Candida and parasitic infection: Helminths, trichomoniasis, lice, scabies, and malaria
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
Pyrantel pamoate, a pyrimidine derivative, acts by paralyzing nematodes, allowing them to be expelled. Its action is similar to depolarizing neuromuscular blocking agents (41). Pyrantel pamoate is very poorly absorbed, with half remaining in the intestinal tract unabsorbed. This poor absorption is the basis for its recommendation as first-line therapy in pregnancy. Blood levels of pyrantel pamoate are quite low, but it is not known whether it crosses the placenta. Animal teratology studies were negative, and no human malformations have been reported (compatible with pregnancy category B, but never labeled by the FDA). Pyrantel pamoate is considered safe for use while breastfeeding, due to its low absorption. Side effects (gastrointestinal complaints) are generally minimal and are not increased in pregnancy. Pyrantel doses can be calculated from the pamoate form or the free base (1mg base = 2.9mg pamoate form). Anthelmintic doses are 5 to 10 mg/kg pyrantel base or 15 to 30mg/kg pyrantel pamoate (maximum daily dose, 1-g pyrantel base) (41).
Extradural hematoma
Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor in Essentials of Anesthesia for Neurotrauma, 2018
Anesthetic considerations are similar to that of any time-critical emergency neurosurgery requiring craniotomy for decompression of increased ICP. The process should be a seamless continuation of ongoing resuscitation. Care must be taken to maintain adequate cerebral perfusion pressure (CPP) throughout by avoiding hypotension through considered anesthetic agent choices in addition to careful titration of fluid or blood product resuscitation and vasopressors. Adequate analgesia and anesthesia therapy can also help to improve the outcome by reducing cerebral oxygen consumption (CMRO2). There is much debate about the best anesthetic for such patients; however, it is understood that while rapidly evaporating agents may reduce CMRO2, they may also cause cerebral vasodilatation and loss of autoregulation with respect to CO2. However, this effect is thought to be minimal at concentrations below 1 MAC and Sevoflurane (used for maintenance of general anesthesia) is thought to have the most favorable profile. Total intravenous anesthesia (TIVA) with Propofol and Remifentanil offer an excellent alternative as it reduces CMRO2, CBF, and ICP. However, the anesthesiologist must be aware of the significant risk of hypotension with the technique. Neuromuscular blocking agents can be used to reduce movement and offer a good surgical field.
Critical care, neurology and analgesia
Evelyne Jacqz-Aigrain, Imti Choonara in Paediatric Clinical Pharmacology, 2021
The incidence of these complications can be reduced by restricting the use of neuromuscular blocking agents to circumstances where their benefits clearly outweigh the risks associated with their administration. If these agents are to be used, then their use should be kept to a minimum; they should either be given by intermittent dosing schedules or, when given by continuous infusion, these should be routinely discontinued to allow for recovery of neuromuscular function and assessment of the underlying degree of sedation. Monitoring of the depth of neuromuscular blockade using train-of-four transcutaneous stimulation of the ulnar nerve, can allow for the titration of doses of neuromuscular blocking agents when given by continuous infusion and allow for the minimisation of the total doses received.
Deep versus moderate neuromuscular block in laparoscopic bariatric surgeries: effect on surgical conditions and pulmonary complications
Published in Egyptian Journal of Anaesthesia, 2019
Mohamed M. Abu Yazed, Sameh Abdelkhalik Ahmed
The introduction of neuromuscular blocking agents in anesthesia has been associated with numerous benefits. It specifically improves the intubation condition, increases the depth of anesthesia, decreases airway edema, and improves surgical exposure [1–3]. Despite that, it has also been associated with several drawbacks, such as postoperative dysfunction of respiratory muscles that predispose to postoperative pulmonary complications [4,5]. The risk of postoperative respiratory complications increases significantly in morbidly obese patients, sometimes approaching 100% incidence, especially with increasing body mass index (BMI) and presence of obesity hypoventilation syndrome [6]. Respiratory complications must be considered and properly managed in the perioperative management of bariatric surgeries, as they account for about 12% of mortality rates [7].
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].
Comparison of vecuronium or rocuronium for rapid sequence induction in morbidly obese patients: a randomized study
Published in Egyptian Journal of Anaesthesia, 2020
Mohamed M. Abu Yazed, Sameh Abdelkhalik Ahmed
The primary outcome of our study was the onset of relaxation, which represented the duration of time from when the neuromuscular blocking agents were injected to when 95% suppression of the height of the twitches was achieved. The secondary outcome was the intubation score in the first trial of video laryngoscopy. Furthermore, the time for intubation (the time elapsed between the intravenous administration of the muscle relaxants and successful intubation) was calculated and recorded. In addition, the duration of time for which the muscle relaxed, which was from the time at which 95% suppression of the TOF twitches was achieved to the time at which 25% of the twitch height was regained, was recorded. When failure of intubation occurred after two trials by an expert anesthesiologist, the muscle relaxation process was reversed by sugammadex 4 mg/kg (IBW), which could be repeated and by switching off the anesthesia until the patient regained spontaneous ventilation and a conscious level; these patients were excluded from the study.
Related Knowledge Centers
- Anesthesia
- Nerve Block
- Neuromuscular Junction
- Respiration
- Tracheal Intubation
- Paralysis
- Skeletal Muscle
- Mechanical Ventilation
- General Anaesthetic
- Analgesic