Sedation and neuromuscular paralysis in the ICU

Patients receiving mechanical ventilation usually require sedation and/or analgesia. The patient's underlying disease state and the indications for mechanical ventilation should be considered before selecting and administering sedative agents. The risk of prolonged sedation after discontinuation of drug therapy can be reduced with careful selection of agents and their dosing regimen. There must be a clear reason for using muscle relaxants because there are disadvantages to their use.     

Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized,prospective study

BACKGROUND: Acute anterior glenohumeral dislocations have been commonly treated with closed reduction and the use of intravenous sedation. Recently, the use of intra-articular lidocaine has been advocated as an alternative to sedation, since intravenous access and patient monitoring are not required. The purpose of this study was to evaluate the value of local anesthesia compared with that of the commonly used intravenous sedation during the performance of a standardized reduction technique. METHODS: In a prospective, randomized study, skeletally mature patients with an isolated glenohumeral joint dislocation and no associated fracture were randomized to receive either intravenous sedation or intra-articular lidocaine to facilitate reduction of the dislocation. Reduction was performed with the modified Stimson method. The two groups were compared with regard to the rate of successful reduction, pain as rated on a visual analog scale, time required for the reduction, time from the reduction until discharge from the emergency department, and cost. RESULTS: Thirty patients were enrolled in the study. Five (two in the lidocaine group and three in the sedation group) required scapular manipulation in addition to the Stimson technique to reduce the dislocation. The lidocaine group spent significantly less time in the emergency department (average time, seventy-five minutes compared with 185 minutes in the sedation group, p < 0.01). There was no significant difference between the two groups with regard to pain (p = 0.37), success of the Stimson technique (p = 1.00), or time required to reduce the shoulder (p = 0.42). The cost of the intravenous sedation was $97.64 per patient compared with $0.52 for use of the intra-articular lidocaine. CONCLUSIONS: Use of intra-articular lidocaine to facilitate reduction with the Stimson technique is a safe and effective method for treating acute shoulder dislocations in an emergency room setting. Intra-articular lidocaine requires less money, time, and nursing resources than does intravenous sedation to facilitate reduction with the Stimson technique.     

Anterior dislocation of the shoulder: a simple method of reduction.

An effective method for reducing anterior dislocation of the glenohumeral joint which does not require either sedation or traction is described. The patient performs the manoeuvre. A series of 32 consecutive patients were treated by this method. Easy reduction was achieved in 72 per cent, with no complications and patients spent less than half as long in the accident and emergency department as when it is not successful. We recommend this simple technique as a first method of reduction in patients presenting to accident and emergency departments.     

"Self-taming": an alternative to the prevention of succinylcholine-induced pain

Muscle pain associated with single-bolus administration of suxamethonium is reported to be one of the common complications of this technique. Since suxamethonium is the most commonly used relaxant in our department and priming with nondepolarizing muscle relaxants is also reported to be linked with complications, while the literature concerning this problem is very contradictory, we wondered if the so-called "self-taming" method represents an alternative to pretreatment with nondepolarizing muscle relaxants. One hundred thirty-two patients (69 male, 63 female) were randomly allocated to three groups. Anesthesia was induced with thiopentone 7 mg/kg body weight. Group 1 (n = 44) was pretreated with 2 mg pancuronium bromide 3 min prior to full relaxation with suxamethonium 1.5 mg/kg. Group 2 (n = 43) received no pretreatment. Group 3 (n = 45) received 4 mg suxamethonium i.v. after induction. One minute later the remaining dose of suxamethonium was applied ("self-taming"). Muscle fasciculation and postoperative myalgia were verified by means of a score. Neuromuscular transmission was recorded on a monitor after controlled train-of-four stimulus and time of onset of neuromuscular blockade was measured. With regard to muscle fasciculation, postoperative pain, and onset of neuromuscular blockade, "self-taming" with suxamethonium yielded results identical to pretreatment with pancuronium bromide. It may therefore be considered as an alternative to pretreatment with nondepolarizing muscle relaxants.     

When is it safe to reduce fracture dislocation of shoulder under sedation? Proposed treatment algorithm

Introduction

Shoulder dislocations are common. It is known that incongruent shoulder should be promptly reduced. However, when associated with fracture of the proximal humerus, there is a clinical dilemma if reduction under sedation is a safe option. We wanted to establish when it is safe to attempt reduction of a shoulder fracture dislocation under sedation in emergency room.

Methods

This is a retrospective cohort study assessing consecutive patients presenting with a dislocation of a gleno-humeral joint with an associated fracture of the humerus between 2007 and 2015. The radiographs and patients’ records were examined. The number of fragments according to Neer’s criteria and size of fragments were recorded.

Results

We identified 102 patients who presented with 104 cases of fracture dislocation of shoulder joint. 10 of the dislocations were posterior, remainder were anterior. All posterior dislocations were reduced under general anaesthesia. Sixty-two anterior fracture dislocations had attempted reduction under sedation in emergency department. Eight of those were unsuccessful, and patient required general anaesthetic for further management. In five of those cases, significant displacement of humeral head in relation to the shaft after attempted reduction.

Conclusion

We propose pragmatic approach to the initial treatment of fracture dislocations of shoulder. In type I injury, where there is an anterior dislocation with greater tuberosity fracture, one should attempt a reduction under sedation; 94% of attempted reductions under sedation were successful and no fracture propagation occurred. In case of a type II injury, when the fracture is involving a surgical neck of the humerus with or without greater tuberosities fracture, our experience suggests that no attempt of reduction is undertaken under sedation and patient has general anaesthetic. Posterior dislocation with any fracture remains an unsolved problem, but in our series no attempt of reduction under sedation was made.

     

Anesthetic management of two patients with amyotrophic lateral sclerosis (ALS)

We experienced anesthetic management of two cases of amyotrophic lateral sclerosis (ALS). Case 1. A 46-year-old woman underwent emergency operation for ileus. Abdominal muscle relaxation and analgesia were obtained by combined spinal and epidural anesthesia. To avoid prolongation of muscle relaxation, awake intubation without muscle relaxants was performed. After the operation, she awoke smoothly and was extubated without any complications. Case 2. A 65-year-old woman underwent emergency operation for gastric fistula malfunction. We performed anesthetic management only with epidural anesthesia. During and after the operation, she was in good general condition and had no pain. For the patients with ALS, prolongation of muscle relaxation and residual neuromuscular block effect may cause difficult tracheal extubation and postoperative respiratory complications. We observed carefully the condition of the patients with ALS, and were able to choose the minimum invasive anesthetic methods for each case.     

Legg reduction maneuver for patients with anterior shoulder dislocation

Few manual techniques for reducing anterior shoulder dislocations are easy to perform in the clinical setting, and many of these techniques require sedation. The authors describe a technique, the Legg reduction maneuver, that is easy to perform on site and requires no premedication. Clinical experience indicates that proper use of this maneuver can successfully relocate a patient's anterior shoulder dislocation. The relocated arm can then be placed in an immobilizer and receive further medical management as appropriate. The Legg reduction maneuver allows the physician to work with the natural tendencies of muscle groups in the patient, rather than against them. Thus, the technique can be performed without sedation. In addition, because no traction is placed on the injured shoulder, the potential for neurovascular injury is decreased.     

Assessment of alfentanil by intravenous infusion as long-term sedation in intensive care

The use of an alfentanil infusion for sedation of critically ill patients in intensive care was investigated in 16 patients who were entered consecutively into the study. The mean duration of stay was 8 days. Supplements of Diazemuls and muscle relaxants were administered if required. The success of the technique was judged by nursing and medical staff and, in particular, the wakefulness of patients was noted. No patient could recall events that occurred during their infusion. An outline protocol is described.     

Anesthetic management of two patients with polymyositis

We report anesthetic experience of two patients suffering from polymyositis. The first case is a 56 year old woman who underwent tympanoplasty for cholesteatoma of the middle ear. Anesthesia was induced with thiopental and deepened with oxygen-nitrous oxide and sevoflurane. No muscle relaxant was used for endotracheal intubation and for maintaining anesthesia. Another is a 61 year old man who underwent open reduction and internal fixation for condyle fracture of the tibia. Epidural catheter was inserted at L 3-L 4. Epidural blockade was established with 2% mepivacaine, and sedation was achieved by intravenous midazolam. Concerning the anesthetic management of a patient with polymyositis, there are some informations on the appropriate use of muscle relaxants. It is generally believed that the patient is sensitive to nondepolarizing muscle relaxants and the use of antagonist drug (reversal) may cause muscle weakness, severe dysrhythmia, et al. Therefore we think it is appropriate to manage such a patient without muscle relaxants.     

Application of muscle relaxants in Germany. A survey of German anaesthesia departments

AIM. The aim of this study was to evaluate the use and application of muscle relaxants and neuromuscular monitoring in Germany. METHODS. A total of 2,996 questionnaires were sent out to the heads of German anaesthesia departments and private anaesthesia practices.The questions covered frequency of muscle relaxants used,how they were used, and neuromuscular monitoring. Influences on the way muscle relaxants were used could be derived from the desire for specific properties of a muscle relaxant, the desire for different monitoring conditions and from the size of the institution.We correlated these features with application practice using logistic regression analyses. RESULTS. Of the 2,996 questionnaires 2,058 could be analysed (68.6%).Amongst those were 102 level one hospitals (5%) and 903 private practices (44%).The replies from 350 (17%) departments were based on surveyed data, 1,613 (78.5%) were based on estimations. The desire for certain properties of muscle relaxants correlated with the use in practice, as were the desire for a non-depolarizing replacement for succinylcholine, the size of the department and the frequency of use of neuromuscular monitoring.Over 50% of all German anaesthesia departments limited the use of muscle relaxants to three.The use of laryngeal masks reduced the use of muscle relaxants. CONCLUSIONS. The survey regarding use of muscle relaxants in Germany could for the first time give an overview on the use of anaesthesia-specific substances in Germany. From the different frequencies of use and use modalities,conclusions could be drawn towards a standard of application for the year 2000.Changes in this standard would raise the need for further trend surveys.The methods of statistical analysis and survey evaluation can be used as a base for further surveys.     

The use of conscious sedation for pain control during forearm fracture reduction in children: does race matter?

Recent reports in the medical literature indicate that certain racial disparities have been identified in healthcare. The authors sought to identify the potential relationship between the use of pain medications in African-American and Caucasian children undergoing forearm fracture reduction. This retrospective cohort study was performed at a university-affiliated tertiary care children's hospital emergency department. All Caucasian and African-American patients who underwent a closed reduction of a fractured ulna or radius over the 2-year observational period were enrolled. Patients were excluded from the study if they were admitted to the hospital for an open reduction or had multiple injuries. The relationship between race, gender, insurance status, time of admission, length of stay in the emergency department, fracture characteristics, and the use of conscious sedation was analyzed. t tests, chi-square tests, and stepwise logistic regression were used for data analysis. A total of 503 patients were included, 83% Caucasian and 17% African-American. Four hundred four patients received conscious sedation as part of their fracture reduction procedure and 99 did not. Univariate analysis showed that African-American and Caucasian children had different forearm fracture patterns (P = 0.0116) and different severities of angulation (P = 0.0094). Multivariate statistical analysis revealed that higher amounts of fracture translation (P < 0.0001) and angulation (P < 0.0027) and younger age of the patient (P = 0.0059) were significant predictors of conscious sedation use. Race was not found to be significantly associated with the use of conscious sedation (P = 0.0606 in univariate analysis, P = 0.1678 in multivariate analysis). The authors found that the decision to use conscious sedation for pediatric forearm fractures was not influenced by race, but was influenced by certain fracture characteristics and patient age.     

Evidence in orthopaedics: comparison of intra-articular lidocaine vs. intravenous analgesia and sedation for reduction of acute shoulder dislocation

Abstract Acute shoulder dislocation is the most common joint dislocation managed in emergency department. It has been commonly treated with closed reduction and the use of intravenous analgesia and sedation (IVAS). Recently, intra-articular lidocaine (IAL) has been advocated as an alternative to sedation, since intravenous access and patient monitoring are not required. A careful literature analysis was performed to establish which anesthetic method is best indicated to reach a reduction that is easily performed, effective, relatively painless and safe, and to allow for expeditious discharge of the patient. To find the best evidence on the topic, we searched in the Cochrane Library, Health Technology Assessment (HTA) database, TRIP, Medline, CINAHL, and EMBASE. In the four prospective randomized clinical trials found, no statistically significant difference was detected between IAL and IVAS for reduction of acute anterior shoulder dislocations with regard to pain score, difficulty of reduction, and success rate. Although we cannot definitively state which is the best anesthetic method, we conclude that intra-articular injection of lidocaine is an excellent alternative for those patients for whom IVAS is not indicated.     

Equipment for electro-convulsive therapy

ECT (electro-convulsive therapy) has been used for the treatment of depressive patients. First it was applied in patients only with sedatives without muscle relaxants, but now we employ muscle relaxants to avoid convulsion and its complications. It is called modified ECT (mECT). General anesthesia using muscle relaxant for ECT is now increasingly employed in Japan. Furthermore, there are some reports that ECT is effective not only in depressive patients but in chronic pain patients. This is why anesthesiologists are especially interested in ECT. In this chapter, clinical application, equipment and complications of ECT are discussed.     

Intravenous regional anaesthesia (Bier’s block) for pediatric forearm fractures in a pediatric emergency department—Experience from 2003 to 2014

Study objectivesTo evaluate the efficacy (length of stay in the emergency department and failure rate of Bier’s block) and safety profile (death and major complications) of Bier’s block in its use for manipulation and reduction of paediatric forearm fractures.MethodsThis is a retrospective cohort study of pediatric patients in KKWomen’s and Children’s Hospital Children’s Emergency Department with forearm fractures between Jan 2003 and Dec 2014 who underwent manipulation and reduction using Bier’s block. Demographic data, time from registration to discharge, major complications and success rate were collated in a standardized data collection form. A subanalysis of the Bier’s block group from 2009 to 2014 was performed and compared to a corresponding data set of paediatric patients who underwent manipulation and reduction of forearm fractures using ketamine for procedural sedation from 2009 to 2014.Results1781 cases of paediatric forearm fractures were analysed. The mean age of patients in the Bier’s block group was 12.0 years (range 5.5–17.8 years old). Of all patients undergoing Bier’s block, 1471 out of 1781 patients were male (82.7%). The mean length of stay (LOS) in the department was 168 ± 72 min, measured from time of registration till departure. From our subanalysis of data from 2009 to 2014, the mean LOS for the Bier’s block group was shorter − 170 min compared to 238 min for the ketamine group (P < 0.0001).2 patients had failed Bier’s block which required a repeat procedural sedation using ketamine. 96% of patients who underwent Bier’s block were discharged with an outpatient orthopaedic appointment. There were no deaths or major complications identified in our study.ConclusionBier’s block is a safe technique for reduction of fractures when used in the appropriate population and fracture types, with a low failure rate and no major complications including death. Compared to the ketamine group, it has a shorter length of stay in the emergency department. We recommend the adoption of this practice for manipulation and reduction of pediatric forearm fractures in the Emergency Department with a formalised protocol to reduce and prevent any human errors that can potentially result in complications.     

Cost-benefit analysis of neuromuscular blocking agents

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - At present, the cost of muscle relaxants is too small compared with other costs of anaesthesia, surgery, and hospital stay,...     

Comparison between propofol and dexmedetomidine in postoperative sedation after extensive cervical spine surgery

Purpose  

Patients undergoing extensive cervical spine surgery (ECSS) occasionally require emergency reintubation due to postoperative airway complications. To avoid it, an endotracheal tube is retained in patients maintained under sedation overnight. This study was conducted to determine whether dexmedetomidine would be superior in sedative effects to propofol for postoperative sedation after ECSS.     

Sedation and neuromuscular paralysis in the ICU

Critically ill patients receiving mechanical ventilation in the ICU usually require sedative therapy and, less frequently, neuromuscular blocking agents. A combination of a sedative agent and an opioid are typically administered by continuous intravenous infusion to relieve discomfort and distress. How sedatives and neuromuscular blocking agents are used can have a significant influence on patient outcome. This article outlines the pharmacology of the commonly used drugs that are of particular relevance to the critically ill. The changes in pharmacokinetics and pharmacodynamics associated with critical illness may lead to marked accumulation and prolongation of the drug effect. Excess sedation is detrimental to patient outcome by prolonging the duration of ventilatory support and intensive care stay. The use of sedation scores and regular sedation breaks has been associated with improved outcomes by reducing excess sedation. Delerium is a common complication of critical illness and is associated with an increased morality and long-term neurocognitive problems. Recognition of delirium and appropriate management may improve outcome.     

Das Long-QT-Syndrom in der Anästhesie

The long QT syndrome (LQTS) is a rare, congenital or acquired disease, which may lead to fatal cardiac arrhythmias (torsade de pointes, TdP). In all LQTS subtypes, TdPs are caused by disturbances in cardiac ion channels. Diagnosis is made using clinical, anamnestic and electrocardiographic data. Triggers of TdPs are numerous and should be avoided perioperatively. Sufficient sedation and preoperative correction of electrolyte imbalances are essential. Volatile anaesthetics and antagonists of muscle relaxants should be avoided and high doses of local anaesthetics are not recommended to date. Propofol is safe for anaesthesia induction and maintenance. The acute therapy of TdPs with cardiovascular depression should be performed in accordance with the guidelines for advanced cardiac life support and includes cardioversion/defibrillation and magnesium. Torsades de pointes may be associated with bradycardia or tachycardia resulting in specific therapeutic and prophylactic measures.     

Anaesthesia for Friedreich's ataxia. Case report

Friedreich's ataxia is an inherited neuromuscular disorder often associated with significant cardiac disease and requiring special care during anaesthesia because of increased sensitivity to muscle relaxants. We report a 37 years old female patient with Friedreich's ataxia who underwent anaesthesia for total hip replacement because of degenerative hip arthritis. Anaesthesia was induced with alfentanil and propofol. Endotracheal intubation was achieved without the use of any muscle relaxants and muscle relaxants were avoided throughout the operation. Anaesthesia was maintained with propofol infusion and intermittent bolus doses of alfentanil. At the end of the procedure recovery from anaesthesia was fast and uneventful. When there is no absolute indication for neuromuscular blocking agents as its the case for many orthopaedic operations, avoiding these drugs would simply avoid many potential complications due to muscle relaxant use in this group of patients.