British journal of anaesthesia
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Researchers induced awake paralysis in 10 volunteers using separately both suxamethonium and rocuronium. Both the BIS A2000 (2003) and BIS Vista monitor (2013) were tested.
BIS decreased immediately after paralysis and did not fully recover until muscle recovery. BIS values decreased to as low as 44, despite the subject being awake.
In more than half of the 20 trials the BIS value decreased to below 60 at some point. In one case this lasted for almost 4 minutes, representing 76% of the total paralysis time for that subject.
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Patients with butyrylcholinesterase (BChE) deficiency can experience prolonged paralysis after receiving suxamethonium or mivacurium. We hypothesized that patients suspected of BChE deficiency had a higher risk of being awakened while paralysed and having respiratory complications if neuromuscular monitoring was not applied before awakening. ⋯ Patients with BChE deficiency are at higher risk of being awakened while paralysed if neuromuscular monitoring is not applied or used; neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is administered.
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Editorial Comment
Restrict relaxants, be aware, and know the limitations of your depth of anaesthesia monitor.
Interesting editorial accompanying Dr Peter Schuller's excellent study of BIS values in awake, paralysed volunteers.
The editors make a very interesting point critiquing the probabilistic, database-based approach to processed-EEG awareness monitors like BIS: (emphasis added)
"This database-driven approach may have limitations, in particular for the detection of intraoperative wakefulness: it is very unlikely that data from an awake and paralyzed subject are included in this database. Therefore, the resulting anaesthesia index has not been trained with a dataset that contains this clinical situation..."
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Randomized Controlled Trial
Effect of subanaesthetic ketamine on plasma and saliva cortisol secretion.
The commonality between chronic conditions that are treated with low-dose ketamine, such as specific chronic pain conditions, depression, and post-traumatic stress disorder, can be found in relation to the stress system, particularly the hypothalamus-pituitary-adrenal axis. In this study we assess the effect of ketamine on the stress system by measuring plasma and saliva cortisol production during and following exposure to low-dose ketamine. ⋯ This study was registered in the Dutch Trial Register under number NTR2717 at www.trialregister.nl.
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Randomized Controlled Trial
Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial.
Low fibrinogen (Fg) concentrations in trauma haemorrhage are associated with poorer outcomes. Cryoprecipitate is the standard source for Fg administration in the UK and USA and is often given in the later stages of transfusion therapy. It is not known whether early cryoprecipitate therapy improves clinical outcomes. The primary aim of this feasibility study was to determine whether it was possible to administer cryoprecipitate, within 90 min of admission to hospital. Secondary aims were to evaluate laboratory measures of Fg and clinical outcomes including thrombotic events, organ failure, length of hospital stay and mortality. ⋯ Early Fg supplementation using cryoprecipitate is feasible in trauma patients. This study supports the need for a definitive RCT to determine the effect of early Fg supplementation on mortality and other clinical outcomes.