Leeches are rare cause of foreign body in airways. A 23-year-old male, experiencing epistaxis and difficulty in swallowing is presented. During nasopharyngoscopy, a moving leech was observed on the nasopharynx posterior wall in midline location, and removal of the leech was decided under general anaesthesia. The flexible nasopharyngoscopy was inserted, but removal was unsuccessful due to the leech’s movements. Leeches are blood-sucking parasites, so neuromuscular blocking agent was given to prevent the movement. After administration, motion of the leech was lost and easily removed undamaged. In patients presenting with unexplained epistaxis, hemoptysis, dyspnea, and foreign body sensation in the airway, leech infestation should be included as the differential diagnosis and history of contact with stream water should be questioned. We concluded that use of low dose neuromuscular blocking agents facilitates the gentle removal, and could be necessary for successful management of removal of leech under general anaesthesia.

Opioids, such as alfentanil, are used to facilitate endotracheal intubation without the use of neuromuscular blocking agents in patients undergoing elective surgery.The goal of this study was to evaluate the endotracheal intubation conditions when remifentanil or alfentanil was used with propofol without the application of neuromuscular blocking agents.Patients and One hundred American Society of Anesthesiologists (ASA) grade I patients scheduled for elective surgery were enrolled in this prospective, randomized, triple-blinded study. The patients were randomized to group A (alfentanil) or R (remifentanil). In group A, alfentanil (50 mcg/kg) was intravenously injected over 10 seconds, and after 45 seconds or at the occurrence of apnea, propofol (2 mg/kg) was intravenously injected over 5 seconds. Thirty seconds after the administration of propofol, laryngoscopy and endotracheal intubation were attempted. In group R, remifentanil (5 mcg/kg) was administered instead of alfentanil. Intubation conditions, including ease of laryngoscopy, patency of the vocal cords, jaw relaxation, limb movement (1-4 score), and also,demographic data were evaluated. There were no demographic data differerences between groups (age, weight, and sex). Further, laryngoscopy, jaw relaxation, and limb movement scores were similar in the R and A groups and there were no significant differences, but vocal cords were significantly more patent in group R than those in group A (P = 0. 028). The results of this study showed that remifentanil, similar to alfentanil, provided excellent conditions for endotracheal intubation when used with propofol for the induction of anesthesia; however, remifentanil improved the patency of the vocal cords to a greater extent than alfentanil..

Botulinum toxin (BT) is a potent presynaptic neuromuscular blocking agent which induces selective, reversible muscle weakness for months when injected intramuscularly. During recent years BT has revolutionized the treatment of previously intractable symptoms of detrusor overactivity. Based on a systematic search of the PubMed database, a review of the current literature on the use of onabotulinum toxin A (Botox®) in the treatment of neurogenic detrusor overactivity is presented.Onabotulinumtoxin A Urinary Bladder, overactive Urinary Bladder, Neurogenic Botulinum toxin (BT) is a potent presynaptic neuromuscular blocking agent which induces selective, reversible muscle weakness for months when injected intramuscularly. During recent years BT has revolutionized the treatment of previously intractable symptoms of detrusor overactivity. Based on a systematic search of the PubMed database, a review of the current literature on the use of onabotulinum toxin A (Botox®) in the treatment of neurogenic detrusor overactivity is presented. onabotulinum toxin A proved to be highly effective in the majority of studies, even though a wide range of injection techniques and dosages were described. The onset of the effect usually appeared before 2 weeks, and reached a peak within 2-6 weeks, with the clinical effect being maintained for approximately 6-8 months, or even longer. Depending on the dose, a number of patients developed high residual volume and clean intermittent self/helper catheterization (CIC) may become necessary. only a few side effects were described, and intravesical onabotulinum toxin A injection seems to be well tolerated. however, details on injection technique, dose interval between injections, etc. are still under debate and only a few randomized, placebo controlled studies have been published..

This study was conducted to evaluate the onset, duration of action and potency of cis-atracurium in dogs. Ten apparently healthy dogs of various breeds were used in this study. The age and weight of the dogs were 3.2 ± 2.4 year and 17.7 ± 4.8 kg, respectively. All dogs pre-medicated with acepromazine 0.05 mg/kg and morphine 0.5 mg/kg. After induction of general anesthesia with thiopental, the dogs were intubated and anesthesia maintained with halothane in oxygen. After reaching good depth of anesthesia, cis-atracurium were injected intravenously at the dose of 0.1 mg/kg and neuromuscular blockade (NMB) evaluated by counting visual responses to train-of-four (TOF) nerve stimulation on ulnar nerve. All four responses eliminated in 9 out of 10 dogs. The onset was 4.8 ± 1.3 min and the duration of NMB lasted for 24.4 ± 9 min. The quality of relaxation was good according to surgeons. It is concluded that cis-atracurium is an effective neuromuscular blocking agent in the dog, although its potency varies slightly in different dogs.

Thalassemia is an inherited defect in the production of globulin chains transmitted by autosomal recessive inheritance. Anaesthetic management of these patients is challenging, being associated with hypersplenism, unanticipated difficult airway and vertebral malformations, perioperative high blood pressure, systemic features of iron overload, cardiac and hepatic failure and anaemia.   In this case, we highlight the anaesthetic concerns in a child of beta thalassemia intermedia with high levels of Hemoglobin F posted for splenectomy along with cholecystectomy. To avoid need of postoperative mechanical ventilation due to low oxygen carrying capacity of blood and anaerobic metabolism during the period of surgical stress, epidural catheter inserted despite possibility of epidural hematoma or bleed because of thrombocytopenia. Patient had an enhanced recovery in term of decrease oxygen demand, decrease postoperative nausea and vomiting, early ambulation and patient satisfaction. Intraoperative epidural also decreases need of neuromuscular blocking agent and intravenous analgesia. This lead to faster awakening from anaesthesia even in the presence of decrease oxygen carrying capacity due to anaemia and acidosis (anaerobic metabolism). Use of regional anesthesia should be considered in similar cases after assessing risk and benefits for individual cases.

Opioids, such as alfentanil, are used without neuromuscular blocking Javascript:FormatThis('B')agents to facilitate endotracheal intubation in patients undergoing elective surgery. The goal of this study was to evaluate the possibility of endotracheal intubation with propofol and remifentanil and compare it to propofol and alfentanil, without neuromuscular blocking agents. Patients and A hundred ASA I patients undergoing elective inpatient surgery were scheduled in this prospective, randomized, double-blind study. The patients were divided into two groups: alfentanil (control group) and remifentanil (study group). In the control group, 50 μg/kg alfentanil was IV injected over 10 seconds, and after 45 seconds or occurrence of apnea, 2 mg/kg propofol was IV injected over 5 seconds. Thirty seconds after the administration of propofol, laryngoscopy and tracheal intubation were attempted. In the study group, only 5 μg/kg remifentanil was administered instead of alfentanil. Intubating conditions were assessed on the basis of ease of laryngoscopy, vocal cords opening, jaw relaxation, and limb movement (1 - 4 score). Intubation scores were analyzed by nonparametric tests and compared between the two groups. There were no demographic differences such as age,weight and sex between the groups. Although, laryngoscopy, jaw relaxation, and limb movement scores were similar in both groups and there were no significant differences, vocal cord opening was significantly wider in the study group than the control group(P = 0. 028). This study revealed that the use of propofol and remifentanil provided excellent conditions for tracheal intubation in most patients in the same way as propofol and alfentanil, and the score of vocal cord opening in the study group was better than alfentanil group. Therefore, to avoid administering muscle relaxants, remifentanil and propofol can be used for laryngoscopy and endotracheal intubation in healthy young patients.

Muscle relaxant agents usually use to facilitate tracheal intubation; however, sometimes limitations exist. Magnesium (Mg) sulfate is a candidate for muscle relaxant substitute. This study was designed to determine the effect of Mg sulfate accompanied with propofol and fentanyl in patients undergoing ophthalmic surgery.
In a double?blind randomized protocol and before tracheal intubation, Mg sulfate 40, 45, or 50 mg/kg in 100 ml of saline (Groups 1–3, respectively) or saline alone (Group 4) were administrated intravenously in 100 patients (n = 25 in each group) with the American Society of Anesthesiologist (ASA) physical Status I, II, or III. The patients’ intubation condition in all subjects were determined and described.
The patients’ demographic data including age, ASA, systolic and diastolic blood pressures, intraocular pressure, and body mass index were not significantly different between the groups. A better mask ventilation feasibility in Mg sulfate 45 group (Group 2) was observed when compared with Mg sulfate 50 (Group 3) (P = 0.022) and saline group (Group 4) (P = 0.021). In addition, the vocal cord movement and muscle relaxant requirement in saline group were significantly different from others groups (P Intravenous administration of Mg sulfate accompanied with propofol and fentanyl facilitates the tracheal intubation without neuromuscular blocking agents. To avoid Mg level increasing in plasma; however, the low dose of Mg sulfate is suggested.

The study of neuromuscular blocking agents (NMBAs) in the management of acute respiratory distress syndrome (ARDS) has provided conflicting results in terms of their effect on mortality.

The main purpose of this study was to evaluate mortality in ARDS patients who underwent NMBA.

A retrospective secondary analysis of 4,200 patients with ARDS was collected from two academic medical centers, Tehran, Iran. This study was performed to assess the impact of NMBAs use in ARDS patients with different subgroups including mild and moderate-to-severe ARDS, age more and less than 65 years, having medical turnover vs. not-having, and high acute nursing care vs. moderate to low nursing care. The primary outcome was the ICU mortality

In the subjects without medical turnover, the moderate dose of NMBAs significantly reduces the mortality of patients (P=0.044). In patients who need high acute nursing care, increasing the NMBAs dose significantly reduces patients' mortality (P=0.010). In addition, increasing the NMBAs doses significantly reduces ICU LOS (p <0.001). Logistic regression analysis revealed that the high dose vs. low dose of NMBAs was increased the risk of mortality among patients between 80 to 84 years old (OR: 3.142, 95% CI: 1.461-6.756, P=0.003). However, higher doses of NMBA than low doses reduce the risk of death in patients between 50 and 54 years of age (OR: 0.432, 95% CI: 0.267-0.798, P=0.006).

this study provides evidence that the administration of different doses of NMBAs had no effect on patients’ mortality with mild or moderate-to-severe ARDS.