이미금,손운락,김용범 대한마취통증의학회 2014 Korean Journal of Anesthesiology Vol.67 No.1

Background: This study investigated the effect of pneumoperitoneum on the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery. Methods: Thirty adult patients undergoing laparoscopic abdominal surgery were studied. Anesthesia was induced with 1.5 mg/kg of propofol, 12 ug/kg of alfentanil and 0.6 mg/kg of rocuronium and maintained with 2 vol% of sevoflurane and 0.05-0.2 μg/kg/min remifentanil. The neuromuscular relaxation was monitored by Train-of-Four (TOF) and post-tetanic count (PTC). Additional rocuronium of 0.2 mg/kg was administered for deep neuromuscular blockade at 30 min after pneumoperitoneum. Before (PPpre) and 30 min after pneumoperitoneum (PPpost), PTC was measured at 6 min intervals. The relationship between PTC and the time interval to reappearance of T1 response was observed. Results: The mean ± SD of the intervals between the detection of 4 counts of the PTC and the first response to TOF stimulation was 13.0 ± 1.1 min and 16.4 ± 6.3 min PPpre and PPpost, respectively (P = 0.20). There were significant negative relationships between PTC observed and the time interval to reappearance of T1 response (adjusted R2 = 0.869, P < 0.001 for PPpre data, and adjusted R2 = 0.561, P < 0.001 for PPpost data). Comparing the difference of regression equation between PPpre and PPpost data using a parallelism test, there was no statistically significant difference (P = 0.193). Conclusions: This study showed that PP with intra-abdominal pressure at the level of 13-14 mmHg did not affect the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery.

Effects of hydrocortisone-presensitized sugammadex on recovery from neuromuscular blockade induced by rocuronium: a rodent in vivo study

Choi Hey-Ran,Yang Hong Seuk,Choi Jae-Moon,Park Chungon,인준용,김용범 대한마취통증의학회 2022 Anesthesia and pain medicine Vol.17 No.2

Background: Sugammadex is a specific antagonist of aminosteroidal neuromuscular blocking agents with 1:1 binding to guest molecules. Sugammadex can also bind to other drugs having a steroid component in its chemical structure. In this in vivo experiment, we investigated the differences in the recovery of rocuronium-induced neuromuscular blockade using sugammadex pre-exposed with two different concentrations of hydrocortisone.Methods: The sciatic nerves and tibialis anterior muscles of 30 adult Sprague–Dawley rats were prepared for the experiment. The sciatic nerves were stimulated using a train-of-four (TOF) pattern with indirect supramaximal stimulation at 20 s intervals. After 15 min of stabilization, a 250 μg loading dose and 125 μg booster doses of rocuronium were serially administered until > 95% depression of the first twitch tension of TOF stimulation (T1) was confirmed. The study drugs were prepared by mixing sugamadex with the same volume of three different stock solutions (0.9% normal saline, 10 mg/ml hydrocortisone, and 100 mg/ml hydrocortisone). The recovery of rats from neuromuscular blockade was monitored by assessing T1 and the TOF ratio (TOFR) simultaneously until T1 was recovered to > 95% and TOFR to > 0.9.Results: In the group injected with sugammadex premixed with a high concentration of hydrocortisone, statistically significant intergroup differences were observed in the recovery progression of T1 and TOFR (P < 0.050).Conclusions: When sugammadex was pre-exposed to a high dose of hydrocortisone only, recovery from neuromuscular blockade was delayed. Delayed recovery from neuromuscular blockade is not always plausible when sugammadex is pre-exposed to steroidal drugs.