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Johnson KB. Driving Residual Neuromuscular Blockade to Zero: Precision Matters. Anesth Analg 2024; 139:532-535. [PMID: 39151136 DOI: 10.1213/ane.0000000000007064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Affiliation(s)
- Ken B Johnson
- From the Department of Anesthesiology, Perioperative & Pain Medicine, University of Utah
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Sieg L, Heiderich S. [Update: Neuromuscular Blockade during General Anesthesia]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:494-504. [PMID: 39197441 DOI: 10.1055/a-2195-8785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2024]
Abstract
The correct use of muscle relaxants and neuromuscular monitoring during anesthesia has been subject of controversial discussions for decades. Particularly important in clinical practice are identification and management of residual neuromuscular blockages and avoidance of associated complications. Despite the differences in the molecular mechanisms of action between depolarizing and non-depolarizing muscle relaxants the blockade of the postsynaptic nicotinic acetylcholine receptor remains a common ending pathway. Due to its unfavorable side effect profile, succinylcholine should only be used in justified exceptional cases. The use of muscle relaxants generally reduces the complication rate in airway management. However, even the single use of muscle relaxants increases the likelihood of postoperative pulmonary complications. These complications associated with the use of muscle relaxants, such as residual neuromuscular blockade, must be anticipated. The application of guideline-based approaches, including continuous neuromuscular monitoring and the application of muscle relaxant reversal agents, may significantly reduce the rate of adverse events associated with the use of muscle relaxants.
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Brull SJ, Fuchs-Buder T. Accuracy and Precision of Acceleromyography, Electromyography, and Mechanomyography: Time to Rethink What We Know. Anesthesiology 2024; 141:204-207. [PMID: 38980163 DOI: 10.1097/aln.0000000000005054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital Nancy, Nancy, France
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Tobias JD, Epstein RH, Rice-Weimer J, Yemele Kitio SA, Brull SJ, Kalsotra S. Pediatric Intraoperative Electromyographic Responses at the Adductor Pollicis and Flexor Hallucis Brevis Muscles: A Prospective, Comparative Analysis. Anesth Analg 2024; 139:36-43. [PMID: 38885397 DOI: 10.1213/ane.0000000000006926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Peripheral nerve stimulation with a train-of-four (TOF) pattern can be used intraoperatively to evaluate the depth of neuromuscular block and confirm recovery from neuromuscular blocking agents (NMBAs). Quantitative monitoring can be challenging in infants and children due to patient size, equipment technology, and limited access to monitoring sites. Although the adductor pollicis muscle is the preferred site of monitoring, the foot is an alternative when the hands are unavailable. However, there is little information on comparative evoked neuromuscular responses at those 2 sites. METHODS Pediatric patients undergoing inpatient surgery requiring NMBA administration were studied after informed consent. Electromyographic (EMG) monitoring was performed simultaneously in each participant at the hand (ulnar nerve, adductor pollicis muscle) and the foot (posterior tibial nerve, flexor hallucis brevis muscle). RESULTS Fifty patients with a mean age of 3.0 ± standard deviation (SD) 2.9 years were studied. The baseline first twitch amplitude (T1) of TOF at the foot (12.46 mV) was 4.47 mV higher than at the hand (P <.0001). The baseline TOF ratio (TOFR) before NMBA administration and the maximum TOFR after antagonism with sugammadex were not different at the 2 sites. The onset time until the T1 decreased to 10% or 5% of the baseline value (T1) was delayed by approximately 90 seconds (both P =.014) at the foot compared with the hand. The TOFR at the foot recovered (TOFR ≥0.9) 191 seconds later than when this threshold was achieved at the hand (P =.017). After antagonism, T1 did not return to its baseline value, a typical finding with EMG monitoring, but the fractional recovery (maximum T1 at recovery divided by the baseline T1) at the hand and foot was not different, 0.81 and 0.77, respectively (P =.68). The final TOFR achieved at recovery was approximately 100% and was not different between the 2 sites. CONCLUSIONS Although this study in young children demonstrated the feasibility of TOF monitoring, interpretation of the depth of neuromuscular block needs to consider the delayed onset and the delayed recovery of TOFR at the foot compared to the hand. The delay in achieving these end points when monitoring the foot may impact the timing of tracheal intubation and assessment of adequate recovery of neuromuscular block to allow tracheal extubation (ie, TOFR ≥0.9).
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Affiliation(s)
- Joseph D Tobias
- From the Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio University, Columbus, Ohio
| | - Richard H Epstein
- Department of Anesthesiology, Perioperative Medicine & Pain Management, University of Miami, Miami, Florida
| | - Julie Rice-Weimer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Sidhant Kalsotra
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Wang A, Tsivitis A, Ma S, Jin Z, Al Bizri E, Moore R. The safety and efficacy of sugammadex for reversing neuromuscular blockade in younger children and infants. Expert Opin Drug Saf 2024; 23:845-853. [PMID: 38938223 DOI: 10.1080/14740338.2024.2373906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Sugammadex, a novel selective antagonist of non-depolarizing neuromuscular blocking agents, has been shown to rapidly and effectively reverse moderate and deep paralysis in adults and pediatric patients over age 2, improving patient recovery and reducing the risk of postoperative complications. AREAS COVERED Since the use of sugammadex in patients under age 2 is not widely studied, we aim to provide an overview on the drug's application and potential use in infants and neonates. There is a limited but growing body of evidence for the safe, efficacious use of sugammadex in children under age 2. Relevant studies were identified from the most updated data including case reports, clinical trials, systematic reviews, and meta analyses. EXPERT OPINION The results suggest that at a dose of 2 to 4 mg/kg of sugammadex can be safely used to rapidly and effectively reverse neuromuscular blockade in neonates and infants; it is non-inferior based on incidence of adverse events compared to neostigmine. Additionally, sugammadex doses between 8 and 16 mg/kg may be used as a rescue agent for infants during 'can't intubate, can't ventilate' crisis. Overall, sugammadex offers new value in the perioperative care of patients under age 2, with further studies warranted to better understand its application and full effect in the pediatric population.
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Affiliation(s)
- Ashley Wang
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Alexandra Tsivitis
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Sijia Ma
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Ehab Al Bizri
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Robert Moore
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
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Rodney G, Raju P, Brull S. Neuromuscular block management: evidence-based principles and practice. BJA Educ 2024; 24:13-22. [PMID: 38495745 PMCID: PMC10941205 DOI: 10.1016/j.bjae.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
| | - P. Raju
- Ninewells Hospital, Dundee, UK
| | - S.J. Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
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Bucheery BA, Isa HM, Rafiq O, Almansoori NA, Razaq ZAA, Gawe ZA, Almoosawi JA. Residual Neuromuscular Blockade and Postoperative Pulmonary Complications in the Post-anesthesia Care Unit: A Prospective Observational Study. Cureus 2023; 15:e51013. [PMID: 38264400 PMCID: PMC10803948 DOI: 10.7759/cureus.51013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/25/2024] Open
Abstract
Background Neuromuscular blocking agents (NMBAs) are employed during general anesthesia induction for endotracheal intubation and to facilitate specific surgeries requiring muscle relaxation. However, residual neuromuscular blockade (RNMB) can lead to respiratory complications in post-anesthesia care units (PACUs). This study investigates RNMB incidence in PACUs and its association with postoperative airway and respiratory issues. Methods A prospective observational study on patients undergoing general anesthesia with NMBAs was conducted at the Department of Anesthesia, Salmaniya Medical Complex, Bahrain, over six months (April to September 2023). Train-of-four (TOF) ratios were calculated using an acceleromyograph upon PACU arrival. Data on demographics, perioperative variables, and postoperative complications were recorded. Results Among 82 patients, 30 (36.6%) had RNMB upon PACU arrival. RNMB incidence declined: 17.1% at 10 minutes, 6.1% at 20 minutes, and 2.4% at 30 minutes, resolving by 40 minutes. Demographics and procedure duration showed no correlation with RNMB. Postoperative respiratory complications affected 23.2% of patients, notably higher in those with RNMB (p = 0.001). Among patients with TOF <90% at PACU arrival, 46.7% experienced complications compared to 9.6% with TOF ≥90% (p<0.001). Participants without RNMB had a significantly higher weight (p = 0.046). Airway support was required for 30% of patients, all with TOF <90% (p<0.001). Conclusion This study emphasizes the importance of assessing and monitoring neuromuscular function to detect and prevent RNMB in PACUs. RNMB presence correlated with an increased susceptibility to postoperative respiratory complications. Regular quantitative neuromuscular monitoring is advisable in clinical practice to proactively mitigate RNMB incidence and its complications.
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Affiliation(s)
| | - Hasan M Isa
- Department of Pediatrics, Arabian Gulf University, Manama, BHR
- Department of Pediatrics, Salmaniya Medical Complex, Manama, BHR
| | - Owais Rafiq
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
| | | | | | - Zeana A Gawe
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
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Lim L, Lee J, Hwang SY, Lee H, Oh SY, Kang C, Ryu HG. Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery. J Am Coll Surg 2023; 237:606-613. [PMID: 37350477 DOI: 10.1097/xcs.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear. STUDY DESIGN Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery. RESULTS Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups. CONCLUSIONS EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.
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Affiliation(s)
- Leerang Lim
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Jihyuk Lee
- Radiology (J Lee), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - So Yeong Hwang
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Hannah Lee
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Seung-Young Oh
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
- Surgery (Oh), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Christine Kang
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
| | - Ho Geol Ryu
- From the Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital (Lim, Hwang, H Lee, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
- Critical Care Medicine (Oh, Kang, Ryu), Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, Korea
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Sun Q, Zhang T, Liu J, Cui Y, Tan W. A 20-year bibliometric analysis of postoperative pulmonary complications: 2003-2022. Heliyon 2023; 9:e20580. [PMID: 37860522 PMCID: PMC10582290 DOI: 10.1016/j.heliyon.2023.e20580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/23/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023] Open
Abstract
Background Postoperative pulmonary complications (PPCs) are known to adversely affect surgical outcomes and patient prognoses, yet no published study provides a qualitative and quantitative analysis of the latest trends and developments in the field of PPCs. Therefore, we conducted a bibliometric analysis of 20 years of publications related to PPCs. Methods We examined publications on PPCs published between 2003 and 2022 in the Web of Science Core Collection database to assess trends in the field in four dimensions: trends in publications, major research power, keywords, and co-cited publications. Results A total of 1881 articles were analyzed using CiteSpace and VOSviewer. Overall, the number of publications on PPCs has increased in the last two decades, with 42.72% of the publications being produced in the last five years. The United States of America had the highest number of articles, accounting for 21.91% of the total. The institution with the highest number of publications was the University of Genoa, which published 54 articles and showed a general lack of inter-institutional collaboration. The most productive author was Paolo Pelosi, with no core group of authors identified in the field of PPCs. The keyword co-occurrence analysis indicated that the focus of research has shifted over the past 20 years in terms of risk factors, type of surgery, and so on, while "enhanced recovery", "prehabilitation", "driving pressure" and "sugammadex" have received the most recent attention. In the analysis of co-cited literature, the most recent clusters that received attention were driving pressure, lung cancer patient, enhanced recovery, and neuromuscular blockade. Conclusion This bibliometric study suggests that pulmonary protective ventilation strategies, neuromuscular blockade reversal, and pulmonary prehabilitation strategy will be the focus of attention in the coming period. More large-scale studies and strengthened institutional collaboration are necessary to generate robust evidence for guiding individualized prevention of PPCs.
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Affiliation(s)
- Qi Sun
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Tianhao Zhang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Jiayun Liu
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Yong Cui
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Wenfei Tan
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
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Poelaert J, Hunter JM. Educating anaesthetists on neuromuscular monitoring: the challenges continue. Br J Anaesth 2023; 131:429-431. [PMID: 37380566 DOI: 10.1016/j.bja.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023] Open
Abstract
The need to introduce guidelines on neuromuscular monitoring emphasising the use of quantitative techniques that record the train-of-four ratio is now recognised by an increasing number of national anaesthetic societies in the Western world. But the challenge of convincing individual anaesthetists to adopt and use this practice routinely remains. For >10 yr, it has been recognised that all staff in anaesthetic departments need to have regular training in modern neuromuscular monitoring techniques. We discuss a publication in this journal that describes the challenges of setting up multicentre training in Spain to expand the use of quantitative neuromuscular monitoring and their short-term results.
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Affiliation(s)
- Jan Poelaert
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Anaesthesia, ICU and Chronic Pain Therapy, Hospital Maria Middelares, Ghent, Belgium.
| | - Jennifer M Hunter
- Department of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Díaz-Cambronero Ó, Mazzinari G, Errando CL, Garutti I, Gurumeta AA, Serrano AB, Esteve N, Montañes MV, Neto AS, Hollmann MW, Schultz MJ, Argente Navarro MP. An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia. Br J Anaesth 2023; 131:482-490. [PMID: 37087332 DOI: 10.1016/j.bja.2023.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 02/11/2023] [Accepted: 02/28/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND The incidence of postoperative residual curarisation remains unacceptably high. We assessed whether an educational intervention on perioperative neuromuscular block management can reduce it. METHODS In this multicentre, cluster randomised crossover trial, centres were allocated to receive an educational intervention either in a first or a second period. The educational intervention consisted of a lecture about neuromuscular management key points, including quantitative neuromuscular monitoring and use of reversal agents. The lecture was streamed to allow repetition. Additionally, memory cards were distributed in each operating theatre. The primary outcome was postoperative residual curarisation in the PACU. Secondary outcomes were frequency of quantitative neuromuscular monitoring, use of reversal agents, and incidence of postoperative pulmonary complications during hospital stay. Measurements were performed before randomisation and after the first and the second period. The effect of the educational intervention was estimated using multivariable mixed effects logistic regression models. RESULTS We included 2314 subjects in 34 Spanish centres. Postoperative residual curarisation incidence was not affected by the educational intervention (odds ratio [OR] 0.90 [95% confidence interval {CI}: 0.51-1.58]; P=0.717 and 1.30 [0.73-2.30]; P=0.371] for first and second time-period interaction). The educational intervention increased the quantitative neuromuscular monitor usage (OR 2.04 [95% CI: 1.31-3.19]; P=0.002), the use of reversal agents was unchanged (OR 0.79 [95% CI: 0.50-1.26]; P=0.322), and the incidence of postoperative pulmonary complications decreased (OR 0.19 [95% CI: 0.10-0.35]; P<0.001). CONCLUSIONS An educational intervention on perioperative neuromuscular block management did not reduce the incidence of postoperative residual curarisation nor increase reversal, despite increased quantitative neuromuscular monitoring. Sugammadex reversal was associated with reduced postoperative residual curarisation. The educational intervention was associated with a decrease in postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION NCT03128151.
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Affiliation(s)
- Óscar Díaz-Cambronero
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Perioperative Medicine Research Group, Hospital Universitario y Politécnico la Fe, Valencia, Spain.
| | - Guido Mazzinari
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Perioperative Medicine Research Group, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | | | - Ignacio Garutti
- Department of Anesthesiology, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | - Alfredo A Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ana B Serrano
- Department of Anesthesiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Neus Esteve
- Department of Anesthesiology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Maria V Montañes
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Perioperative Medicine Research Group, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maria P Argente Navarro
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Perioperative Medicine Research Group, Hospital Universitario y Politécnico la Fe, Valencia, Spain
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Si S, Zhao X, Su F, Lu H, Zhang D, Sun L, Wang F, Xu L. New advances in clinical application of neostigmine: no longer focusing solely on increasing skeletal muscle strength. Front Pharmacol 2023; 14:1227496. [PMID: 37601044 PMCID: PMC10436336 DOI: 10.3389/fphar.2023.1227496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Neostigmine is a clinical cholinesterase inhibitor, that is, commonly used to enhance the function of the cholinergic neuromuscular junction. Recent studies have shown that neostigmine regulates the immune-inflammatory response through the cholinergic anti-inflammatory pathway, affecting perioperative neurocognitive function. This article reviews the relevant research evidence over the past 20 years, intending to provide new perspectives and strategies for the clinical application of neostigmine.
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Affiliation(s)
- Shangkun Si
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaohu Zhao
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fan Su
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hongxiu Lu
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dongbin Zhang
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Li Sun
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fulei Wang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Li Xu
- Shandong University of Traditional Chinese Medicine, Jinan, China
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Schmidt M, Rössler J, Brooker J, Lara-Erazo V, Ekrami E, Pu X, Turan A, Sessler DI, Ruetzler K. Postoperative oxygenation assessed by SpO 2/FiO 2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study. J Clin Anesth 2023; 88:111138. [PMID: 37148836 DOI: 10.1016/j.jclinane.2023.111138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/31/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Residual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization. DESIGN Retrospective cohort analysis. SETTING Postoperative recovery area of a tertiary care hospital. PATIENTS Adults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex. INTERVENTIONS None. MEASUREMENTS The primary outcome was the lowest SpO2/FiO2 ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications. MAIN RESULTS Among 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO2/FiO2 ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of -3.5 (95% confidence interval: -5.3, -1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease. CONCLUSIONS Postoperative minimum SpO2/FiO2 ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.
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Affiliation(s)
- Marc Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jack Brooker
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Valentina Lara-Erazo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Xuan Pu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Blum LV, Steeger E, Iken S, Lotz G, Zinn S, Piekarski F, Zacharowski K, Raimann FJ. Effect of quantitative versus qualitative neuromuscular blockade monitoring on rocuronium consumption in patients undergoing abdominal and gynecological surgery: a retrospective cohort study. J Clin Monit Comput 2023; 37:509-516. [PMID: 35986228 PMCID: PMC10068638 DOI: 10.1007/s10877-022-00909-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 08/09/2022] [Indexed: 10/15/2022]
Abstract
The level of neuromuscular blockade can be assessed by subjective (qualitative) and objective (quantitative) methods. This study aims to compare the dosage of the neuromuscular blocking agents (NMBA) rocuronium and the need for reversion by sugammadex between those methods. A retrospective, observational analysis was conducted. In the tactile qualitative-neuromuscular monitoring-group (tactile NMM) (n = 244), muscle contractions were assessed tactilely. In the quantitative neuromuscular monitoring-group (n = 295), contractions were accessed using an acceleromyograph. Primary endpoints were dosage of rocuronium per minute operation-time (milligram per kilogram bodyweight per minute (mg/kgBW/min)), count of repeated rocuronium administrations and use of sugammadex. Secondary endpoints were: NMM use before repeated NMBA application or extubation, time to extubation, post-operative oxygen demand. A total of n = 539 patients were included. n = 244 patients were examined with tactile NMM and 295 patients by quantitative NMM. Quantitative NMM use resulted in significantly lower rocuronium dosing (tactile NMM: 0.01 (± 0.007) mg/kgBW/min vs. quantitative NMM: 0.008 (± 0.006) mg/kgBW/min (p < 0.001)). In quantitative NMM use fewer repetitions of rocuronium application were necessary (tactile NMM: 83% (n = 202) vs. quantitative NMM: 71% (n = 208) p = 0.007). Overall, 24% (n = 58) in the tactile NMM-group, and 20% (n = 60) in the quantitative NMM-group received sugammadex ((p = 0.3), OR: 1.21 (0.81-1.82)). Significantly fewer patients in the quantitative NMM-group required oxygen-supply postoperative (quantitative NMM: 43% (n = 120)) vs. tactile NMM: 57% (n = 128)) (p = 0.002). The use of quantitative assessment of NMBA results in a lower overall dosage and requires fewer repetitions of rocuronium application. Therefore, quantitative monitoring systems should be used to monitor NMBA intraoperatively to reduce NMBA dosing, while achieving continuous neuromuscular blockade.
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Affiliation(s)
- Lea Valeska Blum
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Ellen Steeger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sonja Iken
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Gösta Lotz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sebastian Zinn
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Florian Piekarski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Florian Jürgen Raimann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
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15
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Carron M, Tamburini E, Ieppariello G, Linassi F. Reversal of neuromuscular block with sugammadex compared with neostigmine and postoperative pulmonary complications in obese patients: meta-analysis and trial sequential analysis. Br J Anaesth 2023; 130:e461-e463. [PMID: 37028987 DOI: 10.1016/j.bja.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023] Open
Affiliation(s)
- Michele Carron
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padova, Padova, Italy.
| | - Enrico Tamburini
- Department of Medicine - DIMED, Section of Anaesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Giovanna Ieppariello
- Institute of Anaesthesia and Intensive Care - Azienda Ospedale Università Padova, Padova, Italy
| | - Federico Linassi
- Department of Anaesthesia and Intensive Care, Ca' Foncello Treviso Regional Hospital, Treviso, Italy
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16
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Carrillo-Torres O, Pliego-Sánchez MG, Pérez-Muñoz VJ, Sánchez-Jurado J, Camacho-Vacherón V, Carrillo-Ruíz JD. Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study. BMC Anesthesiol 2023; 23:107. [PMID: 37005560 PMCID: PMC10067182 DOI: 10.1186/s12871-023-02027-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/24/2023] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION NMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity. OBJECTIVE To investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00). METHODS We performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old. RESULTS We included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB. CONCLUSIONS The rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.
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Affiliation(s)
| | | | | | | | | | - José Damián Carrillo-Ruíz
- Research Direction & Neurosurgery Service at Hospital General de México, Mexico City, Mexico.
- Neuroscience Coordination of Psychology Faculty at Mexico Anahuac University, Av. Anahuac 46, Lomas Anahuac, Naucalpan de Juárez, Estado de México, 52786, Mexico.
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17
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Bruceta M, Singh PM, Bonavia A, Carr ZJ, Karamchandani K. Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study. J Anaesthesiol Clin Pharmacol 2023; 39:232-238. [PMID: 37564851 PMCID: PMC10410049 DOI: 10.4103/joacp.joacp_289_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 08/12/2023] Open
Abstract
Background and Aims The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. Material and Methods This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. Results A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). Conclusion The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.
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Affiliation(s)
- Melanio Bruceta
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State University College of Medicine, Hershey, PA, USA
| | - Preet M. Singh
- Department of Anesthesiology, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State University College of Medicine, Hershey, PA, USA
| | - Zyad J. Carr
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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18
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Huang C, Wang X, Gao S, Luo W, Zhao X, Zhou Q, Huang W, Xiao Y. Sugammadex Versus Neostigmine for Recovery of Respiratory Muscle Strength Measured by Ultrasonography in the Postextubation Period: A Randomized Controlled Trial. Anesth Analg 2023; 136:559-568. [PMID: 36279410 PMCID: PMC9907681 DOI: 10.1213/ane.0000000000006219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although sugammadex is well known for its use in reducing the incidence of residual neuromuscular blockade, this has not always been translated to improved clinical measures of postoperative respiratory muscle strength. Expiratory muscles play an important role in airway clearance and inspiratory muscle capacity augmentation, yet they have not been well studied. Therefore, we tested the hypothesis on whether sugammadex could enhance expiratory muscle strength recovery more completely than neostigmine in the immediate postextubation period. METHODS Adult patients having microlaryngeal surgery under total intravenous anesthesia were randomized to receive sugammadex or neostigmine. The thickening fraction of internal oblique abdominal muscle (TF IO ) and diaphragm excursion, respectively, reflecting expiratory and inspiratory muscle strength, were measured via ultrasonography at 3 time points: before induction (baseline), train-of-four ratio (TOFR) recovery to 0.9, and 30 minutes after postanesthesia care unit (PACU) arrival. The primary outcome was the change in TF IO from baseline to TOFR ≥0.9. The postoperative changes of diaphragm excursion from baseline, incidences of TF IO and diaphragm excursion returning to baseline levels, and the time from TOFR 0.9 to 0.95 and 1 were also measured. RESULTS Among 58 patients, a significant difference in the change in TF IO from baseline to TOFR ≥0.9 between the sugammadex and neostigmine groups was observed: mean ± standard deviation, 9% ± 6% vs 16% ± 9%; difference in means: -6% (95% confidence interval [CI], -10 to -2); and adjusted P =.005 (adjusting for imbalanced variables between 2 groups). Sugammadex resulted in smaller changes in diaphragm excursion from baseline to TOFR ≥0.9 compared with neostigmine: difference in means: -0.83 cm (99.4% CI, -1.39 to -0.28 cm; Bonferroni-corrected P < .001). After 30 minutes in the postanesthesia care unit (PACU),33% of patients reversed with sugammadex versus 14% of those receiving neostigmine reached baseline TF IO levels (99.4% CI, -14 to 52; Bonferroni-corrected P > .999). The incidences of TF IO and diaphragm excursion returning to baseline were relatively low (<40%) in both groups despite TOFR reaching 1. The median time from TOFR of 0.9 to 0.95 and to 1 among patients receiving sugammadex was 7 and 10× faster than those receiving neostigmine (0.3 vs 2 minutes, Bonferroni-corrected P = .003; 0.5 vs 5.3 minutes, Bonferroni-corrected P < .001, respectively). CONCLUSIONS Sugammadex provides a more complete recovery of expiratory muscle strength than neostigmine at TOFR ≥0.9. Our data suggest that the respiratory muscle strength might still be impaired despite TOFR reaching 1.
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Affiliation(s)
- Chanyan Huang
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xuan Wang
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaowei Gao
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Luo
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xu Zhao
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Zhou
- the Department of Medical Statistics, Clinical Trials Unit, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenqi Huang
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Xiao
- From the Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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19
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Timko NJ, Mraovic B. Is Parallel Processing With Anesthesia Induction Rooms and Early Operating Room Cleaning Safe and Efficient? Anesth Analg 2023; 136:e11-e12. [PMID: 36638523 DOI: 10.1213/ane.0000000000006315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Noah J Timko
- Department of Anesthesiology and Perioperative Medicine, University of Missouri School of Medicine, Columbia, Missouri,
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20
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Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, de Boer HD, Sorbello M, Jankovic R, Kranke P. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2023; 40:82-94. [PMID: 36377554 DOI: 10.1097/eja.0000000000001769] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n = 24 000) to the finally relevant clinical studies ( n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).
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Affiliation(s)
- Thomas Fuchs-Buder
- From the Department of Anaesthesiology, Intensive Care and Peri-operative Medicine, CHRU de Nancy, Nancy, France (TF-B), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (C-S.R), Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany (HL), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AA), Department of Anaesthesiology & Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (A-MH), Department of Anesthesiology, CUB Hôpital Erasme, Bruxelles, Belgium (DS), Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany (JH), Department of Anesthesia and Intensive Care, Hôpital Bichat-Claude Bernard, Université de Paris, Paris, France (DL), Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospitals of Wuerzburg, Wuerzburg, Germany (MP, PK), Department of Anesthesiology Pain Medicine & Procedural Sedation and Analgesia Martini General Hospital Groningen, Groningen, The Netherlands (HDDB), Anesthesia and Intensive Care, AOU Policlinico - San Marco, Catania, Italy (MS), Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia (RJ)
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21
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Díaz-Cambronero O, Serrano A, Abad-Gurumeta A, Garutti Martinez I, Esteve N, Alday E, Ferrando C, Mazzinari G, Vila-Caral P, Errando Oyonarte CL. Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:37-50. [PMID: 36621572 DOI: 10.1016/j.redare.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.
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Affiliation(s)
- O Díaz-Cambronero
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - A Serrano
- Hospital Ramón y Cajal, Madrid, Spain.
| | | | | | - N Esteve
- Hospital Son Espases, Palma de Mallorca, Mallorca, Spain.
| | - E Alday
- Hospital de La Princesa, Madrid, Spain.
| | | | - G Mazzinari
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - P Vila-Caral
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - C L Errando Oyonarte
- Hospital Can Misses, Ibiza, Islas Baleares, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
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22
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Bowdle A, Jelacic S, Michaelsen K. Quantitative Monitoring Practice Change: Comment. Anesthesiology 2023; 138:120-121. [PMID: 36512702 DOI: 10.1097/aln.0000000000004400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andrew Bowdle
- University of Washington, Seattle, Washington (A.B.).
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23
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Blobner M, Hunter JM, Ulm K. How robust are the STRONGER and STIL-STRONGER studies? Br J Anaesth 2023; 130:e41-e44. [PMID: 36182557 DOI: 10.1016/j.bja.2022.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 01/11/2023] Open
Abstract
In 2020, the Sugammadex vs Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER) study provided evidence for the first time that use of sugammadex is associated with fewer postoperative pulmonary complications than use of neostigmine. In a recent publication in the British Journal of Anaesthesia, a secondary analysis of the same data, the Association Between Neuromuscular Blockade Reversal Agent Choice and Postoperative Pulmonary Complications (STIL-STRONGER) study, has produced similar evidence of the advantages of sugammadex over neostigmine in high-risk and older patients undergoing prolonged, elective surgery. Here we consider the implications of the detailed statistical analysis used in these two studies and how its limitations could possibly have enhanced the statistical differences between the two drugs with respect to postoperative pulmonary complications.
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Affiliation(s)
- Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany.
| | - Jennifer M Hunter
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, Faculty of Medicine, University of Liverpool, Liverpool, UK
| | - Kurt Ulm
- Institute of Medical Statistics, School of Medicine, Technical University of Munich, Munich, Germany
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24
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Song S, Cho HB, Park SY, Koo WM, Choi SJ, Yoon S, Park S, Yoo JH, Kim MG, Chung JW, Kim SH. Postoperative mortality in patients with end-stage renal disease according to the use of sugammadex: a single-center retrospective propensity score matched study. Anesth Pain Med (Seoul) 2022; 17:371-380. [PMID: 36317429 PMCID: PMC9663945 DOI: 10.17085/apm.22189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/24/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Clearance of the sugammadex-rocuronium complex is limited to renal excretion. There are restrictions on the use of sugammadex in patients with severe renal impairment. A paucity of data supports the clinical safety of sugammadex in patients with renal impairment. We analyzed mortality after using sugammadex in patients with end-stage renal disease to establish evidence of safety for sugammadex. METHODS We retrospectively collected the medical records of 2,134 patients with end-stage renal disease who were dependent on hemodialysis and underwent surgery under general anesthesia between January 2018 and December 2019. Propensity score matching was used. The primary outcome was the 30-day mortality rate, and secondary outcomes were the 1-year mortality rate and causes of death. RESULTS A total of 2,039 patients were included in the study. Sugammadex was administered as a reversal agent for rocuronium in 806 (39.5%) patients; the remaining 1,233 (60.5%) patients did not receive sugammadex. After matching, 1,594 patients were analyzed; 28 (3.5%) of the 797 patients administered sugammadex, and 28 (3.5%) of the 797 patients without sugammadex, died within 30 days after surgery (P > 0.99); 38 (4.8%) of the 797 patients administered sugammadex, and 45 (5.7%) of the 797 patients without sugammadex, died within 1 year after surgery (P = 0.499). No significant differences in the causes of 30-day mortality were observed between the two groups after matching (P = 0.860). CONCLUSIONS In this retrospective study, sugammadex did not increase the 30-day and 1-year mortality rate after surgery in end-stage renal disease patients.
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Affiliation(s)
- Sanghoon Song
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Ho Bum Cho
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea,Corresponding Author: Sun Young Park, M.D, Ph.D. Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel: 82-2-709-9302, Fax: 82-2-709-0394, E-mail:
| | - Wan Mo Koo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Sang Jin Choi
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Sokyung Yoon
- Department of General Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Hwa Yoo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Mun Gyu Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Ji Won Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Sang Ho Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul, Seoul, Korea
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Neira-Somoza P, Lopez-Lopez D. 'Half-Dose Sugammadex After Neostigmine Versus Neostigmine as a Routine Reversal Agent: A Pilot Randomized Trial'. J Perianesth Nurs 2022; 37:583. [PMID: 36182244 DOI: 10.1016/j.jopan.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - David Lopez-Lopez
- Department of Anesthesiology, Perioperative Care and Pain Medicine. Complexo Hospitalario Universitario de A Coruña. A Coruña, Spain
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Postoperative pulmonary complications and their prevention. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cha YM, Faulk DJ. Management of Neuromuscular Block in Pediatric Patients — Safety Implications. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Marinari G, Foletto M, Nagliati C, Navarra G, Borrelli V, Bruni V, Fantola G, Moroni R, Tritapepe L, Monzani R, Sanna D, Carron M, Cataldo R. Enhanced recovery after bariatric surgery: an Italian consensus statement. Surg Endosc 2022; 36:7171-7186. [PMID: 35953683 PMCID: PMC9485178 DOI: 10.1007/s00464-022-09498-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022]
Abstract
Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.
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Affiliation(s)
- Giuseppe Marinari
- Bariatric Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mirto Foletto
- Bariatric Surgery Unit, Azienda Ospedale Università Padova, Padua, Italy
| | - Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Gorizia, Italy
| | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Vincenzo Bruni
- Bariatric Surgery Unit, Campus Bio Medico University of Rome, Rome, Italy
| | - Giovanni Fantola
- Bariatric Surgery Unit, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Roberto Moroni
- Bariatric Surgery Unit, Policlinico Sassarese, Sassari, Italy
| | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Monzani
- Department of Anesthesia and Intensive Care Units, Humanitas Research Hospital, Humanitas University Milan, Rozzano, Milan, Italy
| | - Daniela Sanna
- Emergency Department, Section of Anesthesiology and Intensive Care, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Michele Carron
- Department of Medicine-DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Via V. Gallucci, 13, 35121, Padua, Italy.
| | - Rita Cataldo
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio Medico University of Rome, Rome, Italy
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Togioka BM, Schenning KJ. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 2022; 39:749-761. [PMID: 35934764 DOI: 10.1007/s40266-022-00969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
| | - Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Schmartz D, Bernard P, Sghaier R, Fils JF, Fuchs-Buder T. A modified TOF-ratio to assess rocuronium-induced neuromuscular block: a comparison with the usual TOF-ratio. Anaesth Crit Care Pain Med 2022; 41:101088. [PMID: 35489709 DOI: 10.1016/j.accpm.2022.101088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The TOFscan is an acceleromyographic neuromuscular monitor that calculates and displays two measurements: first, a train-of-four (TOF) ratio, or ratio of the fourth twitch in the TOF-sequence, T4, and the first twitch, T1 (T4/T1). In addition, a second, modified ratio is displayed (T4/Tr), which refers to the ratio between T4 and a reference twitch (Tr), calculated as the mean value of the four twitches in a TOF-sequence [Tr = (T1 + T2 + T3 + T4)/4]. T4/Tr is calculated before establishment of neuromuscular block. METHODS This prospective observational study included 35 adult patients. NMB induced by a rocuronium bolus of 0.6 mg/kg was continuously monitored at the adductor pollicis with the TOFscan and both TOF-ratios were simultaneously assessed. Primary outcome was the comparison of recovery to a TOF-ratio ≥ 0.9 calculated as T4/T1 and T4/Tr. RESULTS The first value of the T4/T1 ≥ 90% was 90.9 (1.1) % and the simultaneously calculated T4/Tr was 69.6 (9.3) %, P < 0.001. The first value of the T4/Tr ≥ 90% was 90.5 (1.1) %, the simultaneously T4/T1 was 97.3 (2.5) %, P < 0.001. Time from injection of rocuronium to a TOF-ratio ≥ 90% was 56.2 ± 17.1 min for the T4/T1 and 65.3 ± 19.3 min for the T4/Tr, P < 0.001. During onset, a TOF ratio ≤ 20% was reached 145.5 (50.5) s after rocuronium when considering T4/T1, and 114.5 (45) s with the T4/Tr, P < 0.001. CONCLUSION The present study shows the limitations of the usually determined acceleromyographic TOF ratio (T4/T1) in determining adequate neuromuscular recovery. The T4/T1 ratio significantly overestimates recovery compared with the T4/Tr ratio. Clinical decisions of adequate neuromuscular recovery based on the new T4/Tr ratio may reduce the incidence of residual paralysis and improve patient safety.
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Affiliation(s)
- Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, 4, Place Van Gehuchten, 1020 Bruxelles, Belgium.
| | - Paul Bernard
- CHRU de Nancy, Rue du Morvan, 54511 Vandoeuvre-lès-Nancy, France
| | - Raouf Sghaier
- CHRU de Nancy, Rue du Morvan, 54511 Vandoeuvre-lès-Nancy, France
| | | | - Thomas Fuchs-Buder
- CHRU de Nancy, Université de Lorraine, Rue du Morvan, 54511 Vandoeuvre-lès-Nancy, France
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Blobner M, Hollmann MW, Luedi MM, Johnson KB. Pro-Con Debate: Do We Need Quantitative Neuromuscular Monitoring in the Era of Sugammadex? Anesth Analg 2022; 135:39-48. [PMID: 35709443 DOI: 10.1213/ane.0000000000005925] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this Pro-Con article, we debate the merits of using quantitative neuromuscular blockade monitoring. Consensus guidelines recommend their use to guide the administration of nondepolarizing neuromuscular blockade and reversal agents. A major impediment to this guideline is that until recently, reliable quantitative neuromuscular blockade monitors have not been widely available. Without them, anesthesia providers have been trained with and are adept at using a variety of qualitative neuromuscular blockade monitors otherwise known as peripheral nerve stimulators. Although perhaps less accurate, anesthesia providers find them reliable and easy to use. They have a long track record of using them with the perception that their use leads to effective neuromuscular blockade reversal and minimizes clinically significant adverse events from residual neuromuscular blockade. In the recent past, 2 disruptive developments have called upon anesthesia care providers to reconsider their practice in neuromuscular blockade administration, reversal, and monitoring. These include: (1) commercialization of more reliable quantitative neuromuscular monitors and (2) widespread use of sugammadex, a versatile reversal agent of neuromuscular blockade. Sugammadex appears to be so effective at rapidly and effectively reversing even the deepest of neuromuscular blockades, and it has left anesthesia providers wondering whether quantitative monitoring is indeed necessary or whether conventional, familiar, and less expensive qualitative monitoring will suffice? This Pro-Con debate will contrast anesthesia provider perceptions with evidence surrounding the use of quantitative neuromuscular blockade monitors to explore whether quantitative neuromuscular monitoring (NMM) is just another technology solution looking for a problem or a significant advance in NMM that will improve patient safety and outcomes.
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Affiliation(s)
- Manfred Blobner
- From the Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ken B Johnson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
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Cammu G, De Boer HD. Pharmacology and monitoring of a rocuronium-induced neuromuscular block: The complete eternal marriage. Anaesth Crit Care Pain Med 2022; 41:101094. [PMID: 35487409 DOI: 10.1016/j.accpm.2022.101094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Guy Cammu
- Onze-Lieve-Vrouw Ziekenhuis, Anaesthesiology and Critical Care Medicine, Moorselbaan 164, 9300 Aalst, Belgium.
| | - Hans D De Boer
- Martini General Hospital Groningen, Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, van Swietenplein 1, 9728 NT, Groningen, The Netherlands
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Cho SA, Sung TY. Choice of neuromuscular block reversal agent to reduce postoperative pulmonary complications. Anesth Pain Med (Seoul) 2022; 17:121-131. [PMID: 35538653 PMCID: PMC9091678 DOI: 10.17085/apm.22146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
The definition of postoperative pulmonary complications (PPCs) is inconsistent in literature; however, PPCs include pulmonary abnormalities that adversely affect patient outcomes, such as respiratory failure, atelectasis, pneumonia, pleural effusion, and exacerbation of underlying lung conditions. Furthermore, although the incidence of PPCs varies according to its definition, surgery type, and patient population, they can lead to increased morbidity, mortality, duration of hospitalization, and medical costs; thus, efforts to identify and reduce the risk factors are important to improve patient outcomes. Among the risk factors for PPCs, residual neuromuscular block is a representative and preventable anesthesia-related risk factor that is affected by the choice of the reversal agent. However, it is not clear whether the chosen reversal agent, i.e., sugammadex, reduces PPCs better when compared to anticholinesterases. Additionally, the effects of the reversal agents on PPCs in high-risk patients, such as elderly patients, pediatric patients, those with end-stage renal disease, obesity, obstructive sleep apnea, or those undergoing specific surgeries, are diverse. To reduce the PPCs associated with the use of neuromuscular blocking agents, it is important to confirm complete reversal of the neuromuscular block under neuromuscular monitoring. Additionally, efforts to reduce the incidence of PPCs through interdisciplinary communication are required.
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Affiliation(s)
- Sung-Ae Cho
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
- Corresponding author Tae-Yun Sung, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea -Tel: 82-42-600-9316 -Fax: 82-42-545-2132 -E-mail:
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Carron M, Andreatta G, Pesenti E, De Cassai A, Feltracco P, Linassi F, Sergi M, Di Bella C, Di Bello M, Neri F, Silvestre C, Furian L, Navalesi P. Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study. Perioper Med (Lond) 2022; 11:3. [PMID: 35022076 PMCID: PMC8756660 DOI: 10.1186/s13741-021-00231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. Methods A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. Results No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). Conclusions Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.
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Affiliation(s)
- M Carron
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy.
| | - G Andreatta
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - E Pesenti
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - A De Cassai
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Feltracco
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - F Linassi
- Department of Anesthesia and Intensive Care, Ca' Foncello Treviso Regional Hospital, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - M Sergi
- Institute of Anesthesia and Intensive Care, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Di Bella
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - M Di Bello
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - F Neri
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - C Silvestre
- Kidney and Pancreas Transplantation Unit, Azienda Ospedale Università Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - L Furian
- Department of Surgical, Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplantation Unit, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - P Navalesi
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
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Carron M, Tessari I, Linassi F. Sugammadex compared with neostigmine in reducing postoperative pulmonary complications in older patients: a meta-analysis. Br J Anaesth 2022; 128:e259-e262. [DOI: 10.1016/j.bja.2021.12.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 12/20/2022] Open
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.
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Daum P, Smelt J, Ibrahim I. Perioperative management of myasthenia gravis. BJA Educ 2021; 21:414-419. [PMID: 34707886 PMCID: PMC8520038 DOI: 10.1016/j.bjae.2021.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- P. Daum
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - J. Smelt
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - I.R. Ibrahim
- St George's University Hospitals NHS Foundation Trust, London, UK
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Postoperative pulmonale Komplikationen nach chirurgischen Eingriffen. ANÄSTHESIE NACHRICHTEN 2021. [PMCID: PMC8720644 DOI: 10.1007/s44179-021-0039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wong P, Seet E, Kumar CM, Koh KF, Pan TLT, Quah T, Chua NPP. Recommendations for standards of neuromuscular monitoring during anaesthesia. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:852-855. [PMID: 34877589 DOI: 10.47102/annals-acadmedsg.2021159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Patrick Wong
- Department of Anaesthesia, Waikato District Health Board, Hamilton, New Zealand
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Schmartz D, Sghaier R, Bernard P, Fils JF, Fuchs-Buder T. Neuromuscular block in patients 80 years and older: a prospective, controlled study. BMC Anesthesiol 2021; 21:225. [PMID: 34517841 PMCID: PMC8436544 DOI: 10.1186/s12871-021-01443-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background An increasing number of patients older than 80 years are undergoing anesthesia, but little information is available regarding pharmacodynamic effects of myorelaxants in this population. This study aims to compare the time course of rocuronium neuromuscular block in patients ≥ 80 years with those of younger adults. Methods Under total intravenous anesthesia with propofol and sufentanil, time course of a bolus of rocuronium 0.6 mg/kg neuromuscular block was assessed with acceleromyography in patients ≥ 80 and in patients 20–50 years old. Onset time, clinical duration, duration until 90% and 100% recovery of baseline were determined. Results Data from 32 patients were analyzed, 16 were ≥ 80 years and 16 were 20–50 years old. Demographic data are shown in Table 1. In the group ≥ 80, onset time was 190 s ± 46 s compared to 123 s ± 40 s in the group 20–50, P < 0.001 and the clinical duration was 52 [48–69.5] min and 36 [34–41] min, respectively, P < 0.001. Duration to 90% recovery of baseline was 77.5 [71–88.5] min and duration to 100% recovery of baseline was 91.2 [82.2–98] min in patients ≥ 80 years and the corresponding values in the patients 20–50 years old were 53.5 [49–55.5] min and 59.5 [56.5–70.25] min, respectively, P < 0.001. Conclusion Compared to younger adults rocuronium shifted in patients ≥ 80 years from a rapid onset, intermediate acting compound to a slower onset, long-acting compound. Trial registration ClinicalTrials.gov identifier: NCT03551652 (29/05/2018).
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Affiliation(s)
- Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, 4 Place Van Gehuchten, 1020, Bruxelles, Belgium.
| | - Raouf Sghaier
- CHRU de Nancy, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
| | - Paul Bernard
- CHRU de Nancy, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
| | | | - Thomas Fuchs-Buder
- CHRU de Nancy, Université de Lorraine, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
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Con: Deep neuromuscular block should not be maintained during laparoscopic surgery. Anaesth Crit Care Pain Med 2021; 40:100942. [PMID: 34479682 DOI: 10.1016/j.accpm.2021.100942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Giudici G, Piccioni F, Proto P, Valenza F. A comparison of accelerometric monitoring by TOF Watch® SX and electromyographic monitoring by Tetragraph® for recovery from neuromuscular blockade. J Clin Anesth 2021; 75:110481. [PMID: 34388509 DOI: 10.1016/j.jclinane.2021.110481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neuromuscular monitoring has become a standard of care for management of anesthesia. While acceleromyography (AMG) is the most common technology used in clinical practice, guidelines suggest that electromyographic (EMG) devices are ideal for quantitative neuromuscular monitoring. The Tetragraph® is an EMG monitor that has recently been marketed. STUDY OBJECTIVE The aim of this study is to assess the agreement during recovery from neuromuscular blockade of this new monitor with the TOF Watch® SX, and to compare intraobserver variability for the two devices. DESIGN Single-center, prospective, observational clinical study. SETTING Operating room. PATIENTS Twenty-three patients were enrolled and twenty patients were included in the analysis. INTERVENTION A comparison of TOF-ratios measured sequentially from the same hand with the Tetragraph and TOF Watch SX was conducted during spontaneous recovery of neuromuscular function from patients that received rocuronium during surgery. MAIN OUTCOME MEASURES We used Bland-Altman plots for repeated measures to compare TOF-ratios obtained sequentially by the two devices. Subsequent measures with the same device were used to calculate intraobserver variability for each monitor. MAIN RESULTS The bias between AMG and EMG for TOF-ratios range between 0.2 and 1.0 was 0.13 (95% CI 0.08 to 0.18) and the limits of agreement (LoA) were - 0.11 (95% CI -0.20 to -0.06) and 0.37 (95% CI 0.32 to 0.46), respectively. Agreement slightly improved for TOF-ratios higher than 0.8 compared with lower TOF-ratios: the bias was 0.12 (95% CI 0.08 to 0.17) and 0.13 (95% CI 0.08 to 0.19), respectively. EMG relative intraobserver variability was lower compared with AMG (2.0%, IQR 0.0% to 4.5% vs. 3.2%, IQR 1.2% to 6.0%, P = 0.001). CONCLUSIONS Bias between the TOF Watch SX and the Tetragraph TOF-ratios is in line with previous results for AMG and EMG monitors.
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Affiliation(s)
- Giorgio Giudici
- Department of Health Sciences, University of Milan, Milan, Italy.
| | - Federico Piccioni
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Paolo Proto
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Franco Valenza
- Department of Health Sciences, University of Milan, Milan, Italy; Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Azizoğlu M, Özdemir L. Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study. J Patient Saf 2021; 17:352-357. [PMID: 34276037 DOI: 10.1097/pts.0000000000000874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Postoperative residual neuromuscular block (PRNB) is a serious problem that can cause death after surgery. It was aimed to evaluate the adequacy of neuromuscular block (NMB) during endotracheal intubation and the adequacy of neuromuscular recovery during clinically extubation decision and follow-up with the train-of-four ratio (TOFR) using quantitative monitoring. METHODS This study has a prospective-observational single-blind study design. A total of 205 adult patients who underwent elective surgery, who had American Society of Anesthesiologists physical statuses I to III, and who were intubated with neuromuscular blocking agent under general anesthesia were included in the study. Train-of-four ratio measurements were provided single-blindly by another anesthesiologist outside the team. The TOFRs were measured at the time of intubation (TOFRind), before reversal agent administration (TOFRpre-rev) and after (TOFRpost-rev), at the time of extubation (TOFRext), and on admission to the postoperative care unit (TOFRPACU). If clinical signs of PRNB appeared, the recovery protocol was applied and then TOFRrec was measured. Postoperative respiratory complications were also evaluated for the first 24 hours after surgery. RESULTS Endotracheal intubation was performed in 41.5% of the patients (n = 85) without adequate NMB. In 48.8% (n = 100) of the patients, adequate recovery (TOFRext ˂0.9) was not available at the time of extubation. Adequate TOFRPACU rate was found to be significantly higher in those who did not receive additional neuromuscular blocking agent doses (P < 0.001). In the recovery protocol, low-dose sugammadex administered to patients with clinical signs of PRNB significantly increased the TOFRrec rate compared with neostigmine (P ˂ 0.001). The first 24 hours, postoperative respiratory complication rate was 5.4% (n = 11), and the most common hypoxemia was observed. CONCLUSIONS Approximately half of the patients are intubated without sufficient NMB and extubated without sufficient neuromuscular recovery. This suggests that routine use of quantitative neuromuscular monitoring is necessary for patient safety.
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Affiliation(s)
- Mustafa Azizoğlu
- From the Department of Anesthesiology and Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
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Rodney G, Meek T, Klein AA, Nimmo AF. New standards of monitoring guidelines: a reply. Anaesthesia 2021; 76:1428-1429. [PMID: 34324702 DOI: 10.1111/anae.15558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - T Meek
- James Cook University Hospital, Middlesbrough, UK
| | - A A Klein
- Royal Papworth Hospital, Cambridge, UK
| | - A F Nimmo
- Royal Infirmary of Edinburgh, Edinburgh, UK
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The "True" Risk of Postoperative Pulmonary Complications and the Socratic Paradox: "I Know that I Know Nothing". Anesthesiology 2021; 134:828-831. [PMID: 33909882 DOI: 10.1097/aln.0000000000003767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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48
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Debaene B, Frasca D, Moreillon F, D'Hollander AA. 100 Hz-5 s tetanic stimulation to illustrate the presence of "residual paralysis" co-existing with accelerometric 0.90 train-of-four ratio-A proof-of-concept study. Anaesth Crit Care Pain Med 2021; 40:100903. [PMID: 34147687 DOI: 10.1016/j.accpm.2021.100903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND An acceleromyographic train-of-four (TOF) ratio of 0.90 at extubation does not prevent postoperative pulmonary complications in surgical patients receiving non-depolarising muscle relaxants. This recent observation suggests that a more selective neuromuscular transmission monitoring parameter is mandatory to detect more precisely any remaining residual paralysis. The aim of our proof-of-concept study was to evaluate, in patients receiving rocuronium, the degree of 100-Hz, 5-s tetanic fade present when the acceleromyographic TOF ratio has recovered to 0.90. METHODS Twenty adult patients scheduled for surgery under general anaesthesia were included. Before anaesthesia induction, a TOF-Watch SX™ and a VISUAL-ITF© (a prototype monitor for recording isometric force) were positioned on both hands. After induction but before rocuronium injection, a 100-Hz, 5-s tetanus (TET0) was delivered to both ulnar nerves. Thereafter, TOF stimulations every 15 s were delivered to both arms until a TOF ratio > 0.90 was recorded; then, a 100-Hz, 5-s tetanus (TET1) was recorded on the VISUAL-ITF© monitor. The values of the tetanic parameters (force) recorded at TET0 and TET1 were compared using a Wilcoxon rank sum test. RESULTS Compared to TET0, tetanic parameters of TET1 were significantly lower (median [range]): maximal force 36.4 [19.2-82.6] vs. 25.5 [5.0-42.4] Newton (p < 0.005); residual force 36.2 [18.2-82.0] vs. 5.5 [0.20-38.3] Newton (p < 0.0001) and residual force/maximal force ratio 0.98 [0.89-0.99] vs. 0.17 [0.03-0.90] (p < 0.0001). CONCLUSION Our results confirm that even when the acceleromyographic TOF ratios have recovered to above 0.90, the contralateral 100-Hz, 5-s tetanic stimulus may show tetanic fade characteristic of residual neuromuscular block, and may help improve the safety of tracheal extubation.
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Affiliation(s)
- Bertrand Debaene
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, France.
| | - Denis Frasca
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, France
| | - Fabien Moreillon
- Institute of Industrial Technologies and Sciences, University of Applied Sciences and Arts Western Switzerland (HES-SO Geneva/HEPIA), CH-1202 Geneva, Switzerland
| | - Alain A D'Hollander
- Department of Anaesthesiology, University Hospital of Geneva, Geneva, Switzerland
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Supraglottic airway, tracheal intubation, and neuromuscular block: will the ménage à trois endure? Br J Anaesth 2021; 127:174-177. [PMID: 34140158 DOI: 10.1016/j.bja.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 11/21/2022] Open
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50
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Wong P, Kumar CM, Seet E. Recommendations for standards of monitoring during anaesthesia and recovery 2021: caveats regarding neuromuscular monitoring. Anaesthesia 2021; 76:1425. [PMID: 34131908 DOI: 10.1111/anae.15529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/17/2022]
Affiliation(s)
- P Wong
- Waikato District Health Board, Hamilton, New Zealand
| | - C M Kumar
- Khoo Teck Puat Hospital, National Healthcare Group, Singapore, Singapore
| | - E Seet
- Khoo Teck Puat Hospital, National Healthcare Group, Singapore, Singapore
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