New developments in nondepolarizing muscle relaxants.

Anesthesiologists perceive that the ideal muscle relaxant is not yet available, particularly the nondepolarizing one with a rapid onset and a short duration of action. There is also a need for relaxants with different durations of action but which would be free from side effects. During the process of this development several new compounds have been tested and four have reached an advanced state of study; three of these, doxacurium, pipecuronium, and mivacurium are already licensed and rocuronium is likely to be licensed in the near future. Doxacurium and pipecuronium are slow onset and long duration of action compounds but singularly free from cardiovascular side effects. Mivacurium has an onset comparable to that of atracurium and vecuronium but with a duration of action which is intermediate in duration between these drugs and succinylcholine. Rocuronium is a drug with a fast onset of action capable of being used in place of succinylcholine but with a duration of action which is similar to that of vecuronium.     

Ventricular fibrillation and rhabdomyolysis after administration of succinylcholine

Succinylcholine is a depolarising muscle relaxant. Because of its quick onset of action, it is particularly used in situations which require urgent intubation. However, there have been several reports of cardiac arrest after administration of succinylcholine. We describe the case of a young woman who developed ventricular fibrillation and rhabdomyolysis following succinylcholine administration. Possible mechanisms and treatment are discussed.     

Effects of succinylcholine in an organotypic spinal cord-skeletal muscle coculture of embryonic mice

Intoxication with organophosphorus compounds is an important clinical problem worldwide. Although the core treatments – atropine, oximes and diazepam – are defined, high case fatalities were reported for intoxication with organophosphorus insecticides. In particular the role of oximes is not completely understood since they might benefit only patients poisoned by specific pesticides or patients with moderate poisoning and few randomised trials of such poisoning have been performed. This justifies the need for new in vitro test-systems like cocultures of spinal cord and muscle tissue, which have been recently introduced. However this test-system is not yet fully characterized. In order to estimate the applicability of cocultures of spinal cord and muscle tissue their sensitivity to succinylcholine (di-acetylcholine), a depolarizing muscle relaxant in clinical use, was tested.     

Muscle relaxants; effects on respiratory and circulatory dynamics

There are exceptions and variations to the general clinical rule that muscle relaxants depress respiration and have no effect on circulation. Variation may be attributed to differences in animal species, in individual response, in muscle affected, in drug used and in dose employed. Conclusions about muscle relaxants derived from animal experiments cannot always be assumed to apply to man. The "respiratory sparing" action of a muscle relaxant cannot be relied upon in any individual patient. Facilities for adequate artificial respiration must always be available when any dose of any muscle relaxant drug is administered. Muscle relaxants affect circulation by inhibition of parasympathetic and sympathetic ganglia, by anticholinesterase activity and by release of histamine.     

The pressure exerted on the tracheal wall by two endotracheal tube cuffs: A prospective observational bench-top, clinical and radiological study

Background

Recent studies have questioned our previous understanding on the effect of nitrous oxide on muscle relaxants, since nitrous oxide has been shown to potentiate the action of bolus doses of mivacurium, rocuronium and vecuronium. This study was aimed to investigate the possible effect of nitrous oxide on the infusion requirements of cisatracurium.

Methods

70 ASA physical status I-III patients aged 18-75 years were enrolled in this randomized trial. The patients were undergoing elective surgery requiring general anesthesia with a duration of at least 90 minutes. Patients were randomized to receive propofol and remifentanil by target controlled infusion in combination with either a mixture of oxygen and nitrous oxide (Nitrous oxide/TIVA group) or oxygen in air (Air/TIVA group). A 0.1 mg/kg initial bolus of cisatracurium was administered before tracheal intubation, followed by a closed-loop computer controlled infusion of cisatracurium to produce and maintain a 90% neuromuscular block. Cumulative dose requirements of cisatracurium during the 90-min study period after bolus administration were measured and the asymptotic steady state rate of infusion to produce a constant 90% block was determined by applying nonlinear curve fitting to the data on the cumulative dose requirement during the study period.

Results

Controller performance, i.e. the ability of the controller to maintain neuromuscular block constant at the setpoint and patient characteristics were similar in both groups. The administration of nitrous oxide did not affect cisatracurium infusion requirements. The mean steady-state rates of infusion were 0.072 +/- 0.018 and 0.066 +/- 0.017 mg * kg-1 * h-1 in Air/TIVA and Nitrous oxide/TIVA groups, respectively.

Conclusions

Nitrous oxide does not affect the infusion requirements of cisatracurium.

Trial registration

ClinicalTrials.gov NCT01152905; European Clinical Trials Database at http://eudract.emea.eu.int/2006-006037-41.     

Effects on Respiratory and Circulatory Dynamics

There are exceptions and variations to the general clinical rule that muscle relaxants depress respiration and have no effect on circulation.Variation may be attributed to differences in animal species, in individual response, in muscle affected, in drug used and in dose employed.Conclusions about muscle relaxants derived from animal experiments cannot always be assumed to apply to man.The “respiratory sparing” action of a muscle relaxant cannot be relied upon in any individual patient. Facilities for adequate artificial respiration must always be available when any dose of any muscle relaxant drug is administered.Muscle relaxants affect circulation by inhibition of parasympathetic and sympathetic ganglia, by anticholinesterase activity and by release of histamine.     

Histamine release by some new skeletal muscle relaxants studied at the rat ileum

The effects of 6 non-depolarizing muscle relaxants on histamine release were investigated, pharmacologically, using histamine and histamine antagonists, e.g. mepyramine, clemastine, dimotane. The results showed that gallamine, pancuronium, vecuronium, atracurium, tubocurarine and alcuronium produced concentration-dependent contractions in the rat ileum, gallamine and pancuronium being the most effective agents in producing muscle contraction. The H1 blocker, mepyramine, reduced the contractions produced by the muscle relaxants, as well as that produced by histamine. However, there was always some residual contraction, not blocked by high concentrations of mepyramine in the case of the muscle relaxants, but not in the case of histamine, the contraction of which was totally blocked by high concentrations of mepyramine. These results also suggested that, in part, the contraction produced by muscle relaxants, may be due to a mechanism other than histamine release, e.g. release of other mediators and/or an effect on intracellular calcium ions. Since very high concentrations of atracurium and vecuronium (40-50 times higher than clinical concentrations) were used in this study to produce marked contractions, the implication is that in clinical concentrations, they have little effect on histamine release. In contrast, gallamine and pancuronium can release histamine even at low concentrations, i.e. at or near their clinical concentrations in man. These, therefore, are the cause of the adverse reactions seen after drug administration.     

高龄患者腹腔镜直肠癌根治术不同麻醉方法的比较

目的观察比较3种麻醉方法对高龄腹腔镜直肠癌根治术患者的呼吸循环功能和麻醉效果的影响。方法将45例高龄腹腔镜直肠癌根治术患者随机分成3组,每组15例。EA组,连续硬膜外阻滞麻醉组;GA组,静吸复合全身麻醉组;EGA组,小剂量硬膜外阻滞复合静吸全身麻醉组。观察3组麻醉开始前(T0)、麻醉诱导期(T1)、气管插管时(T2)、拔除气管导管时(T3)的HR、SBP、DBP、MAP、PETCO2、ECG,GA组与EGA组同时监测异氟醚MAC、气道压、手术结束自主呼吸恢复时间、自主呼吸潮气量达标、拔管时间、肌松情况及患者麻醉苏醒时间。结果 EA组有13例麻醉效果优良,SpO295%,PETCO2维持在正常范围;EGA组术毕自主呼吸恢复时间、潮气量达标、拔管时间均明显短于GA组(P0.01)。EA组在麻醉10～15 min后血压下降程度与GA组、EGA组麻醉诱导期血压下降相似(P0.05),EGA组在气管插管/拔管期血压波动不明显,而GA组血压显著升高(P0.01);EA组与GA组麻醉效果相似,EGA组麻醉效果优于GA组(P0.05)。结论 EGA组椎管内局麻药用量、全麻维持药用量、肌松药用量等均相应减少,呼吸循环功能较为稳定,术毕麻醉苏醒快,自主呼吸恢复和潮气量达标迅速,多数患者术毕即可拔除气管导管,是高龄腹腔镜直肠癌根治术患者理想的麻醉方法。     

Organophosphorus pesticide‐induced butyrylcholinesterase inhibition and potentiation of succinylcholine toxicity in mice

Succinylcholine is the most important rapid‐acting depolarizing muscle relaxant during anesthesia. Its desirable short duration of action is controlled by butyrylcholinesterase, the detoxifying enzyme. There are two reported cases of prolonged paralysis from succinylcholine in patients poisoned with the organophosphorus insecticides parathion and chlorpyrifos. The present study examines the possibility that other organophosphorus and methylcarbamate pesticides might also prolong succinylcholine action by inhibiting butyrylcholinesterase using mice treated intraperitoneally as a model and relating inhibition of blood serum hydrolysis of butyrylthiocholine to potentiated toxicity (mouse mortality). The organophosphorus plant defoliant tribufos (4 h pretreatment, 160 mg/kg) and organophosphorus plant growth regulator ethephon (1 h pretreatment, 200 mg/kg) potentiate the toxicity of succinylcholine by seven‐ and fourfold, respectively. Some other pesticides or analogs are more potent sensitizers for succinylcholine toxicity with threshold levels of 0.5, 1.0, 1.7, 8, 10, and 67 mg/kg for phenyl saligenin cyclic phosphonate, profenofos, methamidophos, tribufos, chlorpyrifos, and ethephon, respectively. Enhanced mortality from succinylcholine is generally observed when serum butyrylcholinesterase is inhibited 55–94%. Mivacurium, a related nondepolarizing muscle relaxant also detoxified by butyrylcholinesterase, is likewise potentiated by at least threefold on 4 hour pretreatment with tribufos (25 mg/kg) or profenofos (10 mg/kg). © 1998 John Wiley & Sons, Inc. J Biochem Toxicol 13: 113–118, 1999     

显微血管减压术对面肌痉挛患者生活质量的影响

目的:研究显微血管减压术对面肌痉挛(HFS Hemifacial Spasm)患者生活质量的影响。方法:对2014年至2016年底在哈医大一院神经外科四科接受显微血管减压手术(MVD Mcrovascular Decompression)治疗的40名面肌痉挛患者进行生活质量量表(QOL Quality of Life)评分,对患者的疗效及治疗前后生活质量的变化情况进行统计学分析。结果:治疗后,MVD的明显缓解率为95%,手术前后不同生活质量项目评分的差异具有统计学意义(P<0.05),术前QOL量表评分总值为21.83±2.01,术后总值为2.15±0.8,术后QOL量表评分总值较术前显著降低(P<0.05)。结论:显微血管减压手术对面肌痉挛患者的症状缓解效果显著,同时可以明显改善患者的生活质量,特别是对患者内心窘迫的改善最为明显。     

微血管减压术治疗面肌痉挛术后相关并发症的临床分析

目的:总结面肌痉挛患者的术后并发症的发生情况并分析其原因。方法:回顾性分析了1548名在我院行微血管减压术治疗面肌痉挛的患者的临床资料,所有患者接受电话随访或者门诊随访,随访时间均超过2年,总结其临床疗效及术后并发症的发生情况。结果:微血管减压术后痊愈率及明显缓解率分别为92.5%及4.2%。249名(16.09%)患者出现不同的并发症,其中最常见的并发症为面瘫及术后手术区域皮肤感觉障碍,无死亡及重大并发症患者。听力损害发生率为3.5%。其他并发症包括脑脊液漏、后组颅神经损伤、外展神经损伤、颅内出血等。结论:微血管减压术是治疗面肌痉挛的安全有效操作,以手术区域感觉障碍及迟发性面瘫是主要的并发症,持久性的或者严重的并发症比较少见。     

Synthesis of quaternary ammonium salts of 16E-[4-(2-alkylaminoethoxy)-3-methoxybenzylidene]androstene derivatives as skeletal muscle relaxants

Synthesis of eighteen new quaternary ammonium salts of 16E-arylidene androstene derivatives as skeletal muscle relaxants is reported in the present study. The effects of possibly extended interonium distances on muscle relaxant activity are discussed. All the quaternary ammonium steroids produced reduction in the twitch responses, when screened for in vitro neuromuscular blocking activity using isolated chick biventer cervicis muscle preparation. However, the variable interonium distance, which is believed to range from 11 to 17 Å in these quaternary compounds and is associated with the built in flexibility of these structures about the single bonds on the moieties linked to ring D of the steroid skeleton, resulted in varied degrees of muscle relaxant activity. Some of the compounds also inhibited acetylcholinesterase activity in low concentrations so that they would not be directly suitable for use as muscle relaxants.     

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

Background

Asymptomatic severe mitral valve (MV) regurgitation with preserved left ventricular function is a challenging clinical entity as data on the recommended treatment strategy for these patients are scarce and conflicting. For asymptomatic patients, no randomised trial has been performed for objectivising the best treatment strategy.

Methods

The Dutch AMR (Asymptomatic Mitral Regurgitation) trial is a multicenter, prospective, randomised trial comparing early MV repair versus watchful waiting in asymptomatic patients with severe organic MV regurgitation. A total of 250 asymptomatic patients (18–70 years) with preserved left ventricular function will be included. Intervention will be either watchful waiting or MV surgery. Follow-up will be 5 years. Primary outcome measures are all-cause mortality and a composite endpoint of cardiovascular mortality, congestive heart failure, and hospitalisation for non-fatal cardiovascular and cerebrovascular events. Secondary outcome measures are total costs, cost-effectiveness, quality of life, echocardiographic and cardiac magnetic resonance parameters, exercise tests, asymptomatic atrial fibrillation and brain natriuretic peptide levels. Additionally, the complication rate in the surgery group and rate of surgery in the watchful waiting group will be determined.

Implications

The Dutch AMR trial will be the first multicenter randomised trial on this topic. We anticipate that the results of this study are highly needed to elucidate the best treatment strategy and that this may prove to be an international landmark study.     

The British antibiotic and silver-impregnated catheters for ventriculoperitoneal shunts multi-centre randomised controlled trial (the BASICS trial): study protocol

Background

Insertion of a ventriculoperitoneal shunt (VPS) for the treatment of hydrocephalus is one of the most common neurosurgical procedures in the UK, but failures caused by infection occur in approximately 8% of primary cases. VPS infection is associated with considerable morbidity and mortality and its management results in substantial cost to the health service. Antibiotic-impregnated (rifampicin and clindamycin) and silver-impregnated VPS have been developed to reduce infection rates. Whilst there is some evidence showing that such devices may lead to a reduction in VPS infection, there are no randomised controlled trials (RCTs) to support their routine use.

Methods/design

Overall, 1,200 patients will be recruited from 17 regional neurosurgical units in the UK and Ireland. Patients of any age undergoing insertion of their first VPS are eligible. Patients with previous indwelling VPS, active and on-going cerebrospinal fluid (CSF) or peritoneal infection, multiloculated hydrocephalus requiring multiple VPS or neuroendoscopy, and ventriculoatrial or ventriculopleural shunt planned will be excluded. Patients will be randomised 1:1:1 to either standard silicone (comparator), antibiotic-impregnated, or silver-impregnated VPS. The primary outcome measure is time to VPS infection. Secondary outcome measures include time to VPS failure of any cause, reason for VPS failure (infection, mechanical failure, or patient failure), types of bacterial VPS infection (organism type and antibiotic resistance), and incremental cost per VPS failure averted.

Discussion

The British antibiotic and silver-impregnated catheters for ventriculoperitoneal shunts multi-centre randomised controlled trial (the BASICS trial) is the first multi-centre RCT designed to determine whether antibiotic or silver-impregnated VPS reduce early shunt infection compared to standard silicone VPS. The results of this study will be used to inform current neurosurgical practice and may potentially benefit patients undergoing shunt surgery in the future.

Trial registration

International Standard Randomised Controlled Trial Number: ISRCTN49474281.     

Anionic cyclophanes as potential reversal agents of muscle relaxants by chemical chelation

A series of carboxyl-containing cyclophanes have been designed and synthesised as chemical chelators (or host molecules) of cationic muscle relaxant drugs (or guest molecules). Three of these cyclophane derivatives, 1-3, have been shown by NMR to form 1:1 complexes with the muscle relaxants pancuronium, and gallamine, in D(2)O, with association constants up to 10(4) M(-1). When tested in an in vitro chick biventer muscle preparation, the cyclophanes reversed the neuromuscular block induced by pancuronium and gallamine, with having the most effective reversal against pancuronium (EC(50) 40 microM.     

Soluble guanylate cyclase-dependent relaxation is reduced in the adult rat bronchial smooth muscle

Cyclic nucleotides are relaxants of the airway smooth muscle, yet most of the available data were obtained in adult animals. The expression and activity of cyclases have been reported to be developmentally regulated in the lung, and little is known about the age-related changes in their bronchial muscle relaxation potential. We evaluated and compared the newborn and adult rat bronchial smooth muscle response to cyclic AMP- and GMP-dependent agonists in isometric mounted bronchial rings. In acetylcholine-precontracted bronchial muscle, the relaxant response to the cAMP agonist forskolin was not age dependent, but the relaxant response to the nitric oxide (NO) donor sodium nitroprusside (SNP) was significantly greater (P<0.01) in the newborn. To further evaluate the cGMP pathway, we stimulated the soluble guanylate cyclase (sGC) with the specific agonists BAY 41-2272 and YC-1. In keeping with the SNP dose-response curves, the sGC agonists significantly relaxed the newborn, but not the adult bronchial muscle. Protein expression of the sGC alpha1- and beta1-subunits were significantly lower (P<0.01) in the adult compared with the newborn bronchial tissue. Consistent with these results, the NO-stimulated sGC activity was significantly greater in the newborn compared with the adult (P<0.01). In conclusion, the bronchial smooth muscle cGMP-, but not cAMP-dependent, relaxant response is developmentally regulated and significantly reduced in the adult rat.     

Anesthesia for eye operations in the aged

Aged persons appear to fear eye operations. Hence both patient and surgeon are more at ease with the use of a general anesthetic, particularly if the anesthetist has visited the patient before the operation and reassured him. Early ambulation, ordinarily so desirable in the aged, is curtailed in most eye operations because the head and eyes must be completely quiet. Since barbiturates are not well tolerated by aged patients, Dramamine is used instead preoperatively. Dramamine adequately sedates but does not cause depression or hallucinations. Morphine is contraindicated because of its pupillary action; Demerol is the drug of choice for preoperative medication. Xylocaine applied directly to the pyriform fossa and vocal cords prevents laryngospasm, coughing and straining. Then, following induction with Pentothal, a Guedel airway is introduced into the oropharynx and through it a continuous flow of oxygen is maintained throughout the procedure. Relaxation of the eyelids is aided by the use of various muscle relaxants, succinylcholine being the relaxant of choice because it is rapidly eliminated. By administering narcotics intravenously during the course of the operation the amount of Pentothal needed can be held to a minimum. To prevent any slowing of the respiration, Nalline is administered in conjunction with the narcotic. In dealing with debilitated patients, Nalline is usually given in conjunction with the preoperative narcotic. Any latent slowing of the respiration can be promptly relieved by an additional dose of Nalline.     

THE EFFECT OF SMOOTH MUSCLE ON THE INTERCELLULAR SPACES IN TOAD URINARY BLADDER

Phase microscopy of toad urinary bladder has demonstrated that vasopressin can cause an enlargement of the epithelial intercellular spaces under conditions of no net transfer of water or sodium. The suggestion that this phenomenon is linked to the hormone's action as a smooth muscle relaxant has been tested and verified with the use of other agents effecting smooth muscle: atropine and adenine compounds (relaxants), K⁺ and acetylcholine (contractants). Furthermore, it was possible to reduce the size and number of intercellular spaces, relative to a control, while increasing the rate of osmotic water flow. A method for quantifying these results has been developed and shows that they are, indeed, significant. It is concluded, therefore, that the configuration of intercellular spaces is not a reliable index of water flow across this epithelium and that such a morphologic-physiologic relationship is tenuous in any epithelium supported by a submucosa rich in smooth muscle.     

Reduction of surgical site infection using a novel intervention (ROSSINI): study protocol for a randomised controlled trial

Background

Surgical site infection (SSI) is a common complication following abdominal surgery. It is associated with considerable morbidity and mortality, and its management results in significant cost to health services within both primary and secondary care. Some surgeons believe that the use of a wound-edge protection device may reduce the incidence of SSI. Whilst there is some encouraging evidence showing that such devices may lead to a reduction in SSI, there are no controlled trials of sufficient size or quality to support their routine use.

Methods/Design

750 patients will be recruited from around 20 surgical units within the United Kingdom. Patients undergoing laparotomy through any major abdominal incision for any indication, elective or emergency, are eligible. Patients under the age of 18, those undergoing a laparoscopic assisted procedure or who have undergone laparotomy within the previous 3 months, and those who are unable to give informed consent will be excluded. Patients will be randomised (1:1 ratio) to the use of a wound-edge protection device or no wound-edge protection device during surgery.Follow up will consist of blinded clinical wound reviews at 5-7 days and 30-33 days postoperatively with a self-completed questionnaire covering the intervening period. Quality of life questionnaires will be completed prior to surgery and at the subsequent wound review points and information on resource usage will also be captured.The primary outcome measure is SSI within 30 days of surgery. Secondary outcomes include the impact of the degree of wound contamination, patient comorbidity, and operative characteristics on the efficacy of a wound-edge protection device in reducing SSI and whether the use of a wound-edge protection device has an effect on health-related quality of life or length of hospital stay and is cost-effective.

Discussion

Rossini is the first multicentre observer-blinded randomised controlled trial of sufficient size and quality to establish whether the use of a wound-edge protection device in adult patients undergoing abdominal surgery leads to a lower rate of SSI. The results of this study will be used to inform current surgical practice and may potentially benefit patients undergoing surgery in the future.

Trial registration number

Current Controlled Trials ISRCTN: ISRCTN40402832

     

Effect of muscle relaxants on the motor endplate of diabetic and glucocorticoid pretreated rats

The susceptibility to d-tubocurarine, gallamine, pancuronium, succinylcholine, and decamethonium of the motor endplate innervated by the anterior tibial nerve was studied in alloxan diabetic rats and in rats pretreated with cortisone and dexamethasone. The sensitivity to various muscle relaxants of cholinergic receptors in the motor endplate of alloxan diabetic and glucocorticoid-treated rats was changed. Beside alterations in affinity, in some cases the kinetics of action were also altered as compared to controls. The phenomenon is suggested to be brought about by a modulator substance circulating in the blood of alloxan diabetic and glucocorticoid-treated rats.