Abdominal Compartment Syndrome
Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba in Acute Care Surgery and Trauma, 2016
A small prospective trial of 10 patients using a single-dose cisatracurium demonstrated the effectiveness of neuromuscular blockade in reducing IAP, but the effectiveness of therapy appeared to be diminished at higher levels of IAP [23]. There is one retrospective cohort study that was able to demonstrate improved time to fascial closure among trauma patients who underwent damage control laparotomy. Patients who were administered a continuous infusion of neuromuscular blockade were more likely to achieve primary fascial closure by postlaparotomy day 7. Although this has not been replicated in patients with IAH, neuromuscular blockade was an independent predictor of time to fascial closure that suggests that brief trials can be utilized as a temporizing measure [24]. The adverse effects of paralytics (myopathy, neuropathy, and prolonged mechanical ventilation) must be carefully weighed into the decision to use these agents to decrease abdominal muscle tone and increase abdominal compliance.
Geriatrics
Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor in Manual of Neuroanesthesia, 2017
As age increases, sensitivity of drugs increases due to loss of neuronal tissue and other systems in the body. Thus, the amount of a drug that is required for the same effect when compared to a younger patient is decreased. At the same time, as the metabolism and excretion also decrease, there is increase in duration of action of drugs. So it is advised to use those drugs that are not dependent on body metabolism, such as cisatracurium, or decrease the dosages or use those drugs that are short acting.6 As age increases, the MAC requirement to achieve adequate depth of anesthesia for inhalation drugs decreases. Thus, an 80-year-old patient who is on 66% N2O requires only 0.3% sevoflurane to achieve a minimum alveolar concentration (MAC) of 1. Meperidine and benzodiazepines cause more postoperative delirium when compared to their younger counterparts. Thus, according to the Beers criteria, it is advised not to use them in geriatric patients. Alternative medications should be used.
Neuropharmacology: Age-related changes
Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor in Essentials of Geriatric Neuroanesthesia, 2019
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).
Emerging drugs for treating the acute respiratory distress syndrome
Published in Expert Opinion on Emerging Drugs, 2019
Timothy D. Shaw, Daniel F. McAuley, Cecilia M. O’Kane
The leading pharmacological supportive therapy for ARDS is neuromuscular blockade, which facilitates lung-protective ventilation by reducing patient-ventilator desynchrony. Cisatracurium besylate is a benzylisoquinoline compound which acts as a non-depolarising skeletal muscle relaxant. A meta-analysis of three trials that studied cisatracurium in ARDS, enrolling 431 patients, demonstrated NBM to significantly reduce risk of death at 28 days (RR 0.66; 95% CI, 0.50–0.87; p = 0.003), at ICU discharge (RR 0.70; 95% CI, 0.55–0.89; p = 0.004) and on discharge from hospital (RR 0.72; 95% CI, 0.58–0.91; p = 0.005) [33]. Cisatracurium was also associated with reduced risk of barotrauma (RR 0.43; 95% CI, 0.20–0.90; p = 0.02) and increased oxygenation at 48 hours. However, there was no reduction in the duration of mechanical ventilation or risk of ICU-acquired weakness. A more recent phase 3 RCT with 30 patients reported that a 48-hour infusion of cisatracurium in patients with early moderate-to-severe ARDS was associated with increased oxygenation with favourable transpulmonary pressures during both the expiratory and inspiratory phases [34].
Absorption of ibuprofen orodispersible tablets in early postoperative phase – a pharmacokinetic study
Published in Current Medical Research and Opinion, 2018
A. Piirainen, M. Kokki, H. M. Lidsle, M. Lehtonen, V. P. Ranta, H. Kokki
All surgeries were performed under standardized general anesthesia. Patients received diazepam 10 mg by mouth as premedication 60 minutes before the procedure. Anesthesia was induced with intravenous (IV) propofol and maintained with sevoflurane in oxygen and air. For intraoperative analgesia, a remifentanil infusion of 250–500 μg/h was used and the infusion was stopped as the surgeon made the last stitch. Cisatracurium was used for muscle relaxation to facilitate endotracheal intubation. At the end of surgery, the residual neuromuscular blockade was reversed with glycopyrrolate–neostigmine to train-of-four value of 0.9 or higher. Blood pressure, heart rate, peripheral oxygen saturation, neuromuscular block, anesthetic gas, and end-tidal CO2 partial pressure were monitored continuously. To ensure an adequate level of anesthesia, state and response entropy indexes were kept at a 40–60 level through the anesthesia by adjusting the inhaled sevoflurane concentration accordingly (Cardiocap/5, GE Healthcare, Helsinki, Finland).
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.
Related Knowledge Centers
- Anesthesia
- Ester
- Hydrolysis
- Surgery
- Skeletal Muscle
- Mechanical Ventilation
- Intubation
- Neuromuscular-Blocking Drug
- Atracurium Besilate
- Laudanosine