Opioid-free general anesthesia in patient with Steinert syndrome (myotonic dystrophy)
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Introduction: We report on the anesthetic management using opioid-free method of a patient with Steinert syndrome (myotonic dystrophy, MD), autosomal dominant dystrophy which is characterized by consistent contracture of muscle following stimulation. A myotonic crisis can be induced by numerous factors including hypothermia, shivering, and mechanical or electrical stimulation. In patients with MD, hypersensitivity to anesthetic drugs, especially muscle relaxants and opioids, may complicate postoperative management. If opioids are employed (systemic or neuraxial), then ICU care and continuous pulse oximetry must be considered given the high risk for respiratory depression and aspiration. Patients with MD present high sensitivity to the usual anesthetics such as volatile and muscle relaxants (both depolarizing and nondepolarizing). Opioids may induce muscle rigidity in this type of MD. Therefore, omitting opioids is recommended. Due to hypersensitivity to opioids and increased susceptibility to intra- and postoperative complications, it is recommended to introduce opioid-free anesthesia (OFA), for example, with use of dexmedetomidine (DEX). This is a new method of conducting general anesthesia without opioids and is based on concept of multimodal approach to pain management. Methods: A 31-year-old male patient (183 cm, 69 kg) was scheduled for laparoscopic operation of cholecystectomy. The patient received intravenously (IV): propofol in a dose of 250 mg followed by continuous infusion, rocuronium in a dose of 20 mg, and DEX in a loading dose of 0.6 μg/kg over 10 minutes followed by continuous infusion of dose of 0.2 μg/kg/hour. Results: The course of anesthesia and postoperative period were uneventful. The patient exited the operating theatre in a good medical state, with vitals within normal limits and fully regained consciousness. Conclusion: DEX is effective and safe for moderately painful procedures in patients with the elevated risk of respiratory and cardiovascular failure. This substance provides adequate analgesia level during surgeries of patients suffering from MD.Keywords:
Dexmedetomidine
Aim To investigate whether rocuronium can affect bispcetral index during different effect-site concentration of propofol.Methods Sixty ASA Ⅰ or Ⅱpatients undergoing elective surgery were enrolled in the study,based on Ce of propofol,the patients randomly divided into four groups(R2 and R3)and(C2 and C3)(n=15).When the Ce of propofol reached 4.0 mg·L-1 and OAA/S score was below one,a laryngeal mask airway was inserted,Ce was then maintained at 2.0 mg·L-1 or 3.0 for 20min.Rocuronium 2ED950.6 mg·kg-1 was given in groups R2 and R3,normal saline(5ml)was given in the other two groups.BIS values were recorded before induction of propofol immediately(T1),injection of rocuronium or normal saline immediately(T2),TOF reaching 0(T3),the first TOF twitch of muscle recovering to 5 %(T4).The need of time was also recorded when TOF returned to T3 and T4 in groups R2 and R3.Results There was no significant difference in sex,age,body weight among four groups.There was no significant difference in the effect of different effect-site concentration of propofol on muscle relaxation of rocuronium.There was no significant difference in BIS between groups C2 and C3 when T1-T4.The BIS of T3 and T4 were significantly lower than T2 in group R2 but not in group R3,C2 and C3.Compared with the same Ce,there was no significant difference between group R2,C2 and group R3,C3.Conclusion The different effect-site concentration of propofol had no obvious effect on muscle relaxation of rocuronium,but rocuronium altered the BIS scores in moderately sedated patients but not in deeply sedated patients.The scores of BIS were decreased after a bolus 2 times ED95 of rocuronium when Ce of propofol set at 2.0 mg·L-1,but when Ce of propofol set at 3.0 mg·L-1,there were no changes in BIS scores.
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Rocuronium Bromide
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Objective To compare intubating conditions after induction with a propofol-ephedrine combination or propofol alone, following administration of rocuronium. Methods A double blind, prospective,controlled trial was conducted. One hundred adult patients were randomly assigned to receive either propofol 2.5mg/kg and ephedrine 15mg/kg in combination or propofol 2.5mg/kg give over 30s, followed by rocuronium 0.6mg/kg given over 5s.Tracheal intubation was performed 1 min later Jaw relaxation,vocal cord position and diaphragmatic response were used to assess intubation conditions. Results Tracheal intubation was successful in all patients.There was a significantly higher proportion of intubating conditions graded as excellent in the propofol-ephedrine group(84%) than in the propofol group (32%) (P0.05).Vocal cord position and response to intubation were significantly better in the propofol-ephedrine group.Mean arterial pressure was maintained at pre-induction levels in the propofol-ephedrine group.Conclusion Induction with propofol and ephedrine in combination could provide significandy better intubating conditions than propofol alone,when followed by rocuronium.
Rocuronium Bromide
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서 론최근에는 마취시 정맥마취제가 많이 사용되고 있는데 이 러한
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Objective To investigate whether rocuronium could affect bispcetral index during different effect-site concentration of propofol.Methods Sixty ASA Ⅰ or Ⅱ patients undergoing elective surgery were enrollded in the study,based on Ce of propofol,the patients randomly divided into four groups with 15 cases in each group (group R2 and R3) and (group C2 and C3).When the Ce of propofol reached 4.0 μg/ml and OAA/S score was below one,a laryngeal mask airway was inserted,Ce was then maintained at 2.0 μg/ml or 3.0 μg/ml for 20 min. Rocuronium of 0.6 mg/kg about 2ED95 was given in groups R2 and R3,normal saline in the volume of 5 ml was given in the other two groups. BIS、HR and MAP values were recorded before induction of propofol immediately(T1),at the time of injection rocuronium or normal saline(T2),when TOF reached 0(T3) and at the first TOF twitch of muscle recovered to 5% (T4). Results The BIS at T3and T4were significantly lower than that at T2in group R2,but not in group R3,C2 or C3. Compared with the same Ce,there was no significant difference between group R2,C2 and group R3,C3. Conclusion Rocuronium could reduce the BIS scores in moderately sedated patients but not in deeply sedated patients.
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Dexmedetomidine undoubtedly is a useful sedative in the intensive care setting because it has a minimal effect on the respiratory system. Dexmedetomidine infusions lasting more than 24 hours have not been approved since the first approval was acquired in the US in 1999. However, in 2008, dexmedetomidine infusions for prolonged use were approved in Colombia and in the Dominican Republic, and the number of countries that have granted approval for prolonged use has been increasing every year. This review discusses the literature examining prolonged use of dexmedetomidine and confirms the efficacy and safety of dexmedetomidine when it is used for more than 24 hours. Dexmedetomidine was administered at varying doses (0.1-2.5 μg/kg/hour) and durations up to 30 days. Dexmedetomidine seems to be an alternative to benzodiazepines or propofol for achieving sedation in adults because the incidences of delirium and coma associated with dexmedetomidine are lower than the corresponding incidences associated with benzodiazepines and propofol, although dexmedetomidine administration can cause mild adverse effects such as bradycardia. Controlled comparative studies on the efficacy and safety of dexmedetomidine and other sedatives in pediatric patients have not been reported. However, dexmedetomidine seems to be effective in managing extubation, reducing the use of conventional sedatives, and as an alternative for inducing sedation in patients for whom traditional sedatives induce inadequate sedation. Prolonged dexmedetomidine infusion has not been reported to have any serious adverse effects. Dexmedetomidine appears to be an alternative long-term sedative, but further studies are needed to establish its efficacy and safety.
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α2-adrenergic receptor distributes in all the tissues of the body,so the research of dexmedetomidine clinical applications and its correlation with α2-adrenergic receptor should not only be limited to the sedative and analgesic effect.Because dexmedetomidine also have many notable roles in other clinical scenarios.Recently it has been found that dexmedetomidine could exert protective effect on multiple organs,treat alcohol withdrawal symptoms and inhibit fear memory formation,the relevant research progress is to be reviewed.
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More than 200 studies and reports have been published regarding the use of dexmedetomidine in infants and children. We reviewed the English literature to summarize the current state of knowledge of this drug in children for the practicing anesthesiologist. Dexmedetomidine is an effective sedative for infants and children that only minimally depresses the respiratory system while maintaining a patent airway. However, dexmedetomidine does depress the cardiovascular system. Specifically, bradycardia, hypotension, and hypertension occur to varying degrees depending on the age of the child. Hypertension is more prevalent when larger doses of dexmedetomidine are given to infants. Consistent with its 2-hour elimination half-life, recovery after dexmedetomidine may be protracted in comparison with other sedatives. Dexmedetomidine provides and augments analgesia and diminishes shivering as well as agitation postoperatively. The safety record of dexmedetomidine suggests that it can be used effectively and safely in children, with appropriate monitoring and interventions to manage cardiovascular sequelae.
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Background Similar to volatile anaesthetics, propofol may influence neuromuscular transmission. We hypothesised that the administration of propofol influenced the potency of rocuronium depending on the duration of the administration. Methods After consent, patients scheduled for elective surgery randomly received rocuronium either after induction of anaesthesia with propofol (2 min of propofol, n = 36) or after 30 min of propofol infusion (30 min of propofol, n = 36). Remifentanil was given in both groups. Neuromuscular monitoring was performed by calibrated electromyography. The dose–response relationship of rocuronium was determined with a single‐bolus technique (0.07, 0.1, 0.15, 0.2, 0.3 and 0.45 mg/kg rocuronium). The primary endpoints were the ED 50 and ED 95 of rocuronium after 2 and 30 min propofol. Data are presented as means with (95% confidence interval). The trial is registered with the Eudra‐ CT : 2009‐012815‐16. Results A total of 72 patients were included. Time to maximal neuromuscular blockade was significantly shorter in patients after 30 min of propofol [3.3 min (2.9–3.7)] compared with patients anaesthetised with 2 min of propofol [4.6 min (4.0–5.2)]. After 30 min of propofol, the slope of the dose–response curve was significantly steeper (30 min of propofol: 4.34 [3.62–5.05]; 2 min of propofol: [3.34 (2.72–3.96)], resulting in lower ED 95 values of rocuronium (30 min of propofol: 0.287 mg/kg [0.221–0.368]; 2 min of propofol [0.391 mg/kg (0.296–0.520)]. The ED 50 were not different between groups. Conclusion The potency of rocuronium was significantly enhanced after propofol infusion for 30 min. Estimates of potency those are usually determined during steady‐state anaesthesia might underestimate rocuronium requirements for endotracheal intubation at the time of induction.
ED50
Rocuronium Bromide
Neuromuscular transmission
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在那里的背景是很少研究估计 propofol 的效果地点集中是否能在控制目标的注入(TCI ) 期间预言麻药深度在 eldedy 病人感应。这研究试图在 eldedy patients.Methods 在 TCI 正式就职期间评估在 propofol 的效果地点集中和麻醉的深度之间的关系有麻醉学者( ASA )的一个美国社会的 90 个病人( 60-80 年) 1-3 的物理地位，经历在一般麻醉下面安排了腹、胸的外科随机被分配进三个组，组 S1 ， S2 和 S3 (在每个组的 30 个病人)之一。在组 S1 的病人与 4.0 g/ml 的目标血浆集中收到了 propofol；在组 S2 的病人与起始的目标血浆收到了 propofol 3 分钟以后被提起到 4.0 g/ml 的 2.0 g/ml 的集中；在组 S3 的病人收到了 3 步的一个灌输的计划；从是的 2.0 g/ml 的目标血浆集中开始由 1 g/ml 增加了 stepwised 直到 4.0 g/ml 的目标血浆集中被完成，在二步之间的间隔是 3 分钟。当一个观察员对 1 的机警 / 镇静(OAA/S ) 分数的评价被完成时， remifentanil (4.0 ng/ml 的效果地点集中(Ce )) 和 rocuronium 0.9 mg/kg 被管理。气管的 intubation 被开始在 rocuronium 以后的 2 分钟注射。propofol Ce，血压(BP ) ，心率(HR ) ，和 bispectral 索引(二度) 的变化被记录。结果当 1 的一个 OAA/S 分数被完成时， propofol 的 Ce 是(1.7ed .Results 八个病人((3.1 ?? 肀？？
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Rocuronium Bromide
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