Neuromuscular Blockade and Reversal: an Overview of Key Concepts
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Table 2. 2012 AGS Beers Criteria for Potentially
Table 2. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Strength of Organ System/ Recommendat Quality of Recomm Therapeutic Category/Drug(s) Rationale ion Evidence endation References Anticholinergics (excludes TCAs) First-generation antihistamines Highly anticholinergic; Avoid Hydroxyzin Strong Agostini 2001 (as single agent or as part of clearance reduced with e and Boustani 2007 combination products) advanced age, and promethazi Guaiana 2010 Brompheniramine tolerance develops ne: high; Han 2001 Carbinoxamine when used as hypnotic; All others: Rudolph 2008 Chlorpheniramine increased risk of moderate Clemastine confusion, dry mouth, Cyproheptadine constipation, and other Dexbrompheniramine anticholinergic Dexchlorpheniramine effects/toxicity. Diphenhydramine (oral) Doxylamine Use of diphenhydramine in Hydroxyzine special situations such Promethazine as acute treatment of Triprolidine severe allergic reaction may be appropriate. Antiparkinson agents Not recommended for Avoid Moderate Strong Rudolph 2008 Benztropine (oral) prevention of Trihexyphenidyl extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease. Antispasmodics Highly anticholinergic, Avoid Moderate Strong Lechevallier- Belladonna alkaloids uncertain except in Michel 2005 Clidinium-chlordiazepoxide effectiveness. short-term Rudolph 2008 Dicyclomine palliative Hyoscyamine care to Propantheline decrease Scopolamine oral secretions. Antithrombotics Dipyridamole, oral short-acting* May -
Appendix A: Potentially Inappropriate Prescriptions (Pips) for Older People (Modified from ‘STOPP/START 2’ O’Mahony Et Al 2014)
Appendix A: Potentially Inappropriate Prescriptions (PIPs) for older people (modified from ‘STOPP/START 2’ O’Mahony et al 2014) Consider holding (or deprescribing - consult with patient): 1. Any drug prescribed without an evidence-based clinical indication 2. Any drug prescribed beyond the recommended duration, where well-defined 3. Any duplicate drug class (optimise monotherapy) Avoid hazardous combinations e.g.: 1. The Triple Whammy: NSAID + ACE/ARB + diuretic in all ≥ 65 year olds (NHS Scotland 2015) 2. Sick Day Rules drugs: Metformin or ACEi/ARB or a diuretic or NSAID in ≥ 65 year olds presenting with dehydration and/or acute kidney injury (AKI) (NHS Scotland 2015) 3. Anticholinergic Burden (ACB): Any additional medicine with anticholinergic properties when already on an Anticholinergic/antimuscarinic (listed overleaf) in > 65 year olds (risk of falls, increased anticholinergic toxicity: confusion, agitation, acute glaucoma, urinary retention, constipation). The following are known to contribute to the ACB: Amantadine Antidepressants, tricyclic: Amitriptyline, Clomipramine, Dosulepin, Doxepin, Imipramine, Nortriptyline, Trimipramine and SSRIs: Fluoxetine, Paroxetine Antihistamines, first generation (sedating): Clemastine, Chlorphenamine, Cyproheptadine, Diphenhydramine/-hydrinate, Hydroxyzine, Promethazine; also Cetirizine, Loratidine Antipsychotics: especially Clozapine, Fluphenazine, Haloperidol, Olanzepine, and phenothiazines e.g. Prochlorperazine, Trifluoperazine Baclofen Carbamazepine Disopyramide Loperamide Oxcarbazepine Pethidine -
Ketamine As a General Anesthesia Adjunct Michaela Wilcox, DNP
Ketamine as a General Anesthesia Adjunct Michaela Wilcox, DNP (c), RN Dept. of Nurse Anesthesia, Moffett & Sanders School of Nursing, Samford University Structured Abstract Background Ketamine is a unique anesthetic agent with both anesthetic and analgesic properties. Ketamine is primarily a N-Methyl-D-Aspartic acid (NMDA) antagonist that also works on glutamine, nicotinic, muscarinic, monoaminergic and opioid receptors. The uses of ketamine are numerous and include treatment of chronic pain, acute pain, depression, as a multimodal pain adjunct, opioid-sparing agent and as an adjunct in enhanced recovery after surgery (ERAS) protocols. A 49-year-old female presented for a lumbar lateral interbody fusion extreme, anterior lumbar spine arthrodesis L3/4 with revision and instrumentation. Based on the surgical need for both sensory and motor nerve monitoring intraoperatively, the anesthetic plan included minimal sevoflurane, succinylcholine for induction and a propofol intravenous (IV) infusion with boluses of ketamine to maintain unconsciousness. A bispectral index (BIS) monitor (Aspect Medical Systems, Natick, MA) was placed on the patient’s forehead prior to induction and utilized intraoperatively to maintain a goal of 40-60. General anesthesia was achieved with fentanyl 100 mcg, lidocaine 100 mg, propofol 200 mg, ketamine 50 mg and succinylcholine 160 mg IV. Laryngoscopy was successfully performed using a McGrath MAC video laryngoscope (Medtronic, Minneapolis, MN). Following induction, a propofol IV infusion was initiated and sevoflurane maintained at 0.3 minimum alveolar concentration. Ketamine 10 mg IV was administered every hour. Upon conclusion of the procedure, the patient was extubated and transported to postoperative recovery unit, where she had no complaints of nausea, vomiting or pain. -
(Antimuscarinic) Drugs?
© July - August 2018 How well do you know your anticholinergic (antimuscarinic) drugs? nticholinergic drugs, prescribed for a variety of clini- Acal conditions, are amongst the most frequently used prescription drugs in BC (Table 1). Also referred to as “an- timuscarinics,” such drugs specifically block muscarinic receptors for acetylcholine (ACh).1 Muscarinic ACh recep- tors are important in the parasympathetic nervous system that governs heart rate, exocrine glands, smooth muscles, clude drugs whose active metabolites are potent- as well as brain function. In contrast, nicotinic ACh recep- ly antimuscarinic,5 or which often cause typical tors stimulate contraction of striated muscles. This Letter is AC adverse effects such as dry mouth or urinary intended to remind clinicians of commonly used drugs that retention.6 People taking antihistamines, antide- have anticholinergic (AC), or technically, antimuscarinic pressants, antipsychotics, opioids, antimuscarinic properties, and of their potential adverse effects. inhalers, or many other drugs need to know that Beneficial and harmful effects of anticholinergic drugs have blockade of ACh receptors can cause bothersome been known for centuries. In Homer’s Odyssey, the nymph or even dangerous adverse effects (Table 3). pharmacologist Circe utilized central effects of atropinics Subtle and not-so-subtle toxicity in the common plant jimson weed (Datura stramonium) to cause delusions in the crew of Odysseus. Believing they Students often learn the adverse effects of anticho- had been turned into pigs, they could be herded.2 linergics from a mnemonic, e.g.: “Blind as a bat, Sometimes a drug is recommended specifically for its an- mad as a hatter, red as a beet, hot as a hare, dry as ticholinergic potency. -
Reference List of Drugs with Potential Anticholinergic Effects 1, 2, 3, 4, 5
ANTICHOLINERGICS: Reference List of Drugs with Potential Anticholinergic Effects 1, 2, 3, 4, 5 J Bareham BSP © www.RxFiles.ca Aug 2021 WHENEVER POSSIBLE, AVOID DRUGS WITH MODERATE TO HIGH ANTICHOLINERGIC ACTIVITY IN OLDER ADULTS (>65 YEARS OF AGE) Low Anticholinergic Activity; Moderate/High Anticholinergic Activity -B in combo Beers Antibiotics Antiparkinsonian Cardiovascular Agents Immunosuppressants ampicillin *ALL AVAILABLE AS amantadine SYMMETREL atenolol TENORMIN azaTHIOprine IMURAN cefOXitin GENERIC benztropine mesylate COGENTIN captopril CAPOTEN cyclosporine NEORAL clindamycin bromocriptine PARLODEL chlorthalidone GENERIC ONLY hydrocortisone CORTEF gentamicin (Oint & Sol’n NIHB covered) carbidopa/levodopa SINEMET digoxin LANOXIN, TOLOXIN methylprednisolone MEDROL piperacillin entacapone COMTAN dilTIAZem CARDIZEM, TIAZAC prednisone WINPRED dipyridamole PERSANTINE, ethopropazine PARSITAN vancomycin phenelzine NARDIL AGGRENOX disopyramide RYTHMODAN Muscle Relaxants pramipexole MIRAPEX Antidepressants baclofen LIORESAL ( on intrathecal only) procyclidine KEMADRIN furosemide LASIX amitriptyline ELAVIL cyclobenzaprine FLEXERIL selegiline ELDEPRYL hydrALAZINE APRESOLINE clomiPRAMINE ANAFRANIL isosorbide ISORDIL methocarbamol ROBAXIN OTC trihexyphenidyl ARTANE desipramine NORPRAMIN metoprolol LOPRESOR orphenadrine NORFLEX OTC doxepin >6mg SINEQUAN Antipsychotics NIFEdipine ADALAT tiZANidine ZANAFLEX A imipramine TOFRANIL quiNIDine GENERIC ONLY C ARIPiprazole ABILIFY & MAINTENA -
The Quest for the Origin and Prevention of Postoperative Myalgia Following Succinylcholine : New Insights in an Old Problem
The quest for the origin and prevention of postoperative myalgia following succinylcholine : new insights in an old problem Citation for published version (APA): Schreiber, J-U. (2010). The quest for the origin and prevention of postoperative myalgia following succinylcholine : new insights in an old problem. Datawyse / Universitaire Pers Maastricht. https://doi.org/10.26481/dis.20100702js Document status and date: Published: 01/01/2010 DOI: 10.26481/dis.20100702js Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers. Link to publication General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal. -
Anesthesia and Analgesia in Laboratory Animals
GUIDELINES ON ANESTHESIA AND ANALGESIA IN LABORATORY ANIMALS University of South Florida provides the following guidelines for use by IACUC-certified faculty and staff. CONTENTS PAGE A. Background……………………………………………………….…………………………… 1 B. Definitions....……………………………………………………..…………………………….. 2 C. General Considerations……………………………………….,…………………………….. 3 D. Controlled Substances……………………………………….……………………………… 3 E. Pre-Anesthetic Treatments………………………………….………………………………. 4 F. General Anesthetics………………………………………….………………………………. 4 G. Neuromuscular Blocking Agents………………………….……………………………….. 5 H. Monitoring Anesthesia…………………………………….…………………………………. 6 I. Analgesics……………………………………………………………………………………… 7 J. Comments regarding Anesthetics and Analgesics……………………………………... 7 REFERENCE TABLES PAGE I. Signs of Pain and Distress in Laboratory Animals………………………………………… 10 II. Commonly Used Anesthetics and Analgesics for Mice….………..…...….………...…… 11 III. Commonly Used Anesthetics and Analgesics for Rats……………………………...…… 12 IV. Commonly Used Anesthetics and Analgesics for Gerbils……….……………..…….. 13 V. Commonly Used Anesthetics and Analgesics for Hamsters…….……………..……. 14 VI. Commonly Used Anesthetics and Analgesics for Guinea Pigs….…………….….……. 15 VII. Commonly Used Anesthetics and Analgesics for Rabbits.……...…………….………… 16 VIII. Commonly Used Anesthetics and Analgesics for Dogs.…………………….…………… 17 IX. Commonly Used Anesthetics and Analgesics for Cats.……………………..…………… 18 X. Commonly Used Anesthetics and Analgesics for Pigs ..……………..….………………..19 XI. Commonly Used Anesthetics and Analgesics -
Metered-Dose Inhalers (Mdis): Anti-Cholinergic Drugs
Texas Vendor Drug Program Drug Use Criteria: Aerosolized Agents - Metered-Dose Inhalers (MDIs): Anti-Cholinergic Drugs Publication History 1. Developed January 1995. 2. Revised April 2021; March 2019; March 2017; November 2015; March 2014; August 2012; June 2012; October 2010; January 2008; January 2003; January 2002; January 2001; March 2000; January 2000; February 1999; February 1998; February 1997; August 1995. Notes: All criteria may be applied retrospectively. The information contained is for the convenience of the public. The Texas Health and Human Services Commission is not responsible for any errors in transmission or any errors or omissions in the document. Medications listed in the tables and non-FDA approved indications included in these retrospective criteria are not indicative of Vendor Drug Program formulary coverage. Prepared by: • Drug Information Service, UT Health San Antonio. • The College of Pharmacy, The University of Texas at Austin 1 1 Dosage 1.1 Adults Ipratropium (Atrovent®), a short-acting, inhalational anticholinergic agent, is FDA- approved to manage bronchospasm associated with chronic bronchitis and emphysema, collectively known as chronic obstructive pulmonary disease (COPD). Ipratropium is considered a second-line agent in the treatment of asthma as the bronchodilatory effects seen with ipratropium are less than those seen with beta- adrenergic drugs. While not FDA approved, the Expert Panel 3 guidelines from the National Heart Lung and Blood Institute document benefit when multiple ipratropium doses are administered adjunctively with beta2-agonists in the emergency department to manage more severe acute asthma exacerbations, and the Global Initiative for Asthma (GINA) guidelines state that ipratropium may be considered an alternative bronchodilator in patients who experience adverse effects to short-acting beta2-agonists (e.g., tachycardia, arrhythmia, tremor). -
A Meta-Analysis on the Effect of Dexamethasone on The
Journal of Clinical Medicine Article A Meta-Analysis on the Effect of Dexamethasone on the Sugammadex Reversal of Rocuronium-Induced Neuromuscular Block 1, 2,3, 2,3, , 1,3, , Chang-Hoon Koo y, Jin-Young Hwang y, Seong-Won Min * z and Jung-Hee Ryu * z 1 Department of Anesthesiology & Pain medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; [email protected] 2 Department of Anesthesiology & Pain medicine, SMG-SNU Boramae Medical Center, Seoul 07061, Korea; [email protected] (J.-Y.H.) 3 Department of Anesthesiology & Pain medicine, Seoul National University College of Medicine, Seoul 03080, Korea * Correspondence: [email protected] (S.-W.M.); [email protected] (J.-H.R.); Tel.: +82-2-870-2518 (S.-W.M.); +82-31-787-7497 (J.-H.R.); Fax: +82-2-870-3863 (S.-W.M.); +82-31-787-4063 (J.-H.R.) These two authors equally contributed to this work as co-first authors. y These two authors equally contributed to this work as co-corresponding authors. z Received: 1 April 2020; Accepted: 21 April 2020; Published: 24 April 2020 Abstract: Sugammadex reverses the rocuronium-induced neuromuscular block by trapping the cyclopentanoperhydrophenanthrene ring of rocuronium. Dexamethasone shares the same steroidal structure with rocuronium. The purpose of this study was to evaluate the influence of dexamethasone on neuromuscular reversal of sugammadex after general anesthesia. Electronic databases were searched to identify all trials investigating the effect of dexamethasone on neuromuscular reversal of sugammadex after general anesthesia. The primary outcome was time for neuromuscular reversal, defined as the time to reach a Train-of-Four (TOF) ratio of 0.9 after sugammadex administration. -
CONTRAINDICATIONS ------Pediatric Patients (486 on DETROL LA, 224 on Placebo) Is Available
HIGHLIGHTS OF PRESCRIBING INFORMATION • Controlled Narrow-Angle Glaucoma: use caution in patients being These highlights do not include all the information needed to use Detrol® treated for narrow-angle glaucoma. (5.3) LA safely and effectively. See full prescribing information for Detrol LA. • Myasthenia Gravis: use caution in patients with myasthenia gravis. (5.6) • QT Prolongation: Consider observations from the thorough QT study in ® Detrol LA (tolterodine tartrate extended release capsules) clinical decisions to prescribe DETROL LA to patients with a known For oral administration history of QT prolongation or to patients who are taking Class IA (e.g., Initial U.S. Approval: December 2000 quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic medications (5.7) ----------------------------INDICATIONS AND USAGE--------------------------- Detrol LA is an antimuscarinic indicated for the treatment of overactive ------------------------------ADVERSE REACTIONS------------------------------- bladder with symptoms of urge urinary incontinence, urgency, and frequency. The most common adverse reactions (incidence >4% and >placebo) were dry (1) mouth , headache, constipation and abdominal pain. (6.1) ----------------------DOSAGE AND ADMINISTRATION----------------------- • 4 mg capsules taken orally once daily with water and swallowed To report SUSPECTED ADVERSE REACTIONS, contact Pfizer Inc. at whole. (2.1) 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. • 2 mg capsules taken orally once daily with water and swallowed whole in the presence of: ------------------------------DRUG INTERACTIONS------------------------------- o mild to moderate hepatic impairment (Child-Pugh • Potent CYP3A4 inhibitors: Co-administration may increase systemic class A or B) (2.2) exposure to DETROL LA. Reduce DETROL LA dose to 2 mg once o severe renal impairment [Creatinine Clearance (CCr) daily. -
(ORG 9487) Versus Mivacurium and Succinylcholine
1648 Anesthesiology 1999; 91:1648–54 © 1999 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Evaluation of Neuromuscular and Cardiovascular Effects of Two Doses of Rapacuronium (ORG 9487) versus Mivacurium and Succinylcholine Rafael Miguel, M.D.,* Thomas Witkowski, M.D.,† Hideo Nagashima, M.D.,‡ Robert Fragen, M.D.,§ Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/91/6/1648/398091/0000542-199912000-00016.pdf by guest on 01 October 2021 Richard Bartkowski, M.D.,i Francis F. Foldes, M.D.,‡† Colin Shanks, M.D.§† Background: This study compares the neuromuscular block- tively, vs. 112 s; P < 0.01). Clinical duration was longer in all ing and cardiovascular effects of rapacuronium (ORG 9487), a groups compared with the succinylcholine group; however, new aminosteroid nondepolarizing muscle relaxant, to recom- clinical duration in the 1.5 mg/kg rapacuronium group was mended intubating doses of succinylcholine and mivacurium. shorter compared with the mivacurium group (15 vs. 21 min, Methods: Adult patients were randomized in an open-label respectively; P < 0.01). Heart rate changes were mild in the 1.5 fashion to receive 1–5 mg/kg fentanyl before 1.5 mg/kg propo- mg/kg rapacuronium, succinylcholine, and mivacurium fol induction followed by 1.5 or 2.5 mg/kg rapacuronium, 1.0 groups. The patients in the 2.5mg/kg rapacuronium group had mg/kg succinylcholine, or 0.25 mg/kg mivacurium (i.e., 0.15 significantly higher heart rates compared with patients in the mg/kg followed by 0.1 mg/kg 30 s later). mivacurium group. No differences were found in blood pres- Results: Patient neuromuscular blockade status was moni- sure changes among patients in the four groups. -
Anticholinergic Drugs Toxicity
Prescription drug toxicity Anticholinergic drug toxicity Anticholinergic syndrome is produced by the inhibition of cholinergic neurotransmission at muscarinic receptor sites. It commonly follows the ingestion of a wide variety of prescription and over-the-counter medications. Signs and symptoms Clinical manifestations are caused by CNS effects, peripheral nervous system effects, or both. Common manifestations are as follows: Flushing Dry skin and mucous membranes Mydriasis with loss of accommodation Altered mental status Fever Additional manifestations include the following: Sinus tachycardia Decreased bowel sounds Urinary retention Hypertension Pathophysiology Substances with anticholinergic properties competitively antagonize acetylcholine muscarinic receptors; this predominantly occurs at peripheral (eg, heart, salivary glands, sweat glands, GI tract, urinary tract) postganglionic parasympathetic muscarinic receptors. Anticholinergic substances minimally compete with acetylcholine at other sites (eg, autonomic ganglia). Central nervous system manifestations result from central cortical and subcortical muscarinic receptor antagonism. The degree of CNS manifestation is related to the drug's ability to cross the blood-brain barrier. 1 Agents with anticholinergic properties are as follows: Anticholinergics o Atropine, scopolamine Antihistamines o Chlorpheniramine o Cyproheptadine o Diphenhydramine o Promethazine Antipsychotics o Chlorpromazine o Clozapine o Thioridazine Antispasmodics o Clidinium o Hyoscyamine o Propantheline