Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium

Murphy, Glenn S.; Szokol, Joseph W.; Marymont, Jesse H.; Vender, Jeffery S.; Avram, Michael J.; Rosengart, Todd K.; Alwawi, Eihab

doi:10.1213/01.ane.0000057602.27031.c8

Cited by 54 publications

(34 citation statements)

References 21 publications

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“…Pancuronium (0.2 mg ⅐ kg Ϫ1 ⅐ h Ϫ1 ) was used throughout the whole procedure, facilitating mechanical ventilation and providing muscle relaxation. This is common during cardiac surgery (15,33). We checked for absence of corneal reflexes and of reaction to a pain stimulus in the nasal cartilage before administration of pancuronium, indicating adequate anesthesia.…”

Section: Methodsmentioning

confidence: 99%

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery

Alders¹,

Groeneveld²,

Kanter³

et al. 2004

American Journal of Physiology-Heart and Circulatory Physiology

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and correlated well (r ϭ 0.85, P ϭ 0.02, n ϭ 7) with oxygen consumption calculated from blood flow, hemoglobin, and blood gas measurements (mean 22.8 Ϯ 4.7 mol⅐min Ϫ1 ⅐g dry wt Ϫ1). Local blood flow and oxygen consumption were significantly correlated (r ϭ 0.63 for pooled normalized data, P Ͻ 0.0001, n ϭ 60). We calculate that, in the heart at normal workload, the variance of left ventricular oxygen delivery at submilliliter resolution is explained for 43% by heterogeneity in oxygen demand. regional blood flow; metabolism; myocardium; magnetic resonance spectroscopy MYOCARDIAL BLOOD FLOW is highly heterogeneous, as demonstrated in many different species, with various methods (radioactive, colored and fluorescent microspheres, molecular tracers, MRI, and PET), and under different experimental circumstances, such as open-versus closed-chest and anesthetized versus awake animals (5,9,19,22,26,27). Myocardial perfusion shows similar heterogeneity in the human heart (47). This heterogeneity is largely of spatial nature, although there is also some temporal variation (27). Local blood flow can differ by a factor five among small areas of the left ventricle, even in the normal heart. Interestingly, regional blood flow is rather stable over a substantial time period, at least for several hours, but some data even indicate a relatively stable local blood flow over days (44). From an anatomic and mechanical point of view, this heterogeneity is difficult to understand because the heart appears rather homogeneous and biomechanical models predict homogeneous contraction. The question thus remains: which factors contribute to heterogeneous blood flow? Heterogeneity in oxygen consumption (V O 2 ) between different areas of the left ventricle may explain at least part of the heterogeneity of myocardial blood flow. Indeed, it has been shown in previous studies (9,19) that indirect indicators of local aerobic metabolism show heterogeneity. For instance, a correlation between local blood flow and fatty acid uptake has been shown (24). Others (38, 39) have reported a rather good correlation between local myocardial blood flow and local myocardial V O 2 (MV O 2 ) measured by [18 O]water in the isolated buffer-perfused rabbit heart. Low-flow areas had lower V O 2 and highflow areas had higher V O 2 . Further studies showed that areas of the left ventricle that receive a relatively low amount of blood flow are not in a hypoxic state, suggesting local adaptation of blood flow to oxygen demand (8,11,14). However, direct measurement of aerobic metabolic flux in small myocardial regions became possible only recently. Regional V O 2 and regional blood flow can be estimated with PET, although this technique still does not permit analysis at sufficiently high spatial resolution to study cardiac heterogeneity in small tissue areas (1,34,37).To investigate the distribution of MV O 2 at high spatial resolution, a new combination of isotope labeling protocol and mathematical analysis of 13 C incorporation into the tricarboxylic acid (TCA) cycle ...

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Section: Methodsmentioning

confidence: 99%

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery

Alders¹,

Groeneveld²,

Kanter³

et al. 2004

American Journal of Physiology-Heart and Circulatory Physiology

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“…D Di is sc cu us ss si io on n Residual NMB after cardiac surgery is well-documented. [2][3][4] Its occurrence is not surprising given the numerous predisposing factors associated with cardiac surgery: long-acting neuromuscular blocking agents, planned postoperative ventilation, magnesium sulphate, co-morbidities, advanced age, hypothermic CPB, volatile agents, acidosis, hypocalcemia, aminoglycosides, vancomycin, furosemide, mannitol, betablockers, and calcium channel blockers. 5 To the best of our knowledge, however, these are the first reported cases of complete paralysis lasting more than ten hours after cardiac surgery.…”

Section: Conclusion : Nous Devons éViter D'administrer De Fortes Dosementioning

confidence: 99%

“…The orbicularis oculi is more resistant to non-depolarizing agents than the adductor pollicis and direct facial muscle stimulation can occur unintentionally around the eye. 4 Alternative techniques, such as phonomyography, 15 have been proposed for monitoring NMB during cardiac surgery, …”

Section: Conclusion : Nous Devons éViter D'administrer De Fortes Dosementioning

confidence: 99%

Prolonged (more than ten hours) neuromuscular blockade after cardiac surgery: report of two cases

Olivieri

Plourde

2005

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : We examine two cases of prolonged neuromuscular blockade (NMB) after cardiac surgery. To the best of our knowledge, these are the first reported cases of complete paralysis lasting more than ten hours after surgery.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : We attribute the extended durations of NMB (more than ten hours) to high doses of NMB drugs in combination with magnesium sulphate and moderate renal failure. Advanced age, hepatic disease, aminoglycoside exposure, hypocalcemia, and possible interaction between rocuronium and pancuronium may have played minor roles.C Co on nc cl lu us si io on n: : We should avoid administering large doses of NMB agents, even in the context of planned postoperative ventilation. If NMB is not monitored intraoperatively in patients who are at risk of prolonged NMB, then train-of-four response should be measured in the intensive care unit. Adequate sedation should be provided until proper recovery of neuromuscular function is documented. E examine two cases of prolonged neuromuscular blockade (NMB) after cardiac surgery. We attribute the extended durations of complete paralysis (more than ten hours) to high doses of NMB drugs in combination with magnesium sulphate and moderate renal failure. ObjectifC Ca as se e 1 1 A 67-yr-old woman was referred to the anesthesia service for prolonged NMB after mitral valve replacement.The patient had been transferred to our hospital for surgical treatment of bacterial endocarditis and critical mitral stenosis. The patient was treated initially for two weeks with ampicillin and gentamicin and one week of ampicillin alone. Her past medical history included rheumatic mitral valve stenosis (with previous commissurotomy), pulmonary hypertension and chronic atrial fibrillation. Height and weight were 165 cm and 63 kg. Laboratory investigations revealed anemia, hypokalemia, and mild pre-renal failure (Table I). Preoperative medications included furosemide, digoxin, ramipril, iv heparin, flurazepam, ampicillin, and potassium chloride.

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“…Follow-up studies 2,[6][7][8][9][10] demonstrated that early extubation-known as "fast track" cardiac anesthesia-does not pose additional risks, positioning early extubation as the standard of care in cardiac surgery. 3 A 2011 American College of Cardiology guideline 11 gave a class 1 recommendation for an anesthetic directed toward early postoperative extubation among low-to medium-risk CABG patients.…”

mentioning

confidence: 99%

Quality Improvement Intervention to Decrease Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery

Hefner¹,

Tripathi²,

Abel³

et al. 2016

American Journal of Critical Care

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BackgroundIn 2010, the incidence of prolonged mechanical ventilation (> 24 hours) after isolated coronary artery bypass graft (CABG) surgery was 26.9% at the study site, The Ohio State University Wexner Medical Center, compared with the national like-hospital rate of 10.9%. Objectives To use the principles of lean management to reduce the incidence of prolonged mechanical ventilation and to assess the sustainability of that reduction over time. Methods A multidisciplinary prolonged ventilation task force conducted a gap analysis leading to 3 interventions: (1) a standardized extubation protocol, (2) dry erase boards in patients' rooms to facilitate team communication, and (3) edits of the postoperative order set within the electronic health record. Outcomes of mechanical ventilation in CABG patients before and after the interventions are compared. Results All target outcomes changed significantly after the interventions, including a reduction in the median hours of initial mechanical ventilation (from 11.4 hours to 6.9 hours, P < .001). The percentage of patients reintubated did not increase (a decrease from 11.8% to 3.5% was not significant, P = .08). The rate of prolonged ventilation decreased from 29.4% to 8.6% (P = .004), and this reduction was sustained for 4 years after the interventions. Conclusions Success factors included the multidisciplinary task force and continual protocol reeducation among front-line staff.

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Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium

Abstract: The use of long-acting muscle relaxants in fast-track cardiac surgical patients is associated with significant residual neuromuscular block in the intensive care unit, including signs and symptoms of residual paresis.

Cited by 54 publications

References 21 publications

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery

Prolonged (more than ten hours) neuromuscular blockade after cardiac surgery: report of two cases

Quality Improvement Intervention to Decrease Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery

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Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium

Abstract: The use of long-acting muscle relaxants in fast-track cardiac surgical patients is associated with significant residual neuromuscular block in the intensive care unit, including signs and symptoms of residual paresis.

Cited by 54 publications

References 21 publications

Myocardial O2consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O2delivery

Myocardial O2consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O2delivery

Prolonged (more than ten hours) neuromuscular blockade after cardiac surgery: report of two cases

Quality Improvement Intervention to Decrease Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery

Contact Info

Product

Resources

About

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery

Myocardial O₂consumption in porcine left ventricle is heterogeneously distributed in parallel to heterogeneous O₂delivery