Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach

BACKGROUND

Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients.

METHOD

We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results.

RESULTS

We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance.

CONCLUSIONS

The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.

Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle

Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.

Residual Neuromuscular Blockade and Postoperative Pulmonary Complications in the Post-anesthesia Care Unit: A Prospective Observational Study

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.

Effect of acute normovolemic hemodilution on anesthetic effect, plasma concentration, and recovery quality in elderly patients undergoing spinal surgery

OBJECTIVE

To explore the effect of acute normovolemic hemodilution (ANH) on the anesthetic effect, plasma concentration, and postoperative recovery quality in elderly patients undergoing spinal surgery.

METHODS

A total of 60 cases of elderly patients aged 65 to 75 years who underwent elective multilevel spinal surgery were assigned randomly into the ANH group (n = 30) and control group (n = 30). Hemodynamic and blood gas analysis indexes were observed and recorded before ANH (T1), after ANH (T2), immediately after postoperative autologous blood transfusion (T3), 10 min (T4), 20 min (T5), 30 min (T6), 40 min (T7), and 50 min (T8) after the transfusion, and at the end of the transfusion (i.e., 60 min; T9). At T3 ~ 9, bispectral index (BIS) and train-of-four (TOF) stimulation were recorded and the plasma propofol/cisatracurium concentration was determined. The extubation time and recovery quality were recorded.

RESULTS

The ANH group presented a lower MAP value and a higher SVV value at T2, and shorter extubation and orientation recovery time (P < 0.05) compared with the control group. BIS values at T8 and T9 were lower in the ANH group than those in the control group (P < 0.05). TOF values at T7 ~ 9 were lower in the ANH group than those in the control group (P < 0.05). There were no statistically significant differences in the postoperative plasma concentrations of propofol and cisatracurium between the groups (P > 0.05).

CONCLUSION

During orthopedic surgery, the plasma concentration of elderly patients is increased after autologous blood transfusion of ANH, and the depth of anesthesia and muscle relaxant effect are strengthened, thus leading to delayed recovery of respiratory function and extubation.

Educating anaesthetists on neuromuscular monitoring: the challenges continue

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.

An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia

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.

Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya

BACKGROUND

Anesthetic monitoring within standards defined by various professional anesthesia organizations has been shown to reduce perioperative mortality. Given the scarce resources for anesthesia and surgery in low- to middle-income countries, we sought to determine the availability of recommended monitoring devices in major referral hospitals in Kenya.

METHODS

We purposely selected the 16 major referral hospitals in Kenya. A cross-sectional survey was conducted in 103 operating theaters, 96 postanesthesia care unit (PACU) beds, and 16 areas where procedural sedation was routinely administered. A checklist questionnaire based on the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines of 2015 was used to determine the availability of basic and functional monitoring devices.

RESULTS

We determined that only 1 of 16 (6.25%) hospitals had all the monitoring devices recommended by the AAGBI. Automated noninvasive blood pressure (NIBP) monitoring and pulse oximetry were present in all operating theaters. Continuous electrocardiography (ECG) was available in 102 of 103 (99%) operating theaters, skin temperature monitoring probes in 73 of 103 (70.9%), and capnography in 49 (47.6%). A nerve stimulator was accessible in 5 of 16 (31.25%) hospitals. There were functional patient monitors in all operating theaters (100%). One of the regional referral hospitals did not have a PACU. We encountered 9 of 96 (9.4%) PACU beds without any monitoring devices. Pulse oximetry was the most common device (84.4%) in the PACU beds equipped with monitoring. In 5 of 16 (31.25%) procedural sedation areas, pulse oximetry was the only monitoring device, whereas there were no devices in 2 of 16 (12.5%) areas. Portable multiparameter devices used for patient transport were present in 5 of 16 (31.25%) hospitals.

CONCLUSIONS

The availability of recommended monitoring devices in major referral hospitals in Kenya is inadequate. Thus, there are challenges to anesthetic monitoring in these hospitals, and perioperative patient safety is jeopardized. We recommend the universal provision of basic monitoring devices and suggest the use of the data collected in this study to affect policy change and safe anesthesia practice in our country.

The Impact of Rocuronium and Sugammadex on Length of Stay in Patients Undergoing Open Spine Surgery: A Propensity Score-Matched Analysis

Enhanced Recovery After Surgery (ERAS), an all-encompassing perioperative care approach, has been demonstrated to enhance surgical results, mitigate postoperative issues, and decrease the length of hospital stay (LOS) in diverse surgical specialties. In this retrospective study, our objective was to examine the influence of muscle relaxant selection on LOS and perioperative results in adult patients undergoing open spine surgery. Specifically, we compared 201 patients who received cisatracurium and neostigmine with 201 patients who received rocuronium and sugammadex, after 1:1 propensity score matching. The utilization of the rocuronium and sugammadex combination in anesthesia for open spinal surgery did not lead to a reduction in the LOS but was associated with a decreased incidence of postoperative chest radiographic abnormalities, including infiltration, consolidation, atelectasis, or pneumonia (p = 0.027). In our secondary analysis, multivariate analysis revealed multiple determinants influencing the prolonged LOS (>7 days) during open spine surgery. Bispectral index-guided anesthesia emerged as a protective factor, while variables such as excessive intraoperative blood loss and fluid administration as well as postoperative chest radiographic abnormalities independently contributed to prolonged LOS.

An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients

OBJECTIVES

The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions.

DESIGN

A retrospective cohort study.

SETTING

At a tertiary teaching hospital.

PARTICIPANTS

Patients younger than 18, with congenital heart disease, who underwent cardiac surgery.

INTERVENTIONS

Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001).

CONCLUSIONS

Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.

Safety of sugammadex for reversal of neuromuscular block: A postmarketing study based on the World Health Organization pharmacovigilance database

AIM

Residual neuromuscular blockade is a common complication after general anaesthesia. Sugammadex can reverse the action of aminosteroid neuromuscular blockers. This study aimed to explore sugammadex safety issues in the real world and determine the spectrum of adverse reactions.

METHODS

All sugammadex-related adverse events reported in VigiBase between 2010 and 2019 were classified by group queries according to the Medical Dictionary for Regulatory Activities. A disproportionality analysis of data was performed using the information component (IC); positive IC values were deemed significant.

RESULTS

Overall, 16 219 410 adverse events were reported and 2032 were associated with sugammadex. The frequent reactions were recurrence of neuromuscular blockade (n = 54, IC 6.74, IC₀₂₅ 6.33), laryngospasm (n = 53, IC 6.05, IC₀₂₅ 5.64), bronchospasm (n = 119, IC 5.63, IC₀₂₅ 5.36) and bradycardia (n = 169, IC 5.13, IC₀₂₅ 4.90). Fatal cases were more likely among patients with cardiac disorders, especially those over 65 years. In addition, the common adverse drug reactions (ADRs) differed between different age groups (P < .01). ADRs were higher in the 0-17 years age group than in other age groups. The onset time of common ADRs was typically within 1 day and 68.9% occurred within half an hour after sugammadex administration.

CONCLUSIONS

Anaesthesiologists should carefully monitor the anaesthesia recovery period to correct the ADRs caused by sugammadex and recommend monitoring neuromuscular function throughout the anaesthesia process. Sugammadex should be used carefully in patients with cardiovascular diseases, and electrocardiography and hemodynamic changes should be monitored after medication.

Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

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.

Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center

Introduction

Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine.

Methods

We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes.

Results

Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs.

Discussion

Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution.

Clinical trial registration

[https://clinicaltrials.gov/] identifier number [NCT03579589].

Receptor subunit compositions underly distinct potencies of a muscle relaxant in fast and slow muscle fibers

A line of studies in the 1960s–1980s suggested that muscle relaxants do not work uniformly on all skeletal muscles, though its mechanism has not been clarified. We showed here that a classical non-depolarizing muscle relaxant pancuronium inhibits fast muscle fibers at lower concentration compared to slow muscle fibers in zebrafish. The difference of effective concentration was observed in locomotion caused by tactile stimulation as well as in synaptic currents of the neuromuscular junction induced by motor neuron excitation. We further showed that this difference arises from the different composition of acetylcholine receptors between slow and fast muscle fibers in the neuromuscular junction of zebrafish. It will be interesting to examine the difference of subunit composition and sensitivity to muscle relaxants in other species.

Neuromuscular monitoring during general anaesthesia: a review of current national and international guidelines

Background

The extent to which neuromuscular monitoring is included in professional anaesthesia society guidelines is unclear. Our aim was to comprehensively review neuromuscular monitoring guidelines published by these societies.

Methods

National societies were identified using the World Federation of Societies of Anaesthesiologists' member list and further manual searches were undertaken to identify multinational societies and specialist medical colleges. A web search and secondary literature search were conducted to locate guidelines for monitoring during anaesthesia. The income of each nation or group of nations was determined using the World Bank classification.

Results

Forty guidelines were identified. Of 38 nations or classifiable groups of nations, 25 (66%) were high-income nations and 13 (34%) were middle-income nations. Neuromuscular monitoring was mentioned in 36 (90%) of the 40 guidelines. Availability of neuromuscular monitoring was mentioned in 17 (47%) guidelines (mandated in eight [47%] and recommended in nine [53%]). Use of neuromuscular monitoring was mentioned in 26 (72%) guidelines (mandated in three [12%] and recommended in 23 [88%]). Quantitative neuromuscular monitoring was specified in nine (25%) of the guidelines, with the type of monitoring unspecified in the remaining 27 (75%) of the 36 guidelines. Quantitative monitoring was only mandated in one guideline, and this was only when monitoring equipment was available.

Conclusions

We identified a gap in the availability of professional anaesthesia society neuromuscular monitoring guidelines, particularly in middle- and low-income nations. Recommendations about availability, use and type of monitoring varied among guidelines. An effort to improve the availability and consistency of guidelines is required.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Phonomyography on Perioperative Neuromuscular Monitoring: An Overview

Complications related to neuromuscular blockade (NMB) could occur during anesthesia induction, maintenance, and emergency. It is recommended that neuromuscular monitoring techniques be utilized perioperatively to avoid adverse outcomes. However, current neuromuscular monitoring methods possess different shortcomings. They are cumbersome to use, susceptible to disturbances, and have limited alternative monitoring sites. Phonomyography (PMG) monitoring based on the acoustic signals yielded by skeletal muscle contraction is emerging as an interesting and innovative method. This technique is characterized by its convenience, stable signal quality, and multimuscle recording ability and shows great potential in the application field. This review summarizes the progression of PMG on perioperative neuromuscular monitoring chronologically and presents the merits, demerits, and challenges of PMG-based equipment, aiming at underscoring the potential of PMG-based apparatuses for neuromuscular monitoring.

Effect of active forced air warming during the first hour after anesthesia induction and intraoperation avoids hypothermia in elderly patients

Background

The study aimed at exploring an optimal temperature model of forced air warming during the first hour after induction and intraoperation to prevent hyperthermia for elderly patients undergoing laparoscopic abdominal surgery.

Methods

There were 218 patients that were randomly divided into 3 groups warmed with a forced-air warmer during surgery: Group L (intraoperative warming set to 38 °C, n = 63), Group H (intraoperative warming set to 42 °C, n = 65) and Group LH (intraoperative warming set to 42 °C for the first hour then set to 38 °C, n = 65). Core temperature in the preoperative room and PACU was measured by a tympanic membrane thermometer and in the operation room, a nasopharyngeal temperature probe was recorded. The rate of perioperative hypothermia, defined as a reduction in body temperature to < 36 °C was recorded as the primary outcome. Intraoperative anesthetic dosage, recovery time, adverse events, thermal comfort and satisfaction score were measured as secondary outcome.

Results

The incidence of intraoperative and postoperative hypothermia was significantly lower in Group LH and Group H than Group L (18.75 and 15.62% vs 44.44%, P<0.001; 4.69 and 4.69% vs 20.63%, P<.05). Anesthetic dosage of rocuronium was lower in Group L than other two groups, with the opposite result of recovery time. The number of patients with shivering was higher in Group L but sweating was higher in Group H. Both of the thermal comfort and satisfaction score was highest in Group LH.

Conclusion

A temperature pattern of forced air warming set at 42 °C during the first hour after anesthesia induction and maintained with 38 °C was a suitable choice for elderly patients undergoing laparoscopic abdominal surgery lasting for more than 120 min.

Trial registration

Chictr.org.cn ChiCTR-2,100,053,211.

The effects of two-handed jaw thrust on i-gel™ placement in anesthetized non-paralyzed patients

BACKGROUND

I-gel^TM is a second-generation supraglottic airway device with a non-inflatable cuff. In this prospective randomized investigation, we evaluated the effects of two-handed jaw thrust technique on i-gel insertion in anesthetized non-paralyzed patients.

METHODS

Seventy-four adult patients were allocated to two groups (N.=37 each). In the jaw thrust group, two-handed jaw thrust technique was applied to facilitate i-gel insertion. In the control group, conventional i-gel insertion was performed. The success rate at the first attempt, air leakage pressure, insertion time, and postoperative sore throat incidence were recorded.

RESULTS

The success rate at the first attempt was higher in the jaw thrust group (37 [100%] vs. 31 [84%], difference of 16%, 95% confidence interval for the difference: 1 to 33%, P=0.03). The median air leakage pressure was higher in the jaw thrust group than in the control group (20 [interquartile range 13] vs. 17 [interquartile range 3] cmH<inf>2</inf>O, difference: 6, 95% confidence interval of the difference: 3 to 8, P<0.01). The mean insertion time was shorter in the jaw thrust group (27±14 vs. 41±29 seconds, difference: 14 seconds, 95% confidence interval of the difference: 3 to 24, P=0.01). The incidence of postoperative sore throat at the postoperative one hour was lower in the jaw thrust group (seven [20%] vs. 15 [41%], difference 22%, 95% confidence interval for the difference: -1 to 42%, P=0.04).

CONCLUSIONS

The two-handed jaw thrust technique facilitated i-gel insertion compared to the conventional technique in anesthetized non-paralyzed patients.

Investigation of potential neuropharmacological activity of neostigmine-glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine-glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle-twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine-glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine-glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine-glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine-glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.

Required dose of sugammadex or neostigmine for reversal of vecuronium-induced shallow residual neuromuscular block at a train-of-four ratio of 0.3

Residual shallow neuromuscular block (NMB) is potentially harmful and contributes to critical respiratory events. Evidence for the optimal dose of sugammadex required to reverse vecuronium‐induced shallow NMB is scarce. The aims of the present study were to find suitable doses of sugammadex and neostigmine to reverse a residual vecuronium‐induced NMB from a time of flight (TOF) ratio of 0.3–0.9 and evaluate their safety and efficacy. In total, 121 patients aged 18–65 years were randomly assigned to 11 groups to receive placebo, sugammadex (doses of 0.125, 0.25, 0.5, 1.0, or 2.0 mg/kg), or neostigmine (doses of 10, 25, 40, 55, or 70 μg/kg). The reversal time of sugammadex and neostigmine to antagonize a vecuronium‐induced shallow residual NMB (i.e., TOF ratio of 0.3) and related adverse reactions were recorded. Several statistical models were tested to find an appropriate statistical model to explore the suitable doses of sugammadex and neostigmine required to reverse a residual vecuronium‐induced NMB. Based on a monoexponential model with the response variable on a logarithmic scale, sugammadex 0.56 mg/kg may be sufficient to reverse vecuronium‐induced shallow residual NMB at a TOF ratio of 0.3 under anesthesia maintained with propofol. Neostigmine may not provide prompt and satisfactory antagonism as sugammadex, even in shallow NMB.

A survey of current management of neuromuscular block and reversal in Australia and New Zealand

In recent years there has been a significant investment in education on the management of neuromuscular blockade and increased availability of sugammadex in anaesthetic practice. This survey aimed to examine contemporary practice of Australian and New Zealand anaesthetists in managing neuromuscular blockade and its reversal. A web-based, voluntary survey was distributed to a cohort of 1000 Fellows of the Australian and New Zealand College of Anaesthetists. We received 229 completed responses (survey response rate of 23%). Seventy-one percent (95% confidence interval (CI) 64% to 76%) of the survey respondents thought that 5% or fewer of the patients in their hospital display clinically significant postoperative paralysis. Only 35% (95% CI 18% to 29%) thought that quantitative neuromuscular twitch monitors should be used to monitor neuromuscular block, and the dose and time given for reversal agents was often inconsistent with published recommendations. Sugammadex was the preferred reversal agent for 78% (95% CI 72% to 83%) of survey respondents, but they indicated that cost remains a significant barrier to its widespread uptake. Despite the low response rate, this survey identified that some reported practices in Australia and New Zealand deviate from guidelines and current recommendations in the management of neuromuscular blockade. If the respondents are representative of the broader anaesthetic community, there appears be a greater preference for sugammadex over neostigmine for reversal of neuromuscular blockade.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications: a prospective, randomised, double-blind trial in high-risk older patients

BACKGROUND

Residual neuromuscular block is associated with an increased risk of postoperative pulmonary complications in retrospective studies. The aim of our study was to investigate prospectively the incidence of postoperative pulmonary complications after reversal with either sugammadex (SUG) or neostigmine (NEO) in high-risk older patients.

METHODS

We randomly allocated 180 older patients with significant morbidity (ASA physical status 3) ≥75 yr old to reversal of rocuronium with either SUG or NEO. Adverse events in the recovery room and pulmonary complications (defined by a 5-point [0-4; 0=best to 4=worst] outcome score) on postoperative Days 1, 3, and 7 were compared between groups.

RESULTS

Data from 168 patients aged 80 (4) yr were analysed; SUG vs NEO resulted in a reduced probability (0.052 vs 0.122) of increased pulmonary outcome score (impaired outcome) on postoperative Day 7, but not on Days 1 and 3. More patients in the NEO group were diagnosed with radiographically confirmed pneumonia (9.6% vs 2.4%; P=0.046). The NEO group showed a non-significant trend towards longer hospital length of stay across all individual centres (combined 9 vs 7.5 days), with a significant difference in Malaysia (6 vs 4 days; P=0.011).

CONCLUSIONS

Reversal of rocuronium neuromuscular block with SUG resulted in a small, but possibly clinically relevant improvement in pulmonary outcome in a select cohort of high-risk older patients.

CLINICAL TRIAL REGISTRATION

ACTRN12614000108617.

Spontaneous recovery of neuromuscular blockade is an independent risk factor for postoperative pulmonary complications after abdominal surgery: A secondary analysis

BACKGROUND

In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven.

OBJECTIVE

To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs).

DESIGN

The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data.

SETTING

Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016.

PATIENTS

Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases.

INTERVENTIONS

The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery.

MAIN OUTCOME MEASURES

The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed.

RESULTS

From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82).

CONCLUSION

Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02158923.

Sugammadex is associated with shorter hospital length of stay after open lobectomy for lung cancer: a retrospective observational study

Background

Sugammadex is associated with few postoperative complications. Postoperative pulmonary complications (PPC) are related to prolonged hospitalizations. Present study explored whether the use of sugammadex could reduce PPCs and thereby reduce hospital length of stay (LOS) after lung surgery.

Methods

We reviewed the medical records of patients who underwent elective open lobectomy for lung cancer from January 2010 to December 2015. Patients were divided into the sugammadex group and pyridostigmine group.

The primary outcome was hospital LOS and secondary outcomes were postoperative complications and overall survival at 1 year. The cohort was subdivided into patients with and without prolonged LOS to explore the effects of sugammadex on outcomes in each group. Risk factors for LOS were determined via multivariate analyses. After propensity score matching, 127 patients were assigned to each group.

Results

Median hospital LOS was shorter (10.0 vs. 12.0 days) and the incidence of postoperative atelectasis was lower (18.1 vs. 29.9%) in the sugammadex group. However, no significant difference in overall survival between the groups was seen over 1 year (hazard ratio, 0.967; 95% confidence interval, 0.363 to 2.577). Sugammadex was a predictor related to LOS (exponential coefficient 0.88; 95% CI 0.82–0.95).

Conclusions

Our data suggest that sugammadex is a preferable agent for neuromuscular blockade (NMB) reversal than cholinesterase inhibitors in this patient population.

Trial registration

This study registered in the Clinical Research Information Service of the Korea National Institute of Health (approval number: KCT0004735, Date of registration: 21 January 2020, Retrospectively registered).

REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study

BACKGROUND

Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery.

METHODS

A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications.

RESULTS

A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs).

CONCLUSIONS

The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.

Residual neuromuscular blockade and late neuromuscular blockade at the post-anesthetic recovery unit: prospective cohort study

Introduction and objectives

The use of neuromuscular blockers during surgery represented a landmark for anesthesiology. However, their use can prompt residual Neuromuscular Blockade (_RNMB) and objective monitoring of neuromuscular function is crucial to warrant the recovery of muscle strength. The present study aimed to estimate the incidence of _RNMB and late Neuromuscular Blockade (_LNMB) at the Post-Anesthetic Recovery Unit (PACU).

Method

The study included 85 patients, 43 of which received cisatracurium and 42 of which, rocuronium. The depth of the Neuromuscular Blockade (NMB) was assessed by Train Of Four (TOF). NMB reversal was performed with the administration of neostigmine and atropine._RNMB was defined when a patient presented TOF below 90% at the PACU.

Results

_RNMB at the PACU was diagnosed in 39.5% and 40.5% of the patients receiving cisatracurium and rocuronium, respectively (p = 1.0). _LNMB at the PACU was found in 32.6% and 16.7% of the patients receiving cisatracurium and rocuronium, respectively (p = 0.131).

Conclusions

The incidence of_RNMB remains significant despite the use of intermediate-acting neuromuscular blockers and reversal agents. There was no statistically significant difference in the incidence of _RNMB or _LNMB in patients receiving cisatracurium or rocuronium. The use of objective NMB monitoring is effective for the diagnosis of _RNMB, as well as for treatment management.

Application of Neuromuscular Monitoring in Pediatric Anesthesia: A Survey in China

PURPOSE

To determine the popularity of neuromuscular monitoring in pediatric anesthesia.

DESIGN

Self-filled electronic questionnaire survey.

METHODS

Anesthesiologists were notified through a professional network platform of anesthesiology by mobile phone. The survey deadline was December 23, 2019.

FINDINGS

A total of 883 valid questionnaires were collected. A total of 738 (83%) anesthesiologists stated that they had never used neuromuscular monitoring in pediatric anesthesia, and 638 (72%) anesthesiologists stated that they were not equipped with neuromuscular monitors. A total of 869 (98.75%) anesthesiologists had used neostigmine, but only 291 (33%) anesthesiologists reported routine postoperative administration for the reversal of neuromuscular block.

CONCLUSIONS

Neuromuscular monitoring in pediatric anesthesia needs to be further popularized. However, how to effectively and safely use neuromuscular antagonists are also important issues that require attention from anesthesiologists.

The future of neuromuscular blocking agents

PURPOSE OF REVIEW

The present review provides a summary of the literature on recent development of new neuromuscular blocking agents and presents clinically well established and new reversal agents.

RECENT FINDINGS

Anesthesiologists are still waiting for the ideal neuromuscular blocking agent with a succinylcholine-like rapid onset and offset without side effects. Recent drug development led to a new series of neuromuscular compounds, called the chlorofumarates such as gantacurium, CW002, and CW011. These drugs have a promising pharmacodynamic profile; importantly, they can rapidly be reversed by L-cysteine adduction without relevant side effects. In addition, a new spectrum of reversal agents are currently examined in preclinical studies: adamgammadex sodium, a modified γ-cyclodextrin derivate that forms an inactive tight inclusion complex with rocuronium or vecuronium and calabadions, capable of reversing both benzylisoquinolines and steroidal neuromuscular blocking agents.

SUMMARY

Although the recent advancements in neuromuscular research are very promising, to date, the presented drugs are currently not available for clinical use. Clinical studies will determine the role of these developments in anesthesia practice. Therefore, well established combinations such as rocuronium-sugammadex are popular in clinical practice to offer quick paralysis for intubation and to optimize surgical conditions, while providing a fast neuromuscular recovery at the end of surgery.

Effects of Sugammadex on Post-Operative Pulmonary Complications in Laparoscopic Gastrectomy: A Retrospective Cohort Study

The use of sugammadex can reduce post-operative residual neuromuscular blockade, which is known to increase the risk of post-operative respiratory events. However, its effect on post-operative pulmonary complications is not obvious. This study was performed to evaluate the effects of sugammadex on post-operative pulmonary complications in patients undergoing laparoscopic gastrectomy between 2013 and 2017. We performed propensity score matching to correct for selection bias. Post-operative pulmonary complications (i.e., pneumonia, respiratory failure, pleural effusion, atelectasis, pneumothorax, and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. We also evaluated admission to the intensive care unit after surgery, re-admission or an emergency room visit within 30 days after discharge, length of hospital stay, re-operation, and mortality within 90 days post-operatively as secondary outcomes. In the initial cohort of 3802 patients, 541 patients were excluded, and 1232 patients were analyzed after propensity score matching. In the matched cohort, pleural effusion was significantly reduced in the sugammadex group compared to the neostigmine group (neostigmine 23.4% vs. sugammadex 18%, p = 0.02). Other pulmonary complications and secondary outcomes were not significantly different between the groups. In comparison to neostigmine, the use of sugammadex was associated with a lower incidence of post-operative pleural effusion in laparoscopic gastrectomy.

Clinical Practice Guideline for the Management of Neuromuscular Blockade: What Are the Recommendations in the USA and Other Countries?

Purpose of Review

This review addresses various societal guidelines, standards, and consensus statements regarding optimal neuromuscular blockade management. We discuss the historical evolution of neuromuscular management as a means of identifying possible future trends.

Recent Findings

While a recent international panel of experts has called for abandoning clinical assessment and subjective evaluation using a peripheral nerve stimulator in favor of adopting quantitative monitoring, few anesthesia societies mandate similar practices at the moment.

Summary

The current status of neuromuscular monitoring in the world is still variable and unsatisfactory. Nevertheless, a positive trend can be observed in the anesthesia community to adopt and learn this neglected technique. The development of user-friendly monitoring devices should also help this process, but anesthesia national societies still need to do a lot to replace outdated and substandard practices.

Awareness during emergence from anesthesia: Features and future research directions

The anesthesia awareness with recall (AAWR) phenomenon represents a complication of general anesthesia consisting of memorization of intraoperative events reported by the patient immediately after the end of surgery or at a variable distance from it. Approximately 20% of AAWR cases occur during emergence from anesthesia. Clinically, these unexpected experiences are often associated with distress especially due to a sense of paralysis. Indeed, although AAWR at the emergence has multiple causes, in the majority of cases the complication develops when the anesthesia plan is too early lightened at the end of anesthesia and there is a lack of use, or misuse, of neuromuscular monitoring with improper management of the neuromuscular block. Because the distress caused by the sense of paralysis represents an important predictor for the development of severe psychological complications, the knowledge of the phenomenon, and the possible strategies for its prophylaxis are aspects of considerable importance. Nevertheless, a limited percentage of episodes of AAWR cannot be prevented. This paradox holds also during the emergence phase of anesthesia which represents a very complex neurophysiological process with many aspects yet to be clarified.

Onset and duration of cis-atracurium neuromuscular block during fentanyl and lidocaine infusions in isoflurane-anaesthetised dogs

BACKGROUND

This retrospective study assessed the onset and duration of the neuromuscular block (NMB) induced by cis-atracurium 0.15 mg/kg intravenously with and without fentanyl or lidocaine infusions in 45 isoflurane-anaesthetised dogs.

METHODS

Dogs with neuromuscular function assessed by a calibrated train-of-four (TOF) monitor with stimulation (every 13 s) of the peroneal nerve were included. The onset and duration of the NMB were defined as the time from cis-atracurium administration until TOF=0 and the time during TOF=0 display, respectively.

RESULTS

The NMB onset was shorter during fentanyl (mean±sd) (1.9±0.7 minutes; P=0.0042) and lidocaine (2.0±0.7 minutes; P=0.0154) compared with control (2.9±0.8 minutes). The NMB duration was shorter in the fentanyl (27.5±7.3 minutes; P=0.0491), but not in the lidocaine group (32.3±6.9 minutes; P=0.0790), compared with control (33.7±9.1 minutes). The NMB onset was poorly but significantly correlated with the dose of fentanyl and lidocaine administered before cis-atracurium (r=-0.3396; P=0.0225). The fentanyl and lidocaine groups received more crystalloid and colloid boluses than the control.

CONCLUSIONS

Fentanyl and lidocaine shortened the NMB onset and the former decreased the NMB duration. Further prospective studies are required to clarify whether this was associated with an indirect decrease in blood pressure or a direct interaction between cis-atracurium and fentanyl and lidocaine.

Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports

Background

Sugammadex is a modified gamma-cyclodextrin that acts by selectively encapsulating free amino-steroidal neuromuscular relaxants. Several case reports have been published on the use of sugammadex in patients with neuromuscular disorders that include neuromuscular junction diseases, myopathies, neuropathies, and motor neurone disorders. The primary aim of this review is to systematically review the evidence on the use of sugammadex in patients with this heterogeneous group of diseases and provide recommendations for clinical practice.

Methods

A systematic electronic search of Medline, Embase and CINAHL databases was done until June 2019, to identify case reports describing the use of sugammadex in adult surgical patients with neuromuscular disorders.

Results

Of the 578 records identified through database searches, 43 articles were finally included for the systematic review. Of these, 17 reports were on patients with myopathy, 15 reports on myasthenia gravis, 9 reports on motor neuron diseases and 2 reports on neuropathies.

Conclusions

Majority of the articles reviewed report successful use of sugammadex to reverse steroidal muscle relaxants, especially rocuronium, in patients with neuromuscular diseases. However, with sugammadex, unpredictability in response and uncertainty regarding optimum dose still remain issues. Quantitative neuromuscular monitoring to ensure complete reversal and adequate postoperative monitoring is strongly recommended in these patients, despite the use of sugammadex.

Respiratory muscle activity after spontaneous, neostigmine- or sugammadex-enhanced recovery of neuromuscular blockade: a double blind prospective randomized controlled trial

Background

The use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. In previous studies, we found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex. It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. In this study, we wanted to assess the effect of commonly used degrees of NMB and their possible reversal strategies on respiratory muscle activity after the return of normal neuromuscular transmission.

Methods

This is a randomized, controlled, parallel-group, single-centre, double-blind study in patients scheduled for intracranial surgery at a tertiary academic hospital in Belgium. All participants received target controlled propofol/remifentanil anesthesia and were randomized into one of five groups, receiving either a shallow NMB with no reversal (shallow/saline), a shallow NMB with sugammadex reversal (shallow/sugammadex), a moderate NMB with neostigmine reversal (moderate/neostigmine), a moderate NMB with sugammadex reversal (moderate/sugammadex), or a deep NMB with sugammadex reversal (deep/sugammadex). Primary and secondary outcome parameters were diaphragm and intercostal electromyographic (EMG) activity at the moment of resumed spontaneous breathing activity, defined as a maximal interval of 10 min after the first spontaneous breath.

Results

For the five groups, a total of 55 patients could be included in the final analysis. Median time of spontaneous breathing analyzed was 5 min (IQR 3–9.5 min). Both the moderate/sugammadex and the moderate/neostigmine groups had lower levels of diaphragm EMG compared to the shallow/sugammadex group. The moderate/neostigmine group had lower levels of intercostal EMG activity compared to the shallow/saline group.

Conclusions

In this study, the depth of neuromuscular blockade and type of reversal strategy impacts respiratory muscle activity at the moment of resumed spontaneous breathing and recovery of neuromuscular blockade. Both groups that received moderate NMB had lower levels of diaphragm EMG, compared to the shallow NMB group with sugammadex reversal. Compared to the shallow NMB group with no reversal, the moderate NMB with neostigmine reversal group had lower intercostal EMG activity.

Trial registration

Clinicaltrials.gov NCT01962298 on October 9, 2013 and EudraCT 2013–001926-25 on October 10, 2013.

Anesthesia and Enhanced Recovery After Head and Neck Surgery

Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.

Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit

INTRODUCTION

The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU).

METHODS

An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed.

RESULTS

A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB.

CONCLUSION

PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.