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Peri-operative medicine
Published in Henry J. Woodford, Essential Geriatrics, 2022
Cholinesterase inhibitors can interact with muscle relaxants. The effects of depolarising neuromuscular blocking drugs (e.g. suxamethonium) can be prolonged, and the effects of non-depolarising neuromuscular blocking drugs can be decreased or reversed, thus requiring higher doses.17 Galantamine or rivastigmine can be stopped two days prior to elective surgery, but donepezil has a longer half-life and takes over two weeks to clear from the body, so it is usually continued. Memantine can enhance the central nervous system toxicity of ketamine.
Medical Management of Chemical Warfare Agents
Published in Brian J. Lukey, James A. Romano, Salem Harry, Chemical Warfare Agents, 2019
If BuChE is inhibited (prevented from performing its usual metabolic activity) by nerve agent intoxication, the hydrolysis of drugs containing ester linkages will also be impaired. Consequently, toxic levels of these drugs will be more easily achieved, and the normal metabolic (physiological) actions of these drugs will continue for a much longer period of time than usual. As an example, the duration of action of the neuromuscular blocking drug succinylcholine, which produces total paralysis of all skeletal muscles, including those of respiration, is usually only a few minutes. During these few minutes, the patient is artificially ventilated. With the inhibition of BuChE produced by nerve agents, this drug’s effect could persist for many hours, greatly extending the period of time that the patient would require artificial ventilation. Unconsciousness produced by etiomidate would be extended from a few minutes to hours.
Adult Anaesthesia
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
Daphne A. Varveris, Neil G. Smart
Propofol is often used in combination with remifentanil, an ultra short-acting synthetic opioid, as part of a total intravenous anaesthesia (TIVA) technique. Remifentanil is metabolized by non-specific plasma esterases and with a context sensitive half-time of 3 minutes and elimination half-time of 6 minutes, it has minimal active metabolites. Used by infusion including target control with the Minto pharmacokinetic model, remifentanil has a short, predictable duration of action with no accumulating effect. Deep intra-operative analgesia can be achieved quickly and yet reversed rapidly. This can contribute to improved intraoperative cardiovascular stability and may also be used to negate the need for neuromuscular blocking drugs, useful when nerve monitoring is required. At the end of surgery, faster recovery and less respiratory depression are achieved in comparison with other opioids but the short duration of action means that alternative post-operative analgesia is required.2 Remifentanil can also be used to provide sedation during awake fibre-optic intubation. By suppressing airway reflexes, it facilitates excellent intubating conditions (Figure 32.2).3
Pharmacological management of adult patients with acute respiratory distress syndrome
Published in Expert Opinion on Pharmacotherapy, 2020
Maria Gabriella Matera, Paola Rogliani, Andrea Bianco, Mario Cazzola
Mechanical ventilation does not influence the body’s inflammatory response and stress response although it can improve the respiratory function of patients with ARDS. Therefore it is combined with pharmacologic therapies. The pharmacologic management of ARDS entails at least three aspects: etiologic, pathophysiological, and support. ARDS is primarily managed by identifying the underlying disease and administering appropriate, disease-specific treatment. There is evidence that in patients with sepsis-associated ARDS the use of adequate antibiotics and source control can allow obtaining good outcomes [14], although still an important fraction of patients with pneumonia die. Neuromuscular blocking drugs are critical because they provide optimal ventilator synchrony, reduce peak airway pressures, reduce oxygen consumption, and improve pulmonary compliance [15]. However, also corticosteroids, inhalation of nitric oxide (NO) and vasodilators, β2-adrenoceptor (AR) agonists, surfactant therapy, agents that accelerate lung water resolution and ion transports are suggested as pharmacological treatments [6,9,15] (Table 1). Nevertheless, no pharmacologic therapy has been shown to ensure a reduction in either short-term or long-term mortality [16], although the complex pathophysiology of ARDS provides multiple potential targets for pharmacologic therapy.
A reappraisal of the value of video-EEG recording in the emergency department
Published in Expert Review of Neurotherapeutics, 2020
Umberto Raucci, Stefano Pro, Matteo Di Capua, Giovanni Di Nardo, Maria Pia Villa, Pasquale Striano, Pasquale Parisi
Claassen et al. [121] also identified non convulsive seizures with cEEG monitoring in 25% of 570 critical care patients; in a subgroup of 110 patients who had seizures before monitoring, non-convulsive seizures were observed on cEEG in 43% of the cases. In one prospective study, 75% of diagnoses of NCSE or non-convulsive seizures on cEEG were not preceded by clinical seizures. In these cases, symptoms may be subtle or absent [9] as well as in coma, associated with NCSE in over 10% of patients [122]. Moreover, cEEG is mandatory when specific EEG patterns are recognized on routine recording [123] such as GPEDs, PLEDs, or BIPEDs. Several conditions have been reported to be correlated with NCSE, with incidences of up to 30% in subarachnoid hemorrhage, head injury, intracerebral hemorrhage, CNS infections. The incidence may be even higher in post-anoxic encephalopathy, ranging from 10 to 60%. When neuromuscular blocking drugs are used cEEG should be initiated as soon as possible, as higher morbidity and mortality has been observed, and early treatments are likely to be more effective [124].
The acute respiratory distress syndrome: pathophysiology, current clinical practice, and emerging therapies
Published in Expert Review of Respiratory Medicine, 2018
Matthias Derwall, Lukas Martin, Rolf Rossaint
The routine use of neuromuscular blocking drugs has been discussed controversially. Papazian and colleagues published a multicenter clinical trial in 340 patients with severe ARDS that were matched to receive either 48 h pharmacological paralysis or placebo during the first two days of their ARDS [28]. In this study, the use of neuromuscular drugs was associated with a reduced 90 day mortality with a number needed to treat (NNT) of 11. In a subgroup analysis in patients with a Horowitz index of less than 120, the NNT was even lower with seven patients to prevent one death at 90 days. Remarkably, no higher risk for ICU-acquired weakness was observed for patients in the paralysis group [28]. However, muscle paralysis should be restricted to the most severe forms of ARDS and may only be used in the early phase of the disease.