Neuromuscular blockade - Revision history

Bsumida1 at 11:45, 4 July 2022

2022-07-04T11:45:06Z

← Older revision		Revision as of 04:45, 4 July 2022
Line 12:		Line 12:

	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)
	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
Line 56:		Line 56:

	* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal

Bsumida1 at 11:43, 4 July 2022

2022-07-04T11:43:42Z

← Older revision		Revision as of 04:43, 4 July 2022
Line 12:		Line 12:

	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)
			'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
Line 61:		Line 62:

	With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).		With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).
	'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

	'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)		'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)
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	''Posterior Tibial Nerve''		''Posterior Tibial Nerve''

	Generally used with AMG.		Generally used with AMG.
	~~'''Fade'''~~

	'''Fade'''		'''Fade'''

Bsumida1 at 11:42, 4 July 2022

2022-07-04T11:42:43Z

← Older revision		Revision as of 04:42, 4 July 2022
Line 12:		Line 12:

	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)


	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
Line 32:		Line 31:

	All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that generate measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.		All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that generate measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.



	'''Qualitative Monitoring'''		'''Qualitative Monitoring'''

	In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.		In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.



	'''Methods of assessment'''		'''Methods of assessment'''
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	* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal



Line 65:		Line 61:

	With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).		With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).
			'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

	'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)		'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)
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	Generally used with AMG.		Generally used with AMG.
			'''Fade'''

	'''Fade'''		'''Fade'''

Bsumida1: Formatting

2022-07-04T11:41:29Z

Formatting

← Older revision		Revision as of 04:41, 4 July 2022
Line 8:		Line 8:
	* Rocuronium		* Rocuronium
	* Vecuronium		* Vecuronium


	''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):		''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):
Line 18:		Line 17:

	* Succinylcholine		* Succinylcholine
	~~Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.~~

	Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.		Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.

Line 35:		Line 32:

	All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that generate measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.		All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that generate measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.



Line 40:		Line 38:

	In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.		In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.



Line 61:		Line 60:

	* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal


	''Post Tetanic Count (PTC)''		''Post Tetanic Count (PTC)''

	With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).		With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).
	'''Sites of Use (for graphics, can refer to UpToDate'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

	'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)		'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)
Line 72:		Line 71:

	Generally the preferred site of monitoring. It is easily accessible. There is a lower chance of direct muscle stimulation which is not an assessment of nerve function/neuromuscular blockade. If surgical positioning interferes with intraoperative monitoring, can consider measuring closer to the end of the case if able to access the limb at that time.		Generally the preferred site of monitoring. It is easily accessible. There is a lower chance of direct muscle stimulation which is not an assessment of nerve function/neuromuscular blockade. If surgical positioning interferes with intraoperative monitoring, can consider measuring closer to the end of the case if able to access the limb at that time.
			''Facial Nerve''
	''Facial Nerve''		''Facial Nerve''

Line 77:		Line 77:

	May be necessary depending on surgical positioning, however is prone to more inaccuracies due to direct muscle stimulation. The palpated muscles may either be the orbicularis occuli (which generally correlates with diaphragm and larynx recovery) as well as the geniohyoid muscle (upper airway recovery).		May be necessary depending on surgical positioning, however is prone to more inaccuracies due to direct muscle stimulation. The palpated muscles may either be the orbicularis occuli (which generally correlates with diaphragm and larynx recovery) as well as the geniohyoid muscle (upper airway recovery).
			''Posterior Tibial Nerve''
	''Posterior Tibial Nerve''		''Posterior Tibial Nerve''

	''Posterior Tibial Nerve''		''Posterior Tibial Nerve''

	Generally used with AMG.		Generally used with AMG.

	'''Fade'''		'''Fade'''

Bsumida1 at 11:39, 4 July 2022

2022-07-04T11:39:45Z

← Older revision		Revision as of 04:39, 4 July 2022
Line 8:		Line 8:
	* Rocuronium		* Rocuronium
	* Vecuronium		* Vecuronium
	~~''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):~~

	''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):		''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):
Line 14:		Line 14:
	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)

	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
			'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing sustained depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

	* Succinylcholine		* Succinylcholine
			Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.

	Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.		Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.
Line 30:		Line 32:
	* Kinemyography (KMG)		* Kinemyography (KMG)

			These monitors calculate a train of four ratio (TOFR) which the provider uses to determine the depth of paralysis. This ratio is the magnitude of the 4th twitch divided by the magnitude of the 1st twitch. A higher ratio indicates lighter paralysis. Prior to extubation, for example, providers look for a TOFR of at least >0.9 indicating almost complete recovery of muscle strength/function.

			All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that generate measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.

	These monitors calculate a train of four ratio (TOFR) which the provider uses to determine the depth of paralysis. This ratio is the magnitude of the 4th twitch divided by the magnitude of the 1st twitch. A higher ratio indicates lighter paralysis. Prior to extubation, for example, providers look for a TOFR of at least >0.9 indicating almost complete recovery of muscle strength/function.

	All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.

	'''Qualitative Monitoring'''		'''Qualitative Monitoring'''

	In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.		In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.


	'''Methods of assessment'''		'''Methods of assessment'''
Line 54:		Line 56:
	4 twitches = 70-75%		4 twitches = 70-75%

	When administering reversal drugs, TOFC ~~are~~ used to determine readiness or dosing of medication.		When administering reversal drugs, TOFC is used to determine readiness or dosing of medication.

	* If using Neostigmine/Glycopyrrolate: generally given when TOFC is 4		* If using Neostigmine/Glycopyrrolate: generally given when TOFC is 4

	* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal



	''Post Tetanic Count (PTC)''		''Post Tetanic Count (PTC)''

	With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).		With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).
			'''Sites of Use (for graphics, can refer to UpToDate'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

	'''Sites of Use (for graphics, can refer to UpToDate'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)		'''Sites of Use (for helpful graphics, can refer to [https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print UpToDate]'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

	''Ulnar Nerve''		''Ulnar Nerve''

	Generally the preferred site of monitoring. It is easily accessible. There is a lower chance of direct muscle stimulation which is not an assessment of nerve function/neuromuscular blockade. If surgical positioning interferes with intraoperative monitoring, can consider measuring closer to the end of the case if able to access the limb at that time.		Generally the preferred site of monitoring. It is easily accessible. There is a lower chance of direct muscle stimulation which is not an assessment of nerve function/neuromuscular blockade. If surgical positioning interferes with intraoperative monitoring, can consider measuring closer to the end of the case if able to access the limb at that time.
			''Facial Nerve''

	''Facial Nerve''		''Facial Nerve''

	May be necessary depending on surgical positioning, however is prone to more inaccuracies due to direct muscle stimulation. The palpated muscles may either be the orbicularis occuli (which generally correlates with diaphragm and larynx recovery) as well as the geniohyoid muscle (upper airway recovery).		May be necessary depending on surgical positioning, however is prone to more inaccuracies due to direct muscle stimulation. The palpated muscles may either be the orbicularis occuli (which generally correlates with diaphragm and larynx recovery) as well as the geniohyoid muscle (upper airway recovery).
			''Posterior Tibial Nerve''

	''Posterior Tibial Nerve''		''Posterior Tibial Nerve''

	Generally used with AMG.		Generally used with AMG.

	'''Fade'''		'''Fade'''
Line 96:		Line 99:
	'''Sugammadex:''' 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		'''Sugammadex:''' 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal

	Considerations for ~~sugammadex~~ include the risk of arrhythmias, hypersensitivity reactions (increased with larger doses). Although there is concern with the use of ~~sugammadex~~ in patients with kidney dysfunction (as it is renally cleared), recent studies have shown its safe use in patients with end stage renal disease (ESRD)<ref>{{Cite journal\|last=Paredes\|first=Stephania\|last2=Porter\|first2=Steven B.\|last3=Porter\|first3=Ivan E.\|last4=Renew\|first4=J. Ross\|date=2020-12\|title=Sugammadex use in patients with end-stage renal disease: a historical cohort study\|url=https://pubmed.ncbi.nlm.nih.gov/32949009/\|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie\|volume=67\|issue=12\|pages=1789–1797\|doi=10.1007/s12630-020-01812-3\|issn=1496-8975\|pmid=32949009}}</ref>.		Considerations for Sugammadex include the risk of arrhythmias, hypersensitivity reactions (increased with larger doses). Although there is concern with the use of Sugammadex in patients with kidney dysfunction (as it is renally cleared), recent studies have shown its safe use in patients with end stage renal disease (ESRD)<ref>{{Cite journal\|last=Paredes\|first=Stephania\|last2=Porter\|first2=Steven B.\|last3=Porter\|first3=Ivan E.\|last4=Renew\|first4=J. Ross\|date=2020-12\|title=Sugammadex use in patients with end-stage renal disease: a historical cohort study\|url=https://pubmed.ncbi.nlm.nih.gov/32949009/\|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie\|volume=67\|issue=12\|pages=1789–1797\|doi=10.1007/s12630-020-01812-3\|issn=1496-8975\|pmid=32949009}}</ref>.

	==References==		==References==

	[[Category:Drug reference]]		[[Category:Drug reference]]

Bsumida1 at 13:53, 3 July 2022

2022-07-03T13:53:29Z

← Older revision		Revision as of 06:53, 3 July 2022
Line 8:		Line 8:
	* Rocuronium		* Rocuronium
	* Vecuronium		* Vecuronium
			''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):

	''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):		''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):

	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)


	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
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	'''Qualitative Monitoring'''		'''Qualitative Monitoring'''

	In lieu of EMG, ~~provider~~ may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.		In lieu of EMG, providers may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.

	'''Methods of assessment'''		'''Methods of assessment'''

Bsumida1 at 13:51, 3 July 2022

2022-07-03T13:51:45Z

← Older revision		Revision as of 06:51, 3 July 2022
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	~~{{Infobox drug reference~~
	~~\| trade_names =~~
	~~\| drug_class =~~
	~~\| drug_class_color =~~
	~~\| uses =~~
	~~\| contraindications =~~
	~~\| routes =~~
	~~\| dosage =~~
	}}

	'''Neuromuscular blockade''' involves the use of neuromuscular blocking agents (NMBAs) (i.e. paralytics) to facilitate endotracheal intubation and/or surgical procedures.		'''Neuromuscular blockade''' involves the use of neuromuscular blocking agents (NMBAs) (i.e. paralytics) to facilitate endotracheal intubation and/or surgical procedures.

Bsumida1 at 13:48, 3 July 2022

2022-07-03T13:48:39Z

← Older revision		Revision as of 06:48, 3 July 2022
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	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)


	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

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	These monitors calculate a train of four ratio (TOFR) which the provider uses to determine the depth of paralysis. A higher ratio indicates lighter paralysis. Prior to extubation, for example, providers look for a TOFR of at least >0.9 indicating almost complete recovery of muscle strength/function.		These monitors calculate a train of four ratio (TOFR) which the provider uses to determine the depth of paralysis. This ratio is the magnitude of the 4th twitch divided by the magnitude of the 1st twitch. A higher ratio indicates lighter paralysis. Prior to extubation, for example, providers look for a TOFR of at least >0.9 indicating almost complete recovery of muscle strength/function.

	All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.		All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.
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	* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal



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	'''Neostigmine:''' 0.03-0.07 mg/kg IV (max 5 mg)		'''Neostigmine:''' 0.03-0.07 mg/kg IV (max 5 mg)

	<big>~~'''~~Newer Agents~~'''~~</big>		=== <big>Newer Agents</big> ===

	'''Sugammadex:''' 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal		'''Sugammadex:''' 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal

	~~Alth~~		Considerations for sugammadex include the risk of arrhythmias, hypersensitivity reactions (increased with larger doses). Although there is concern with the use of sugammadex in patients with kidney dysfunction (as it is renally cleared), recent studies have shown its safe use in patients with end stage renal disease (ESRD)<ref>{{Cite journal\|last=Paredes\|first=Stephania\|last2=Porter\|first2=Steven B.\|last3=Porter\|first3=Ivan E.\|last4=Renew\|first4=J. Ross\|date=2020-12\|title=Sugammadex use in patients with end-stage renal disease: a historical cohort study\|url=https://pubmed.ncbi.nlm.nih.gov/32949009/\|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie\|volume=67\|issue=12\|pages=1789–1797\|doi=10.1007/s12630-020-01812-3\|issn=1496-8975\|pmid=32949009}}</ref>.

	==References==		==References==

	[[Category:Drug reference]]		[[Category:Drug reference]]

Bsumida1 at 13:42, 3 July 2022

2022-07-03T13:42:03Z

← Older revision		Revision as of 06:42, 3 July 2022
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	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)

	'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:		'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

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	* Kinemyography (KMG)		* Kinemyography (KMG)



			These monitors calculate a train of four ratio (TOFR) which the provider uses to determine the depth of paralysis. A higher ratio indicates lighter paralysis. Prior to extubation, for example, providers look for a TOFR of at least >0.9 indicating almost complete recovery of muscle strength/function.

	All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.		All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.
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	'''Qualitative Monitoring'''		'''Qualitative Monitoring'''

	In lieu of EMG, provider may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.		In lieu of EMG, provider may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.

			'''Methods of assessment'''

			''Train of Four Count (TOFC)''

			Electrical stimulus is applied to a peripheral nerve and the number of twitches counted corresponds to the amount/percent of acetylcholine receptors blocked:

			1 twitch = >95%

			2 twitches = 85-90%

			3 twitches = 80-85%

			4 twitches = 70-75%

			When administering reversal drugs, TOFC are used to determine readiness or dosing of medication.

			* If using Neostigmine/Glycopyrrolate: generally given when TOFC is 4

			* If using Sugammadex: 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal


			''Post Tetanic Count (PTC)''

			With PTC, a large 50 Hz stimulus is applied for 5 seconds followed by subsequent 1 Hz stimuli over 20 seconds. PTC is used when the TOFC is zero. PTC can indicate time to recovery (e.g. a PTC of 1 indicates recovery from paralysis in approximately 30 minutes).

			'''Sites of Use (for graphics, can refer to UpToDate'''<ref>{{Cite web\|title=UpToDate\|url=https://www.uptodate.com/contents/monitoring-neuromuscular-blockade/print\|access-date=2022-07-03\|website=www.uptodate.com}}</ref>)

			''Ulnar Nerve''

			Generally the preferred site of monitoring. It is easily accessible. There is a lower chance of direct muscle stimulation which is not an assessment of nerve function/neuromuscular blockade. If surgical positioning interferes with intraoperative monitoring, can consider measuring closer to the end of the case if able to access the limb at that time.

			''Facial Nerve''

			May be necessary depending on surgical positioning, however is prone to more inaccuracies due to direct muscle stimulation. The palpated muscles may either be the orbicularis occuli (which generally correlates with diaphragm and larynx recovery) as well as the geniohyoid muscle (upper airway recovery).

			''Posterior Tibial Nerve''

			Generally used with AMG.

	'''Fade'''		'''Fade'''

	Fade is the progressive decrease in amplitude in response to nerve stimulation as a result of increased levels of paralysis. This is important ~~Of note, fade is generally not observed when depolarizing agents such~~ as ~~succinylcholine~~ are ~~used (instead, there is~~ a ~~uniform decrease~~ in amplitude). ~~Fade may still be observed with depolarizing agents if patients are in phase II of paralysis where there~~ is ~~desensitization of~~ the ~~neuromuscular junction after prolonged acetylcholine channel opening~~.		Fade is the progressive decrease in amplitude in response to nerve stimulation as a result of increased levels of paralysis. This is important as twitches are counted until the provider appreciates a significant drop in amplitude. It is difficult to assess twitches/fade when the TOFR is >0.4 (which is still a significant paralysis).

	~~===Precautions<!-- List precautions for use of the drug~~. ~~If none, this section may be removed. -->===~~

	~~==Pharmacology==~~		Of note, fade is generally not observed when depolarizing agents such as succinylcholine are used (instead, there is a uniform decrease in amplitude). Fade may still be observed with depolarizing agents if patients are in phase II of paralysis where there is desensitization of the neuromuscular junction after prolonged acetylcholine channel opening.

	==~~=Pharmacodynamics<!-- Describe the effects of the drug on the body. If appropriate, add subsections by organ system -->=~~==		==Reversal Methods (with dosing)==

	====~~Mechanism of action<!~~-~~- Describe the mechanism of action for the primary uses of the drug~~. ~~-->====~~		===Traditional Agents===
			'''Glycopyrrolate''' (given first to prevent bradycardia): 0.1-0.2 mg/kg IV

	~~====Adverse effects<!-~~- ~~Describe any potential adverse effects of the drug~~. ~~-->====~~		'''Neostigmine:''' 0.03-0.07 mg/kg IV (max 5 mg)

	~~===Pharmacokinetics~~<~~!-- Describe the pharmacokinetics of the drug. --~~>~~===~~		<big>'''Newer Agents'''</big>

	~~==Chemistry and formulation<!~~-- ~~Describe the chemistry and formulation of the drug. -->==~~		'''Sugammadex:''' 4 mg/kg for 1-2 twitches, 2 mg/kg for 3-4 twitches, 16 mg/kg for immediate reversal

	~~==History<!-- Describe the historical development of the drug. -->==~~		Alth

	==References==		==References==

	[[Category:Drug reference]]		[[Category:Drug reference]]

Bsumida1 at 13:01, 3 July 2022

2022-07-03T13:01:37Z

← Older revision		Revision as of 06:01, 3 July 2022
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	}}		}}

	Neuromuscular blockade involves the use of neuromuscular blocking agents (NMBAs) (i.e. paralytics) to facilitate endotracheal intubation and/or surgical procedures.		'''Neuromuscular blockade''' involves the use of neuromuscular blocking agents (NMBAs) (i.e. paralytics) to facilitate endotracheal intubation and/or surgical procedures.

	==Drugs used==		==Drugs used==
	Non-depolarizing agents bind to and INHIBIT acetylcholine receptors at the end plate of the neuromuscular junction. Common examples below include:		'''Non-depolarizing agents''' bind to and INHIBIT acetylcholine receptors at the end plate of the neuromuscular junction. Common examples below include:

	Steroidal non-depolarizing agents (hepatic and/or renal excreted):		''Steroidal non-depolarizing agents'' (hepatic and/or renal excreted):

	* Rocuronium		* Rocuronium
	* Vecuronium		* Vecuronium

			''Benzylisoquinolinium non-depolarizing agents'' (broken down by Hoffman Elimination):
	Benzylisoquinolinium non-depolarizing agents (broken down by Hoffman Elimination):

	* Cisatrocurium (the cis-enantiomer of atrocurium)		* Cisatrocurium (the cis-enantiomer of atrocurium)

			'''Depolarizing agents''' on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:
	Depolarizing agents on the other hand bind and ACTIVATE acetylcholine receptors causing depolarization of the neuromuscular junction (i.e. muscle contraction) followed by paralysis. The prototypical example being:

	* Succinylcholine		* Succinylcholine


	Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.		Depolarizing agents have different implications for neuromuscular blockade monitoring as discussed below.

	==Monitoring==		==Monitoring==
	Train of Four		===Train of Four===
			'''Equipment (Quantitative Monitoring)'''

	In order to assess the level of paralysis during an anesthesia event, train of four monitoring (either quantitative or qualitative) is typically used throughout the duration of the procedure (e.g. during routine assessments) and prior to extubation. Quantitative train of four monitoring is the most accurate assessment of neuromuscular blockade and is preferred as it mitigates the risk of residual paralysis and subsequent post-op pulmonary complications<ref>{{Cite web\|last=Brull\|first=Sorin\|title=Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities\|url=https://pubs.asahq.org/crawlprevention/governor?content=%2fanesthesiology%2farticle%2f126%2f1%2f173%2f660%2fCurrent-Status-of-Neuromuscular-Reversal-and\|url-status=live\|access-date=2022-07-03\|website=pubs.asahq.org}}</ref>. Equipment that can be used includes:		In order to assess the level of paralysis during an anesthesia event, train of four monitoring (either quantitative or qualitative) is typically used throughout the duration of the procedure (e.g. during routine assessments) and prior to extubation. Quantitative train of four monitoring is the most accurate assessment of neuromuscular blockade and is preferred as it mitigates the risk of residual paralysis and subsequent post-op pulmonary complications<ref>{{Cite web\|last=Brull\|first=Sorin\|title=Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities\|url=https://pubs.asahq.org/crawlprevention/governor?content=%2fanesthesiology%2farticle%2f126%2f1%2f173%2f660%2fCurrent-Status-of-Neuromuscular-Reversal-and\|url-status=live\|access-date=2022-07-03\|website=pubs.asahq.org}}</ref>. Equipment that can be used includes:
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	* Kinemyography (KMG)		* Kinemyography (KMG)

	=~~==Absolute contraindications<!-- List absolute contraindications~~ for use of the ~~drug~~. ~~If none~~, ~~this section~~ may ~~be removed~~. -->===
			All of the above involve the stimulation of peripheral nerves, the differences being what is actually measured. EMG measures evoked muscle responses (a.k.a. action potentials). AMG measures the acceleration of thumb contraction using Newton's Second Law of Motion (Force = Mass x Acceleration). KMG uses mechanosensors that general measurable electrical signals. All are valid for use in quantitative train of four monitoring. AMG and KMG require unrestricted motion of the hand or muscle interrogated while EMG does not. AMG and KMG are also subject to the phenomenon of "reverse fade." EMG on the other hand can be affected by electrical interference in the operating room (cautery) but nonetheless is usually the monitoring device of choice.

			'''Qualitative Monitoring'''

			In lieu of EMG, provider may also use a nerve stimulator and palpate for muscle contraction in order to assess depth of paralysis. This is less accurate and generally overestimates recovery from paralysis<ref>{{Cite journal\|last=Azizoğlu\|first=Mustafa\|last2=Özdemir\|first2=Levent\|date=2021-08-01\|title=Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study\|url=https://pubmed.ncbi.nlm.nih.gov/34276037/\|journal=Journal of Patient Safety\|volume=17\|issue=5\|pages=352–357\|doi=10.1097/PTS.0000000000000874\|issn=1549-8425\|pmid=34276037}}</ref>. The risk of this is residual paralysis which contributes to higher rates of post-op pulmonary complications.

			'''Fade'''

			Fade is the progressive decrease in amplitude in response to nerve stimulation as a result of increased levels of paralysis. This is important Of note, fade is generally not observed when depolarizing agents such as succinylcholine are used (instead, there is a uniform decrease in amplitude). Fade may still be observed with depolarizing agents if patients are in phase II of paralysis where there is desensitization of the neuromuscular junction after prolonged acetylcholine channel opening.

	===Precautions<!-- List precautions for use of the drug. If none, this section may be removed. -->===		===Precautions<!-- List precautions for use of the drug. If none, this section may be removed. -->===