Articles: neuromuscular-blocking-agents-adverse-effects.
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Why is this important?
First, because it identifies new novel risk factors for residual neuromuscular block (experienced surgeon, non-CRNA anesthesia provider...) and secondly, because the subtext reveals the lengths our specialty goes to avoid simply monitoring using qualitative NMB monitoring (TOFR)!
What did they find?
Rudolph et al. created a REsidual neuromuscular block Prediction Score (REPS) using Massachusetts General PACU data, applying covariate analysis to identify 10 risk factors, some more surprising than others:
- Hepatic failure
- Neurological disease
- High-neostigmine dose > 60 mcg/kg
- Metastatic solid tumour
- Female sex
- Less than 120 min between NMBD administration and extubation
- Aminosteroid NMBD
- BMI more than 35
- Absence of nurse anaesthetist (CRNA)
- Having an experienced surgeon
Be smart:
These risk factors might suggest patients who need more careful monitoring, but you will probably be better off just using qualitative monitoring routinely. The utility of REPS itself is only modest with NPV & PPVs of 85% each.
The other takeaway is that rNMB is still demonstratably common, occurring in 20% of this cohort!
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Historical Article
Neuromuscular blocking agents induced anaphylaxis: Results and trends of a French pharmacovigilance survey from 2000 to 2012.
Perioperative anaphylaxis mainly involves neuromuscular blocking agents (NMBAs) with an IgE-mediated mechanism. In France, this life-threatening condition is reported by anesthetists and allergologists, and two safety alerts concerning suxamethonium were raised in 2011 and 2012. This led to start a national survey over the 2000-2012 period which objectives were to provide a descriptive analysis, to estimate incidence rates, and to analyze the trends over this period. ⋯ Suxamethonium and rocuronium are markedly more involved in perioperative anaphylaxis than the other available NMBAs. Patients should be more informed about their perioperative anaphylaxis and its consequences.
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Int. Immunopharmacol. · Sep 2018
Cisatracurium induces mast cell activation and pseudo-allergic reactions via MRGPRX2.
Pseudo-allergic reactions occur when patients receive muscle relaxants during perioperative anesthesia. These reactions may result in a serious threat to the patient's life, particularly to a child's life. Cisatracurium, a relatively new NMBA, has resulted in bronchospasms and cardiovascular collapse. However, the mechanisms underlying the anaphylactoid reactions caused by cisatracurium have not been fully elucidated. ⋯ Cisatracurium activated MRGPRX2 and triggered mast cell degranulation, leading to anaphylactoid reactions. Therefore, strategies targeting MRGPRX2 might potentially block cisatracurium-induced pseudo-allergic reactions.
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Neuromuscular blocking drugs (NMBD) are administered intra-operatively to facilitate intubation and to achieve muscle relaxation for surgical procedures. Incomplete reversal of NMBD can lead to adverse events in the postoperative period. Patients with obstructive sleep apnea (OSA) may be at higher risk of complications related to the use of NMBD. The objectives of this systematic review were to determine whether: 1) OSA patients are at higher risk of postoperative complications from the use of NMBD than non-OSA patients, and 2) the choice of NMBD reversal agent affects the risk of postoperative complications in OSA patients. ⋯ OSA patients who receive intraoperative NMBD may be at higher risk for postoperative hypoxemia, respiratory failure and residual neuromuscular blockade compared to non-OSA patients. There is some, albeit very limited evidence that NMBD reversal with sugammadex may be associated with less PPCs than neostigmine in patients with OSA. More high-quality studies are needed.
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J Am Assoc Nurse Pract · Jun 2018
Effects of the use of neuromuscular blocking agents on acute respiratory distress syndrome outcomes: A systematic review.
Acute respiratory distress syndrome (ARDS) is a high-mortality disease with limited treatment options. Optimization of gas exchange while limiting damage to the lungs is key. The use of neuromuscular blocking agents may limit hypoxemia while preventing ventilator-induced lung injury. ⋯ Secondary analysis from two separate groups concluded the improved outcomes, with no evidence of increased risk of critical illness polyneuropathy or myopathy, suggest that the use of NMBAs in severe ARDS is appropriate.