Recent advances – 1 – MGMC Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics, PhD(physiology)

Xenon Xenon derives its name from the Greek for `stranger' because of its rarity, representing 0.0875 ppm. It is odorless, nonpungent, nontoxic, nonexplosive, environmentally friendly

A bit history Discovered in 1898, it is manufactured by fractional distillation of air and is used commercially for lasers, high intensity lamps, ash bulbs, jet propellant in the aerospace industry, X-ray tubes, and in medicine. Anesthetic practice for fifty years …

Xenon potently inhibits N-methyl-D-aspartate (NMDA) receptors non-competitively, with little effect on GABA A receptors or non-NMDA glutamatergic receptors Xenon has been reported to competitively inhibit 5HT3 A receptor MAC value of 63 % -- 71 %

Blood gas partition coefficient of 0.15 % Fast in and out Better than nitrous and desflurane Ideal in opd procedures

CVS Hemodynamic stable No change in HR – -decreased cortisol and catecholamines Less need for fentanyl Normal LV function assessed by TEE

CNS xenon increases CBF; despite changes in CBF, reactivity to carbon dioxide is maintained , changes in blood flow can be reversed with hyperventilation CMRO2 may not change Analgesic in contrast to other anaesthetics that require anaesthetic or supra‐anaesthetic doses to act as a neuroprotectant, xenon may be effective at more clinically acceptable concentrations

Greatness xenon has no mutagenic or carcinogenic properties. No embryotoxic or teratogenic changes were found in pregnant women No malignant hyperthermia No damage to liver and kidney profiles No damage to coagulation and platelet profiles

Then what's the problem The cost will work out 350 US $ for a case Recycling may decrease xenon appears to be environmentally safe.

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Summary Stranger B/G 0.15 MAC - 71% Fastest recovery Cardiostable Neuroprotective Analgesia Cost Recycling

Sugammadex

Sugammadex Anton Bom working for a cyclodextrin to solubilize rocuronium Found it engulfing Possibly tested in vivo Reversal agent for future ?? Su – sugar ----- gammadex – gamma cyclodextrin

Cyclodextrin molecule with water solubility and lipid engulfment

Sugammadex exerts its action by forming very tight complexes in 1:1 ratio with steroidal neuromuscular blocking drugs (rocuronium > vecuronium >> pancuronium) and functions as an irreversible chelating agent. Bound suggamadex eliminated via the kidney

Aminosteroid only Sugammadex has no effect on acetylcholinesterase. This eliminates the need for anticholinergic drugs, thus avoiding their undesirable side effects. It is ineffective against succinylcholine and benzylisoquinolinium neuromuscular blockers, such as mivacurium, atracurium and cisatracurium

Sugammadex at doses of 2. 0- 4 Sugammadex at doses of 2.0- 4.0 mg /kg has been shown to safely reverse moderate NMB induced by rocuronium in a dose dependent manner in surgical patient 0.5 Vs 7.5 minutes Even after rocuronium infusions 16 mg /kg – CICV situations with rocuronium

Formulation The drug is available in IV formulation only; vials of 200 mg (2 ml) or 500 mg (5 ml) and is for non-refrigerated storage Old age pediatrics – ok But less than 2 years – ??

Side effects hypotension, coughing, movement, vomiting, dry mouth, parosmia, a sensation of changed temperature Paresthesia of the arm of intravenous administration Endogenous steroidal hormones and steroidal drugs lack the quaternary nitrogen which rocuronium and vecuronium possess- no clinical impact

should be avoided in pregnant and lactating patients till studies are conducted and its safety is proven. Kidney failure – go for cis atracurium rather than sugammadex Around 4000 rupees

After reversal, surgeon tells , I have forgotten to keep drainage tube Yes we can give back rocuronium But better use nonsteroidal drugs

Tips Relaxant use during skin closure – ok CICV – best No recurarization, but --- Knowledge of TOF count and dosage adjustment of sugammadex needed Rocuronium-sugammadex complex can be displaced by fusidic acid or high doses of flucloxacillin

Summary Gamma cyclo dextrin Water and fat soluble Encapsulation of amino steroids – but endo steroids Rapid reversal without anticholinesterase side effects , CICV !! 2 – 16 mg / kg --Recurarization ?? side effects ? Re injection ? Kidney failure , pregnancy , less than 2 years ?