Acta Anaesthesiologica ScandinavicaVolume 59, Issue 7 p. 946-947 Letter to the Editor Magnesium-induced recurarisation after reversal of rocuronium-induced neuromuscular block with sugammadex. Findings vs. speculation M. Carron, Corresponding Author M. Carron Correspondence M. Carron, Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy E-mail: [email protected]Search for more papers by this authorC. Ori, C. OriSearch for more papers by this author M. Carron, Corresponding Author M. Carron Correspondence M. Carron, Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Padova, Italy E-mail: [email protected]Search for more papers by this authorC. Ori, C. OriSearch for more papers by this author First published: 12 May 2015 https://doi.org/10.1111/aas.12551Citations: 1 Conflict of interest: Carron M. and Ori C. have received payments for lectures from Merck Sharp & Dohme (MSD), Italy. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1Unterbuchner C, Ziegleder R, Graf B, Metterlein T. Magnesium-induced recurarisation after reversal of rocuronium-induced neuromuscular block with sugammadex. Acta Anaesthesiol Scand 2015; 59: 536– 40. 2Eger EI 2nd, Gong D, Koblin DD, Bowland T, Ionescu P, Laster MJ, Weiskopf RB. The effect of anesthetic duration on kinetic and recovery characteristics of desflurane versus sevoflurane, and on the kinetic characteristics of compound A, in volunteers. Anesth Analg 1998; 86: 414– 21. 3Paul M, Fokt RM, Kindler CH, Dipp NC, Yost CS. Characterization of the interactions between volatile anesthetics and neuromuscular blockers at the muscle nicotinic acetylcholine receptor. Anesth Analg 2002; 95: 362– 7. 4Carron M. Sugammadex after the reappearance of four twitches during train-of-four stimulation: monitoring and dose considerations. Anesthesiology 2014; 120: 508. 5Czarnetzki C, Tassonyi E, Lysakowski C, Elia N, Tramèr MR. Efficacy of sugammadex for the reversal of moderate and deep rocuronium-induced neuromuscular block in patients pretreated with intravenous magnesium: a randomized controlled trial. Anesthesiology 2014; 121: 59– 67. 6Bom A, Hope F, Rutherford S, Thomson K. Preclinical pharmacology of sugammadex. J Crit Care 2009; 24: 29– 35. Citing Literature Volume59, Issue7August 2015Pages 946-947 ReferencesRelatedInformation

Background. Although post liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation.Methods. Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl.Results. The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects.Conclusions. Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

Failed airway situations are potentially catastrophic events and require a correct approach with appropriate tools. Recently, Ventrain has been presented as a manual device for emergency ventilation through a small-bore cannula, which can provide expiratory assistance by applying the Venturi effect.

Advances in surgical techniques and follow-up of patients with complex congenital heart disease who were corrected in childhood increasingly survive to adolescence or adulthood. Increasingly anesthesiologists encounter these cases for major noncardiac surgery, including orthotopic liver transplantation (OLT) wherein there is an augmented risk of significant perioperative hemodynamic instability. We performed a successful OLT in a 12-year-old boy with end-stage cryptogenetic liver fibrosis and hepatopulmonary syndrome who was born with a double outflow right ventricle, pulmonary atresia, and pulmonary artery hypoplasia corrected at the age of 1 month. By the time he was considered for OLT his altered pulmonary valve apparatus resulted in severe pulmonary regurgitation, dilated right atrium and ventricle, and elevated right heart pressures. After a temporarily successful angioplasty he was at first placed on the waiting list, then removed, and finally relisted following implantation of a prosthetic pulmonary valve that resulted in significant reduction of right heart pressures.

BACKGROUND:Exposure to general anaesthesia during critical stages of brain development results in long-lasting cognitive impairment. Co-administration of protective agents could minimize the detrimental effects of anaesthesia. Co-administration of R(+)pramipexole (PPX), a synthetic aminobenzothiazol derivative that restores mitochondrial integrity, prevents anaesthesia-induced mitochondrial and neuronal damage and prevents early development of cognitive impairment. Here, we determine the protective effects of PPX into late adulthood in male and female rats.METHODS:Postnatal day 7 rats of both sexes were exposed to mock anaesthesia or combined midazolam, nitrous oxide, and isoflurane anaesthesia for 6 h with or without PPX. Cognitive abilities were assessed between 5 and 7 months of age using Morris water maze spatial navigation tasks.RESULTS:Examination of spatial reference memory revealed that female, but not male, neonatal rats exposed to anaesthesia showed slowing of acquisition rates, which was significantly improved with PPX treatment. Examination of memory retention revealed that both male and female anaesthesia-treated rats have impaired memory retention performance compared with sham controls. Co-treatment with PPX resulted in improvement in memory retention in both sexes.CONCLUSION:PPX provides long-lasting protection against cognitive impairment known to occur when very young animals are exposed to anaesthesia during the peak of brain development. Anaesthesia-induced cognitive impairment appears to be sex-specific with females being more vulnerable than males, suggesting that they could benefit more from early prevention.

Editor—Polymyositis was considered responsible for a delayed onset and reversal of rocuronium-induced neuromuscular block (NMB) by sugammadex.1Suzuki T Nameki K Shimizu H Shimizu Y Nakamura R Ogawa S Efficacy of rocuronium and sugammadex in a patient with dermatomyositis.Br J Anaesth. 2012; 108: 703doi:10.1093/bja/aes087Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar We recently cared for a female patient, aged 67 yr (weight, 60 kg; height, 155 cm), with polymyositis associated with Sjogren’s syndrome, undergoing laparoscopic sigmoid resection for diverticulitis. Her medications included prednisone 12.5 mg daily and methotrexate 15 mg weekly, and on preoperative evaluation, she was noted to have severe weakness of the extremities. Anaesthesia was induced with fentanyl 3 μg kg−1 and propofol 2 mg kg−1 and maintained with desflurane and remifentanil, titrated to a state entropy value of 35 (5). After loss of consciousness, the left ulnar nerve was supramaximally stimulated near the wrist with square-wave 0.2 ms pulses, delivered as 2 Hz train-of-four (TOF) pulses at 15 s intervals. The resulting adductor pollicis muscle contractions were quantified acceleromyographically (TOF-Watch SX, Organon Teknik, Ireland). Stabilization, calibration, and baseline responses were recorded at anaesthesia induction before rocuronium administration, and neuromuscular monitoring was continued until the TOF ratio returned to ≥1.0. NMB was achieved with a rocuronium 0.9 mg kg−1 bolus before tracheal intubation. This reduced the TOF ratio from 1.07 to 0.0 in 80 s. NMB was maintained with subsequent boluses of rocuronium, titrated to achieve moderate NMB for the first 30 min, and then, in the following period, deep NMB [1–5 post-tetanic counts (PTCs)] to ensure adequate surgical conditions (rocuronium 220 mg total dose) (Fig. 1). At the end of the uneventful, 210 min surgical procedure, remifentanil was stopped and sugammadex 4 mg kg−1 was administered to reverse the deep NMB. Complete reversal of NMB, from 1 PTC to a TOF ratio of 1.11, was achieved within 90 s. Desflurane was then discontinued, the patient awakened, and the tracheal tube removed. The patient had no evidence of residual or recurrent NMB in the postoperative period. Polymyositis is histopathologically characterized by perivascular non-suppurative inflammatory infiltrates leading to muscle fibre degeneration.1Suzuki T Nameki K Shimizu H Shimizu Y Nakamura R Ogawa S Efficacy of rocuronium and sugammadex in a patient with dermatomyositis.Br J Anaesth. 2012; 108: 703doi:10.1093/bja/aes087Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 2Flusche G Unger-Sargon J Lambert DH Prolonged neuromuscular paralysis with vecuronium in a patient with polymyositis.Anesth Analg. 1987; 66: 188-190doi:10.1213/00000539-198666020-00017Crossref PubMed Google Scholar, 3Saarnivaara LH Anesthesia for a patient with polymyositis undergoing myectomy of the cricopharyngeal muscle.Anesth Analg. 1988; 67: 701-702doi:10.1213/00000539-198807000-00016Crossref PubMed Scopus (4) Google Scholar, 4Brown S Shupak RC Patel C Calkins JM Neuromuscular blockade in a patient with active dermatomyositis.Anesthesiology. 1992; 77: 1031-1033doi:10.1097/00000542-199211000-00028Crossref PubMed Scopus (8) Google Scholar Clinically, it causes symmetrical, proximal muscle weakness. There is no evidence that the disease affects the neuromuscular junction itself.2Flusche G Unger-Sargon J Lambert DH Prolonged neuromuscular paralysis with vecuronium in a patient with polymyositis.Anesth Analg. 1987; 66: 188-190doi:10.1213/00000539-198666020-00017Crossref PubMed Google Scholar, 3Saarnivaara LH Anesthesia for a patient with polymyositis undergoing myectomy of the cricopharyngeal muscle.Anesth Analg. 1988; 67: 701-702doi:10.1213/00000539-198807000-00016Crossref PubMed Scopus (4) Google Scholar, 4Brown S Shupak RC Patel C Calkins JM Neuromuscular blockade in a patient with active dermatomyositis.Anesthesiology. 1992; 77: 1031-1033doi:10.1097/00000542-199211000-00028Crossref PubMed Scopus (8) Google Scholar Thus, the onset of action of rocuronium and the reversal of rocuronium-induced NMB by sugammadex should be within the normal range, as observed in our case, and not affected by the inflammatory processes of the muscle.1Suzuki T Nameki K Shimizu H Shimizu Y Nakamura R Ogawa S Efficacy of rocuronium and sugammadex in a patient with dermatomyositis.Br J Anaesth. 2012; 108: 703doi:10.1093/bja/aes087Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The patient in the Suzuki and colleagues1Suzuki T Nameki K Shimizu H Shimizu Y Nakamura R Ogawa S Efficacy of rocuronium and sugammadex in a patient with dermatomyositis.Br J Anaesth. 2012; 108: 703doi:10.1093/bja/aes087Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar report was 75 yr old, which may have been an important factor contributing to his delayed onset and recovery from rocuronium-induced NMB by sugammadex.5Matteo RS Ornstein E Schwartz AE Ostapkovich N Stone JG Pharmacokinetics and pharmacodynamics of rocuronium (Org 9426) in elderly surgical patients.Anesth Analg. 1993; 77: 1193-1197doi:10.1213/00000539-199312000-00019Crossref PubMed Scopus (112) Google Scholar, 6Kruijt Spanjer MR Bakker NA Absalom AR Pharmacology in the elderly and newer anaesthesia drugs.Best Pract Res Clin Anaesthesiol. 2011; 25: 355-365doi:10.1016/j.bpa.2011.06.002Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar The onset of rocuronium is longer in older than in younger adults.5Matteo RS Ornstein E Schwartz AE Ostapkovich N Stone JG Pharmacokinetics and pharmacodynamics of rocuronium (Org 9426) in elderly surgical patients.Anesth Analg. 1993; 77: 1193-1197doi:10.1213/00000539-199312000-00019Crossref PubMed Scopus (112) Google Scholar This is primarily attributed to diminished cardiac output, which increases the time to equilibration between the plasma and the neuromuscular junction.5Matteo RS Ornstein E Schwartz AE Ostapkovich N Stone JG Pharmacokinetics and pharmacodynamics of rocuronium (Org 9426) in elderly surgical patients.Anesth Analg. 1993; 77: 1193-1197doi:10.1213/00000539-199312000-00019Crossref PubMed Scopus (112) Google Scholar 6Kruijt Spanjer MR Bakker NA Absalom AR Pharmacology in the elderly and newer anaesthesia drugs.Best Pract Res Clin Anaesthesiol. 2011; 25: 355-365doi:10.1016/j.bpa.2011.06.002Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The time for reversal of rocuronium-induced NMB by sugammadex may also be prolonged in the elderly.6Kruijt Spanjer MR Bakker NA Absalom AR Pharmacology in the elderly and newer anaesthesia drugs.Best Pract Res Clin Anaesthesiol. 2011; 25: 355-365doi:10.1016/j.bpa.2011.06.002Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar 7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar Although sugammadex facilitates rapid reversal from rocuronium-induced NMB in adults of all ages, reversal of rocuronium-induced NMB with sugammadex is somewhat slower in the elderly.7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar When sugammadex was administered at the time of spontaneous reappearance of the second twitch of TOF, the geometric mean time from sugammadex administration to recovery of the TOF ratio to 0.9 was longer in patients ≥65 yr than those aged 18–64 yr (2.9 vs 2.3 min, P=0.022).7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar With increasing age, the geometric mean time increased from 2.3 min (adults) to 3.6 min (patients ≥75 yr).7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar This difference has been attributed to the lower cardiac output in older patients, which leads to a slower distribution of sugammadex.6Kruijt Spanjer MR Bakker NA Absalom AR Pharmacology in the elderly and newer anaesthesia drugs.Best Pract Res Clin Anaesthesiol. 2011; 25: 355-365doi:10.1016/j.bpa.2011.06.002Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar 7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar The elderly may also experience altered perfusion within the muscles, thus changing the distribution and redistribution rates of rocuronium, sugammadex, and the rocuronium–sugammadex complex.6Kruijt Spanjer MR Bakker NA Absalom AR Pharmacology in the elderly and newer anaesthesia drugs.Best Pract Res Clin Anaesthesiol. 2011; 25: 355-365doi:10.1016/j.bpa.2011.06.002Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar 7McDonagh DL Benedict PE Kovac AL et al.Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients.Anesthesiology. 2011; 114: 318-329doi:10.1097/ALN.0b013e3182065c36Crossref PubMed Scopus (96) Google Scholar In conclusion, in patients with Sjogren’s syndrome, polymyositis alone seems to not affect the onset of action of rocuronium and the reversal of rocuronium-induced deep NMB by sugammadex. The observations of Suzuki and colleagues1Suzuki T Nameki K Shimizu H Shimizu Y Nakamura R Ogawa S Efficacy of rocuronium and sugammadex in a patient with dermatomyositis.Br J Anaesth. 2012; 108: 703doi:10.1093/bja/aes087Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar may have been at least partly attributed to the older age of their patient. M.C. has received payments for lectures from MSD. C.O. has received payments and travel funding for lectures and as a member of the MSD Advisory Board.

Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.

Acta Anaesthesiologica ScandinavicaVolume 57, Issue 5 p. 674-674 LETTER TO THE EDITOR Missed citation? P. FELTRACCO, P. FELTRACCOSearch for more papers by this authorC. ORI, C. ORISearch for more papers by this author P. FELTRACCO, P. FELTRACCOSearch for more papers by this authorC. ORI, C. ORISearch for more papers by this author First published: 25 February 2013 https://doi.org/10.1111/aas.12084 Address: Paolo Feltracco Dipartimento di Medicina UOC Anestesia e Terapia Intensiva Via Cesare Battisti 257 35100, Azienda Ospedaliera Padova Padova 35128 Italy e-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 Beleña JM, Nuñez M, Yuste J, Plaza-Nieto F, Jiménez-Jiménez FJ, Serrano S. Spontaneous intracranial hypotension syndrome treated with a double epidural blood patch. Acta Anaesthesiol Scand 2012; 56: 1332– 1335. 2 Kim SY, Hong JH. Epidural blood patches in a patient with multi-level cerebrospinal fluid leakage that was induced by spontaneous intracranial hypotension. Korean J Pain 2010; 23: 46– 50. 3 Feltracco P, Barbieri S, Milevoj M, Ori C. Simultaneous epidural blood patches at different intervertebral spaces for spontaneous intracranial hypotension. Br J Anaesth 2010; 105: 868– 869. Volume57, Issue5May 2013Pages 674-674 ReferencesRelatedInformation

Sugammadex, the first selective relaxant-binding agent indicated to reverse the neuromuscular blockade induced during general anesthesia, was recently introduced into clinical practice. In the present report, the following issues pertinent to the use of sugammadex in anesthesia practice are discussed: the intraoperative use of NMBAs and the incidence of postoperative residual curarization (PORC); the efficacy and safety of rocuronium plus sugammadex compared to succinylcholine for rapid sequence induction; the availability of sugammadex in hospitals; and, finally, some relevant legal medical aspects. Sugammadex is considerably more expensive than neostigmine, but its use can be advocated based on its safety and efficacy profile as a reversal agent of steroidal neuro muscular blocking agents (NMBAs), and as a mean to prevent PORC. The availability of sugammadex in Italian hospitals may have a beneficial impact on patient safety. This is due to the fact that PORC is a common and dangerous condition that may lead to postoperative inhalational events, hypoxemia, and pneumonia; and at the moment, it is not completely preventable even when advanced neuro-muscolar monitoring techniques are applied". In the case of rapid sequence intubation (RSI), rocuronium (1.2 mg/kg) administration followed by sugammadex represents a better choice in terms of efficacy and safety than succinylcholine. If a new drug is proven to be safer and more efficient than the one it is replacing, hospitals should consider the new drug and make it available, at least for selected patients or in situations at risk of severe complications. It is reasonable to hypothesize that, when discussing informed consent for elective procedures, patients and families may want to know if the admitting facilities have the superior agent available, and that the absence of such agent could create concerns and complains.

We read with great interest the paper by Van Lancker et al. concerning the reversal of rocuronium-induced neuromuscular blockade in morbidly obese patients using doses of sugammadex adjusted on the basis of different weight-based dosing scalars [1]. Sugammadex, a modified γ-cyclodextrin, has been developed as a reversal agent for aminosteroid neuromuscular blocking agents, particularly rocuronium, and acts by encapsulating and inactivating unbound rocuronium forming tight 1:1 complexes [2]. Approved dosing options of sugammadex for moderate (reappearance of second twitch), deep (1-2 post-tetanic counts) and immediate reversal of rocuronium-induced neuromuscular blockade are 2, 4 and 16 mg.kg−1, respectively [2]. Adjusting the dose of sugammadex based on actual body weight is valid for normal-weight subjects whose total body weight (TBW), lean body weight (LBW) and ideal body weight (IBW) are similar [3]. However, in morbidly obese patients the physiological and anthropometric changes associated with obesity alter the pharmacokinetic properties of most drugs, so that a different dosing regimen is required for sugammadex as well as for other anaesthetic drugs [3]. The pharmacokinetic profile of sugammadex is similar to that of rocuronium, and rocuronium dosed according to IBW is recommended in morbidly obese patients [3]. Sugammadex is highly hydrophilic and distributes into the central compartment, primarily into the plasma and possibly into the extracellular fluid [2], so a loading dose of sugammadex based on TBW is illogical, as fat mass is excluded from its distribution [1]. So, as suggested by the authors, sugammadex should be adjusted on the basis of IBW or LBW in morbidly obese patients [1]. However, in Van Lancker et al.’s study the reversal was administered when the train-of-four ratio (TOF) reached 0.9 [1]. There is evidence that upper airway dysfunction (e.g. dysphagia or partial upper airway obstruction) may occur even with recovery of the TOF ratio to 0.9 [4, 5], and a TOF threshold of 1.0 is now recommended, particularly in morbidly obese patients who are at high risk of postoperative respiratory complications [2, 6]. In our experience, sugammadex dosed on the basis of TBW makes it possible to reach the TOF ratio of one quickly and in all cases. Also, rapid recovery may be an expression of the effectiveness of the dose of sugammadex [2]. The time of reversal decreases with the increase in the dose of sugammadex administered, as shown by dose-finding studies [2]. Sugammadex seems to guarantee a quicker recovery from neuromuscular blockade if it is administered on the basis of TBW rather than on IBW or LBW [1]. Furthermore, even if the authors did not experience recurarisation, an inadequate dose of sugammadex may be incapable of sustaining the redistribution of rocuronium from the peripheral to the central compartment, particularly after high dosage or in the presence of altered metabolism and elimination of rocuronium [1, 7]. Finally, sugammadex is well tolerated, with very few untoward side effects reported, including when administered at higher doses than those clinically recommended [2]. In conclusion, although it is reasonable to use IBW or LBW on the basis of the pharmacokinetic profile of sugammadex, we believe that TBW should continue to be considered the safe and effective dosage regimen for complete reversal from neuromuscular blockade with sugammadex in morbidly obese patients.

Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post-lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.

Editor—Morbid obesity (MO) is associated with important physiological and anthropometric changes that alter the pharmacokinetic properties of most drugs.1Ingrande J Lemmens HJ Dose adjustment of anaesthetics in the morbidly obese.Br J Anaesth. 2010; 105: i16-i23Abstract Full Text Full Text PDF PubMed Google Scholar, 2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar, 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Knowledge of these changes and careful consideration of the optimal dosing are necessary for safe and effective anaesthesia in MO patients.1Ingrande J Lemmens HJ Dose adjustment of anaesthetics in the morbidly obese.Br J Anaesth. 2010; 105: i16-i23Abstract Full Text Full Text PDF PubMed Google Scholar, 2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar, 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Ideal body weight (IBW), lean body weight (LBW), and total body weight (TBW) are dosing scales for the commonly used anaesthetic agents.1Ingrande J Lemmens HJ Dose adjustment of anaesthetics in the morbidly obese.Br J Anaesth. 2010; 105: i16-i23Abstract Full Text Full Text PDF PubMed Google Scholar, 2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar, 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar The most common methods for the calculation of IBW and LBW are Devine's and Janmahasatian's formulas, respectively.2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar However, these are not intuitive, straightforward, or quick in emergency situations.2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar, 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 4Stehman CR Buckley RG Dos Santos FL et al.Bedside estimation of patient height for calculating ideal body weight in the emergency department.J Emerg Med. 2011; 41: 97-101Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Therefore, we aimed to provide a simplified method for determining IBW and LBW using 200 consecutive male [mean (range) age (yr) 38.4 (18–65); mean (sd) BMI (kg m−2) 47.7 (6.5)] and 200 consecutive female [age (yr) 41.1 (18–70); BMI (kg m−2) 45.5 (4.8)] patients undergoing bariatric surgery at our University Hospital. A linear regression analysis was performed on the IBW and LBW as derived from Devine's and Janmahasatian's formulas, respectively.2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar 3Leykin Y Miotto L Pellis T Pharmacokinetic considerations in the obese.Best Pract Res Clin Anaesthesiol. 2011; 25: 27-36Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar It was based on the equation y=α x, where y is the IBW or LBW, x the h2, and α the best-fit values estimated by the model that should be inserted into the following simplified formula: IBW or LBW=BMI (best fit) h2. The linear regression analysis determined that the best-fit BMI of values derived from Devine's equation for IBW was 22.85 for men and 20.55 for women. Likewise, the best-fit BMI of values derived from Janmahasatian's equation for LBW was 25.92 for men and 21.38 for women (Fig. 1). As there is a direct relationship between body weight and height for a given BMI,4Stehman CR Buckley RG Dos Santos FL et al.Bedside estimation of patient height for calculating ideal body weight in the emergency department.J Emerg Med. 2011; 41: 97-101Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 5Matsuzawa Y Tokunaga K Kotani K Keno Y Kobayashi T Tarui S Simple estimation of ideal body weight from body mass index with the lowest morbidity.Diabetes Res Clin Pract. 1990; 10: S159-S164Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 6Lemmens HJ Brodsky JB Bernstein DP Estimating ideal body weight—a new formula.Obes Surg. 2005; 15: 1082-1083Crossref PubMed Scopus (99) Google Scholar, 7Hume R Prediction of lean body mass from height and weight.J Clin Pathol. 1966; 19: 389-391Crossref PubMed Scopus (223) Google Scholar a simplified formula has been proposed to estimate IBW, that is, IBW=BMI h2.5Matsuzawa Y Tokunaga K Kotani K Keno Y Kobayashi T Tarui S Simple estimation of ideal body weight from body mass index with the lowest morbidity.Diabetes Res Clin Pract. 1990; 10: S159-S164Abstract Full Text PDF PubMed Scopus (50) Google Scholar 6Lemmens HJ Brodsky JB Bernstein DP Estimating ideal body weight—a new formula.Obes Surg. 2005; 15: 1082-1083Crossref PubMed Scopus (99) Google Scholar Some authors have found that a BMI of 22 represents the best generic value for both men and women to replace BMI in this simplified formula.5Matsuzawa Y Tokunaga K Kotani K Keno Y Kobayashi T Tarui S Simple estimation of ideal body weight from body mass index with the lowest morbidity.Diabetes Res Clin Pract. 1990; 10: S159-S164Abstract Full Text PDF PubMed Scopus (50) Google Scholar 6Lemmens HJ Brodsky JB Bernstein DP Estimating ideal body weight—a new formula.Obes Surg. 2005; 15: 1082-1083Crossref PubMed Scopus (99) Google Scholar Unfortunately, the BMI value of 22 identified by these earlier reports is not gender-specific, which is important given the differences in fat and lean mass between men and women.8Levitt DG Heymsfield SB Pierson Jr, RN Shapses SA Kral JG Physiological models of body composition and human obesity.Nutr Metab. 2007; 4: 19Crossref Scopus (17) Google Scholar 9Geer EB Shen W Gender differences in insulin resistance, body composition, and energy balance.Gend Med. 2009; 6: 60-75Abstract Full Text PDF PubMed Scopus (563) Google Scholar Instead, we propose that a BMI value of 21 should be used for women and a BMI value of 23 should be used for men when estimating IBW. Interestingly, there are no data available for a simplified means to estimate LBW in MO patients. From our results, we suggest using a BMI of 22 in the simplified formula for females and a BMI of 26 for males. The gender-specific values that should replace the BMI in the new simplified formula for estimating LBW are greater than those used for the estimation of IBW, which is appropriate. While in normal-weight patients, the IBW and LBW are similar,1Ingrande J Lemmens HJ Dose adjustment of anaesthetics in the morbidly obese.Br J Anaesth. 2010; 105: i16-i23Abstract Full Text Full Text PDF PubMed Google Scholar 2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar this is not the case in MO patients, where LBW increases with increasing TBW.1Ingrande J Lemmens HJ Dose adjustment of anaesthetics in the morbidly obese.Br J Anaesth. 2010; 105: i16-i23Abstract Full Text Full Text PDF PubMed Google Scholar 2Lemmens HJ Perioperative pharmacology in morbid obesity.Curr Opin Anaesthesiol. 2010; 23: 485-491Crossref PubMed Scopus (60) Google Scholar In addition, for a given BMI, men have higher lean mass and more visceral and hepatic adipose tissue, whereas women in particular have elevated general adiposity and subcutaneous adipose tissue.8Levitt DG Heymsfield SB Pierson Jr, RN Shapses SA Kral JG Physiological models of body composition and human obesity.Nutr Metab. 2007; 4: 19Crossref Scopus (17) Google Scholar 9Geer EB Shen W Gender differences in insulin resistance, body composition, and energy balance.Gend Med. 2009; 6: 60-75Abstract Full Text PDF PubMed Scopus (563) Google Scholar We suggest that our formulas provide an easy, quick, reproducible, and gender-specific estimation of IBW and LBW in MO patients. None declared.

Posterior reversible encephalopathy syndrome (PRES) is a rare disease characterized by altered mental status, seizures, headache, vomiting and visual disturbances, most often described after transplantation and immunosuppressive therapy. PRES is commonly first diagnosed by the neuroradiologist, rather than the clinician, as it is characterized by very typical magnetic resonance imaging (MRI) features, i.e., hyperintense lesions in the territories of the posterior cerebral artery. Here we report our experience in the Intensive Care Unit (ICU) with a case of tacrolimus-related PRES after liver transplant, presenting with sudden neurological deterioration and diffuse and massive hyperintensities upon brain MRI. Discontinuation of tacrolimus, as prompted by the established literature, permitted the patient to eliminate tacrolimus-associated toxicity, whereas its substitution with everolimus and mycofenolic acid allowed the maintenance of immunosuppression while avoiding acute organ rejection and reducing the dosage of corticosteroids. The lowering of blood pressure with drugs reported in the literature for use in PRES proved to be effective but challenging, requiring the use of multiple drugs and only slowly leading to proper control of hypertensive peaks. Nonetheless, hypertension management and supportive therapy allowed for a complete neurological restitutio ad integrum of the patient. In conclusion, tacrolimus-related brain adverse events need to be promptly recognized, especially during the first months after transplantation. When tacrolimus-related PRES occurs, immunosuppressive therapy may be safely and efficiently switched to everolimus and mycofenolic acid. This strategy may help not only to avoid acute organ rejection but also to reduce the dosage of corticosteroids, which might interfere with proper control of hypertension.

BACKGROUND:Despite the common use of tracheostomy in lung transplant (LT) patients, little data exist regarding the indications, timing, periprocedural complications, and impact on outcomes of the procedure.METHODS:We retrospectively analyzed some characteristics and timing of all tracheostomies performed in our lung transplant recipients during a 5-year period.RESULTS:Between January 2004 and November 2009, 31 of 126 lung transplant patients (24.6%) underwent a tracheostomy. They included 14 men with a mean age of 42 years (range, 10 to 61 years) and 17 women with a mean age of 45 years (range, 10 to 64 years). Twenty eight patients undergoing a tracheostomy had a prior bilateral sequential LT and 4 had accepted a single lung. Tracheostomy was surgically performed (ST) in 6 of 31 patients (19.3%); percutaneous tracheostomy (PT) techniques were applied for the other 25 (80.6%) cases. The decision to perform a tracheostomy was made within 4 days from LT in 21 of 31 patients (67.7%), within 8 days in 6 (19.3%) and after 10 days for the other 4 (12.9%) cases. There were no major complications during the PT procedures; no conversion to ST, no loss of airway, no paratracheal insertion, and no accidental tracheal extubation. No pneumothorax, pneumomediastinum, hypotension, hypoxemia, or arrythmyas were recorded in the early post-procedural period. The mean post-LT duration of cannulation was 17 days (range, 5 to 72 days).DISCUSSION:An early tracheostomy may be of considerable benefit for the debilitated patient who will likely require prolonged mechanical ventilation because of a complicated intraoperative course and poor recovery of graft function. PT was performed more quickly and was associated with fewer postoperative complications than ST. We recommend an aggressive strategy in the immediate posttransplant period when extubation fails or is delayed for various reasons.

Early exposure to general anesthesia (GA) causes developmental neuroapoptosis in the mammalian brain and long-term cognitive impairment. Recent evidence suggests that GA also causes functional and morphological impairment of the immature neuronal mitochondria. Injured mitochondria could be a significant source of reactive oxygen species (ROS), which, if not scavenged in timely fashion, may cause excessive lipid peroxidation and damage of cellular membranes. We examined whether early exposure to GA results in ROS upregulation and whether mitochondrial protection and ROS scavenging prevent GA-induced pathomorphological and behavioral impairments. We exposed 7-day-old rats to GA with or without either EUK-134, a synthetic ROS scavenger, or R(+) pramipexole (PPX), a synthetic aminobenzothiazol derivative that restores mitochondrial integrity. We found that GA causes extensive ROS upregulation and lipid peroxidation, as well as mitochondrial injury and neuronal loss in the subiculum. As compared to rats given only GA, those also given PPX or EUK-134 had significantly downregulated lipid peroxidation, preserved mitochondrial integrity, and significantly less neuronal loss. The subiculum is highly intertwined with the hippocampal CA1 region, anterior thalamic nuclei, and both entorhinal and cingulate cortices; hence, it is important in cognitive development. We found that PPX or EUK-134 co-treatment completely prevented GA-induced cognitive impairment. Because mitochondria are vulnerable to GA-induced developmental neurotoxicity, they could be an important therapeutic target for adjuvant therapy aimed at improving the safety of commonly used GAs.