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Neuropharmacology: Age-related changes
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Essentials of Geriatric Neuroanesthesia, 2019
Katleen Wyatt Chester, Olivia Johnson Morgan, Kruti Shah
Anticipated actions of paralytic agents are also altered in geriatric patients. Elderly patients have fewer motor units and less muscle volume compared to adult patients. Older adults experience longer times to onset of paralysis from reduced cardiac output and blood flow to muscles (41). Great responses are seen with NMBAs that are hydrophilic, since the plasma compartment and total body water are reduced in this population (41). Clearance of the agents and duration of effects are prolonged from age-related changes of the renal and hepatic systems. Changes in blood flow to the liver combined with reduced renal function can alter vecuronium clearance by as much as 50% (41). The reduced clearance rates yield higher recovery indices in elderly patients. The recovery index is defined as the time from 75% block to 25% block. In elderly patients, these times can be increased as much as 200%. Vecuronium recovery times increased from 15 to 50 minutes and rocuronium times from 13 to 22 minutes from increasing age. Unlike vecuronium or rocuronium, cisatracurium is cleared by plasma esterases, and no appreciable differences in the actions of this paralytic have been noted in elderly patients (41).
Neuromuscular care
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Essentials of Anesthesia for Neurotrauma, 2018
Ankur Khandelwal, Hemanshu Prabhakar
Cisatracurium, the 1R cis–1′R cis isomer of atracurium, comprises approximately 15% of atracurium by weight, but more than 50% in terms of NM blocking activity. Cisatracurium 0.1 to 0.2 mg/kg produces adequate conditions for tracheal intubation within 2–3 minutes. Clinical recovery occurs in about 45 to 60 minutes. Continuous infusion dosing ranges from 1 to 3 µg/kg/min. Like atracurium, cisatracurium is metabolized by Hofmann elimination to laudanosine and a monoquaternary acrylate. In contrast, however, no ester hydrolysis of the parent molecule occurs. It is approximately four times as potent as atracurium and produces five times less laudanosine in contrast to atracurium. Moreover, it does not cause histamine release. Renal clearance is about 16% of total.
Transplantation
Published in Brian J Pollard, Gareth Kitchen, Handbook of Clinical Anaesthesia, 2017
Richard Wadsworth, Greg Cook, Andrew Roscoe, Zoka Milan, Ross Macnab, Kailash Bhatia
An IV agent, opioid and muscle relaxant are most commonly used. Propofol and thiopentone are suitable but the dose should be titrated to minimise the risk of hypotension. Fentanyl and remifentanil are the preferred opioids. The liver metabolizes morphine but its metabolites are excreted in the urine. Cis-atracurium and atracurium are the muscle relaxants of choice.
Personalized medicine targeting different ARDS phenotypes: The future of pharmacotherapy for ARDS?
Published in Expert Review of Respiratory Medicine, 2023
Florian Blanchard, Arthur James, Mona Assefi, Natacha Kapandji, Jean-Michel Constantin
Two major trials have assessed the impact of neuromuscular blocking agents (NMBA) during ARDS [33,67]. The ACURASIS trial randomized moderate-to-severe ARDS patients to receive 48 hours of cisatracurium or a placebo [33]. Cisatracurium was associated with an improved 90-day survival rate, increased ventilator-free and ICU-free days, and decreased barotrauma. Nine years later, the ROSE trial randomized moderate-to-severe ARDS patients to receive 48 hours of either Cisatracurium or a placebo [67]. The trial was stopped early for futility with no difference in mortality or ventilator-free conditions. Multiple differences between the trials may explain these divergent results, including earlier randomization, lighter sedation, and a lower incidence of reverse-triggering dyssynchrony [68,69]. A recent meta-analysis combining these two trials with three others demonstrated no benefit in mortality or ventilator-free days, but showed an improvement of oxygenation for 72 hours and a lower risk of barotrauma [70]. Similar results were found in the COVID-19 cohort and pediatric patients with ARDS [71,72]. Guidelines proposed to limit the use of NMBA in cases of deep sedation in order to facilitate lung protective ventilation or prone positioning [73]. Yet some experts suggest that NMBA can be used when ‘physiologically and clinically indicated’ [68].
Awake thoracic epidural anesthesia for uniportal video-assisted thoracoscopic pleural decortication: A prospective randomized trial
Published in Egyptian Journal of Anaesthesia, 2022
Mohamed Rabeea, Esam Abdalla, Hussein Elkhayat, Fatma Nabil
The patient was placed in supine position. After preoxygenation, induction of anesthesia was done with fentanyl (2 μg/kg), propofol (1.5–2 mg/kg), and cisatracurium (0.15 mg/kg) to facilitate tracheal intubation. An appropriately sized DLT was inserted with direct laryngoscopy and advanced till the endobronchial cuff passed the vocal cords, then the DLT was rotated 90 degrees clockwise or anticlockwise to be advanced either to the right or the left main bronchus. The correct position of the DLT was confirmed by inserting a fibreoptic bronchoscope through the tracheal lumen. Then, the patient was connected to the anesthesia machine. Anesthesia was maintained with isoflurane and maintenance doses of cisatracurium. The patient was placed in the lateral decubitus position where the surgical side up and with slight flexion of the table. Surgery conducted on the same fashion as group TEA except Valsalva maneuver, where surgeon ask the anesthesiologist to ventilate both lungs and inflate the operated site with a pressure of 35 mmHg. By the end of surgery, neuromuscular blockade was reversed with neostigmine (0.05 mg/kg) and atropine (0.02 mg/kg) to be followed by extubation, then shifting the patient to the PACU.
Listening to recorded mother’s voice versus intravenous dexmedetomidine to minimize postoperative emergence delirium in children after hypospadias repair surgeries: A prospective randomized trial
Published in Egyptian Journal of Anaesthesia, 2022
Omar Soliman, Fatma Nabil, Hany M. Osman
In OT, before induction of anesthesia, preoperative anxiety was reassessed again by the principal investigator using the mYPAS-SF. During inhalational induction with sevoflurane, the child’s acceptance of the face mask was assessed using the MAS. The intravenous medications included fentanyl (0.5 µg/kg), propofol (1 mg/kg), and cis-atracurium (0.15 mg/kg) to facilitate endotracheal intubation. The soundtracks were stopped, and the headphones were removed just prior to endotracheal intubation. GA was maintained with sevoflurane (2–3%) in 50% oxygen and 50% air. Incremental doses of cis-atracurium (0.03 mg/kg) were used if needed. Before surgical incision, dorsal penile block was done by the surgeon using the landmark method with 3–5 ml of bupivacaine 0.25%. Intraoperatively, intravenous paracetamol (15 mg/kg), ondansetron (0.1 mg/kg), and dexamethasone (0.2 mg/kg) were given.