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Epstein RH, Nemes R, Renew JR, Brull SJ. Area under the curve and amplitude of the compound motor action potential are clinically interchangeable quantitative measures of neuromuscular block: a method comparison study. BJA OPEN 2024; 11:100293. [PMID: 38974718 PMCID: PMC11226963 DOI: 10.1016/j.bjao.2024.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/22/2024] [Indexed: 07/09/2024]
Abstract
Background Current guidelines recommend quantitative neuromuscular block monitoring during neuromuscular blocking agent administration. Monitors using surface electromyography (EMG) determine compound motor action potential (cMAP) amplitude or area under the curve (AUC). Rigorous evaluation of the interchangeability of these methods is lacking but necessary for clinical and research assurance that EMG interpretations of the depth of neuromuscular block are not affected by the methodology. Methods Digitised EMG waveforms were studied from 48 patients given rocuronium during two published studies. The EMG amplitudes and AUCs were calculated pairwise from all cMAPs classified as valid by visual inspection. Ratios of the first twitch (T1) to the control T1 before administration of rocuronium (T1c) and train-of-four ratios (TOFRs) were compared using repeated measures Bland-Altman analysis. Results Among the 2419 paired T1/T1c differences where the average T1/T1c was ≤0.2, eight (0.33%) were outside prespecified clinical limits of agreement (-0.148 to 0.164). Among the 1781 paired TOFR differences where the average TOFR was ≥0.8, 70 (3.93%) were outside the prespecified clinical limits of agreement ((-0.109 to 0.134). Among all 7286 T1/T1c paired differences, the mean bias was 0.32 (95% confidence interval 0.202-0.043), and among all 5559 paired TOFR differences, the mean bias was 0.011 (95% confidence interval 0.0050-0.017). Among paired T1/T1c and TOFR differences, Lin's concordance correlation coefficients were 0.98 and 0.995, respectively. Repeatability coefficients for T1/T1c and TOFR were <0.08, with no differences between methods. Conclusions Quantitative assessment neuromuscular block depth is clinically interchangeable when calculated using cMAP amplitude or the AUC.
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Affiliation(s)
- Richard H. Epstein
- Department of Anesthesiology, Perioperative Medicine & Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Réka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Johnathan R. Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Sorin J. Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
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Haberkorn S, Twite M, Klockau K, Whitney G, Faulk DJ. Quantitative Monitoring Maximizes Cost-Saving Strategies When Antagonizing Neuromuscular Block With Sugammadex. Cureus 2024; 16:e68551. [PMID: 39364519 PMCID: PMC11449403 DOI: 10.7759/cureus.68551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Introduction Weight-based dosing combined with variable patient weights in pediatric anesthesia can lead to significant medication excess and waste from single-use medication vials packaged for dosing in adults. Medication aliquots have been proposed as a strategy to decrease waste and therefore expense when using high-cost medications such as sugammadex. Appropriate dosing of sugammadex to antagonize neuromuscular block is based on the results of quantitative monitoring, though the use of these monitors is not routine. In this quality improvement project, we demonstrate cost savings from aliquoting sugammadex from large, single-use vials and using quantitative monitoring to guide accurate and appropriate dosing. Methods After institutional review and approval, patients receiving rocuronium neuromuscular block during their anesthetic care between October 10 and December 9, 2022, were included for analysis. Sugammadex aliquots were prepared under sterile conditions in the operating room pharmacy according to current compounding guidelines. Quantitative neuromuscular monitoring with electromyography-based monitors was used to guide accurate sugammadex dosing. Cost analysis included the actual savings achieved when aliquots were used instead of single-use vials, the potential savings if aliquots had been used as opposed to single-use vials, and the actual savings achieved when quantitative monitoring indicated that adequate spontaneous recovery was reached and sugammadex administration was not needed. Results A total of 200 patients were included in the analysis. In 73 patients, a 200 mg/2 ml vial of sugammadex was utilized, while 86 patients received sugammadex from pre-filled aliquot syringes of 50 mg/0.5 ml. Forty-one patients did not require sugammadex antagonism as they achieved spontaneous recovery to a train-of-four ratio ≥90%. Conclusion Administration of sugammadex from aliquots rather than manufacturer-packaged single-use vials, with dosing guided by quantitative neuromuscular monitoring, produced a net cost savings of approximately $46 per case and projected net annual cost savings of nearly $370,000 in our institution. Forty percent of the net cost savings came from confirmation by quantitative monitoring of adequate spontaneous recovery to a train-of-four ratio ≥90%.
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Affiliation(s)
- Steve Haberkorn
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | - Mark Twite
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | | | - Gina Whitney
- Department of Anesthesiology, University of Colorado, Aurora, USA
| | - Debra J Faulk
- Department of Anesthesiology, University of Colorado, Aurora, USA
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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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Maqusood S, Bele A, Verma N, Dash S, Bawiskar D. Sugammadex vs Neostigmine, a Comparison in Reversing Neuromuscular Blockade: A Narrative Review. Cureus 2024; 16:e65656. [PMID: 39205735 PMCID: PMC11352768 DOI: 10.7759/cureus.65656] [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: 07/01/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBA) has grown due to the development of laparoscopic and minimally invasive procedures. Respiratory insufficiency, an elevated risk of aspiration, postoperative pulmonary complications, and subsequent reintubation are among the risks linked to the residual block. The normal clinical practice calls for the pharmacologic "reversal" of these agents with either sugammadex or neostigmine prior to extubation. The administration of neostigmine is linked to a number of potential complications. In response, anaesthesiologists have begun to prescribe sugammadex more frequently for treating residual block and reversing blockade with NMBA. This review article compares and assesses neostigmine and sugammadex thoroughly in order to determine the extent to which they work as agents to reverse neuromuscular blockade. The review's findings highlight sugammadex's considerable advantages - Sugammadex's ability to quickly and reliably achieve desired train-of-four (TOF) ratios - over neostigmine in reversing neuromuscular blockade in a variety of surgical settings. In contrast, neostigmine's limitations regarding efficacy and rate of reversal were consistently noted in all of the reviewed studies, despite the fact that it is still widely used due to its lower cost and extensive clinical experience. Sugammadex is a superior option for reversing neuromuscular blockade, but incorporating it into standard clinical practice necessitates carefully weighing its potential benefits and drawbacks. Sugammadex provides notable benefits over neostigmine in terms of speed, predictability, and safety.
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Affiliation(s)
- Shafaque Maqusood
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amol Bele
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neeta Verma
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sambit Dash
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dushyant Bawiskar
- Sports Medicine, Abhinav Bindra Targeting Performance, Bangalore, IND
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Henrique Silva Ribeiro A, Verçosa N, Braga ELC, Micuci AJQR, Germano-Filho PA, Cavalcanti IL. Effect of tetanic stimulation prior to train-of-four monitoring on the time to muscle response stabilization with neuromuscular blockade with rocuronium in patients aged 60 to 80 years: A prospective randomized controlled trial. PLoS One 2024; 19:e0303161. [PMID: 38875248 PMCID: PMC11178177 DOI: 10.1371/journal.pone.0303161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/17/2024] [Indexed: 06/16/2024] Open
Abstract
PURPOSE To determine the effect of tetanic stimulation on the time to achieve stabilization of the T1 height, by acceleromyography train-of-four (TOF) ratio monitoring, in patients aged 60 to 80 years. METHODS Randomized, prospective, single-blind, controlled trial in patients aged 60 to 80 years undergoing elective surgery under general anesthesia in two university hospitals in Brazil between December 2019 and March 2022. This trial was performed in accordance with the principles of the Helsinki Declaration and the guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II. Participants were randomly allocated by computer-generated numbers to receive tetanic stimulation (intervention group, n = 25) or not receive tetanic stimulation (control group, n = 25) to achieve T1 height stabilization on TOF ratio monitoring. The primary endpoint was to evaluate the effect of tetanic stimulation on the time to achieve stabilization of the T1 height. We also evaluated the effect on the onset time of rocuronium and time to recover from neuromuscular blockade with a single dose of rocuronium 0.6 mg.kg-1 with spontaneous recovery. RESULTS There was no statistically significant difference between the groups in the time to T1 height stabilization (intervention: 4.3 [2.0-8.0] min; control: 5.8 [2.0-10.5] min; p = 0.202), onset time of the neuromuscular blocking agent (intervention: 1.9 [±0.7] min; control: 2.2 [±1.0] min; p = 0.219), or neuromuscular blockade recovery times to normalized TOF values of 0.7 (intervention: 106.1 [±37.2] min; control: 91.7 [±27.5] min; p = 0.295), 0.8 (intervention: 114.3 [±40.1] min; control: 97.8 [±28.9] min; p = 0.225), 0.9 (intervention: 126.5 [±44.0] min; control: 106.9 [±30.6] min; p = 0.153), and 1.0 (intervention: 138.3 [±43.4] min; control: 123.8 [±43.5] min; p = 0.425). CONCLUSION The results of this study suggest that the recommendation to use tetanic stimulation to shorten the time to T1 height stabilization in neuromuscular monitoring did not alter the stabilization time of the T1 twitch or the pharmacodynamics of neuromuscular blockade with rocuronium in patients aged 60 to 80 years.
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Affiliation(s)
- Angela Henrique Silva Ribeiro
- Department of General Specialized Surgery, Postgraduate Program in Medical Science, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
| | - Nubia Verçosa
- Department of Surgery, Postgraduate Program in Surgical Sciences, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | | | | | - Ismar Lima Cavalcanti
- Department of General Specialized Surgery, Postgraduate Program in Medical Science, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
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Cozowicz C, Zhong H, Poeran J, Illescas A, Liu J, Poultsides LA, Athanassoglou V, Memtsoudis SG. Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis. Eur J Anaesthesiol 2024; 41:374-380. [PMID: 38497249 DOI: 10.1097/eja.0000000000001979] [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: 03/19/2024]
Abstract
BACKGROUND Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.
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Affiliation(s)
- Crispiana Cozowicz
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (CC, SGM), Hospital for Special Surgery, Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College, New York, USA (HZ, AI, JL, SGM), Department of Orthopaedic Surgery/Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, USA (JP), Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA (JL, SGM), Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou (LAP), Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece (LAP) and Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, United Kingdom (VA)
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Espinal LM, Kalsotra S, Rice-Weimer J, Kitio SAY, Tobias JD. Tolerance to preoperative placement of electrodes for neuromuscular monitoring using the Tetragraph™. Saudi J Anaesth 2024; 18:205-210. [PMID: 38654867 PMCID: PMC11033887 DOI: 10.4103/sja.sja_864_23] [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: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 04/26/2024] Open
Abstract
Background Quantitative train-of-four (TOF) monitoring has recently been shown to be feasible in infants and children using a novel electromyography (EMG)-based monitor with a pediatric-sized self-adhesive sensor. However, placement of the sensor and initiation of TOF monitoring may require additional time in the operating room (OR), delaying workflow and the time to induction of anesthesia. The current study evaluates the feasibility of placing the self-adhesive sensor in the preoperative holding area in pediatric patients before arrival to the OR. Methods Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm to provide neurostimulation. After the induction of anesthesia, monitoring was initiated and TOF recording started before the administration of the NMBA. A Likert score (0-10) was used to assess ease of placement, tolerability of the monitor during the preoperative period, and its ability to generate a recorded response in the OR. Results The final study cohort included 40 patients with a median age of 3.7 years. Fourteen patients (35%) pulled off the sensor before arrival to the OR and 26 patients (65%) arrived at the OR with the sensor intact and functioning. Older children were more likely to maintain the sensor until arrival to the OR compared to younger patients (median age of 5.24 versus 1 year, P = 0.0521). A median age of 3.7 years correlated with an 80% chance of arriving in the OR with the sensor intact. Application ease and tolerance of the sensor were higher in the group that maintained the sensor until OR arrival. Conclusion In patients more than 4 years of age, placement of the self-adhesive sensor for EMG-based TOF monitoring may be feasible. However, in younger patients, additional interventions may be required to achieve a similar success rate.
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Affiliation(s)
- Leah M. Espinal
- Heritage College of Osteopathic Medicine - Dublin Campus, Dublin, Ohio and Ohio University, Athens, Ohio, USA
| | - Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Sibelle A. Yemele Kitio
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Kosciuczuk U, Dardzinska A, Kasperczuk A, Dzienis P, Tomaszuk A, Tarnowska K, Rynkiewicz-Szczepanska E, Kossakowska A, Pryzmont M. Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method. J Clin Med 2024; 13:1976. [PMID: 38610741 PMCID: PMC11012245 DOI: 10.3390/jcm13071976] [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: 02/20/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.
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Affiliation(s)
- Urszula Kosciuczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Agnieszka Dardzinska
- Faculty of Biocybernetics and Biomedical Engineering, Bialystok University of Technology, 15-276 Bialystok, Poland;
| | - Anna Kasperczuk
- Faculty of Mechanical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland; (A.K.); (P.D.)
| | - Paweł Dzienis
- Faculty of Mechanical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland; (A.K.); (P.D.)
| | - Adam Tomaszuk
- Faculty of Electrical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland;
| | - Katarzyna Tarnowska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Ewa Rynkiewicz-Szczepanska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Agnieszka Kossakowska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Marta Pryzmont
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
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Yang WL, Wen YL, Xu WM, Xu CL, Yin WQ, Lin JY. Effect of deep neuromuscular block on the quality of early recovery after sleeve gastrectomy in obese patients: a randomized controlled trial. BMC Anesthesiol 2024; 24:101. [PMID: 38493108 PMCID: PMC10943792 DOI: 10.1186/s12871-024-02465-1] [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: 12/14/2023] [Accepted: 02/22/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Deep neuromuscular block (NMB) has been shown to improve surgical conditions and alleviate post-operative pain in bariatric surgery compared with moderate NMB. We hypothesized that deep NMB could also improve the quality of early recovery after laparoscopic sleeve gastrectomy (LSG). METHODS Eighty patients were randomized to receive either deep (post-tetanic count 1-3) or moderate (train-of-four count 1-3) NMB. The QoR-15 questionnaire was used to evaluate the quality of early recovery at 1 day before surgery (T0), 24 and 48 h after surgery (T2, T3). Additionally, we recorded diaphragm excursion (DE), postoperative pain, surgical condition, cumulative dose of analgesics, time of first flatus and ambulation, post-operative nausea and vomiting, time of tracheal tube removal and hospitalization time. MAIN RESULTS The quality of recovery was significantly better 24 h after surgery in patients who received a deep versus moderate block (114.4 ± 12.9 versus 102.1 ± 18.1). Diaphragm excursion was significantly greater in the deep NMB group when patients performed maximal inspiration at T2 and T3 (P < 0.05). Patients who underwent deep NMB reported lower visceral pain scores 40 min after surgery; additionally, these patients experienced lower pain during movement at T3 (P < 0.05). Optimal surgical conditions were rated in 87.5% and 64.6% of all measurements during deep and moderate NMB respectively (P < 0.001). The time to tracheal tube removal was significantly longer in the deep NMB group (P = 0.001). There were no differences in other outcomes. CONCLUSION In obese patients receiving deep NMB during LSG, we observed improved QoR-15 scores, greater diaphragmatic excursions, improved surgical conditions, and visceral pain scores were lower. More evidence is needed to determine the effects of deep NMB on these outcomes. TRIAL REGISTRATION ChiCTR2200065919. Date of retrospectively registered: 18/11/2022.
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Affiliation(s)
- Wan-Li Yang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Ya-Ling Wen
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Wen-Mei Xu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Chi-Liang Xu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Wen-Qin Yin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Jing-Yan Lin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China.
- Department of Anesthesiology, North Sichuan Medical College, Nanchong, Sichuan, 637000, China.
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [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: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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11
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Faulk DJ, Yaster M. Re-paralysis or a canary in the coal mine? Paediatr Anaesth 2024; 34:282-283. [PMID: 37947223 DOI: 10.1111/pan.14799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/31/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Debra J Faulk
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Guo S, Moore J, Moradi L, Rosero E, Sabuncu AC. A compressomyograph train of four monitoring device. Med Eng Phys 2024; 125:104127. [PMID: 38508804 DOI: 10.1016/j.medengphy.2024.104127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/16/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
The monitoring of the neuromuscular blockade is critical for patient's safety during and after surgery. The monitoring of neuromuscular blockade often requires the use of Train of Four (TOF) technique. During a TOF test two electrodes are attached to the ulnar nerve, and a series of four electric pulses are applied. The electrical stimulation causes the thumb to twitch, and the amount of twitch varies depending on the amount of neuromuscular blockade in patient's system. Current medical devices used to assist anesthesiologists to perform TOF monitoring often require free hand movement and do not provide accurate or reliable results. The goal of this work is to design, prototype and test a new medical device that provides reliable TOF results when thumb movement is restricted. A medical device that uses a pressurized catheter balloon to detect the response thumb twitch of the TOF test is created. An analytical model, numerical study, and mechanical finger testing were employed to create an optimum design. The design is tested through a pilot human subjects study. No significant correlation is reported with subjects' properties, including hand size.
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Affiliation(s)
- Shu Guo
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Joe Moore
- Worcester Polytechnic Institute, 2808 Matsu Ln, Opelika, AL 36804, USA
| | - Lee Moradi
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Eric Rosero
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Ahmet C Sabuncu
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA.
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13
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Faulk DJ, Karlik JB, Strupp KM, Tran SM, Twite M, Brull SJ, Yaster M, Austin TM. The Incidence of Residual Neuromuscular Block in Pediatrics: A Prospective, Pragmatic, Multi-institutional Cohort Study. Cureus 2024; 16:e56408. [PMID: 38638790 PMCID: PMC11024486 DOI: 10.7759/cureus.56408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Residual neuromuscular block, defined as a quantitatively measured train-of-four ratio (TOFr) <0.9, is common postoperatively. Using a pragmatic trial design, we hypothesized that qualitative and/or clinical assessment of neuromuscular block would inadequately detect residual block following antagonism with neostigmine or sugammadex. Method After IRB approval and written informed consent, 74 children (aged 2-17 years), undergoing elective surgery and receiving rocuronium, were prospectively enrolled in the study at Children's Hospital Colorado and Children's Healthcare of Atlanta. Routine clinical practice at both institutions consisted of clinical signs and/or qualitative assessment with peripheral nerve stimulators. Children at the Colorado hospital routinely received sugammadex antagonism; whereas children at the Atlanta hospital received neostigmine. Residual neuromuscular block was assessed postoperatively using quantitative electromyography. If TOFr was <0.9, patients received sugammadex until TOFr ≥0.9. Result Qualitative and clinical assessment failed to detect residual block in 29.7% of patients in the neostigmine reversal cohort (adjusted odds ratio (aOR) 29.8, 95% confidence interval (CI): 2.7 to 5,559.5, p-value = 0.002). No residual block was detected in the sugammadex reversal cohort. A correlation between increasing patient weight and incidence of postoperative residual block was observed in the neostigmine cohort (aOR 1.05, 95% CI: 1.02 to 1.10, p-value = 0.002). Conclusion Qualitative and/or clinical assessment of neuromuscular block inadequately detects residual block following neostigmine antagonism.
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Affiliation(s)
- Debra J Faulk
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Joelle B Karlik
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Kim M Strupp
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Stephanie M Tran
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Mark Twite
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Sorin J Brull
- Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, USA
| | - Myron Yaster
- Anesthesiology, Children's Hospital Colorado, Denver, USA
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14
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Olesnicky BL, Farrell C, Clare P, Wen S, Leslie K, Delaney A. The effect of sugammadex on patient morbidity and quality of recovery after general anaesthesia: a systematic review and meta-analysis. Br J Anaesth 2024; 132:107-115. [PMID: 38036323 DOI: 10.1016/j.bja.2023.10.032] [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: 08/29/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Residual neuromuscular block is associated with increased patient morbidity. Therefore prevention of residual neuromuscular block is an important component of general anaesthesia where neuromuscular blocking agents are used. Whereas sugammadex improves reversal based on neuromuscular twitch monitoring parameters, there have been no prospective, adequately powered definitive studies demonstrating that sugammadex is also associated with less patient morbidity. METHODS We performed a systematic review of randomised trials comparing sugammadex with anticholinesterase-based reversal or placebo reversal that reported important patient outcomes beyond the postanaesthesia care unit. RESULTS We identified 43 articles, including 5839 trial participants. Only one trial reported days alive and out of hospital to 30 days (DAOH-30), which showed that the number of DAOH-30 was similar in those allocated to sugammadex compared with neostigmine-based reversal (25 days [19-27] vs 24 days [21-27], median difference 0.00 [-2.15 to 2.15]). Pooled analyses of data from 16 trials showed an estimated odds ratio (OR) for postoperative pulmonary complications of 0.67 (95% confidence interval 0.47-0.95) with sugammadex use. Pooled analysis showed that pneumonia (eight trials OR 0.51 [0.24-1.01] with sugammadex use), hospital length of stay (23 trials, mean difference -0.31 [-0.84 to 0.22] with sugammadex use), and patient-reported quality of recovery (11 trials, varied depending on metric used) are similar in those allocated to sugammadex vs control. The difference seen in mortality (11 trials, OR 0.39 [0.15-1.01] with sugammadex use) would be considered to be clinically significant and warrants further investigation, however, the rarity of these events precludes drawing definitive conclusions. CONCLUSION Although few trials reported on DAOH-30 or important patient outcomes, sugammadex is associated with a reduction in postoperative pulmonary complications, however, this might not translate to a difference in hospital length of stay, patient-reported quality of recovery, or mortality. CLINICAL TRIAL REGISTRATION PROSPERO database (CRD42022325858).
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Affiliation(s)
- Benjamin L Olesnicky
- Department of Anaesthesia, Pain and Perioperative Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Northern Clinical School of Medicine, The University of Sydney, Sydney, NSW, Australia; Northern Sydney Anaesthetic Research Institute, Sydney, NSW, Australia.
| | - Clare Farrell
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Phoebe Clare
- Department of Anaesthesia, Pain and Perioperative Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Northern Sydney Anaesthetic Research Institute, Sydney, NSW, Australia
| | - Shelly Wen
- Department of Anaesthesia, Westmead Hospital, Sydney, NSW, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Anthony Delaney
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia; Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
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15
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Padmaja D, Singam G, Tappa R, Maremanda K, Kabra N, Barada A. Does the objective measurement of muscle strength improve the detection of postoperative residual muscle weakness? J Anaesthesiol Clin Pharmacol 2024; 40:29-36. [PMID: 38666160 PMCID: PMC11042092 DOI: 10.4103/joacp.joacp_186_22] [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: 05/17/2022] [Revised: 06/30/2022] [Accepted: 07/02/2022] [Indexed: 04/28/2024] Open
Abstract
Background and Aims The postoperative residual neuromuscular block (PRNB) has a significant impact on patient safety and well-being, but continues to remain underestimated. Objective evaluation of handgrip strength using a force dynamometer can be useful to identify postoperative muscle weakness. Material and Methods Thirty-two American Society of Anesthesiologists (ASA) class I and II patients who received general anesthesia were included. Patients were extubated after the train-of-four (TOR) ratio (TOFR) was >0.90 and the clinical criteria for motor power recovery were judged as adequate. The measurements of handgrip strength and peak expiratory flow rate (PEFR) were obtained at baseline, 15 min after extubation, and 1, 2, and 4 h postoperatively. The incidence of significant decline from baseline (>25%) was determined. The correlation between handgrip strength and PEFR was assessed using Spearman correlation. The time to return to baseline for muscle grip strength and PEFR was performed using Kaplan-Meier survival analysis. A P value of 0.05 was considered significant for all tests. Results The incidence of the significant decline in handgrip strength from baseline was 100% at 15 and 60 min, 76% at 2 h, and 9.4% at 4 h. There was a strong correlation between muscle grip strength and PEFR (0.89, P < 0.001). None of the patients exhibited the potential complications of PRNB. (PRMB in abstract. It should be uniform) The mean time to return to the baseline value of muscle grip strength was 3.8 h (95% confidence interval [CI] 3.6-3.9), and the mean time to return to baseline for PEFR was 3.2 h (95% CI 2.9-3.4 h). Conclusion Objective assessment of muscle grip strength using a force dynamometer has the potential to be a new objective metric to monitor postoperative muscle weakness.
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Affiliation(s)
- Durga Padmaja
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Geetha Singam
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rabbani Tappa
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Krishnarao Maremanda
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Nitesh Kabra
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Anupama Barada
- Medical Student and Research Assistant, China Medical University, Shenyang, China
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16
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Lewis A. An Overview of Ethical Issues Raised by Medicolegal Challenges to Death by Neurologic Criteria in the United Kingdom and a Comparison to Management of These Challenges in the USA. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:79-96. [PMID: 36634197 DOI: 10.1080/15265161.2022.2160516] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Although medicolegal challenges to the use of neurologic criteria to declare death in the USA have been well-described, the management of court cases in the United Kingdom about objections to the use of neurologic criteria to declare death has not been explored in the bioethics or medical literature. This article (1) reviews conceptual, medical and legal differences between death by neurologic criteria (DNC) in the United Kingdom and the rest of the world to contextualize medicolegal challenges to DNC; (2) summarizes highly publicized legal cases related to DNC in the United Kingdom, including the nuanced 2022 case of Archie Battersbee, who was transiently considered dead by neurologic criteria, but ultimately determined to be in a vegetative state/unresponsive-wakeful state; and (3) provides an overview of ethical issues raised by medicolegal challenges to DNC in the United Kingdom and a comparison to the management of these challenges in the USA.
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17
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Epstein RH, Perez OF, Hofer IS, Renew JR, Brull SJ, Nemes R. Validation of a convolutional neural network that reliably identifies electromyographic compound motor action potentials following train-of-four stimulation: an algorithm development experimental study. BJA OPEN 2023; 8:100236. [PMID: 38026082 PMCID: PMC10654528 DOI: 10.1016/j.bjao.2023.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/30/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023]
Abstract
Background International guidelines recommend quantitative neuromuscular monitoring when administering neuromuscular blocking agents. The train-of-four count is important for determining the depth of block and appropriate reversal agents and doses. However, identifying valid compound motor action potentials (cMAPs) during surgery can be challenging because of low-amplitude signals and an inability to observe motor responses. A convolutional neural network (CNN) to classify cMAPs as valid or not might improve the accuracy of such determinations. Methods We modified a high-accuracy CNN originally developed to identify handwritten numbers. For training, we used digitised electromyograph waveforms (TetraGraph) from a previous study of 29 patients and tuned the model parameters using leave-one-out cross-validation. External validation used a dataset of 19 patients from another study with the same neuromuscular block monitor but with different patient, surgical, and protocol characteristics. All patients underwent ulnar nerve stimulation at the wrist and the surface electromyogram was recorded from the adductor pollicis muscle. Results The tuned CNN performed highly on the validation dataset, with an accuracy of 0.9997 (99% confidence interval 0.9994-0.9999) and F1 score=0.9998. Performance was equally good for classifying the four individual responses in the train-of-four sequence. The calibration plot showed excellent agreement between the predicted probabilities and the actual prevalence of valid cMAPs. Ten-fold cross-validation using all data showed similar high performance. Conclusions The CNN distinguished valid cMAPs from artifacts after ulnar nerve stimulation at the wrist with >99.5% accuracy. Incorporation of such a process within quantitative electromyographic neuromuscular block monitors is feasible.
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Affiliation(s)
- Richard H. Epstein
- Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Olivia F. Perez
- Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ira S. Hofer
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Sorin J. Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Réka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
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18
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Yoon JJ, Anderson AL, Niesen AD. Undiagnosed Lambert-Eaton Myasthenic Syndrome in the Era of Sugammadex: A Case Report. Clin Neuropharmacol 2023; 46:205-208. [PMID: 37962306 DOI: 10.1097/wnf.0000000000000569] [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: 09/13/2023]
Abstract
OBJECTIVE In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. METHODS We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. RESULTS Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. CONCLUSIONS Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.
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Affiliation(s)
| | - Alexandra L Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam D Niesen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Carvalho H, Verdonck M, Eleveld DJ, Ramirez D, D'Haese J, Flamée P, Geerts L, Wylleman J, Cools W, Barbe K, Struys MMRF, Poelaert J. Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial. J Clin Anesth 2023; 90:111225. [PMID: 37542918 DOI: 10.1016/j.jclinane.2023.111225] [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: 03/22/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Objective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s STUDY OBJECTIVE: The present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements. DESIGN Observational trial. SETTING Tertiary Belgian hospital, from August 2020 up to September 2021. PATIENTS AND INTERVENTIONS Seventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria). MAIN RESULTS Published rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance. CONCLUSIONS Simulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
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Affiliation(s)
- Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium; Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Belgium.
| | - Michaël Verdonck
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Douglas J Eleveld
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - David Ramirez
- Servicio Anestesiología y Reanimación, Fundación Valle de Lili, Cali, Colombia
| | - Jan D'Haese
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Panagiotis Flamée
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Lieselot Geerts
- Department of Anaesthesia, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jasper Wylleman
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Wilfried Cools
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kurt Barbe
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel M R F Struys
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
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20
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Ji Y, Yuan H, Chen Y, Zhang X, Wu F, Tang W, Lu Z, Huang C. Sugammadex Is Associated With Reduced Pulmonary Complications in Patients With Respiratory Dysfunction. J Surg Res 2023; 290:133-140. [PMID: 37267702 DOI: 10.1016/j.jss.2023.04.023] [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: 12/01/2022] [Revised: 04/12/2023] [Accepted: 04/30/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Use of sugammadex is associated with fewer postoperative pulmonary complications (PPCs). This study investigated the relationship between sugammadex and PPCs in specific patients with respiratory dysfunction. MATERIALS AND METHODS We reviewed the electronic medical and anesthesia records of patients with respiratory dysfunction who underwent laparoscopic gastric or intestinal surgery at a single center between May 1, 2018 and December 31, 2019. The patients were divided into the sugammadex group and the nonsugammadex group, based on whether they received sugammadex or neostigmine. Binary logistic regression analyses were used to characterize the differences in incidence of PPC. RESULTS A total of 112 patients were included, of which 46 patients (41.1%) received sugammadex. In the logistic regression analysis, the incidences of PPC were fewer in the sugammadex group. Postoperative fever (odds ratio [OR] 0.330; 95% confidence interval [CI] 0.137-0.793, P = 0.0213), postoperative intensive care unit admission (OR 0.204; 95% CI 0.065-0.644, P = 0.007), cough (OR 0.143; 95% CI 0.061- 0.333, P < 0.001), pleural effusion (all) (OR: 0.280; 95% CI 0.104- 0.759, P = 0.012), pleural effusion (massive) (OR: 0.142; 95% CI 0.031- 0.653, P = 0.012), and difficulty in breathing (OR: 0.111; 95% CI 0.014-0.849, P = 0.039) showed significant differences between the two groups. CONCLUSIONS Sugammadex is associated with a reduction in PPC in patients with respiratory dysfunction.
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Affiliation(s)
- Yiqin Ji
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Hui Yuan
- Department of Anesthesiology, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Yijun Chen
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China.
| | - Xincai Zhang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Fan Wu
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Wan Tang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Zihui Lu
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Changshun Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
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21
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Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
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Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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22
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Li HX, Zheng H, Tang W, Sun YK, Zhang L, Kong XY, Yan T. Postoperative recurarization after sugammadex administration in two patients who received neoadjuvant chemotherapy: case reports and literature review. Can J Anaesth 2023; 70:1529-1538. [PMID: 37407856 DOI: 10.1007/s12630-023-02527-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Preoperative neoadjuvant chemotherapy plays a critical role in multidisciplinary therapy for a variety of malignant tumours. Although oncologists consider myocardial injury to be the most concerning side effect of chemotherapy, unique chemotherapy-mediated skeletal muscular damage has received attention recently. CLINICAL FEATURES We report two unusual cases of postoperative delayed respiratory failure following administration of the recommended sugammadex dosage for patients undergoing lengthy operations with deep neuromuscular blockade (NMB) after neoadjuvant chemotherapy. Based on clinical outcomes, especially the comparison of muscle imaging results in patients at different treatment time points, we concluded that NMB recurrence had a possible correlation with neoadjuvant chemotherapy-induced muscular damage. CONCLUSION The early identification of neoadjuvant chemotherapeutic side effects on NMB could be instrumental for clinical safety, especially in cases of major surgery requiring deep NMB. Thus, the timing of NMB antagonism and the recommended dosage of sugammadex warrant special consideration in these patients. In addition to neuromuscular monitoring during the operation, a more extended and closer observation period in the postanesthesia care unit is warranted.
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Affiliation(s)
- Hui-Xian Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wei Tang
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Kun Sun
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Zhang
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
- Centre of Cancer Research, Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
| | - Xiang-Yi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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23
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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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24
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Zheng J, Du L, Zhang L, Du B, Zhang W, Chen G. Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta-Analysis. Laryngoscope 2023; 133:2055-2065. [PMID: 36625304 DOI: 10.1002/lary.30561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/17/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery. DATA SOURCES PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database. METHODS Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no-deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions. SECONDARY OUTCOME the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications [including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV)]. Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded. RESULTS Four articles with 242 patients were identified for analysis. The results indicated that compared with no-deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio [RR] = 1.29, 95% CI: 1.07-1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR = 0.32; 95% CI: 0.21-0.49) (lower incidence of vocal fold movement [1.85% vs. 34%; RR = 0.08, 95% CI: 0.02-0.41] and coughing [15.53% vs. 38.78%; RR = 0.42, 95% CI: 0.27-0.66]). There were no differences in the overall incidence of postoperative complications (RR = 2.10, 95% CI: 0.12-36.40). CONCLUSIONS Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications. LEVEL OF EVIDENCE 1 Laryngoscope, 133:2055-2065, 2023.
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Affiliation(s)
- Jianqiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lu Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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25
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Kalsotra S, Rice-Weimer J, Tobias JD. Intraoperative electromyographic monitoring in children using a novel pediatric sensor. Saudi J Anaesth 2023; 17:378-382. [PMID: 37601498 PMCID: PMC10435795 DOI: 10.4103/sja.sja_160_23] [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: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 08/22/2023] Open
Abstract
Background Train-of-four (TOF) monitoring is essential in optimizing perioperative outcomes as a means to assess the depth of neuromuscular blockade and confirm recovery following the administration of neuromuscular blocking agents (NMBAs). Quantitative TOF monitoring has been limited in infants and children primarily due to lack of effective equipment. The current study evaluates a novel electromyography (EMG)-based TOF monitor with a recently developed pediatric-sized self-adhesive sensor in infants and children. Methods Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm. The muscle action potentials from the adductor pollicis muscle were recorded throughout surgery at 20-second intervals. Data from the monitor's built-in memory card were later retrieved and analyzed. Results The final study cohort included 51 patients who ranged in age from 0.2 to 7.9 years and in weight from 4.2 to 36.0 kilograms. Thirty patients weighed less than 15 kgs. Supramaximal stimulus current intensity (mA) at a pulse width of 200 μsec was 30 mA in 8%; 40 mA in 29%; 50 mA in 16%; and 60 mA in 20% of the patients. Supramaximal stimulus current intensity (mA) at a pulse width of 300 μsec was 50 mA in 4%; 60 mA in 24%. The muscle action potential baseline amplitude was 8.7 ± 3.3 mV and recovered to 7.2 ± 3.7 mV after antagonism of neuromuscular blockade. The average baseline TOF ratio was 100 ± 3% and recovered to 98 ± 7% after antagonism of neuromuscular blockade. No technical issues were noted with application of the sensor or subsequent use of the monitor. Conclusion Neuromuscular monitoring can be performed intraoperatively in pediatric patients who are less than 8 years of age using a novel commercially available EMG-based monitor with a recently developed pediatric sensor. The novel sensor allows use of an EMG-based monitor in infants and children in whom acceleromyography or subjective (visual) observation of the TOF response may not be feasible. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level, baseline amplitude of the muscle action potential) was feasible in pediatric patients of all sizes including those weighing less than 15 kilograms or when there was limited access to the extremity being monitored.
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Affiliation(s)
- Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
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26
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Li HX, Li BL, Wang TH, Xu X, Wang F, Zhang X, Zhang X, Li HY, Mu B, Sun YL, Zheng H, Yan T. Comparison of the effects of remimazolam tosylate and propofol on postoperative delirium among older adults undergoing major non-cardiac surgery: protocol for a randomised controlled trial. BMJ Open 2023; 13:e071912. [PMID: 37247962 DOI: 10.1136/bmjopen-2023-071912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common cognitive disturbance in elderly individuals that is characterised by acute and fluctuating impairments in attention and awareness. Remimazolam tosylate is a novel, ultrashort-acting benzodiazepine, and there is limited evidence of its correlation with the incidence of early POD. The aim of this study is to evaluate the incidence of POD after anaesthesia induction and maintenance with remimazolam tosylate or propofol in elderly patients undergoing major non-cardiac surgery. METHODS AND ANALYSIS This is a single-centre, randomised controlled trial. 636 elderly patients undergoing major non-cardiac surgery will be enrolled and randomised at a 1:1 ratio to receive total intravenous anaesthesia with either remimazolam tosylate or propofol. The primary outcome is the incidence of POD within 5 days after surgery. Delirium will be assessed twice daily by the 3 min Diagnostic Interview for the Confusion Assessment Method or the Confusion Assessment Method for the intensive care unit (ICU) for ICU patients. Secondary outcomes are the onset and duration of delirium, cognitive function at discharge and within 1-year postoperatively, postoperative analgesia within 5 days, chronic pain at 3 months, quality of recovery and postoperative inflammatory biomarker levels. ETHICS AND DISSEMINATION The study was approved by the institutional ethics committee of the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (approval No. 22/520-3722). Written informed consent will be obtained from each patient before enrolment. The results of this trial will be presented at scientific conferences and in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER ChiCTR2300067368.
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Affiliation(s)
- Hui-Xian Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bao-Li Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tai-Hang Wang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Xu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Zhang
- Department of Pathergasiology, Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
| | - Xin Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Yi Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Mu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Lin Sun
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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27
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Calef A, Castelgrande R, Crawley K, Dorris S, Durham J, Lee K, Paras J, Piazza K, Race A, Rider L, Shelley M, Stewart E, Tamok M, Tate J, Dodd-O JM. Reversing Neuromuscular Blockade without Nerve Stimulator Guidance in a Postsurgical ICU-An Observational Study. J Clin Med 2023; 12:jcm12093253. [PMID: 37176693 PMCID: PMC10179105 DOI: 10.3390/jcm12093253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
We aimed to determine if not using residual neuromuscular blockade (RNB) analysis to guide neuromuscular blockade reversal administration in the postsurgical ICU resulted in consequences related to residual weakness. This single-center, prospective study evaluated 104 patients arriving in a postcardiac surgical ICU. After demonstrating spontaneous movement and T > 35.5 °C, all patients underwent RNB evaluation, and neostigmine/glycopyrrolate was then administered. When patients later demonstrated an adequate Rapid Shallow Breathing Index, negative inspiratory force generation, and arterial blood gas values with minimal mechanical ventilatory support, RNB evaluation was repeated in 94 of the 104 patients, and all patients were extubated. Though RNB evaluation was performed, patients were extubated without considering these results. Eleven of one hundred four patients had not achieved a Train-of-Four (TOF) count of four prior to receiving neostigmine. Twenty of ninety-four patients demonstrated a TOF ratio ≤ 90% prior to extubation. Three patients received unplanned postextubation adjunct respiratory support-one for obvious respiratory weakness, one for pain-related splinting compounding baseline disordered breathing but without obvious benefit from BiPAP, and one for a new issue requiring surgery. Residual neuromuscular weakness may have been unrecognized before extubation in 1 of 104 patients administered neostigmine without RNB analysis. ICU-level care may mitigate consequences in such cases.
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Affiliation(s)
- Andrea Calef
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Rashel Castelgrande
- Department of Surgery, Anne Arundel Medical Center, Anne Arundel, MD 21401, USA
| | - Kristin Crawley
- Department of Surgery, Medstar Medical Group, Baltimore, MD 21201, USA
| | - Sara Dorris
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Joanna Durham
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Kaitlin Lee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jen Paras
- Department of Surgery, INOVA Fairfax Hospital, Fairfax, VA 22042, USA
| | - Kristen Piazza
- Department of Surgery, University of Maryland St Joseph Hospital, Baltimore, MD 21201, USA
| | - Abigail Race
- Department of Surgery, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Laura Rider
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michael Shelley
- Department of Surgery, Maine Medical Center, Portland, ME 04103, USA
| | - Emily Stewart
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Miranda Tamok
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jennifer Tate
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jeffrey M Dodd-O
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Oh SK, Lim BG, Kim H, Lee JH, Lee JE. Performance of a new auxiliary device based on wrist brace to improve accuracy and feasibility in neuromuscular monitoring with acceleromyography in prone-positioned patients undergoing lumbar spine surgery: a prospective randomized clinical trial. J Clin Monit Comput 2023:10.1007/s10877-023-01000-w. [PMID: 37004664 DOI: 10.1007/s10877-023-01000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
Accuracy of acceleromyography (AMG) is not be comparable to that of mechanomyography or electromyography (EMG). In particular, the prone position may reduce the accuracy and feasibility of AMG. We developed a new device based on wrist brace to allow free thumb movement and fix the other parts of the hand and wrist. We aimed to test whether the brace applied to the AMG would increase precision of AMG and agreement with the EMG in the prone position. Fifty-seven patients, undergoing lumbar surgery under general anesthesia, were randomly assigned to groups to which AMG was applied with or without (no) brace (29 in group B vs. 28 in group NB). EMG was performed in the contralateral arm. Repeatability coefficients of the first twitch height (T1) and train-of-four (TOF) ratio were assessed from nine consecutive measurements during spontaneous recovery from rocuronium-induced neuromuscular block and the AMGs of the two groups were compared in prone position. The agreement between AMG and EMG in each group was assessed using the Bland-Altman method. In group B, the repeatability coefficient of T1 was significantly lower during the recovery to T1 of 25% and TOF ratio of 0.9 (P = 0.017 and 0.033, respectively), indicating higher precision. The mean differences of bias (95% limits of agreement) between AMG and EMG in TOF ratio of 0.9 were 6.839 (- 26.54 to 40.22) in group NB and 3.922 (- 21.83 to 29.67) in group B. The wide limits of agreement in group NB was slightly narrowed in group B but without significance. Trial registration: registered on the UMIN Clinical Trials Registry in August 2020 (UMIN000041310).
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Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Heezoo Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Hak Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Eun Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Henricks EM, Pfeifer KJ. Pulmonary assessment and optimization for older surgical patients. Int Anesthesiol Clin 2023; 61:8-15. [PMID: 36794803 DOI: 10.1097/aia.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Evan M Henricks
- Division of Geriatric and Palliative Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kurt J Pfeifer
- Department of Medicine, Section of Perioperative & Consultative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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30
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Liu H, Luo R, Cao S, Zheng B, Ye L, Zhang W. Superiority of sugammadex in preventing postoperative pulmonary complications. Chin Med J (Engl) 2023:00029330-990000000-00478. [PMID: 37027443 DOI: 10.1097/cm9.0000000000002381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Postoperative pulmonary complications often lead to increasing mortality and financial burden. Residual paralysis plays a critical role in postoperative pulmonary complications. This meta-analysis was performed to determine whether sugammadex overmatch neostigmine in reducing postoperative pulmonary complications. METHODS PubMed, Embase, Web of Science, Medline through Ovid, Cochrane Library, Wan fang, China National Knowledge Infrastructure, and Chinese BioMedical Literature Databases were searched from their inception to 24 June 2021. Random effects models were used for all analyses. Cochrane risk of bias tool was used to assess the quality of RCTs, while Newcastle Ottawa Quality Assessment Scale was used to assess for the quality of cohort studies. RESULTS Seventeen studies were included in the meta-analysis. Pooled data from cohort studies showed reversing neuromuscular blocking with sugammadex had less risk of compound postoperative pulmonary complications [relative risk (RR): 0.73; 95% confidence interval (CI): 0.60-0.89; P = 0.002; I2 = 81%], pneumonia (RR: 0.64; 95% CI: 0.48-0.86; I2 = 42%) and respiratory failure (RR: 0.48, 95% CI: 0.41-0.56, I2 = 0%). However, pooled data from RCTs did not show any difference between the two groups in pneumonia (RR: 0.58; 95% CI: 0.24-1.40; I2 = 0%) and respiratory failure. The difference was not found between sugammadex and neostigmine about atelectasis in pooled data from either RCTs (RR: 0.85; 95% CI: 0.69-1.05; I2 = 0%) or cohort studies (RR: 1.01; 95% CI: 0.87 to 1.18; I2 = 0%). CONCLUSION The evidence of superiority of sugammadex was limited by the confounding factors in cohort studies and small scale of RCTs. Whether sugammadex precedes neostigmine in preventing pulmonary complications after surgery is still unknown. Well-designed RCTs with large scale are needed. REGISTRATION PROSPERO CRD 42020191575.
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Affiliation(s)
- Haibei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Rong Luo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shuangjiao Cao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bixing Zheng
- Department of Pain, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Ye
- Department of Pain, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Wensheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
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31
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Pai SL, Grech D, Gayer S, Rodriguez L, Joshi GP, Rajan N. Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings? Minerva Anestesiol 2023; 89:197-205. [PMID: 36326774 DOI: 10.23736/s0375-9393.22.16852-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA -
| | - Dennis Grech
- New Jersey Medical School, Department of Anesthesiology, Rutgers, Newark, NJ, USA
| | - Steven Gayer
- Miller School of Medicine, Department of Anesthesiology, University of Miami, Miami, FL, USA
| | - Leopoldo Rodriguez
- Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, Boulder, CO, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX, USA
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
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32
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Ho AMH, Klar G, Mizubuti GB. A simple technique for dosing neostigmine and glycopyrrolate in children. Can J Anaesth 2023; 70:282-283. [PMID: 36447091 DOI: 10.1007/s12630-022-02369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/11/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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Yang L, Hu N, Chang H, Yang D, Zuo Y. Routine administration of neostigmine after recovery of spontaneous breathing versus neuromuscular monitor-guided administration of neostigmine in pediatric patients: a parallel, randomized, controlled study. Trials 2023; 24:19. [PMID: 36611181 PMCID: PMC9824919 DOI: 10.1186/s13063-023-07066-w] [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] [Received: 11/19/2021] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Neostigmine used to reverse the muscle relaxants should be guided by neuromuscular monitoring, as the degree of spontaneous pre-reversal recovery is the key to success to reverse the neuromuscular block. But neuromuscular monitoring is not always available for some patients during anesthesia and, in consequence, we need to use other clinical judgment to guide the use of neostigmine to reverse the neuromuscular block. In this trial, we aimed to evaluate the incidence of residual neuromuscular blockade (rNMB) in pediatric patients with routine use of neostigmine after recovery of spontaneous breathing compared with the patients with the use of neostigmine guided by neuromuscular monitoring. METHODS A parallel, randomized, controlled noninferiority study was conducted. We enrolled aged 3 months to 12 years old patients who underwent inguinal hernia repair under general anesthesia. The enrolled patients were randomly divided into experimental and control groups. After surgery, children in the experimental group were given 0.02 mg/kg neostigmine after recovery of spontaneous breathing. Children in the control group were given 0.02 mg/kg neostigmine when the train-of-four (TOF) ratio was between 0.4 and 0.9. However, no neostigmine was administered if the TOF ratio was higher than 0.9. The primary outcome was the incidence of rNMB after extubation (TOF ratio < 0.9). Secondary outcomes included the incidence of neostigmine-induced muscle paralysis, end of surgery - extubation interval, end of surgery - exit OR interval, the length of stay in the PACU, the incidence of hypoxia in the PACU, the number of children who required assisted ventilation during the PACU stay, and neostigmine-related adverse events. RESULTS A total of 120 children were included in this study, with 60 in the experimental group and 60 in the control group. There was no significant difference in the incidence of rNMB after extubation between the groups (45/60 vs 44/60, RR 1.02 [95% CI, 0.83 to 1.26], p = 0.84). There was no neostigmine-induced muscle paralysis in either group. Adverse events were similar occurred in both groups. However, time from end of the surgery to leaving the operating room was earlier in the experimental group than in the control group (13.6 ± 5.2 vs 15.7 ± 5.6 min, MD -2.10 min [95% CI, -3.70 to -0.50], p = 0.04). The risk ratio of the incidence of TOF ratio < 0.3 for the experimental group was 31.12 (95%CI, 1.89 to 512.61) compared with the control group (12/60 vs 0/60, p = 0.00) in exploratory analysis. CONCLUSIONS Recovery of spontaneous breathing could be used as a substitute of neuromuscular monitoring to guide neostigmine use in pediatric patients following minor surgeries. However, care should be taken for the residual neuromuscular block. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-IOR-17012890. Registered on 5 October 2017.
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Affiliation(s)
- Lei Yang
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, Guoxuexiang 37, Chengdu, 610041 China
| | - Na Hu
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, Guoxuexiang 37, Chengdu, 610041 China ,grid.488387.8Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hong Chang
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, Guoxuexiang 37, Chengdu, 610041 China
| | - Di Yang
- grid.410646.10000 0004 1808 0950Department of Anesthesiology, Sichuan Provincial Academy of Medical Sciences, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yunxia Zuo
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, Guoxuexiang 37, Chengdu, 610041 China
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Liu S, He B, Deng L, Li Q, Wang X. Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2023; 18:e0282790. [PMID: 36893114 PMCID: PMC9997990 DOI: 10.1371/journal.pone.0282790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/17/2023] [Indexed: 03/10/2023] Open
Abstract
Deep neuromuscular blockade provides better surgical workspace conditions in laparoscopic surgery, but it is still not clear whether it improves perioperative outcomes, not to mention its role in other types of surgeries. We performed this systematic review and meta-analysis of randomized controlled trials to investigate whether deep neuromuscular blockade versus other more superficial levels of neuromuscular blockade provides improved perioperative outcomes in adult patients in all types of surgeries. Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to June 25, 2022. Forty studies (3271 participants) were included. Deep neuromuscular blockade was associated with an increased rate of acceptable surgical condition (relative risk [RR]: 1.19, 95% confidence interval [CI]: [1.11, 1.27]), increased surgical condition score (MD: 0.52, 95% CI: [0.37, 0.67]), decreased rate of intraoperative movement (RR: 0.19, 95% CI: [0.10, 0.33]), fewer additional measures to improve the surgical condition (RR: 0.63, 95% CI: [0.43, 0.94]), and decreased pain score at 24 h (MD: -0.42, 95% CI: [-0.74, -0.10]). There was no significant difference in the intraoperative blood loss (MD: -22.80, 95% CI: [-48.83, 3.24]), duration of surgery (MD: -0.05, 95% CI: [-2.05, 1.95]), pain score at 48 h (MD: -0.49, 95% CI: [-1.03, 0.05]), or length of stay (MD: -0.05, 95% CI: [-0.19, 0.08]). These indicate that deep neuromuscular blockade improves surgical conditions and prevents intraoperative movement, and there is no sufficient evidence that deep neuromuscular blockade is associated with intraoperative blood loss, duration of surgery, complications, postoperative pain, and length of stay. More high-quality randomized controlled trials are needed, and more attention should be given to complications and the physiological mechanism behind deep neuromuscular blockade and postoperative outcomes.
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Affiliation(s)
- Siyuan Liu
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Bin He
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Lei Deng
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Qiyan Li
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Xiong Wang
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
- * E-mail:
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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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36
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Wu EB, Huang SC, Lu HI, Illias AM, Wang PM, Huang CJ, Shih TH, Chin JC, Wu SC. Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis. Br J Anaesth 2023; 130:e119-e127. [PMID: 36038393 DOI: 10.1016/j.bja.2022.07.046] [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: 11/01/2021] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). METHODS This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. RESULTS Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005). CONCLUSIONS During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.
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Affiliation(s)
- En-Bo Wu
- Department of Anaesthesiology, Kaohsiung, Taiwan
| | | | - Hung-I Lu
- Department of Thoracic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Amina M Illias
- Department of Anaesthesiology, Linko Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Pei-Ming Wang
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | | | - Jo-Chi Chin
- Department of Anaesthesiology, Park One International Hospital, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anaesthesiology, Kaohsiung, Taiwan.
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Martyn JAJ, Sparling JL, Bittner EA. Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review. Br J Anaesth 2023; 130:39-50. [PMID: 36175185 DOI: 10.1016/j.bja.2022.08.009] [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: 04/11/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023] Open
Abstract
Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.
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Affiliation(s)
- J A Jeevendra Martyn
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jamie L Sparling
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Tesoro S, Gamba P, Bertozzi M, Borgogni R, Caramelli F, Cobellis G, Cortese G, Esposito C, Gargano T, Garra R, Mantovani G, Marchesini L, Mencherini S, Messina M, Neba GR, Pelizzo G, Pizzi S, Riccipetitoni G, Simonini A, Tognon C, Lima M. Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP). Surg Endosc 2022; 36:7877-7897. [PMID: 36121503 PMCID: PMC9613560 DOI: 10.1007/s00464-022-09577-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy.
| | - Mirko Bertozzi
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Fabio Caramelli
- Anesthesia and Intensive Care Unit, IRCCS Sant'Orsola Polyclinic, Bologna, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children's Hospital, Polytechnical University of Marche, Ancona, Italy
| | - Giuseppe Cortese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
| | - Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giulia Mantovani
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Laura Marchesini
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS San Matteo Polyclinic, Pavia, Italy
| | - Mario Messina
- Division of Pediatric Surgery, Santa Maria Alle Scotte Polyclinic, University of Siena, Siena, Italy
| | - Gerald Rogan Neba
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Vittore Buzzi' Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Simone Pizzi
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Alessandro Simonini
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Costanza Tognon
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Mario Lima
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
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Hyland SJ, Pandya PA, Mei CJ, Yehsakul DC. Sugammadex to Facilitate Neurologic Assessment in Severely Brain-Injured Patients: Retrospective Analysis and Practical Guidance. Cureus 2022; 14:e30466. [DOI: 10.7759/cureus.30466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 11/07/2022] Open
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Lwin NS, Leslie K. Neuromuscular monitoring during general anaesthesia: a review of current national and international guidelines. BJA OPEN 2022; 3:100028. [PMID: 37588583 PMCID: PMC10430869 DOI: 10.1016/j.bjao.2022.100028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/29/2022] [Indexed: 08/18/2023]
Abstract
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.
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Affiliation(s)
- Nyan S. Lwin
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
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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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Wu EB, Hung CT, Luo SD, Wu SC, Lee TY, Chin JC, Tsai PN, Yang JCS. Analgesic and Anesthetic Efficacy of Rocuronium/Sugammadex in Otorhinolaryngologic Surgery: A Propensity Score-Matched Analysis. Pharmaceuticals (Basel) 2022; 15:ph15070894. [PMID: 35890192 PMCID: PMC9318942 DOI: 10.3390/ph15070894] [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] [Received: 06/01/2022] [Revised: 07/01/2022] [Accepted: 07/16/2022] [Indexed: 12/10/2022] Open
Abstract
The use of rocuronium/sugammadex in otorhinolaryngologic surgery improves intubation conditions and surgical rating scales. This study primarily aimed to evaluate the effect of the combination of rocuronium and sugammadex on intraoperative anesthetic consumption. The secondary outcomes were the intraoperative and postoperative morphine milligram equivalent (MME) consumption, duration of intraoperative hypertension, extubation time, incidence of delayed extubation and postoperative nausea and vomiting, pain score, and length of stay. A total of 2848 patients underwent otorhinolaryngologic surgery at a tertiary medical center in southern Taiwan. After applying the exclusion criteria, 2648 of these cases were included, with 167 and 2481 in the rocuronium/sugammadex and cisatracurium/neostigmine groups, respectively. To reduce potential bias, 119 patients in each group were matched by propensity scores for sex, age, body weight, and type of surgery. We found that the rocuronium/sugammadex group was associated with significant preservation of the intraoperative sevoflurane and MME consumption, with reductions of 14.2% (p = 0.009) and 11.8% (p = 0.035), respectively. The use of the combination of rocuronium and sugammadex also significantly increased the dose of intraoperative labetalol (p = 0.002), although there was no significant difference in intraoperative hypertensive events between both groups. In conclusion, our results may encourage the use of the combination of rocuronium and sugammadex as part of volatile-sparing and opioid-sparing anesthesia in otorhinolaryngologic surgery.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Chao-Ting Hung
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Tsung-Yang Lee
- Department of Anesthesiology, Jen-Ai Hospital, Taichung 412, Taiwan;
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, No. 100, Bo’ai 2nd Rd., Zuoying Dist., Kaohsiung City 813, Taiwan;
| | - Peng-Neng Tsai
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan; (E.-B.W.); (C.-T.H.); (S.-C.W.); (P.-N.T.)
| | - Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta-Pei Rd., Niao-Song Dist., Kaohsiung City 833, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 2788)
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Fülesdi B, Brull SJ. Quantitative Neuromuscular Monitoring: "Love All, Trust a Few, Do Wrong to None". Anesth Analg 2022; 135:35-38. [PMID: 35709442 DOI: 10.1213/ane.0000000000006035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Béla Fülesdi
- From the Department of Anesthesiology and Intensive Care, University of Debrecen, Medical Advisory Board of the Ministry of Health, Debrecen, Hungary
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
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Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study. J Clin Anesth 2022; 78:110673. [DOI: 10.1016/j.jclinane.2022.110673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
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Ghiyasinasab M, Morisson L, Laferrière-Langlois P, Geraldo-Demers MA, Gélinas C, Nadeau-Vallée M, Verdonck O, Lahrichi N, Richebé P. Identification of the intraoperative antinociceptive effect of intravenous fentanyl using the Nociception Level (NOL) index versus clinical parameters in patients undergoing gynecological laparoscopic surgery: A secondary analysis of the NOLGYN study. Anaesth Crit Care Pain Med 2022; 41:101102. [PMID: 35643392 DOI: 10.1016/j.accpm.2022.101102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/26/2022] [Accepted: 04/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND While we typically assess nociception balance during general anaesthesia through clinical parameters such as heart rate (HR) and mean arterial pressure (MAP) variation, these parameters are not specific to nociception. OBJECTIVE We hypothesized that using the Nociception Level (NOL) index to assess the analgesic effect of a fentanyl bolus would be superior to standard clinical parameters. DESIGN Ancillary study of the NOLGYN study, a randomized controlled trial comparing intraoperative NOL-guided administration of fentanyl (NOL group) versus standardized care (SC group). SETTING University hospital in Montréal, Canada between November 2018, and December 2019. PATIENTS Women undergoing gynecological laparoscopic surgery. INTERVENTION In our evaluation of intraoperative nociception, we analyzed the analgesic effect of fentanyl using three parameters: MAP, HR, and the Nociception Level (NOL) index. All fentanyl injection events were extracted from the database. MAIN OUTCOME MEASURE The primary endpoint was the difference between values before and after each injection. RESULTS The median of the NOL index before fentanyl injection was 30.5 (IQR 19.4 to 40.7) versus 18.9 (IQR 11.5 to 27.4) after (P < 0.001). The median of MAP was 106.4 mmHg (IQR 99.9 to 113.4) before injection versus 103.2 mmHg (IQR 97.5 to 110.7) after (P < 0.001). The median of HR before injection was 74.2 (IQR 64.2 to 83.8) versus 72.4 (IQR 63.4 to 81.3) after (P < 0.001). CONCLUSIONS The NOL index, HR, and MAP all statistically discriminated the analgesic effect of fentanyl but only the NOL index proved clinically relevant to identify the analgesic effect of one fentanyl injection. TRIAL REGISTRATION www. CLINICALTRIALS gov (NCT03776838) registered in October 2018.
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Affiliation(s)
- Marzieh Ghiyasinasab
- Department of Mathematical and Industrial Engineering, Polytechnique Montréal, Montréal, Québec, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital Research Centre, CIUSSS de l'Est de l'Ile de Montréal, Montréal, Québec, Canada; Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada.
| | - Pascal Laferrière-Langlois
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital Research Centre, CIUSSS de l'Est de l'Ile de Montréal, Montréal, Québec, Canada; Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Marc-André Geraldo-Demers
- Department of Mathematical and Industrial Engineering, Polytechnique Montréal, Montréal, Québec, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada
| | - Mathieu Nadeau-Vallée
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital Research Centre, CIUSSS de l'Est de l'Ile de Montréal, Montréal, Québec, Canada; Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Nadia Lahrichi
- Department of Mathematical and Industrial Engineering, Polytechnique Montréal, Montréal, Québec, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital Research Centre, CIUSSS de l'Est de l'Ile de Montréal, Montréal, Québec, Canada; Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
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Zheng J, Du L, Deng X, Zhang L, Wang J, Chen G. Deep neuromuscular block for minimally invasive lung surgery: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2022; 12:e056816. [PMID: 35613793 PMCID: PMC9131110 DOI: 10.1136/bmjopen-2021-056816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Minimally invasive lung surgery (MILS) gradually became the primary surgical therapy for lung cancer, which remains the leading cause of cancer death. Adequate muscle relaxation by deep neuromuscular block (NMB) is particularly necessary for MILS to provide a satisfactory surgical field. However, deep NMB for MILS remains controversial, as one-lung ventilation may provide an acceptable surgical field. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of deep NMB for MILS. METHODS AND ANALYSIS We will search the PubMed, Cochrane Library, Embase, Ovid Medline, Web of Science, Chinese BioMedical Literature, China National Knowledge Infrastructure, VIP and Wanfang databases from inception to March 2022 to identify randomised controlled trials of adult participants undergoing MILS with deep NMB. Studies published in English or Chinese will be considered. The primary outcome will be the surgical conditions according to the surgeon's perspective. Secondary outcomes will be the incidence of perioperative events and perioperative mortality. Heterogeneity will be assessed by the χ2 test and I2 statistic. Data will be synthesised by both a fixed-effect and a random-effects meta-analysis, with an intention to present the random-effects result if there is no indication of funnel plot asymmetry. Otherwise, metaregression will be used. The Cochrane risk-of-bias tool, trial sequential analysis and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the evidence quality and control the risks of random errors. Funnel plots and Egger's regression test will be used to assess publication bias. ETHICS AND DISSEMINATION Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42021254016.
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Affiliation(s)
- Jianqiao Zheng
- Department of Anesthesiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Xiaoqian Deng
- Department of Anesthesiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Lu Zhang
- Department of Anesthesiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Jia Wang
- Department of Anesthesiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Iwasaki H, Sato H, Takagi S, Kitajima O, Luthe SK, Suzuki T. A comparison between the adductor pollicis muscle and the abductor digiti minimi muscle using electromyography AF-201P in rocuronium-induced neuromuscular block: a prospective comparative study. BMC Anesthesiol 2022; 22:117. [PMID: 35459095 PMCID: PMC9034586 DOI: 10.1186/s12871-022-01656-y] [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: 09/06/2021] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background The AF-201P, a new electromyography (EMG)-based neuromuscular monitor has been developed recently. The aim of this clinical study was to compare two ulnar nerve innervated muscles: the adductor pollicis (AP) muscle and the abductor digiti minimi (ADM) muscle during the recovery from rocuronium-induced neuromuscular block by using EMG AF-201P. Methods Twenty patients undergoing surgery with general anesthesia were enrolled in the study. During total intravenous general anesthesia, train-of-four (TOF) and post-tetanic counts (PTC) responses following 0.9 mg/kg rocuronium administration were concurrently monitored at the AP and the ADM muscles with EMG AF-201P on the opposite arms. At the end of the surgery, sugammadex 2 mg/kg was administered when TOF counts of 2 (TOFC2) was observed at both muscles. The primary outcome of the study was time from administration of rocuronium to first appearance of PTC response (first PTC). The secondary outcomes of the study were time from administration of rocuronium to TOF count of 1 (TOFC1), time from first PTC to TOFC1 (PTC-TOF time), time to TOFC2, and time from administration of sugammadex to TOF ratio ≥ 0.9. Agreement between the two muscles was assessed using the Bland–Altman analysis. Data are expressed as mean ± standard deviation. Results Nineteen patients were included in the analysis. Time to first PTC was significantly faster at the ADM muscle than the AP muscle (24.4 ± 11.4 min vs 32.4 ± 13.1 min, p = 0.006). PTC-TOF time was significantly longer with the ADM muscle than the AP muscle (19.4 ± 7.3 min vs 12.4 ± 10.6 min, p = 0.019). There were no significant differences in time to TOFC2 and sugammadex-facilitated recovery between the two muscles. Bland–Altman analyses showed acceptable ranges of bias and limits of agreement of the two muscles. Conclusions The ADM muscle showed a good agreement with the AP muscle during rocuronium-induced neuromuscular block but faster recovery of PTC response when using EMG. Trial registration UMIN-CTR (Registration No. UMIN000044904). Registered 19 July 2021 -Retrospectively registered, https://center6.umin.ac.jp/cgi-bin/ctr_e/ctr_view.cgi?recptno=R000051290.
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Affiliation(s)
- Hajime Iwasaki
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, 173-8610, Japan.
| | - Hanae Sato
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Shunichi Takagi
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Osamu Kitajima
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Sarah Kyuragi Luthe
- Department of Anesthesia, Indiana University School of Medicine, 1130 W. Michigan St, Fesler Hall 204, Indianapolis, IN, 46202, USA
| | - Takahiro Suzuki
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kamicho, Itabashi-Ku, Tokyo, 173-8610, Japan
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Sun S, Sun Y, Chen R, Yao C, Xia H, Chen X, Lin Y, Yao S. Diaphragm ultrasound to evaluate the antagonistic effect of sugammadex on rocuronium after liver surgery in patients with different liver Child-Pugh grades: study protocol for a prospective, double-blind, non-randomised controlled trial. BMJ Open 2022; 12:e052279. [PMID: 35105573 PMCID: PMC8808392 DOI: 10.1136/bmjopen-2021-052279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The use of muscle relaxants is an indispensable in the general anaesthesia but is prone to accidents, which are often related to residual muscle relaxant. Therefore, how to timely and effectively eliminate the residual effect of muscle relaxants after surgery has become an urgent clinical problem. Rocuronium is a non-depolarising muscle relaxant that is primarily metabolised by the liver. Patients with liver dysfunction can affect the metabolic process of rocuronium, thereby delaying the recovery of muscle relaxation. Sugammadex (SUG) is a novel-specific antagonist of aminosteroidal muscle relaxants, which can effectively antagonise muscle relaxants at different depths. However, whether liver dysfunction affects the antagonistic effect of SUG against rocuronium has not been reported. Therefore, we hypothesise that with the increase of patients' liver Child-Pugh grade, the recovery time of rocuronium antagonised by the same dose of SUG after surgery will be prolonged, and the incidence of muscle relaxation residual will be increased in the short term. METHODS AND ANALYSIS This study is a prospective, double-blind, low-intervention, non-randomised controlled clinical trial involving 99 patients with American Society of Anesthesiologists (ASA) Ⅰ-Ⅲ, body mass index 18.5-24.9 kg/m2, who will undergo laparoscopic radical resection of liver cancer under general anaesthesia in the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. Ultrasonography will be applied to monitor the change rate of diaphragm thickness at different time after extubation to evaluate the occurrence of residual muscle relaxant, which indirectly reflects the dose-effect relationship of SUG antagonising against rocuronium in patients with different liver Child-Pugh grades preoperatively. ETHICS AND DISSEMINATION The protocol was reviewed and approved by the Medical Ethics Committee of Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology (UHCT21012). The findings will be disseminated to the public through peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT05028088.
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Affiliation(s)
- Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rui Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chunlin Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Haifa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Khanna S, Sreedharan R. Con: Sugammadex Should Not Be Used Routinely for Reversal of Neuromuscular Blockade in Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth 2022; 36:1792-1797. [PMID: 35027298 DOI: 10.1053/j.jvca.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sandeep Khanna
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Roshni Sreedharan
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Intensive Care Resuscitation, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
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