BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral an...BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral and non-viral etiologies are treated by traditional ARDS protocols that recommend 12-16 hours of prone position ventilation(PPV)with neuromuscular blocking agents(NMBA)and a trial of inhaled vasodilators(IVd)if oxygenation does not improve.However,debate on the efficacy of adjuncts to PPV and low tidal volume ventilation persists and evidence about the benefits of IVd/NMBA in COVID ARDS is sparse.In our multi-center retrospective review,we evaluated the impact of PPV,IVd,and NMBA on outcomes and lung mechanics in COVID ARDS patients with moderate to severe ARDS.AIM To evaluate the impact of PPV used alone or in combination with pulmonary IVd and/or NMBA in mechanically ventilated patients with moderate to severe ARDS during the COVID-19 pandemic.METHODS A retrospective study at two tertiary academic medical centers compared outcomes between COVID ARDS patients receiving PPV and patients in the supine position.PPV patients were divided based on concurrent use of ARDS adjunct therapies resulting in four subgroups:(1)PPV alone;(2)PPV and IVd;(3)PPV and NMBA;and(4)PPV,IVd,and NMBA.Primary outcomes were hospital and intensive care unit(ICU)length of stay(LOS),mortality,and venovenous extracorporeal membrane oxygenation(VV-ECMO)status.Secondary outcomes included changes in lung mechanics at 24-hour intervals for 7 days.RESULTS Total 114 patients were included in this study.Baseline respiratory parameters and Sequential Organ Failure Assessment scores were significantly worse in the PPV group.ICU LOS and LOS were significantly longer for patients who were proned,but no mortality benefit or difference in VV-ECMO status was found.Among the subgroups,no difference in primary outcomes were found.In the secondary analysis,PPV was associated with a significant improvement in arterial oxygen partial pressure(PaO_(2))/fractional inspired oxygen(FiO_(2))(P/F)ratio from day 1 to day 4(P<0.05)and higher driving pressures day 5 to day 7(P<0.05).The combination of PPV and IVd together resulted in improvements in P/F ratio from day 1 to day 7 and plateau pressure on day 4 and day 6(P<0.05).PPV with NMBA was not associated with improvements in any of the secondary outcomes.The use of all three rescue therapies together resulted in improvements in lung compliance on day 2(P<0.05)but no other improvements.CONCLUSION In mechanically ventilated patients diagnosed with moderate to severe COVID ARDS,PPV and PPV with the addition of IVd produced a significant and sustained increase in P/F ratio.The combination of PPV,IVd and NMBA improved compliance however this did not reach significance.Mortality and LOS did not improve with adjunct therapies.Further research is warranted to determine the efficacy of these therapies alone and in combination in the treatment of COVID ARDS.展开更多
Neuromuscular blocking agents(NMBAs)are extensively used during anesthesia to improve surgical conditions by relaxing skeletal muscle movements.Rapid neuromuscular recovery after surgery is desirable to facilitate the...Neuromuscular blocking agents(NMBAs)are extensively used during anesthesia to improve surgical conditions by relaxing skeletal muscle movements.Rapid neuromuscular recovery after surgery is desirable to facilitate the recovery of muscle function and prevent residual blockade.Decamethonium(C10)is a classic NMBA,which has been restricted over the past decades ascribed to lack of a suitable antidote in clinic.Herein we used carboxylatopillar[6]arene(CP6A)to reverse neuromuscular blocker effect of C10 through direct host-vip encapsulation.NMR and isothermal titration calorimetry served to confirm the complexation between CP6A and C10 with robust affinity[(1.07±0.14)×10^(7)L/mol].The CP6A was further used as a reversal agent of C10,which facilitated to decrease C10 concentration in mice blood and excrete via urinary clearance,resulting in rapid recovery from muscle relaxation.These favorable outcomes might lead us to suggest that this supramolecular strategy could allow patients to regain lucidity much faster than spontaneous recovery from anesthesia.展开更多
OBJECTIVE: To study the pharmacodynamics of vecuronium,atracurium, mivacurium and rocuronium in patients with end-stage renal failure. METHODS: Forty-six patients with end-stage renal failure scheduled for renal trans...OBJECTIVE: To study the pharmacodynamics of vecuronium,atracurium, mivacurium and rocuronium in patients with end-stage renal failure. METHODS: Forty-six patients with end-stage renal failure scheduled for renal transplantation and 53 patients with normal renal function were given either vecuronium, atracurium, mivacurium or rocuronium. The neuromuscular effects were monitored by the evoked response of the adductor pollicis to train-of-four stimulation of the ulnar nerve. RESULTS: Onset of vecuronium, atracurium and mivacurium occurred faster or tended to be faster in patients with end-stage renal failure, but there was no significant difference in onset by rocuronium between the control patients and renal failure patients. Furthermore, the no-response period, duration of action and recovery of atracurium did not differ between the two groups. There was no significant difference in duration of action or recovery of mivacurium between the two groups, whereas its no-response period was significantly prolonged in the patients with end-stage renal failure. There was no difference in no-response period or duration of action after the initial dose of vecuronium or rocuronium between the two groups. However, no-response period and duration of effect by vecuronium and rocuronium were prolonged with increasing incremental doses in patients with end-stage renal failure. CONCLUSIONS: All four muscle relaxants could be safely used in patients with end-stage renal failure. Onset of the relaxants were, in some cases, accelerated and no-response period of mivacurium was prolonged in patients with end-stage renal failure undergoing dialysis therapy. End-stage renal failure prolonged the no-response period and duration of action of vecuronium and rocuronium after repeated incremental doses, but did not alter those attributed to atracurium.展开更多
A tri-block copolymer coupling agent polystyreneblock-poly （n-butyl-acrylate）-block-poly （y-methacryloxypro pylt rimethoxysilane）（PS-b-PnBA-b-PMPS） was synthesized by atom transfer radical polymerization （ATRP...A tri-block copolymer coupling agent polystyreneblock-poly （n-butyl-acrylate）-block-poly （y-methacryloxypro pylt rimethoxysilane）（PS-b-PnBA-b-PMPS） was synthesized by atom transfer radical polymerization （ATRP）, and its molecular structure was characterized by fourier-transform infrared spectra, hydrogen nuclear magnetic resonance and gel permeation chromatography. The glass bead was treated with the block copolymer coupling agent, and then studied by transmission electron microscopy. The result showed that strong interaction was formed between the block copolymer coupling agent and the surface of glass bead, and then the block of poly（n-butylacrylate） formed a layer of film on the surface.展开更多
Adverse rection to local anesthetic agents is uncommon with true hypersensitivity reaction less than 1%of all adverse reactions.Allergic reactions to local anesthetics are classified into type I(IgE-mediated)and type ...Adverse rection to local anesthetic agents is uncommon with true hypersensitivity reaction less than 1%of all adverse reactions.Allergic reactions to local anesthetics are classified into type I(IgE-mediated)and type IV(allergic contact dermatitis).Skin test can be used in evaluating type I allergic reaction while patch testing helps diagnosing allergic contact dermatitis.Physicians also need keep in mind that non-allergic reactions such as toxic effect,sympathetic stimulation,psychomotor reaction,and vasovagal syncope can occur in patients receiving local anesthetics.Perioperative hypersensitivity(POH)reactions have an incidence between 1:353 and 1:18,600 procedures.True anaphylaxis is estimated to occur in 1:3500 to1:20,000 surgeries with clinical manifestations varying from mild skin rash to cardiovascular collapse.Anaphylaxis has a mortality rate of 1.4–4.8%.Patient with perioperative anaphylaxis should be referred to allergist to identify the drug that led to reaction.Treatment of POH includes discontinuing any possible drugs,and with only skin involvement,using antihistamines,and in the presence of hypotension,tachycardia,bronchospasm,or gastrointestinal signs,based on severity treating with appropriate dose of epinephrine,and considering volume expansion and securing airway,if needed.展开更多
BACKGROUND Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels.This drug may potentially interact with neuromu...BACKGROUND Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels.This drug may potentially interact with neuromuscular blocking agents(NMBAs)that act on muscular acetylcholine receptors during general anesthesia.Herein,we present a case of inadequate neuromuscular blockade with rocuronium,a nondepolarizing NMBA,in a dementia patient who had taken donepezil.CASE SUMMARY A 71-year-old man was scheduled for laparoscopic gastrectomy.He had been taking donepezil 5 mg for dementia.General anesthesia was induced with propofol and remifentanil.The depth of neuromuscular blockade was monitored by train-of-four(TOF)stimulation.After the administration of rocuronium,the TOF ratio decreased at an unusually slow rate,and a TOF count of 0 was detected 7 min later.After intubation,a TOF count of 1 was detected within 1 min,and a TOF ratio of 12%was detected within 2 min.The TOF count remained at 4 even with an additional bolus and continuous infusion of rocuronium,suggesting resistance to this NMBA.Instead of propofol,an inhalation anesthetic was administered alongside another NMBA(cisatracurium).Then,the quality of neuromuscular blockade improved,and the TOF count remained at 0-1 for the next 70 min.No further problems were encountered with respect to surgery or anesthesia.CONCLUSION Donepezil may be responsible for inadequate neuromuscular blockade during anesthesia,especially when total intravenous anesthesia is used.展开更多
We report a case of severe anaphylactic shock in a 5-month-old infant who was scheduled to undergo an external inguinal hernia repair under general anesthesia. Rocuronium used for anesthesia induction was the most lik...We report a case of severe anaphylactic shock in a 5-month-old infant who was scheduled to undergo an external inguinal hernia repair under general anesthesia. Rocuronium used for anesthesia induction was the most likely cause of anaphylaxis. High levels of serum tryptase and histamine detected in the blood sample collected during the anaphylactic reaction confirmed the diagnosis of anaphylactic shock. The patient’s clinical status improved within 90 min of intervention by the intravenous injection of vasopressors and a steroid. Surgery was canceled, and the patient stayed in the pediatric intensive care unit (PICU) under artificial ventilation for 5 h before safe extubation. The patient achieved full recovery the next day, without any sequelae. The rescheduled surgery was successfully completed 5 months later under general anesthesia without the use of neuromuscular blocking agents.展开更多
Atrial fibrillation is the most common arrhythmia worldwide,affecting millions of the general population.It is a leading cause of stroke and is associated with many other long-term adverse cardiovascular issues.Long-t...Atrial fibrillation is the most common arrhythmia worldwide,affecting millions of the general population.It is a leading cause of stroke and is associated with many other long-term adverse cardiovascular issues.Long-term management of atrial fibrillation can involve simply controlling the ventricular rate with AV nodal blocking agents(rate control strategy)versus restoring and maintaining sinus rhythm(rhythm control strategy).展开更多
Background Recurarization has previously been described in the context of acute normovolemic hemodilution.The aim of this study was to investigate the impairment of recovery of neuromuscular function after re-transfus...Background Recurarization has previously been described in the context of acute normovolemic hemodilution.The aim of this study was to investigate the impairment of recovery of neuromuscular function after re-transfusion of intraoperative salvaged blood in patients treated with rocuronium.Methods We enrolled 50 patients undergoing general anesthesia for lumbar surgery.Intraoperative blood salvage （IBS） was used in 30 patients （group Ⅰ）; the remaining 20 comprised a control group （group C）.Anesthesia was induced with fentanyl,midazolam,propofol and rocuronium.Rocuronium was infused to maintain neuromuscular blockade during surgery.Blood was collected from the operative field and re-transfused in the post-anesthesia care unit （PACU）.Neuromuscular function was monitored using the train-of-four ratio （TOFr）.Once the train-of-four ratio exceeded 90 in the PACU,neuromuscular function was evaluated every 5 minutes for 30 minutes.The TOFr and incremental recovery of TOFr from baseline were recorded.Salvaged blood was re-transfused at the beginning of the evaluation for patients in group Ⅰ,and afterwards for patients in group C.Blood gas analysis was assessed before anesthesia and in the PACU.Results Incremental recovery of TOFr from baseline was significantly less in group Ⅰ than controls at 25 minutes （6.1±3.2vs.9.1±3.2,respectively; P=0.001） and 30 minutes （7.1±3.2 vs.10.0±2.2,respectively; P=-0.001）.There were no significant differences in gas exchange between the groups.Conclusions In patients who had received a rocuronium infusion during anesthesia,re-transfusion of salvaged blood significantly impaired recovery of neuromuscular function recovery in the PACU,but without significant impairment of respiratory function.展开更多
Several new tetrahydroisoquinolinium salts, analogues of atracurium, were designed and synthesized. These compounds were prepared from optically pure tetrahydropapaverine and hexamethylene diglycidate.
文摘BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral and non-viral etiologies are treated by traditional ARDS protocols that recommend 12-16 hours of prone position ventilation(PPV)with neuromuscular blocking agents(NMBA)and a trial of inhaled vasodilators(IVd)if oxygenation does not improve.However,debate on the efficacy of adjuncts to PPV and low tidal volume ventilation persists and evidence about the benefits of IVd/NMBA in COVID ARDS is sparse.In our multi-center retrospective review,we evaluated the impact of PPV,IVd,and NMBA on outcomes and lung mechanics in COVID ARDS patients with moderate to severe ARDS.AIM To evaluate the impact of PPV used alone or in combination with pulmonary IVd and/or NMBA in mechanically ventilated patients with moderate to severe ARDS during the COVID-19 pandemic.METHODS A retrospective study at two tertiary academic medical centers compared outcomes between COVID ARDS patients receiving PPV and patients in the supine position.PPV patients were divided based on concurrent use of ARDS adjunct therapies resulting in four subgroups:(1)PPV alone;(2)PPV and IVd;(3)PPV and NMBA;and(4)PPV,IVd,and NMBA.Primary outcomes were hospital and intensive care unit(ICU)length of stay(LOS),mortality,and venovenous extracorporeal membrane oxygenation(VV-ECMO)status.Secondary outcomes included changes in lung mechanics at 24-hour intervals for 7 days.RESULTS Total 114 patients were included in this study.Baseline respiratory parameters and Sequential Organ Failure Assessment scores were significantly worse in the PPV group.ICU LOS and LOS were significantly longer for patients who were proned,but no mortality benefit or difference in VV-ECMO status was found.Among the subgroups,no difference in primary outcomes were found.In the secondary analysis,PPV was associated with a significant improvement in arterial oxygen partial pressure(PaO_(2))/fractional inspired oxygen(FiO_(2))(P/F)ratio from day 1 to day 4(P<0.05)and higher driving pressures day 5 to day 7(P<0.05).The combination of PPV and IVd together resulted in improvements in P/F ratio from day 1 to day 7 and plateau pressure on day 4 and day 6(P<0.05).PPV with NMBA was not associated with improvements in any of the secondary outcomes.The use of all three rescue therapies together resulted in improvements in lung compliance on day 2(P<0.05)but no other improvements.CONCLUSION In mechanically ventilated patients diagnosed with moderate to severe COVID ARDS,PPV and PPV with the addition of IVd produced a significant and sustained increase in P/F ratio.The combination of PPV,IVd and NMBA improved compliance however this did not reach significance.Mortality and LOS did not improve with adjunct therapies.Further research is warranted to determine the efficacy of these therapies alone and in combination in the treatment of COVID ARDS.
基金the Natural Science Foundation of Beijing Municipality(No.7204285)the National Natural Science Foundation of China(Nos.81573354,21772118,21971192)。
文摘Neuromuscular blocking agents(NMBAs)are extensively used during anesthesia to improve surgical conditions by relaxing skeletal muscle movements.Rapid neuromuscular recovery after surgery is desirable to facilitate the recovery of muscle function and prevent residual blockade.Decamethonium(C10)is a classic NMBA,which has been restricted over the past decades ascribed to lack of a suitable antidote in clinic.Herein we used carboxylatopillar[6]arene(CP6A)to reverse neuromuscular blocker effect of C10 through direct host-vip encapsulation.NMR and isothermal titration calorimetry served to confirm the complexation between CP6A and C10 with robust affinity[(1.07±0.14)×10^(7)L/mol].The CP6A was further used as a reversal agent of C10,which facilitated to decrease C10 concentration in mice blood and excrete via urinary clearance,resulting in rapid recovery from muscle relaxation.These favorable outcomes might lead us to suggest that this supramolecular strategy could allow patients to regain lucidity much faster than spontaneous recovery from anesthesia.
文摘OBJECTIVE: To study the pharmacodynamics of vecuronium,atracurium, mivacurium and rocuronium in patients with end-stage renal failure. METHODS: Forty-six patients with end-stage renal failure scheduled for renal transplantation and 53 patients with normal renal function were given either vecuronium, atracurium, mivacurium or rocuronium. The neuromuscular effects were monitored by the evoked response of the adductor pollicis to train-of-four stimulation of the ulnar nerve. RESULTS: Onset of vecuronium, atracurium and mivacurium occurred faster or tended to be faster in patients with end-stage renal failure, but there was no significant difference in onset by rocuronium between the control patients and renal failure patients. Furthermore, the no-response period, duration of action and recovery of atracurium did not differ between the two groups. There was no significant difference in duration of action or recovery of mivacurium between the two groups, whereas its no-response period was significantly prolonged in the patients with end-stage renal failure. There was no difference in no-response period or duration of action after the initial dose of vecuronium or rocuronium between the two groups. However, no-response period and duration of effect by vecuronium and rocuronium were prolonged with increasing incremental doses in patients with end-stage renal failure. CONCLUSIONS: All four muscle relaxants could be safely used in patients with end-stage renal failure. Onset of the relaxants were, in some cases, accelerated and no-response period of mivacurium was prolonged in patients with end-stage renal failure undergoing dialysis therapy. End-stage renal failure prolonged the no-response period and duration of action of vecuronium and rocuronium after repeated incremental doses, but did not alter those attributed to atracurium.
文摘A tri-block copolymer coupling agent polystyreneblock-poly （n-butyl-acrylate）-block-poly （y-methacryloxypro pylt rimethoxysilane）（PS-b-PnBA-b-PMPS） was synthesized by atom transfer radical polymerization （ATRP）, and its molecular structure was characterized by fourier-transform infrared spectra, hydrogen nuclear magnetic resonance and gel permeation chromatography. The glass bead was treated with the block copolymer coupling agent, and then studied by transmission electron microscopy. The result showed that strong interaction was formed between the block copolymer coupling agent and the surface of glass bead, and then the block of poly（n-butylacrylate） formed a layer of film on the surface.
文摘Adverse rection to local anesthetic agents is uncommon with true hypersensitivity reaction less than 1%of all adverse reactions.Allergic reactions to local anesthetics are classified into type I(IgE-mediated)and type IV(allergic contact dermatitis).Skin test can be used in evaluating type I allergic reaction while patch testing helps diagnosing allergic contact dermatitis.Physicians also need keep in mind that non-allergic reactions such as toxic effect,sympathetic stimulation,psychomotor reaction,and vasovagal syncope can occur in patients receiving local anesthetics.Perioperative hypersensitivity(POH)reactions have an incidence between 1:353 and 1:18,600 procedures.True anaphylaxis is estimated to occur in 1:3500 to1:20,000 surgeries with clinical manifestations varying from mild skin rash to cardiovascular collapse.Anaphylaxis has a mortality rate of 1.4–4.8%.Patient with perioperative anaphylaxis should be referred to allergist to identify the drug that led to reaction.Treatment of POH includes discontinuing any possible drugs,and with only skin involvement,using antihistamines,and in the presence of hypotension,tachycardia,bronchospasm,or gastrointestinal signs,based on severity treating with appropriate dose of epinephrine,and considering volume expansion and securing airway,if needed.
文摘BACKGROUND Donepezil is an acetylcholinesterase inhibitor used to improve cognition and delay disease progression in dementia patients by increasing acetylcholine levels.This drug may potentially interact with neuromuscular blocking agents(NMBAs)that act on muscular acetylcholine receptors during general anesthesia.Herein,we present a case of inadequate neuromuscular blockade with rocuronium,a nondepolarizing NMBA,in a dementia patient who had taken donepezil.CASE SUMMARY A 71-year-old man was scheduled for laparoscopic gastrectomy.He had been taking donepezil 5 mg for dementia.General anesthesia was induced with propofol and remifentanil.The depth of neuromuscular blockade was monitored by train-of-four(TOF)stimulation.After the administration of rocuronium,the TOF ratio decreased at an unusually slow rate,and a TOF count of 0 was detected 7 min later.After intubation,a TOF count of 1 was detected within 1 min,and a TOF ratio of 12%was detected within 2 min.The TOF count remained at 4 even with an additional bolus and continuous infusion of rocuronium,suggesting resistance to this NMBA.Instead of propofol,an inhalation anesthetic was administered alongside another NMBA(cisatracurium).Then,the quality of neuromuscular blockade improved,and the TOF count remained at 0-1 for the next 70 min.No further problems were encountered with respect to surgery or anesthesia.CONCLUSION Donepezil may be responsible for inadequate neuromuscular blockade during anesthesia,especially when total intravenous anesthesia is used.
文摘We report a case of severe anaphylactic shock in a 5-month-old infant who was scheduled to undergo an external inguinal hernia repair under general anesthesia. Rocuronium used for anesthesia induction was the most likely cause of anaphylaxis. High levels of serum tryptase and histamine detected in the blood sample collected during the anaphylactic reaction confirmed the diagnosis of anaphylactic shock. The patient’s clinical status improved within 90 min of intervention by the intravenous injection of vasopressors and a steroid. Surgery was canceled, and the patient stayed in the pediatric intensive care unit (PICU) under artificial ventilation for 5 h before safe extubation. The patient achieved full recovery the next day, without any sequelae. The rescheduled surgery was successfully completed 5 months later under general anesthesia without the use of neuromuscular blocking agents.
文摘Atrial fibrillation is the most common arrhythmia worldwide,affecting millions of the general population.It is a leading cause of stroke and is associated with many other long-term adverse cardiovascular issues.Long-term management of atrial fibrillation can involve simply controlling the ventricular rate with AV nodal blocking agents(rate control strategy)versus restoring and maintaining sinus rhythm(rhythm control strategy).
文摘Background Recurarization has previously been described in the context of acute normovolemic hemodilution.The aim of this study was to investigate the impairment of recovery of neuromuscular function after re-transfusion of intraoperative salvaged blood in patients treated with rocuronium.Methods We enrolled 50 patients undergoing general anesthesia for lumbar surgery.Intraoperative blood salvage （IBS） was used in 30 patients （group Ⅰ）; the remaining 20 comprised a control group （group C）.Anesthesia was induced with fentanyl,midazolam,propofol and rocuronium.Rocuronium was infused to maintain neuromuscular blockade during surgery.Blood was collected from the operative field and re-transfused in the post-anesthesia care unit （PACU）.Neuromuscular function was monitored using the train-of-four ratio （TOFr）.Once the train-of-four ratio exceeded 90 in the PACU,neuromuscular function was evaluated every 5 minutes for 30 minutes.The TOFr and incremental recovery of TOFr from baseline were recorded.Salvaged blood was re-transfused at the beginning of the evaluation for patients in group Ⅰ,and afterwards for patients in group C.Blood gas analysis was assessed before anesthesia and in the PACU.Results Incremental recovery of TOFr from baseline was significantly less in group Ⅰ than controls at 25 minutes （6.1±3.2vs.9.1±3.2,respectively; P=0.001） and 30 minutes （7.1±3.2 vs.10.0±2.2,respectively; P=-0.001）.There were no significant differences in gas exchange between the groups.Conclusions In patients who had received a rocuronium infusion during anesthesia,re-transfusion of salvaged blood significantly impaired recovery of neuromuscular function recovery in the PACU,but without significant impairment of respiratory function.
文摘Several new tetrahydroisoquinolinium salts, analogues of atracurium, were designed and synthesized. These compounds were prepared from optically pure tetrahydropapaverine and hexamethylene diglycidate.
