Respiratory Insufficiency Clinical Trial
Official title:
Effect of Neuromuscular Blockade and Reversal by Sugammadex Versus Neostigmine on Breathing When Hypoxic or Hypercapnic in Volunteers
In this study the investigators will assess (i) the effect of partial neuromuscular blockade
(NMB; TOF ratio 0.8 and 0.6) induced by low-dose rocuronium on the ventilatory response to
isocapnic hypoxia and (ii) the effect over time (from TOF 0.6 to TOF 1.0) of the reversal by
sugammadex, neostigmine or placebo in healthy volunteers.
Additionally the investigators will assess the effect of partial NMB (TOF ratio 0.6) induced
by low-dose rocuronium on the ventilatory response to hypercapnia and effect over time (from
TOF 0.6 to TOF 1.0) of the reversal by sugammadex, neostigmine or placebo in healthy
volunteers.
The carotid bodies, located at the bifurcation of the common carotid artery, play a crucial
and life-saving role in the control of breathing in humans. The carotid bodies contain type 1
cells that are primarily sensitive to low oxygen concentrations in arterial blood. In
response to low oxygen the carotid bodies send information to the brainstem respiratory
centers and a brisk hyperventilatory response will be initiated ensuring an increase in
uptake of oxygen via the lungs. Following surgery, a rapid return of the carotid body
function is vital and persistent loss of carotid body function may result in respiratory
complications that occur independent of the effects of anesthetics (incl. muscle relaxants)
on respiratory muscles. Respiratory complications that are related to the loss of carotid
body function include the inability to respond properly to hypoxia as well the inability to
overcome upper airway obstruction. The latter is especially important in patients with sleep
disordered-breathing and obese patients. These patients rely on the optimal function of their
carotid bodies in response to hypoxia or upper airway closure.
Important neurotransmitters involved in the carotid body response to hypoxia include
acetylcholine, which acts through local nicotinergic acetylcholine receptors. Apart from the
observation that muscle relaxants (which are blockers of the acetylcholine receptors) affect
the proper functioning of the carotid bodies, the investigators have no knowledge on the
dynamic effects of muscle relaxants on carotid body function over time or on the relationship
between carotid body function and Train-of-Four (TOF) ratio over time. Additionally, there is
no data on the link between the use of NMB antagonists and return of carotid body function.
Linking TOF ratio to carotid body function is of clinical importance as a possible
relationship will allow clinicians to predict carotid body function from the TOF ratio. The
latter is highly relevant as the investigators show in a previous trial that a large
proportion of patients is extubated at TOF ratio's < 0.7.
Apart from the carotid bodies, chemoreceptors in the brainstem exist that are sensitive to
hypercapnia. This response system is not under control of cholinergic neurotransmission.
Since the investigators may assume that the hypercapnic ventilatory response is not
influenced by muscle relaxants the investigators can use this response to calibrate the
hypoxic ventilatory response as both responses are equally affected by the effect of muscle
relaxants on muscle function.
As stated there is data on the effect of muscle relaxants on carotid body function at one
fixed TOF ratio (TOF ratio fixed at 0.7). No data are available on:
1. Dynamic effect of carotid body function as measured by the hypoxic ventilatory response
at TOF ratio's slowly changing from 0.6 to 1.0;
2. Dynamic effect of reversal of NMB by sugammadex versus neostigmine. Sugammadex and
neostigmine are both reversal agents of neuromuscular blockade. At their institution the
investigators use both agents in clinical practice but remain without knowledge on their
effects on carotid body function. The current proposal is designed to study items 1 and
2 in healthy awake volunteers.
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