General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study*
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Summary There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients’ (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best‐practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16–22) and failed intubation in 1 in 312 (95%CI 1 in 169–667). Obese patients were over‐represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%).Keywords:
Sugammadex
Rapid sequence induction
Sugammadex
Rapid sequence induction
Neuromuscular Blocking Agents
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서 론 Rocuronium은 다른 비탈분극성 근이완제보다 작용 발현 이 빨라 투여 후 60-90초 시점에서 succinylcholine과 유사 한 삽관 환경(intubating condition)을 제공하여, 신속한 기관 내삽관 시 succinylcholine을 대체할 수 있는 근이완제로 알 려져 있다. 1) 그러나 rocuronium의 투여 용량과 투여 후 적정 한 삽관 시점에 대해서는 연구자에 따라 서로 다른 결과가 나타나고 있는데, rocuronium 투여 후 60초 시점에서 삽관 환경이 succinylcholine과 유사하다는 보고가 있는 반면, 2,3) 투여 후 90초는 지나야 적절한 삽관 환경이 제공되었다는 보고도 있다. 4,5)이상적인 삽관 시점에서는 삽관 환경이 우 수함은 물론, 삽관에 의한 혈역학적 변화도 최소로 제한되 어 상대적으로 안정될 것으로 사료되며, 그렇기 때문에 약 제에 따른 이상적인 삽관 시점을 찾는
Haemodynamic response
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Magnesium sulphate has been used in anesthesia because it has relevant clinical features such as: analgesia, autonomic response control and muscle relaxation. Using the agent to establish adequate conditions for tracheal intubation remains controversial. The aim of the study was to compare the effectiveness of magnesium sulfate and rocuronium for rapid sequence tracheal intubation in adults. Double blind, randomized, unicentric, prospective study assessed 68 patients, ASA 1 or 2, over 18 years, scheduled for appendectomy under general anesthesia. Patients were divided into two groups. GM patients received 50 mg.kg-1magnesium sulfate and GR patients, 1 mg.kg-1 rocuronium immediately before anesthesia induction. Arterial Blood Pressure (BP) and Heart Rate (HR) were measured in both groups at five times related to the administration of the drugs studied. The primary variable was the clinical status of tracheal intubation. RBR-4xr92k. GM was associated with no significant hemodynamic parameter change after injection. GM showed 85% (29/34) poor intubation clinical status, 15% (5/34) good, and 0% excellent (< 0.0001). Magnesium sulfate did not provide adequate clinical status when compared to rocuronium at a dose of 50 mg.kg-1 for rapid sequence intubation in adult patients. O sulfato de magnésio vem sendo utilizado em anestesia por apresentar características relevantes à prática da clínica como: analgesia, controle dos reflexos autonômicos e relaxamento muscular. A utilização deste agente para garantir condições adequadas para a intubação traqueal permanece controverso. O objetivo deste trabalho é determinar a efetividade do sulfato de magnésio comparado ao rocurônio para intubação orotraqueal em sequência rápida em pacientes adultos. Este estudo duplamente encoberto, aleatorizado, unicêntrico e prospectivo avaliou 68 pacientes, ASA 1 ou 2, maiores de 18 anos, escalados para cirurgias de apendicectomia sob anestesia geral. Foram alocados em dois grupos, o GM recebeu 50 mg.kg-1 de sulfato de magnésio e o GR, 1 mg.kg-1 de rocurônio imediatamente antes da indução anestésica. Os valores de Pressão Arterial (PA) e Frequência Crdíaca (FC) foram aferidos nos dois grupos em cinco momentos relacionados com a administração dos fármacos do estudo. A variável primária foi condição clínica da intubação. RBR-4xr92k. O GM não apresentou alteração significativa dos parâmetros hemodinâmicos após infusão. O GM apresentou 85% (29/34) de condição pobre, 15% (5/34) condição clínica boa e 0% condição clínica excelente < 0,0001. O sulfato de magnésio não propiciou condições clínicas aceitáveis quando comparado ao rocurônio para intubação orotraqueal em sequência rápida em pacientes adultos quando utilizada a dose de 50 mg.kg-1.
Rapid sequence induction
Muscle relaxation
Rocuronium Bromide
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Rocuronium for caesarean section (CS) under general anaesthesia (GA) is now an alternative to suxamethonium for rapid sequence induction (RSI) owing to sugammadex. However, there are no large well-controlled studies that have been done in this setting. The aim of this study was to find out if a combination of rocuronium and sugammadex confers any benefit over suxamethonium, rocuronium and neostigmine in GA for CS.
Sugammadex
Rapid sequence induction
Rocuronium Bromide
Elective caesarean section
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In many procedures requiring intubation neuromuscular blocking agents are administered during anesthesia to facilitate the intubation of the trachea and to optimize the surgical field. For short procedures (e.g., less than 30 minutes), a short acting neuromuscular blocking agent, such as succinylcholine, is required for rapid sequence induction and intubation. Succinylcholine, a depolarizing neuromuscular blocking agent, produces a reliable neuromuscular block (NMB), has the fastest onset and the shortest duration of all neuromuscular blocking agents, and the recovery of the NMB typically occurs by spontaneous recovery.Alternatives to succinylcholine may include using a longer acting neuromuscular blocking agent in conjunction with a reversal agent to produce a short-term NMB. Rocuronium is a non-depolarizing neuromuscular blocking agent with fast onset, which can be used at higher doses for rapid sequence induction and intubation. Sugammadex is a selective relaxant binding agent indicated for the reversal of moderate to deep NMB, with a high affinity for rocuronium.,A manufacturer shortage of succinylcholine occurred in Canada in May 2019, and at the time this report was written, the drug shortage was anticipated to last until mid-August 2019. In these circumstances, the use of rocuronium with sugammadex may be an alternative to succinylcholine when there is a need for short acting NMB. Neuromuscular blocking agents and reversal agents are associated with various adverse effects, including residual NMB, myalgias, muscle fasciculations, headache, nausea, and vomiting,, and it is unclear how the clinical benefits and harms of using rocuronium with sugammadex compare with using succinylcholine alone. In addition, the cost of sugammadex is significantly higher than other common reversal agents (e.g., neostigmine), and it is unknown if sugammadex is cost effective for routine clinical use.The purpose of this report is to synthesize and critically appraise the available evidence on the clinical effectiveness of rocuronium with sugammadex compared to succinylcholine in patients undergoing surgery who require rapid sequence induction. Additionally, the cost-effectiveness of sugammadex in patients undergoing surgery will be reviewed. This information may be used to inform decision making relating to health policy of the use of sugammadex.
Sugammadex
Neuromuscular Blocking Agents
Rapid sequence induction
Neuromuscular transmission
Neuromuscular monitoring
Muscle relaxation
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Rapid sequence induction
Cricoid pressure
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Many anaesthetists use rocuronium in place of suxamethonium for rapid sequence induction (RSI). This is less common in obstetric anaesthesia as the duration of action of an effective dose of rocuronium exceeds most obstetric procedures. Sugammadex offers the possibility of rapidly reversing profound rocuronium neuromuscular blockade at the end of surgery. We aimed to determine whether rocuronium 1.2 mg/kg used for RSI in the obstetric population would provide good intubating conditions at 60 s and would be effectively reversed by sugammadex at the end of surgery.We present a prospective series of 18 patients who received rocuronium 1.2 mg/kg at induction of anaesthesia, monitored with a train-of-four ratio (TOF)-Watch SX(®) , and reversed using sugammadex 4 mg/kg.The mean (95% CI) onset time of rocuronium was 71 (56-86) s, and the mean (95% CI) time to recovery of the TOF to ≥90%, after the administration of sugammadex 4 mg/kg at the end of surgery, was 86 (69-104) s.Rocuronium 1.2 mg/kg reversed by sugammadex appears to be effective in the obstetric population.
Sugammadex
Rapid sequence induction
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Sugammadex
Rapid sequence induction
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Sugammadex reversiert die Wirkung von Rocuronium durch Enkapsulierung ohne muskarinerge Nebenwirkungen. Bisherige publizierte Studien zeigen eine effektive dosisabhängige Reversierung der neuromuskulären Blockade nach Verwendung von Rocuronium oder Vecuronium. Wir berichten in unserem Fallbericht von einem Patienten, der am Ende der OP nach RSI mit Rocuronium eine tiefe neuromuskuläre Blockade zeigte, die innerhalb weniger Minuten nebenwirkungsfrei reversiert werden konnte.
Sugammadex
Rapid sequence induction
Continuous Infusion
Muscle relaxation
Neuromuscular monitoring
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