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4 03 2010 J P Mulier1 1150 1850 1947 1977 2010 The place of Sugammadex (Bridion ® ) in laparoscopic bariatric surgery Jan Paul Mulier, MD PhD Sint Jan.

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Presentation on theme: "4 03 2010 J P Mulier1 1150 1850 1947 1977 2010 The place of Sugammadex (Bridion ® ) in laparoscopic bariatric surgery Jan Paul Mulier, MD PhD Sint Jan."— Presentation transcript:

1 J P Mulier The place of Sugammadex (Bridion ® ) in laparoscopic bariatric surgery Jan Paul Mulier, MD PhD Sint Jan Brugge-Oostende

2 J P Mulier2 Overview 1. Current state of reversal Limitations / Potential risks with residual blockade Limitations / Potential risks with residual blockade Techniques to reduce need for reversal Techniques to reduce need for reversal 2. Reversal with bridion ® (Sugammadex) Mechanism of action / Pharmacokinetics, pharmacodynamics Mechanism of action / Pharmacokinetics, pharmacodynamics Efficacy / Safety - Practical dosage Efficacy / Safety - Practical dosage 3. Indications for bridion ® (Sugammadex) Can not intubate / can not ventilate Can not intubate / can not ventilate Rapid sequence induction for short procedures Rapid sequence induction for short procedures Continuous deep blockade till end of surgery Continuous deep blockade till end of surgery Sudden / not predicted / need for awakening Sudden / not predicted / need for awakening Need for an amfetamine like arousal effect Need for an amfetamine like arousal effect 4. Practical use in bariatric laparoscopy Anaesthesia induction Anaesthesia induction Anaesthesia maintenance Anaesthesia maintenance Anaesthesia awakening ERAS technique of Bruges Anaesthesia awakening ERAS technique of Bruges

3 J P Mulier3 Limitations of Cholinesterase Inhibitors Relatively slow in reversing neuromuscular blockade Relatively slow in reversing neuromuscular blockade Insufficient or impossible to reverse deep blockade Insufficient or impossible to reverse deep blockade Require concomitant administration of anticholinergics Require concomitant administration of anticholinergics Well-known side effect profile Well-known side effect profile Bartkowski RR. Anesth Analg. 1987;66: Kim KS et al. Anesth Analg. 2004;99: Kopman AF et al. J Clin Anesth. 2005;17:30-35.

4 J P Mulier4 Neostigmine (50 µg/kg) Inadequately Reverses 95% Twitch Depression 5 min 10 min 15 min 20 min ROC 0.6 mg/kg n = 20 TOF ratio 0.33 ± ± ± ± 0.12 TOF < % (20) 95% (19) 85% (17) NEO, neostigmine; ROC, rocuronium; TOF, train-of-four. Kopman AF et al. J Clin Anesth. 2005;17: NEO administered 10 min20 min 30 min T 1 = 100% T 1 = 50% Solid area = height of T 4 Hatched area = height of T 1 Vecuronium Protocol Rocuronium Protocol

5 J P Mulier5 Side Effects Associated With Current Reversal Agents ChE inhibitors in the reversal can cause ChE inhibitors in the reversal can cause Bradycardia / Hypersalivation Bradycardia / Hypersalivation Bronchospasm / Increased bronchial secretions Bronchospasm / Increased bronchial secretions Urinary frequency / Nausea and vomiting Urinary frequency / Nausea and vomiting Coadministration of antimuscarinic agents Coadministration of antimuscarinic agents Tachycardia Tachycardia Dryness of mouth and nose Dryness of mouth and nose Mydriasis / Urinary retention Mydriasis / Urinary retention Neostigmine Methylsulfate Injection [package insert]; Atropine Sulfate Injection, USP [package insert]; Glycopyrrolate Injection, USP [package insert]; ChE, cholinesterase. *Atropine use causes dose-dependent adverse effects.

6 J P Mulier6 Increased Risk Associated With Residual Blockade Increased risk of postoperative pulmonary complications Increased risk of postoperative pulmonary complications coughing, expectoration, pain when breathing, increased risk of aspiration; Hypoxemia, hypercapnia, the need for reintubation, non invasive ventilation coughing, expectoration, pain when breathing, increased risk of aspiration; Hypoxemia, hypercapnia, the need for reintubation, non invasive ventilation delay in meeting PACU discharge criteria and achieving actual discharge delay in meeting PACU discharge criteria and achieving actual discharge Berg H et al. Acta Anaesthesiol Scand. 1997;41: Bissinger U et al. Physiol Res. 2000;49: Eikermann M et al. Anesth Analg. 2006;102: Murphy GS. Minerva Anestesiol. 2006;72: PACU, post anaesthesiology care unit

7 J P Mulier7 What was our answer before Bridion? Waiting for reversal before awakening, extubation and transfer to PACU Waiting for reversal before awakening, extubation and transfer to PACU Turnover time increased or ventilation in PACU Turnover time increased or ventilation in PACU Incomplete reversal at extubation Incomplete reversal at extubation If patient can breath it is oke? If patient can breath it is oke? If patient can lift head it is oke? If patient can lift head it is oke? Ad midazolam so patients are not aware? Ad midazolam so patients are not aware? Earlier decurarisation (spont or neostigmine) Earlier decurarisation (spont or neostigmine) Is every surgeon happy? Is every surgeon happy? Extra dose neostigmine Extra dose neostigmine has only little effect but could even worsen decurarisation. has only little effect but could even worsen decurarisation. Inject water instead of NMB Inject water instead of NMB To make your surgeon happy? To make your surgeon happy? Be a transdisciplinary team Be a transdisciplinary team do you really know what surgeons think? do you really know what surgeons think?

8 J P Mulier8 My technique (before Bridion) to reduce the need for reversal in laparoscopy Measure Abdominal Compliance Measure abdominal compliance and give less relaxants if Compliance is large. Measure abdominal compliance and give less relaxants if Compliance is large. Or use 2 MAC deep inhalation anaesthesia at end surgery. Or use 2 MAC deep inhalation anaesthesia at end surgery. Use pressure support ventilation to prevent patient from breathing against ventilator. Use pressure support ventilation to prevent patient from breathing against ventilator.

9 J P Mulier9 Are NMB needed ? Gynecologic laparoscopy without curare is possible. Gynecologic laparoscopy without curare is possible. Chassard D. Ann Fr Anesth Reanim. 1996;15(7): Chassard D. Ann Fr Anesth Reanim. 1996;15(7): Chassard D Chassard D Only when compliance is very high? Only when compliance is very high? Or when surgeons do not complain? Or when surgeons do not complain?

10 J P Mulier10 APVR description Measure pressure volume relation Measure pressure volume relation Angle is compliance or elastance E Angle is compliance or elastance E Section with Y axis is PV0: pressure at zero vol Section with Y axis is PV0: pressure at zero vol P = 3,30 V + 8,40 mmHg Squared R = 0,96 E : 3,3 mmHg/L PV0 : 8,4 mmHg

11 J P Mulier11 E en PV0 determined by ? factorsPV0P VO sigEE sig AgeNeg0.828Pos0.003* LengthNeg0.356Neg0.245 Body weigthPos0.012*Pos0.294 Bmineg0.054Neg0.272 SexNeg0.596Neg0.536 GravidityNeg0.305Neg0.049* Prev abd operationNeg0.191Neg0.009* Muscle relaxationNeg0.001*Neg0.376 * Sig p<0.05 Mulier Dillemans ESA 2007 Mulier Dillemans ESA 2007

12 J P Mulier12 Patient with no effect of NMB No muscles in abd wall, diaphragm ? No muscles in abd wall, diaphragm ? Fully relaxed by other factors ? Fully relaxed by other factors ? TOF > 90% TOF > 90% TOF = ¼ TOF = ¼ TOF 0/4 and PTC < 5 TOF 0/4 and PTC < 5

13 J P Mulier13 Why NMB sometimes have no effect on APVR? Muscle total relaxed before giving NMB. Muscle total relaxed before giving NMB. Deep anesthesia? Deep anesthesia? Volatile anesthetics? Volatile anesthetics? Muscle very thin or non existent Muscle very thin or non existent Muscle fascia parallel Muscle fascia parallel

14 J P Mulier14 Pig: High dose desfl sevo Zelfde spier relaxatie effect sevo en desfl Zelfde spier relaxatie effect sevo en desfl data JPMulier 2009 data JPMulier 2009

15 J P Mulier15 Effect of valsalva: breathing against ventilator Valsalva is an active muscle contraction different from breathing to increase the abdominal pressure Valsalva is an active muscle contraction different from breathing to increase the abdominal pressure Happens when patient reacts on Controlled Ventilation Happens when patient reacts on Controlled Ventilation

16 J P Mulier16 BMI effect on abdominal P/V relation J Mulier ISPUB 2009 J Mulier ISPUB 2009 Pressure volume relation is linear Pressure volume relation is linear PV0 and E define each patient PV0 and E define each patient J Mulier IFSO 2007 J Mulier IFSO 2007

17 J P Mulier17 Android versus Gynoid fat distribution has a different Elastance

18 J P Mulier18 Waist to Hip ratio (WHR) Man normal WHR: 0,9 Man normal WHR: 0,9 Woman normal WHR: 0,7 Woman normal WHR: 0,7 Android fat distribution Android fat distribution WHR > 0,8 WHR > 0,8 Gynoid fat distribution Gynoid fat distribution WHR < 0,8 WHR < 0,8

19 J P Mulier19 Remember:Patient type with a high mortality risk Elderly male diabetes patient with hypertension and being super obese, no weigth loss. Elderly male diabetes patient with hypertension and being super obese, no weigth loss. Buchwald 2007 Buchwald 2007 Central abdominal fat, not stopped smoking, alcoholic Central abdominal fat, not stopped smoking, alcoholic General risk General risk Asthma and coronary artery disease Asthma and coronary artery disease Cardio pulmonary risks Cardio pulmonary risks

20 J P Mulier20 Two types of android obesity Intra visceral adiposity Extra visceral adiposity Intra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and intra abdominal fat is thick and intra abdominal fat is scant. intra abdominal fat is thick and intra abdominal fat is scant. Subcutaneus Fat Visceral fat

21 J P Mulier21 The obese patient is a challenge for anaesthesia if android shape with intra visceral fat.

22 J P Mulier22 NMB effect on E - PV0 E or Compliance unchanged E or Compliance unchanged E determined by fascia, size and shape E determined by fascia, size and shape PV0 drops =extra volume at same pressure PV0 drops =extra volume at same pressure

23 J P Mulier23 How to change PV0? Mulier Dillemans 2008 NMB NMB Inhalation anesthesia > 2 MAC Inhalation anesthesia > 2 MAC Table inclination: trendelenburg Table inclination: trendelenburg Smaller tidal volume ventilation Smaller tidal volume ventilation Lower peep Lower peep

24 J P Mulier24 How to change E : hip flexion Mulier JP, Dillemans B Obes Surg 2009 Mulier JP, Dillemans B Obes Surg 2009

25 J P Mulier25 Begin – End of first laparoscopy Abdominal compliance changes during pneumoperitoneum Abdominal compliance changes during pneumoperitoneum Inflation volume rises more than 1 liter! Inflation volume rises more than 1 liter! No NMB needed at end of operation ? No NMB needed at end of operation ? One Hour Laparoscopy at 15 mmHg Elongates the Abdominal Wall Mulier IFSO 2009

26 J P Mulier26 Laparoscopy without muscle relaxants ? Laparoscopy is possible without muscle relaxants or at reduced dose if Laparoscopy is possible without muscle relaxants or at reduced dose if adominal compliance > 0,5 L/mmHg adominal compliance > 0,5 L/mmHg IAV > 4 L at 15 mmHg at start laparoscopy IAV > 4 L at 15 mmHg at start laparoscopy Gravidity > 3 Gravidity > 3 Previous multiple laparoscopies/laparotomies Previous multiple laparoscopies/laparotomies > 10 kg weight reduction > 10 kg weight reduction No man with android fat distribution No man with android fat distributionand Sufficient deep sleep Sufficient deep sleep As patient should not breath against ventilator. As patient should not breath against ventilator. Pressure support ventilation Pressure support ventilation Easier to prevent breathing against ventilator Easier to prevent breathing against ventilator

27 J P Mulier27 Are NMB needed in laparoscopy? No if abdominal compliance is large No if abdominal compliance is large Yes as inflation pressure can be lower Yes as inflation pressure can be lower Yes to prevent breathing agains ventilator Yes to prevent breathing agains ventilator After one hour laparoscopy compliance is rosen After one hour laparoscopy compliance is rosen

28 J P Mulier28 PSV PSV is not a valsalva effect: IAV is not changing. PSV is not a valsalva effect: IAV is not changing. PSV is possible during deep muscle relaxation. PSV is possible during deep muscle relaxation. PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. Mulier J, Blacoe D PGA 2009

29 J P Mulier29 Is deep relaxation needed and possible? Time between end pneumoperitoneum and end operation is very short: in 5 min from TOF 0/4 -¼ till 90% is not possible with neostigmine. Time between end pneumoperitoneum and end operation is very short: in 5 min from TOF 0/4 -¼ till 90% is not possible with neostigmine. Sugammadex Sugammadex TOF 0/4 till end pneumoperitoneum TOF 0/4 till end pneumoperitoneum Very deep NMB PTC < 5 is possible till the end Very deep NMB PTC < 5 is possible till the end

30 J P Mulier30 Effect deep muscle relaxation on IAP with constant IAV Gradual pressure drop until flat line Gradual pressure drop until flat line Max effect at TOF 0/4 Max effect at TOF 0/4 At PTC 0 no extra pressure drop At PTC 0 no extra pressure drop TOF 4/4 TOF ¼ PTC 10 PTC 5 PTC 0

31 J P Mulier31 Effect of deep muscle relaxation on abdominal PV loop TOF > 90% TOF > 90% TOF = ¼ - 0/4 TOF = ¼ - 0/4 TOF 0/4 and PTC < 5 TOF 0/4 and PTC < 5

32 J P Mulier32 Conclusion: NMB needed Yes Yes Larger surgical workvolume for lower pressures Larger surgical workvolume for lower pressures At low pressures less structural damage and less post op pain? At low pressures less structural damage and less post op pain? Sometimes no sufficient workspace and angry surgeons: try to do everything. Sometimes no sufficient workspace and angry surgeons: try to do everything. No No Abd Compliance sometimes large enough Abd Compliance sometimes large enough Work at higher intra abd pressure? Work at higher intra abd pressure? 2 MAC inhalation has same effect? 2 MAC inhalation has same effect? Effect of position and of time? Effect of position and of time? Meten is weten (Measuring is knowing!)

33 J P Mulier33 If Yes -> decurarisation needed Only Brideon is able to do so ? Only Brideon is able to do so ?

34 J P Mulier34 Bridions Mechanism of Action Is Unlike Traditional Reversal Agents Adam JM et al. J Med Chem. 2002;45: NMBA NMB Choline + acetate AChE ACh nAChR Conventional NMB Reversal Choline + acetate AChE ACh NMBA nAChR ChE inhibitors (eg, neostigmine) Reversal With Bridion Choline + acetate AChE ACh NMBA nAChR Host molecule ACh, acetylcholine; AChE, acetylcholinesterase. ChE, cholinesterase; nAChR, nicotinic acetylcholine receptor; NMBA, neuromuscular blocking agent; NMB, neuromuscular blockade.

35 J P Mulier35 Cameron KS et al. Org Lett. 2002;4: Gijsenbergh F et al. Anesthesiology. 2005;103: Encapsulation of Rocuronium By Bridion

36 J P Mulier36 What happens when Bridion is injected? = Esmeron

37 J P Mulier37 What happens when Bridion is injected? = Bridion

38 J P Mulier38 What happens when Bridion is injected? = Bridion - Esmeron complex

39 J P Mulier39 What happens when Bridion is injected? = Bridion - Esmeron complex

40 J P Mulier40 What happens when Bridion is injected? = Bridion - Esmeron complex

41 J P Mulier41 Bridion Pharmacokinetics V ss 11 to 14 L V ss 11 to 14 L T ½ elimination 1.8 hours T ½ elimination 1.8 hours Cl estimated to be ~88 mL/min Cl estimated to be ~88 mL/min Major route of elimination: renal Major route of elimination: renal 96% of the dose excreted in urine, of which at least 95% could be attributed to unchanged Bridion 96% of the dose excreted in urine, of which at least 95% could be attributed to unchanged Bridion Cl, clearance; T ½, half-life; V ss, volume of distribution at steady state. Data on file. Bridion ® [summary of product characteristics]Organon, Europe; 2008.

42 J P Mulier42 Various Depths of Blockade Intense block: no response to either TOF or PTC stimulation Intense block: no response to either TOF or PTC stimulation Deep block: response to PTC but not to TOF stimulation Deep block: response to PTC but not to TOF stimulation Moderate block: reappearance of response to TOF stimulation Moderate block: reappearance of response to TOF stimulation Superficial block: reappearance of T4 T4/T1 ratio > 1% Superficial block: reappearance of T4 T4/T1 ratio > 1% No block: T4/T1 ratio > 90 % No block: T4/T1 ratio > 90 % PTC 0 PTC 1 Intense blockDeep blockModerate block TOF count 0 TOF count 1-3 Level of block Response to TOF Response to PTC PTC, posttetanic count; TOF, train-of-four.Fuchs-Buder T et al. Acta Anaesthesiol Scand. 2007;51: Posttetanic count Twitch response Twitch percentage Superficial block TOF count 4 T1/T4 %

43 J P Mulier43 Increased Flexibility in the Time of Reversal Immediate Reversal* Immediate Reversal* Within 3 min following administration of rocuronium, 16 mg/kg Within 3 min following administration of rocuronium, 16 mg/kg Routine Reversal Routine Reversal 4 mg/kg if recovery has reached 1–2 PTC (deep blockade) 4 mg/kg if recovery has reached 1–2 PTC (deep blockade) 2 mg/kg if spontaneous recovery has reached the reappearance of T 2 (moderate blockade) 2 mg/kg if spontaneous recovery has reached the reappearance of T 2 (moderate blockade) Bridion allows full relaxation until the end of surgical procedures *Only recommended with rocuronium-induced blockade. PTC, posttetanic count. Data on file. Bridion ® [summary of product characteristics]. Organon, Europe; 2008.

44 J P Mulier44 Recommended dosage 16 mg/kgintense block 16 mg/kgintense block 4 mg/kgdeep block 4 mg/kgdeep block 2 mg/kgall other blocks 2 mg/kgall other blocks Maximum safety: Maximum safety: overloading t1/2 longer than roc overloading t1/2 longer than roc Fastest reversal Fastest reversal Never recurarisation Never recurarisation Individual variation covered Individual variation covered Less? Less? No studies yet No studies yet Re-occurrence of relaxation Re-occurrence of relaxation TBW or IBW ? TBW or IBW ? No studies yet but as rocuronium is dosed according to IBW and has the same water solubility ??? No studies yet but as rocuronium is dosed according to IBW and has the same water solubility ??? Combination with neostigmine is possible but you get the side effects back. Combination with neostigmine is possible but you get the side effects back.

45 J P Mulier45 Practical bridion use Vial 2 ml, 100 mg/ml 200 mg per vial 2 mg/kg in a 70 kg person: 2 mg/kg in a 70 kg person: 140 mg one vial 140 mg one vial 2 mg/kg in a 200 kg person: 2 mg/kg in a 200 kg person: 400 mg or two vials or IBW 140 mg? 400 mg or two vials or IBW 140 mg? Is the patient, willing to pay for it? Yes if Yes if previous history of rest curarisation previous history of rest curarisation you explain that procedure you explain that procedure is otherwise not safe is otherwise not safe might take longer might take longer Is not possible Is not possible You prevent post op complications? You prevent post op complications?

46 J P Mulier46 Measure Depth of Blockade Intense block: 16 mg/kg Intense block: 16 mg/kg Deep block: 4 mg/kg Deep block: 4 mg/kg Moderate block: 2 mg/kg+ Neostigmine? Moderate block: 2 mg/kg+ Neostigmine? Superficial block: 1 mg/kg + Neostigmine? Superficial block: 1 mg/kg + Neostigmine? No block: 0 mg/kg No block: 0 mg/kg PTC 0 PTC 1 Intense blockDeep blockModerate block TOF count 0 TOF count 1-3 Level of block Response to TOF Response to PTC PTC, posttetanic count; TOF, train-of-four.Fuchs-Buder T et al. Acta Anaesthesiol Scand. 2007;51: Posttetanic count Twitch response Twitch percentage Superficial block TOF count 4 T1/T4 %

47 J P Mulier47 More Rapid Recovery With Bridion From T 2 Following Rocuronium Rocuronium 0.6 mg/kgNeostigmine 50 µg/kg (%) :49:347:59:348:09:348:19:348:29:498:39:498:50:039:00:199:10:199:20:349:30:499:41:04 Rocuronium 0.6 mg/kg Bridion 2 mg/kg(%) :21:0610:32:3810:44:0810:55:3811:07:0811:18:5311:30:3811:42:0811:53:5312:04:3912:13:56 Data from Aurora trial. TOF ratio Twitch height TOF, train-of-four.

48 J P Mulier48 Faster Reversal from Rocuronium at reappearance of 2 Counts CI, confidence interval, NEO, neostigmine.Data from Signal trial. n = 37 NEO 70 µg/kg 95% CI (35.7–59.5 min) Bridion 4 mg/kg 95% CI (2.3–3.3 min) n = 37

49 J P Mulier49 Time From T 1 10% to 90% Within Subject T 1 =10%T 1 =90%T 1 =10%T 1 =90% Rocuronium 1.2 mg/kg + Bridion 16 mg/kg Succinylcholine 1.0 mg/kg Minutes Data from Spectrum trial. n = 56n = 54

50 J P Mulier50 Immediate Reversal of Intense Blockade *P < versus succinylcholine treatment group; results based on intent-to-treat population. SEM, standard error of mean. Data from Spectrum trial. 3 min Bridion administered T 1 to 10% T 1 to 90% * * n = 56n = 54n = 56n = 54

51 J P Mulier51 Rapid Dose-Dependent Reversal From T 2 in Children and Adolescents Following Rocuronium 0.6 mg/kg TOF, train-of-four. *Approved dose in children and adolescents. Data from Libra trial.

52 J P Mulier52 No Dose Adjustment Required With Increasing Age TOF, train-of-four. *Reversal from T 2 following rocuronium 0.6 mg/kg Data from Diamond trial. Bridion ® [summary of product characteristics]. Organon, Europe; n = 48 n = 62 n = 40 Age, yr

53 J P Mulier53 Bridion Has a Demonstrated Safety Profile Bridion has been studied in >2000 clinical trial subjects Bridion has been studied in >2000 clinical trial subjects Safety has been demonstrated in patients with cardiac and pulmonary disease Safety has been demonstrated in patients with cardiac and pulmonary disease Bridion is not recommended in patients with severe renal failure (CrCl <30 ml/min) Bridion is not recommended in patients with severe renal failure (CrCl <30 ml/min) Great caution should be taken in patients with severe hepatic disease Great caution should be taken in patients with severe hepatic disease Dedicated studies in this population have not taken place CrCl, creatinine clearance. Data on file. Bridion ® [summary of product characteristics]. Organon, Europe; 2008.

54 J P Mulier54 Drug-Drug Interactions Affecting the Efficacy of Bridion No clinically relevant drug interactions have been reported with Bridion No clinically relevant drug interactions have been reported with Bridion Pharmacokinetic-pharmacodynamic simulations show that the following displacement interactions are possible: Pharmacokinetic-pharmacodynamic simulations show that the following displacement interactions are possible: Toremifene Toremifene The recovery to T 4 /T 1 ratio of 0.9 could be delayed in patients who have received toremifene on the same day of surgery The recovery to T 4 /T 1 ratio of 0.9 could be delayed in patients who have received toremifene on the same day of surgery Intravenous administration of high-dose flucloxacillin* and fusidic acid Intravenous administration of high-dose flucloxacillin* and fusidic acid The recovery to T 4 /T 1 ratio of 0.9 could be delayed in patients who receive these products in the preoperative phase The recovery to T 4 /T 1 ratio of 0.9 could be delayed in patients who receive these products in the preoperative phase Administration of these products in the postoperative phase (6 hours) is to be avoided Administration of these products in the postoperative phase (6 hours) is to be avoided *Infusion of 500 mg or more. Data on file. Bridion ® [summary of product characteristics]. Organon, Europe; 2008.

55 J P Mulier55 Drug-Drug Interactions Affecting the Efficacy of Other Drugs Pharmacokinetic-pharmacodynamic simulations show that the following capturing interaction is possible: Pharmacokinetic-pharmacodynamic simulations show that the following capturing interaction is possible: Hormonal contraceptives Hormonal contraceptives An interaction between 4 mg/kg Bridion and a progestogen could lead to a decrease in progestogen exposure, 34% of AUC, which is similar to that of a missed dose of oral contraceptive An interaction between 4 mg/kg Bridion and a progestogen could lead to a decrease in progestogen exposure, 34% of AUC, which is similar to that of a missed dose of oral contraceptive AUC, area under the curve. Data on file. Bridion ® [summary of product characteristics]. Organon, Europe; 2008.

56 J P Mulier56 Can not intubate / can not ventilate How frequently ? How frequently ? Did you ever awakened your patient immediately within the first 30 minutes? Did you ever awakened your patient immediately within the first 30 minutes? Conclusion: Conclusion: It feels safe to have a drug available to bring patient immediately back to spontaneous breathing and to cancel the surgery. It feels safe to have a drug available to bring patient immediately back to spontaneous breathing and to cancel the surgery. Always have it never use it? Always have it never use it?

57 J P Mulier57 Rapid sequence / Crush induction Who is at Risk for aspiration? Who is at Risk for aspiration? Food or drank recently Food or drank recently Obstruction Obstruction Pregnant Pregnant Super obese Super obese Previous bariatric surgery Previous bariatric surgery Long procedure: high dose of NMB Long procedure: high dose of NMB No need for bridion or succinylcholine No need for bridion or succinylcholine Short procedure: high dose Rocuronium and bridion Short procedure: high dose Rocuronium and bridion Esmeron 1,2 mg/kg IBW measure TOF: bridion Esmeron 1,2 mg/kg IBW measure TOF: bridion

58 J P Mulier58 Very short and superficial blockade Superficial blockade is sufficient for ECT Superficial blockade is sufficient for ECT Succinylcholine: 0,5 mg/kg (normal: 2 mg/kg) is sufficient Succinylcholine: 0,5 mg/kg (normal: 2 mg/kg) is sufficient Relative rapid onset, within 2 minutes Relative rapid onset, within 2 minutes Spontaneous recovery within 5 minutes possible Spontaneous recovery within 5 minutes possible Rocuronium 0,15 mg/kg (normal: 0,6 mg/kg) slower onset, longer duration Rocuronium 0,15 mg/kg (normal: 0,6 mg/kg) slower onset, longer duration Dose of bridion dependent on TOF Dose of bridion dependent on TOF Neostigmine possible but side effects Neostigmine possible but side effects

59 J P Mulier59 Tof monitoring TOF measurement is needed TOF measurement is needed To justify use of bridion To justify use of bridion To lower dose of bridion To lower dose of bridion

60 J P Mulier60 Immediate effects in morbid obese patients Deep breaths possible Deep breaths possible Less collaps Less collaps Aurosal effect Aurosal effect Like Amfetamine awakening Like Amfetamine awakening Sudden muscle fiber stimulation gives aurosal Sudden muscle fiber stimulation gives aurosal Patient transfers him/her self in bed Patient transfers him/her self in bed 50 % of cases instead of only10% 50 % of cases instead of only10% Spontaneous movements easier Spontaneous movements easier Deep venous trombosis prevention Deep venous trombosis prevention

61 J P Mulier61 Our Results in lap RNY

62 J P Mulier62 Adjustable Gastric band Biliary pancreatic div DuodenalSwitch Jejuno ileal bypass Vertical banded gastroplasty Roux & Y Gastric bypass Sleeve Gastrectomy

63 J P Mulier63 Andere vragen in de anesthesie bij morbide obesitas Pre operatieve voorbereiding Pre operatieve voorbereiding Inductie en intubatie Inductie en intubatie Patient positionering Patient positionering Medicatie dosering Medicatie dosering Extubatie en postoperatief beleid Extubatie en postoperatief beleid Post op pijn behandeling Post op pijn behandeling Enkele items nu belichten

64 J P Mulier64 Waarom onvoldoende spierrelaxatie geven? Restcurarisatie is zeer beangstigend, slecht ademen post op, lage saturatie, hoge CO2 Restcurarisatie is zeer beangstigend, slecht ademen post op, lage saturatie, hoge CO2 Liever geen neostigmine gebruiken omdat Liever geen neostigmine gebruiken omdat Bradycardie tot totaal AV block Bradycardie tot totaal AV block Bronchospasme bij asthma patienten Bronchospasme bij asthma patienten Braken en onwel gevoel post op Braken en onwel gevoel post op Relaxatie moet voldoende uitgewerkt zijn om te decurariseren met neostigmine Relaxatie moet voldoende uitgewerkt zijn om te decurariseren met neostigmine TOF minimum één antwoord TOF minimum één antwoord

65 J P Mulier65 Continuous deep blockade till end of surgery. 3. Laparoscopy 3. Laparoscopy Rapid awakening Rapid awakening Keep your surgeon in the OR Keep your surgeon in the OR Quality surgery = Quality surgery = short surgical time short surgical time High volumes High volumes Quality anaesthesia = Quality anaesthesia = short turn over short turn over High volumes High volumes

66 J P Mulier66 Our Results in lap RNY gastric bypass

67 J P Mulier67 ERAS 1 (early recovery after surgery) Halfway surgery (last 30 min) Halfway surgery (last 30 min) Large abdomen stop esmeron infusion, Large abdomen stop esmeron infusion, Small abd keep esmeron infusion till end of operation. Small abd keep esmeron infusion till end of operation. Last stapler Last stapler Reduce/stop remifentanyl infusion Reduce/stop remifentanyl infusion Start pressure support ventilation Start pressure support ventilation Hypercapnic PSV increases CO and BP Hypercapnic PSV increases CO and BP Keep inhalation conc high if small abd till end of pneumoperitoneum. Keep inhalation conc high if small abd till end of pneumoperitoneum.

68 J P Mulier68 PSV voorkomt tegenademen bij onvoldoende relaxatie PSV is not a valsalva effect: IAV is not changing. PSV is not a valsalva effect: IAV is not changing. PSV is possible during deep muscle relaxation. PSV is possible during deep muscle relaxation. PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. Mulier J, Blacoe D PGA 2009

69 J P Mulier69 Hypercapnia / Pressure support Tablenormocapnyhypercapny Minute vol * L/min 11,6 +/- 1,7 7,1 +/- 1,1 Airw pres * cmH / /- 3 Et PCO2 * mmHg 38 +/ /- 8 O2 sat % 96 +/ /- 2 Ephedrine * mg 30 +/ /- 8 Breathing * min 4 +/ /- 4 Extubation * min 8 +/ /- 5 TablePCVPSV Number of TOF * 0,61,4 Cisatracurium mg * 32 +/ /-2 etPCO2mmHg 44 +/ /- 10 Extubationmin 5 +/ /- 2 J P Mulier, B Dillemans, Use of pressure support ventilation during laparoscopic bariatric surgery is possible and facilitates weaning and extubation. In:Obes Surg 2008; 18:444 J P Mulier, B Dillemans, Hypercapnic lung ventilation reduces airway pressure during laparoscopic surgery. In:Eur J Anesth 2008; 25, S44:78

70 J P Mulier70 ERAS 2 Leaktest Leaktest High volume load High volume load SAP > 140 mmHg SAP > 140 mmHg Et CO2 to 60; PSV give extra suf if tachypnoe Et CO2 to 60; PSV give extra suf if tachypnoe Ephedrine/phenylephrine bolus Ephedrine/phenylephrine bolus dose sufenta till RR < 16 dose sufenta till RR < 16 Last surgical stich Last surgical stich Lower PSV further, keep peep Lower PSV further, keep peep Stop inhalation Stop inhalation TOF 4/4 <50% neostigmine TOF 4/4 <50% neostigmine TOF < 2/4bridion dose according to TOF and IBW TOF < 2/4bridion dose according to TOF and IBW give bridion after patient is secured on the table give bridion after patient is secured on the table

71 J P Mulier71 PSV pain therapy optimalisation Before after extra suf bolus Before after extra suf bolus

72 J P Mulier72 Hypercapnic pressure support: easier SAP rise TableNormocapnicHypercapnic SAP mmHg 143 +/ /- 13 Et P CO2 mmHg 39 +/ * +/-6 CO L/min 6,2 +/- 1,8 14,3 * +/- 2,9 Min Vol L:min 9 +/- 1,3 7,6 *+/- 1,2 Ephedrine mg 11 +/- 7 3 * +/- 3 J P Mulier (2008) Hypercapnic support ventilation during laparoscopic gastric bypass increases the cardiac output. Anesthesiology 2008 A174

73 J P Mulier73 Can anesthesiology help to prevent post op bleeding? yes 110/57 145/78 J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery. Obes Surg 2007; 17: 1051

74 J P Mulier74 Hypercapnic pressure support ventilation Increases cardiac output Increases cardiac output Less wound infections Less wound infections Lowers airway pressures Lowers airway pressures Resp freq: morfine if too low stop PSV Resp freq: morfine if too low stop PSV TV: curarisation corrected by support level TV: curarisation corrected by support level Improves saturation per op if low Improves saturation per op if low Rapid awakening and spontaneous breathing Rapid awakening and spontaneous breathing Non surgical time between OP < 20 min Non surgical time between OP < 20 min Less pain when awakening Less pain when awakening Extra doses given during end of surgery Extra doses given during end of surgery Better post op breathing Better post op breathing less post ventilation less post ventilation

75 J P Mulier75 ERAS 3 Reversed induction technique ? Reversed induction technique ? 50 à 100 mg propofol in bolus 50 à 100 mg propofol in bolus Gastric tube suction, oral cavity clean? Gastric tube suction, oral cavity clean? PSV to Spontaneous, TV > 200 ml PSV to Spontaneous, TV > 200 ml Extubation beach chair if possible Extubation beach chair if possible Diep ademen, benen bewegen Diep ademen, benen bewegen Nooit sedativa, benzodiazepines,… Nooit sedativa, benzodiazepines,… Voldoende pijn medicatie perop starten Voldoende pijn medicatie perop starten Test: patient moet zich zelf verbedden 3 minuten na extubatie! Test: patient moet zich zelf verbedden 3 minuten na extubatie! Turnover time between end surgery - incision next patient < 20 minuten. Turnover time between end surgery - incision next patient < 20 minuten.

76 J P Mulier76 Conclusion Always have Bridion available. Always have Bridion available. Decide when long and deep relaxation is needed till end. Decide when long and deep relaxation is needed till end. Measure TOF ctu or at end Measure TOF ctu or at end Never believe without control clinical relaxation Never believe without control clinical relaxation According to TOF at end operation. According to TOF at end operation. (Nothing) (Nothing) (Neostigmine) (Neostigmine) Bridion Bridion

77 J P Mulier77 Second ESPCOP Scientific meeting Multidisciplinarity Pordenone, Italy 18 sept 2010

78 J P Mulier78 More info More info


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