Background The combination of complete diaphragm inactivity and mechanical ventilation (for more than 18 hours) elicits disuse atrophy of myofibers in animals. We hypothesized that the same may also occur in the human diaphragm. Methods We obtained biopsy specimens from the costal diaphragms of 14 brain-dead organ donors before organ harvest (case subjects) and compared them with intraoperative biopsy specimens from the diaphragms of 8 patients who were undergoing surgery for either benign lesions or localized lung cancer (control subjects). Case subjects had diaphragmatic inactivity and underwent mechanical ventilation for 18 to 69 hours; among control subjects diaphragmatic inactivity and mechanical ventilation were limited to 2 to 3 hours. We carried out histologic, biochemical, and gene-expression studies on these specimens. Results As compared with diaphragm-biopsy specimens from controls, specimens from case subjects showed decreased cross-sectional areas of slow-twitch and fast-twitch fibers of 57% (P = 0.001) and 53% (P = 0.01), respectively, decreased glutathione concentration of 23% (P = 0.01), increased active caspase-3 expression of 100% (P = 0.05), a 200% higher ratio of atrogin-1 messenger RNA (mRNA) transcripts to MBD4 (a housekeeping gene) (P = 0.002), and a 590% higher ratio of MuRF-1 mRNA transcripts to MBD4 (P = 0.001). Conclusions The combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. These findings are consistent with increased diaphragmatic proteolysis during inactivity.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa070447

Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.

https://nrr.org/wp-content/uploads/0000/10/07_ERC_Guidelines_2005_Section7.pdf

European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances.

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European Resuscitation Council (ERC) Guidelines for Resuscitation 2005

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

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The diagnosis and management of anaphylaxis practice parameter: 2010 update.

Hugh A. Sampson, MD, Anne Munoz-Furlong, BA, S. Allan Bock, MD, Cara Schmitt, MS, Robert Bass, MD, Badrul A. Chowdhury, MD, Wyatt W. Decker, MD, Terence J. Furlong, MS, Stephen J. Galli, MD, David B. Golden, MD, Rebecca S. Gruchalla, MD, Allen D. Harlor, Jr, MD, David L. Hepner, MD, Marilyn Howarth, MD, Allen P. Kaplan, MD, Jerrold H. Levy, MD, Lawrence M. Lewis, MD, Phillip L. Lieberman, MD, Dean D. Metcalfe, MD, Ramon Murphy, MD, Susan M. Pollart, MD, Richard S. Pumphrey, MD, Lanny J. Rosenwasser, MD, F. Estelle Simons, MD, Joseph P. Wood, MD, and Carlos A. Camargo, Jr, MD New York, NY, Fairfax and Charlottesville, Va, Boulder and Denver, Colo, Baltimore, Rockville, and Bethesda, Md, Rochester, Minn, Stanford, Calif, Dallas, Tex, Eugene, Ore, Boston, Mass, Philadelphia, Pa, Charleston, SC, Atlanta, Ga, St Louis, Mo, Cordova, Tenn, Scottsdale, Ariz, Manchester, United Kingdom, and Winnipeg, Manitoba, Canada

https://www.jacionline.org/article/S0091-6749(05)00088-6/pdf

Symposium on the Definition and Management of Anaphylaxis: Summary report

Background Anaphylactic and anaphylactoid reactions occurring during anesthesia remain a major cause of concern for anesthesiologists. The authors report the results of a 2-yr survey of such reactions observed during anesthesia in France. Methods Between January 1, 1999, and December 31, 2000, 789 patients who experienced immune-mediated (anaphylaxis) or nonimmune-mediated (anaphylactoid) reactions were referred to one of the 40 participating centers. Anaphylaxis was diagnosed on the basis of clinical history, skin tests, and/or specific immunoglobulin E assay. Results Anaphylactic and anaphylactoid reactions were diagnosed in 518 cases (66%) and 271 cases (34%), respectively. The most common causes of anaphylaxis were neuromuscular blocking agents (NMBAs) (n = 306, 58.2%), latex (n = 88, 16.7%), and antibiotics (n = 79, 15.1%). Rocuronium (n = 132, 43.1%) and succinylcholine (n = 69, 22.6%) were the most frequently incriminated NMBAs. Cross-reactivity between NMBAs was observed in 75.1% of cases of anaphylaxis to an NMBA. No difference was observed between anaphylactoid and anaphylactic reactions when the incidences of atopy, asthma, or drug intolerance were compared. However, atopy, asthma, and food allergy were significantly more frequent in the case of latex allergy when compared with NMBA allergy. Clinical manifestations were more severe in anaphylaxis. The positive predictive value of tryptase for the diagnosis of anaphylaxis was 92.6%; the negative predictive value was 54.3%. The diagnostic value of specific NMBA immunoglobulin E assays was confirmed. Conclusions These results further corroborate the need for systematic screening in the case of anaphylactoid reaction during anesthesia and for the constitution of allergoanesthesia centers to provide expert advice to anesthesiologists and allergists.

Anaphylactic and Anaphylactoid Reactions Occurring during Anesthesia in France in 1999–2000

Between January 1, 1997 and December 31, 1998, 467 patients were referred to one of the allergo-anaesthesia centres of the French GERAP (Groupe d'Etudes des Reactions Anaphylactoides Peranesthesiques) network and were diagnosed as having anaphylaxis during anaesthesia. Diagnosis was established on the basis of clinical history, skin tests and/or a specific IgE assay. The most frequent cause of anaphylaxis was a neuromuscular blocking agent (69.2%). Latex was less frequently incriminated (12.1%) than in previous reports. A significant difference was observed between the incidence of anaphylactic reactions observed with each neuromuscular blocking agent and the number of patients who received each drug during anaesthesia in France throughout the study period (P<0.0001). Succinylcholine and rocuronium were most frequently incriminated. Clinical reactions to neuromuscular blocking drugs were more severe than to latex. The diagnostic value of specific IgE assays was confirmed. These results are consistent with changes in the epidemiology of anaphylaxis related to anaesthesia and are an incentive for the further development of allergo-anaesthesia clinical networks.

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Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques

Papers

Anaphylactic and Anaphylactoid Reactions Occurring during Anesthesia in France in 1999–2000

Anaphylaxis during anaesthesia. Results of a two‐year survey in France