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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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2
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Renew JR, Brull SJ. Moving perioperative care forward while reversing: Is there hidden benefit to neuromuscular blockade antagonism with sugammadex? J Clin Anesth 2024; 96:111357. [PMID: 38103989 DOI: 10.1016/j.jclinane.2023.111357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Affiliation(s)
- J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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3
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Johnson KB. Driving Residual Neuromuscular Blockade to Zero: Precision Matters. Anesth Analg 2024; 139:532-535. [PMID: 39151136 DOI: 10.1213/ane.0000000000007064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Affiliation(s)
- Ken B Johnson
- From the Department of Anesthesiology, Perioperative & Pain Medicine, University of Utah
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4
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Thilen SR, Sherpa JR, James AM, Cain KC, Treggiari MM, Bhananker SM. Management of Muscle Relaxation With Rocuronium and Reversal With Neostigmine or Sugammadex Guided by Quantitative Neuromuscular Monitoring. Anesth Analg 2024; 139:536-544. [PMID: 37171989 DOI: 10.1213/ane.0000000000006511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND The optimal pharmacological reversal strategy for neuromuscular blockade remains undefined even in the setting of strong recommendations for quantitative neuromuscular monitoring by several national and international anesthesiology societies. We evaluated a protocol for managing rocuronium blockade and reversal, using quantitative monitoring to guide choice of reversal agent and to confirm full reversal before extubation. METHODS We conducted a prospective cohort study and enrolled 200 patients scheduled for elective surgery involving the intraoperative use of rocuronium. Providers were asked to adhere to a protocol that was similar to local practice recommendations for neuromusculalr block reversal that had been used for >2 years; the protocol added quantitative monitoring that had not previously been routinely used at our institution. In this study, providers used electromyography-based quantitative monitoring. Pharmacological reversal was accomplished with neostigmine if the train-of-four (TOF) ratio was 0.40 to 0.89 and with sugammadex for deeper levels of blockade. The primary end point was the incidence of postoperative residual neuromuscular blockade (PRNB), defined as TOF ratio <0.9 at time of extubation. We further evaluated the difference in pharmacy costs had all patients been treated with sugammadex. RESULTS A total of 189 patients completed the study: 66 patients (35%) were reversed with neostigmine, 90 patients (48%) with sugammadex, and 33 (17%) patients recovered spontaneously without pharmacological reversal. The overall incidence of residual paralysis was 0% (95% CI, 0-1.9). The total acquisition cost for all reversal drugs was United States dollar (USD) 11,358 (USD 60 per patient) while the cost would have been USD 19,312 (USD 103 per patient, 70% higher) if sugammadex had been used in all patients. CONCLUSIONS A protocol that includes quantitative monitoring to guide reversal with neostigmine or sugammadex and to confirm TOF ratio ≥0.9 before extubation resulted in the complete prevention of PRNB. With current pricing of drugs, the selective use of sugammadex reduced the total cost of reversal drugs compared to the projected cost associated with routine use of sugammadex for all patients.
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Affiliation(s)
- Stephan R Thilen
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - James R Sherpa
- School of Medicine, University of Washington, Seattle, Washington
| | - Adrienne M James
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Kevin C Cain
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | | | - Sanjay M Bhananker
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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5
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Ajetunmobi O, Wong J. In Response. Anesth Analg 2024:00000539-990000000-00921. [PMID: 39178164 DOI: 10.1213/ane.0000000000007195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024]
Affiliation(s)
- Olawale Ajetunmobi
- Department of Anesthesiology Surrey Memorial Hospital Surrey, British Columbia, Canada
| | - Jean Wong
- Department of Anesthesiology and Pain Medicine Women's College Hospital University of Toronto Toronto, Ontario, Canada
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6
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Avidan A, Weissman C. Video Laryngoscopy for Surgical Endotracheal Intubation. JAMA 2024; 332:425-426. [PMID: 38976248 DOI: 10.1001/jama.2024.11560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Affiliation(s)
- Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Charles Weissman
- Hospital Administration, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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7
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Vanlinthout LE, Driessen JJ, Stolker RJ, Lesaffre EM, Berghmans JM, Staals LM. Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach. Paediatr Anaesth 2024; 34:720-733. [PMID: 38676354 DOI: 10.1111/pan.14908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. METHOD We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results. RESULTS We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. CONCLUSIONS The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.
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Affiliation(s)
- Luc E Vanlinthout
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jacques J Driessen
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Emmanuel M Lesaffre
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Universities of Leuven-Hasselt, Hasselt, Belgium
| | - Johan M Berghmans
- Department of Anesthesiology and Perioperative medicine, University of Ghent, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, University of Ghent, Ghent, Belgium
| | - Lonneke M Staals
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Albers-Warlé KI, Reijnders-Boerboom GTJA, Bijkerk V, Torensma B, Panhuizen IF, Snoeck MMJ, Fuchs-Buder T, Keijzer C, Dahan A, Warlé MC. A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM. Anesthesiology 2024; 141:365-374. [PMID: 38728093 DOI: 10.1097/aln.0000000000005050] [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: 05/12/2024]
Abstract
BACKGROUND The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a posttetanic count [PTC] of 1 to 2) and how to implement it has not been reached. The European Society of Anaesthesiology and Intensive Care does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia. METHODS Data from three trials investigating deep NMB during laparoscopic surgery with total intravenous anesthesia (n = 424) were pooled to analyze the required rocuronium dose, when to start continuous infusion, and how to adjust. The resulting algorithm was validated (n = 32) and compared to the success rate in ongoing studies in which the algorithm was not used (n = 180). RESULTS The mean rocuronium dose based on actual bodyweight for PTC 1 to 2 was (mean ± SD) 1.0 ± 0.27 mg · kg-1 ·h-1 in the trials, in which mean duration of surgery was 116 min. An induction dose of 0.6 mg ·kg-1 led to a PTC of 1 to 5 in a quarter of patients after a mean of 11 min. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a 15-min wait after PTC of 0 for return of PTC to 1 or higher. Using the proposed algorithm, a mean 76% of all 5-min measurements throughout surgery were on target PTC 1 to 2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0 to 20 patients (42% on target, P ≤ 0.001, Cohen's d = 1.4 [95% CI, 0.9 to 1.8]) to 81 to 100 patients (61% on target, P ≤ 0.05, Cohen's d = 0.7 [95% CI, 0.1 to 1.2]). CONCLUSIONS This study proposes a dosing algorithm for deep NMB with rocuronium in patients receiving total intravenous anesthesia. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | | | - Veerle Bijkerk
- Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Bart Torensma
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ivo F Panhuizen
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marc M J Snoeck
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Thomas Fuchs-Buder
- Département d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Nancy/Brabois, Nancy, France
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
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Brull SJ, Fuchs-Buder T. Accuracy and Precision of Acceleromyography, Electromyography, and Mechanomyography: Time to Rethink What We Know. Anesthesiology 2024; 141:204-207. [PMID: 38980163 DOI: 10.1097/aln.0000000000005054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital Nancy, Nancy, France
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10
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Wedemeyer Z, Michaelsen KE, Jelacic S, Silliman W, Lopez A, Togashi K, Bowdle A. Accuracy and Precision of Three Acceleromyographs, Three Electromyographs, and a Mechanomyograph Measuring the Train-of-four Ratio in the Absence of Neuromuscular Blocking Drugs. Anesthesiology 2024; 141:262-271. [PMID: 38728090 DOI: 10.1097/aln.0000000000005051] [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: 05/12/2024]
Abstract
BACKGROUND The accuracy and precision of currently available, widely used acceleromyograph and electromyograph neuromuscular blockade monitors have not been well studied. In addition, the normalization of the train-of-four ratio from acceleromyography (train-of-four ratio [T4/T1] divided by the baseline train-of-four ratio) has not been validated in comparison to mechanomyography. METHODS Enrolled patients had surgery under general anesthesia with a supraglottic airway and without any neuromuscular blocking drugs. Three acceleromyograph monitors, three electromyograph monitors, and a mechanomyograph built in the authors' laboratory were tested. Most patients had an electromyograph and the mechanomyograph on one arm and a third monitor on the contralateral arm. Train-of-four ratios were collected every 12 to 20 s for the duration of the anesthetic. At least 1,000 train-of-four ratios were recorded for each device. Gauge repeatability and reproducibility analysis was performed. RESULTS Twenty-eight patients were enrolled. In total, 9,498 train-of-four ratio measurements were collected. Since no neuromuscular blocking drugs were used, the expected train-of-four ratio was 1.0. All of the acceleromyograph monitors produced overshoot in the train-of-four ratio (estimated means, 1.10 to 1.13) and substantial variability (gauge SDs, 0.07 to 0.18). Normalization of the train-of-four ratio measured by acceleromyography improved the estimated mean for each device (0.97 to 1.0), but the variability was not improved (gauge SDs, 0.06 to 0.17). The electromyograph and the mechanomyograph monitors produced minimal overshoot (estimated means, 0.99 to 1.01) and substantially less variation (gauge SDs, 0.01 to 0.02). For electromyography and mechanomyography, 0.3% of all train-of-four ratios were outside of the range 0.9 to 1.1. For acceleromyography, 27 to 51% of normalized train-of-four ratios were outside the range of 0.9 to 1.1. CONCLUSIONS Three currently available acceleromyograph monitors produced overshoot and substantial variability that could be clinically significant. Normalization corrected the overshoot in the average results but did not reduce the wide variability. Three electromyograph monitors measured the train-of-four ratio with minimal overshoot and variability, similar to a mechanomyograph. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Kelly E Michaelsen
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Aidan Lopez
- School of Medicine, University of Washington, Seattle, Washington
| | - Kei Togashi
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California; Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Seattle, Washington
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Obara S, Hirata N, Hagihira S, Yoshida K, Kotake Y, Takagi S, Masui K. What are standard monitoring devices for anesthesia in future? J Anesth 2024; 38:537-541. [PMID: 38748064 DOI: 10.1007/s00540-024-03347-z] [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: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 07/30/2024]
Abstract
Monitoring the patient's physiological functions is critical in clinical anesthesia. The latest version of the Japanese Society of Anesthesiologists' Guidelines for Safe Anesthesia Monitoring, revised in 2019, covers various factors, including electroencephalogram monitoring, oxygenation, ventilation, circulation, and muscle relaxation. However, with recent advances in monitoring technologies, the information provided has become more detailed, requiring practitioners to update their knowledge. At a symposium organized by the Journal of Anesthesia in 2023, experts across five fields discussed their respective topics: anesthesiologists need to interpret not only the values displayed on processed electroencephalogram monitors but also raw electroencephalogram data in the foreseeable future. In addition to the traditional concern of preventing hypoxemia, monitoring for potential hyperoxemia and the effects of mechanical ventilation itself will become increasingly important. The importance of using AI analytics to predict hypotension, assess nociception, and evaluate microcirculation may increase. With the recent increase in the availability of neuromuscular monitoring devices in Japan, it is important for anesthesiologists to become thoroughly familiar with the features of each device to ensure its effective use. There is a growing desire to develop and introduce a well-organized, integrated "single screen" monitor.
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Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
- Center for Pain Management, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
- Surgical Operation Department, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Naoyuki Hirata
- Department of Anesthesiology, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology, Kansai Medical University, 3-1 Shinmachi 2 Chome, Hirakata, Osaka, 573-1191, Japan
| | - Keisuke Yoshida
- Department of Anesthesiology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8540, Japan
| | - Shunichi Takagi
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi Kami-Cho, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Kenichi Masui
- Department of Anesthesiology, Yokohama City University, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Liu B, Wang Y, Li L, Xiong W, Feng Y, Liu Y, Jin X. The effects of laryngeal mask versus endotracheal tube on atelectasis after general anesthesia induction assessed by lung ultrasound: A randomized controlled trial. J Clin Anesth 2024; 98:111564. [PMID: 39089119 DOI: 10.1016/j.jclinane.2024.111564] [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: 10/09/2023] [Revised: 03/05/2024] [Accepted: 07/21/2024] [Indexed: 08/03/2024]
Abstract
STUDY OBJECTIVE This study aims to evaluate the impact of Supreme™ laryngeal masks versus endotracheal tubes on atelectasis during general anesthesia using lung ultrasound (LUS), and provide evidence for respiratory management. DESIGN A single-center, double-blind, randomized controlled trial was conducted. SETTING The study was conducted in both the operating room and the post-anesthesia care unit, with follow-up assessments performed in the ward. PATIENTS Enrollment included 180 cases undergoing non-laparoscopic surgeries in gynecology, urology, and orthopedic limb surgeries. INTERVENTIONS Patients were randomly assigned 1:1 to the endotracheal intubation or laryngeal mask group. MEASUREMENTS LUS scores were recorded across 12 lung regions at baseline, 15 min after airway establishment, at the end of surgery, and 30 min following airway removal. Outcome measures encompassed the oxygenation index, dynamic lung compliance, incidence of postoperative pulmonary complications, throat pain, and other postoperative complications assessed at 24 and 48 h postoperatively. The primary outcome focused on the LUS score in all 12 lung regions at 15 min after airway establishment. MAIN RESULTS Intention-to-treat analysis of 177 subjects revealed endotracheal intubation led to significantly higher LUS scores at 15 min {P < 0.001, mean difference 4.15 ± 0.60, 95% CI [2.97, 5.33]}, end of surgery (P < 0.001, mean difference 3.37 ± 0.68, 95% CI [2.02, 4.72]), and 30 min post-removal (P < 0.001, mean difference 2.63 ± 0.48, 95% CI [1.68, 3.58]). No major complications occurred in the two groups. CONCLUSIONS Compared to endotracheal intubation, laryngeal masks effectively reduce atelectasis formation and progression in gynecological, urological non-laparoscopic, and orthopedic limb surgeries. However, caution is warranted when generalizing these findings to surgeries with a higher risk of laryngeal mask leakage or obese patients. Additionally, the efficacy of laryngeal masks in reducing postoperative atelectasis remains uncertain when comprehensive monitoring of muscle relaxation and reversal therapy is employed.
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Affiliation(s)
- Bin Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yaxin Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Ling Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Wei Xiong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yifan Feng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xu Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100191, China.
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Duarte-Medrano G, Nuño-Lámbarri N, Minnuti-Palacios M, Dominguez-Franco A, Dominguez-Cherit JG, Zamora-Meraz R. Navigating challenges in anesthesia for robotic urological surgery: a comprehensive guide. J Robot Surg 2024; 18:300. [PMID: 39073629 DOI: 10.1007/s11701-024-02055-w] [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: 04/17/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024]
Abstract
Robotic surgery has emerged as a cornerstone in urological interventions, offering effectiveness and safety for patients. For anesthesiologists, this technological advancement presents a myriad of new challenges, spanning from patient selection and assessment to intraoperative dynamics and post-surgical pain management. This article aims to elucidate these challenges and provide guidance for anesthesiologists in navigating the complexities of anesthesia administration in robotic urological procedures. Through a detailed exploration of patient optimization, team coordination, intraoperative adjustments, and post-surgical care, this article serves as a valuable resource for ensuring the success of such interventions.
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Affiliation(s)
- Gilberto Duarte-Medrano
- Anesthesiology Department, Hospital Medica Sur, Puente de Piedra 150, Toriello Guerra Tlalpan, Ciudad de México, CDMX, 14050, Mexico, Mexico.
| | - Natalia Nuño-Lámbarri
- Translational Research Unit, Medica Sur Clinic & Foundation, Puente de Piedra 150, Toriello Guerra Tlalpan, 14050, Mexico, Mexico.
- Department of Surgery, Faculty of Medicine, The National Autonomous University of Mexico (UNAM), Escolar 411A, Copilco Universidad, Coyoacán, Mexico, Mexico.
| | - Marissa Minnuti-Palacios
- Anesthesiology Department, Hospital Medica Sur, Puente de Piedra 150, Toriello Guerra Tlalpan, Ciudad de México, CDMX, 14050, Mexico, Mexico
| | - Analucia Dominguez-Franco
- Anesthesiology Department, Hospital Medica Sur, Puente de Piedra 150, Toriello Guerra Tlalpan, Ciudad de México, CDMX, 14050, Mexico, Mexico
| | - Jose Guillermo Dominguez-Cherit
- Anesthesiology Department, Hospital Medica Sur, Puente de Piedra 150, Toriello Guerra Tlalpan, Ciudad de México, CDMX, 14050, Mexico, Mexico
- Escuela de Medicina, Tecnológico de Monterrey, CDMX, Mexico
| | - Rafael Zamora-Meraz
- Anesthesiology Department, Hospital Medica Sur, Puente de Piedra 150, Toriello Guerra Tlalpan, Ciudad de México, CDMX, 14050, Mexico, Mexico
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Li L, Xu Q, Liu Y, Pang L, Cui Z, Lu Y. Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system. Front Pharmacol 2024; 15:1403988. [PMID: 39114358 PMCID: PMC11303309 DOI: 10.3389/fphar.2024.1403988] [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: 03/20/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Background: Neuromuscular blocking agents (NMBAs) are primarily used during surgical procedures to facilitate endotracheal intubation and optimize surgical conditions. This study aimed to explore the adverse event signals of NMBAs, providing reference for clinical safety. Methods: This study collected reports of atracurium, cisatracurium, rocuronium, and vecuronium as primary suspect drugs in The US Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2023. The adverse events (AEs) reported in the study were retrieved based on the Preferred Terms (PTs) of the Medical Dictionary for Regulatory Activities. In addition, we conducted disproportionality analysis on relevant reports using the reporting odds ratio (ROR) method and Bayesian confidence propagation neural network (BCPNN) method. A positive signal was generated when both algorithms show an association between the target drug and the AE. Results: A total of 11,518 NMBA-related AEs were reported in the FAERS database. The most AEs of rocuronium were collected. NMBA-related AEs involved 27 different system organs (SOCs), all of the four NMBAs had positive signals in "cardiac disorders," "immune system disorders," "respiratory, thoracic and mediastinal disorders" and "vascular disorders." At the PTs level, a total of 523 effective AEs signals were obtained for the four NMBAs. AEs labled in the instructions such as anaphylaxis (include anaphylactic reaction and anaphylactic shock), bronchospasm, respiratory arrest and hypotension were detected positive signals among all NMBAs. In addition, we also found some new AEs, such as ventricular fibrillation for the four NMBAs, hyperglycaemia for atracurium, kounis syndrome and stress cardiomyopathy for rocuronium, hepatocellular injury for cisatracurium, hyperkalaemia for vecuronium. To further investigated the AEs associated with serious clinical outcomes, we found that cardiac arrest and anaphylaxis were the important risk factors for death due to NMBAs. Conclusion: NMBA-related AEs have a significant potential to cause clinically severe consequences. Our study provides valuable references for the safety profile of NMBAs, and considering the limitations of the FAERS database, further clinical data are needed to validate the findings of this study.
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Affiliation(s)
| | | | | | | | | | - Yuanyuan Lu
- Department of Pharmacy, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Turzhitsky V, Bash LD, Urman RD, Kattan M, Hofer I. Factors Influencing Neuromuscular Blockade Reversal Choice in the United States Before and During the COVID-19 Pandemic: Retrospective Longitudinal Analysis. JMIR Perioper Med 2024; 7:e52278. [PMID: 39038283 DOI: 10.2196/52278] [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: 08/29/2023] [Revised: 12/21/2023] [Accepted: 04/09/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Neuromuscular blockade (NMB) agents are a critical component of balanced anesthesia. NMB reversal methods can include spontaneous reversal, sugammadex, or neostigmine and the choice of reversal strategy can depend on various factors. Unanticipated changes to clinical practice emerged due to the COVID-19 pandemic, and a better understanding of how NMB reversal trends were affected by the pandemic may help provide insight into how providers view the tradeoffs in the choice of NMB reversal agents. OBJECTIVE We aim to analyze NMB reversal agent use patterns for US adult inpatient surgeries before and after the COVID-19 outbreak to determine whether pandemic-related practice changes affected use trends. METHODS A retrospective longitudinal analysis of a large all-payer national electronic US health care database (PINC AI Healthcare Database) was conducted to identify the use patterns of NMB reversal during early, middle, and late COVID-19 (EC, MC, and LC, respectively) time periods. Factors associated with NMB reversal choices in inpatient surgeries were assessed before and after the COVID-19 pandemic reached the United States. Multivariate logistic regression assessed the impact of the pandemic on NMB reversal, accounting for patient, clinical, procedural, and site characteristics. A counterfactual framework was used to understand if patient characteristics affected how COVID-19-era patients would have been treated before the pandemic. RESULTS More than 3.2 million inpatients experiencing over 3.6 million surgical procedures across 931 sites that met all inclusion criteria were identified between March 1, 2017, and December 31, 2021. NMB reversal trends showed a steady increase in reversal with sugammadex over time, with the trend from January 2018 onwards being linear with time (R2>0.99). Multivariate analysis showed that the post-COVID-19 time periods had a small but statistically significant effect on the trend, as measured by the interaction terms of the COVID-19 time periods and the time trend in NMB reversal. A slight increase in the likelihood of sugammadex reversal was observed during EC relative to the pre-COVID-19 trend (odds ratio [OR] 1.008, 95% CI 1.003-1.014; P=.003), followed by negation of that increase during MC (OR 0.992, 95% CI 0.987-0.997; P<.001), and no significant interaction identified during LC (OR 1.001, 95% CI 0.996-1.005; P=.81). Conversely, active reversal (using either sugammadex or neostigmine) did not show a significant association relative to spontaneous reversal, or a change in trend, during EC or MC (P>.05), though a slight decrease in the active reversal trend was observed during LC (OR 0.987, 95% CI 0.983-0.992; P<.001). CONCLUSIONS We observed a steady increase in NMB active reversal overall, and specifically with sugammadex compared to neostigmine, during periods before and after the COVID-19 outbreak. Small, transitory alterations in the NMB reversal trends were observed during the height of the COVID-19 pandemic, though these alterations were independent of the underlying NMB reversal time trends.
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Affiliation(s)
| | | | - Richard D Urman
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | | | - Ira Hofer
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
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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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17
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Grillot N, Roquilly A. Tracheal intubation without neuromuscular blocking drugs: isn't it an illusion? Anaesthesia 2024; 79:685-688. [PMID: 38563134 DOI: 10.1111/anae.16287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Nicolas Grillot
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
| | - Antoine Roquilly
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
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18
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Jansson PS, Pimentel MPT, Seethala RR. Emergency department usage of sugammadex in a large regional health system. Acad Emerg Med 2024; 31:713-715. [PMID: 38112045 DOI: 10.1111/acem.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Paul S Jansson
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc P T Pimentel
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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19
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Wang A, Tsivitis A, Ma S, Jin Z, Al Bizri E, Moore R. The safety and efficacy of sugammadex for reversing neuromuscular blockade in younger children and infants. Expert Opin Drug Saf 2024; 23:845-853. [PMID: 38938223 DOI: 10.1080/14740338.2024.2373906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Sugammadex, a novel selective antagonist of non-depolarizing neuromuscular blocking agents, has been shown to rapidly and effectively reverse moderate and deep paralysis in adults and pediatric patients over age 2, improving patient recovery and reducing the risk of postoperative complications. AREAS COVERED Since the use of sugammadex in patients under age 2 is not widely studied, we aim to provide an overview on the drug's application and potential use in infants and neonates. There is a limited but growing body of evidence for the safe, efficacious use of sugammadex in children under age 2. Relevant studies were identified from the most updated data including case reports, clinical trials, systematic reviews, and meta analyses. EXPERT OPINION The results suggest that at a dose of 2 to 4 mg/kg of sugammadex can be safely used to rapidly and effectively reverse neuromuscular blockade in neonates and infants; it is non-inferior based on incidence of adverse events compared to neostigmine. Additionally, sugammadex doses between 8 and 16 mg/kg may be used as a rescue agent for infants during 'can't intubate, can't ventilate' crisis. Overall, sugammadex offers new value in the perioperative care of patients under age 2, with further studies warranted to better understand its application and full effect in the pediatric population.
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Affiliation(s)
- Ashley Wang
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Alexandra Tsivitis
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Sijia Ma
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Ehab Al Bizri
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Robert Moore
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA
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20
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Mao X, Zhang R, Liang X, Liu F, Dai Y, Wang M, Huang H, Fu G. A pharmacovigilance study of FDA adverse events for sugammadex. J Clin Anesth 2024; 97:111509. [PMID: 38880003 DOI: 10.1016/j.jclinane.2024.111509] [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: 02/01/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Sugammadex, a selective steroidal neuromuscular blocking agent reversal agent, is increasingly employed for the rapid restoration of neuromuscular function. This study aimed to conduct a comprehensive evaluation of sugammadex's safety profile. METHODS Adverse events (AEs) related to sugammadex reported in the FDA Adverse Event Reporting System (FAERS) database from January 2009 to September 2023 were extracted. Disproportionality analysis with four measures: reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS) were employed to detect significant AEs. We also inspected for unexpected AEs absent from the sugammadex FDA approval documentation and categorized AEs based on the latest version (26.1) of 'Important Medical Event Terms List (IME list)' developed by the EudraVigilance Expert Working Group. RESULTS A total of 1452 reports were linked to sugammadex. At the preferred terms (PTs) levels, 98 sugammadex-related AEs were identified, including "anaphylactic reaction", "bradycardia", "bronchospasm" and "cardiac arrest". Among them, 37 representing unexpected events were absent from official FDA labeling, and 50 AEs were recognized as IME warranting observation. Notably, 19 PTs denoted serious AEs were absent from labeling yet needing IME surveillance, including: "Kounis syndrome", "angioedema", "pulseless electrical activity" and "laryngeal edema". CONCLUSION The study identified unexpected and potentially life-threatening AEs associated with sugammadex, a valuable agent for rapidly reversing neuromuscular blockade. Clinicians are advised to be mindful of these potential risks, particularly in patients with allergies or existing cardiovascular or respiratory conditions.
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Affiliation(s)
- Xiaoyan Mao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Rong Zhang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Xia Liang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Fan Liu
- Medical Research Center of Shenshan medical center, Sun Yat-sen Memorial Hospital, China
| | - Yuan Dai
- Medical Research Center of Shenshan medical center, Sun Yat-sen Memorial Hospital, China
| | - Meng Wang
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Ganglan Fu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China.
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Zhang H, Dou Y. Precision nursing and intermittent pneumatic compression significantly reduce perioperative deep vein thrombosis in post-surgical ovarian cancer patients. Am J Transl Res 2024; 16:2533-2543. [PMID: 39006274 PMCID: PMC11236644 DOI: 10.62347/iwud6619] [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: 04/07/2024] [Accepted: 05/21/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE This study investigated the efficacy of precision nursing combined with intermittent pneumatic compression (IPC) devices in preventing perioperative deep vein thrombosis (DVT) in patients with ovarian cancer. METHODS A retrospective analysis was conducted on 136 ovarian cancer surgery patients at Xi'an People's Hospital from February 2019 to April 2023. The patients were divided into two groups: 71 patients received precision nursing with IPC intervention (study group), while the remaining received standard nursing care (control group). Key variables analyzed included operation duration, intraoperative blood loss, postoperative blood transfusion requirements, changes in limb circumference, and variations in coagulation parameters activated partial thromboplastin time (APTT), D-Dimer (D-D), Fibrinogen (FIB), and Prothrombin Time (PT) before and after surgery. The incidence of DVT was recorded in both groups to determine risk factors for deep vein thrombosis. RESULTS No significant differences were observed between the groups regarding operation duration, intraoperative blood loss, and postoperative blood transfusion rates (P > 0.05). Post-intervention, significant improvements were noted in the study group, with reduced FIB and D-D levels and increased PT and APTT levels compared to the control group (P < 0.05). Furthermore, the study group exhibited a significantly smaller post-intervention difference in limb circumference and a lower incidence of DVT (P=0.003). Precision nursing combined with IPC, pre-intervention D-D < 498.5, and FIGO stages III+IV were identified as independent factors against DVT development. CONCLUSION Precision nursing paired with an IPC device significantly reduces the risk of perioperative DVT in ovarian cancer patients compared to conventional care.
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Affiliation(s)
- Hong Zhang
- Nursing Department, Xi'an People's Hospital (Xi'an No. 4 Hospital) No. 155 Aerospace East Road, Chang'an District, Xi'an 710000, Shaanxi, China
| | - Yajun Dou
- Gynecological Operating Room, Xi'an People's Hospital (Xi'an No. 4 Hospital) No. 155 Aerospace East Road, Chang'an District, Xi'an 710000, Shaanxi, China
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22
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Yang S, Sun Z, Zhou C, Wei W, Qu N, Shi R, Ma B, Xu W, Ji Q, Zhang J, Wang Y. Feasibility of the enhanced neuromuscular blockade recovery protocol with selective use of sugammadex in thyroid surgery with intraoperative neuromonitoring. Head Neck 2024. [PMID: 38877778 DOI: 10.1002/hed.27826] [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: 09/28/2023] [Revised: 03/31/2024] [Accepted: 05/20/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND To investigate feasibility of utilizing enhanced neuromuscular blocking agents with selective recovery protocol during thyroid surgery with intraoperative neuromonitoring (IONM). METHODS Two-hundred and ninety patients were randomized into two groups: group A 0.3 mg/kg rocuronium and group B 0.6 mg/kg. Sugammadex 2 mg/kg was injected if needed followed initial vagal stimulation (V0). Electromyography signals from vagus and recurrent laryngeal nerves before and after resection were recorded as V1, V2, R1, and R2. RESULTS In group B, 30 patients (20.7%) had V0 signals <100 μV, compared to 9 (6.2%) in group A. After sugammadex administration, 144 patients (99.3%) in both groups achieved positive V1 signals. Group B demonstrated a shorter surgical time from rocuronium injection to V2 stimulation compared to group A, accompanied by a significantly lower incidence of intraoperative body movement (0 vs. 16 patients). CONCLUSIONS 0.6 mg/kg rocuronium with selective use 2 mg/kg sugammadex for IONM in thyroid surgery can meet both anesthesia and surgery demands.
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Affiliation(s)
- Shuwen Yang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhirong Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Changming Zhou
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Wenjun Wei
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ning Qu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Rongliang Shi
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ben Ma
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Weibo Xu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qinhai Ji
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Wang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
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23
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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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24
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Ajetunmobi O, Wong D, Perlas A, Rajaleelan W, Wang S, Huszti E, Jackson T, Chung F, Wong J. Impact of Sugammadex Versus Neostigmine Reversal on Postoperative Recovery Time in Patients With Obstructive Sleep Apnea Undergoing Bariatric Surgery: A Double-Blind, Randomized Controlled Trial. Anesth Analg 2024:00000539-990000000-00835. [PMID: 38848257 DOI: 10.1213/ane.0000000000007013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND Residual neuromuscular blockade can be associated with serious postoperative complications. Sugammadex is a newer neuromuscular blocking drug (NMBD) reversal agent that rapidly and completely reverses rocuronium. Whether sugammadex has any advantages over neostigmine in morbidly obese patients with obstructive sleep apnea (OSA) is unclear. We investigated whether sugammadex would reduce discharge time from the operating room (OR) compared with neostigmine in morbidly obese patients with OSA undergoing bariatric surgery. METHODS This was a prospective, double-blinded randomized controlled superiority trial with 2 parallel groups. Patients were randomized 1:1 into reversal of NMBD with sugammadex or neostigmine. Our inclusion criteria were morbidly obese adult patients with OSA undergoing elective bariatric surgery under general anesthesia. Our exclusion criteria were allergy to rocuronium, sugammadex or neostigmine, malignant hyperthermia, hepatic or renal insufficiency, neuromuscular diseases, and an inability to give consent. The primary outcome was the time from administration of the NMBD reversal agent to discharge from the OR. Secondary outcomes included the time from administration of the NMBD reversal agent to the time the patient opened eyes to command, and the time to extubation. The Mann-Whitney test was used to compare the outcomes between treatment groups. RESULTS We randomized 120 patients into 2 groups of 60 patients. Overall median body mass index (BMI) was 48.1 kg/m2 ([interquartile range, IQR]) [43.0-53.5]. The time from drug administration to discharge from OR was 13.0 minutes [10.0-17.0] in the sugammadex group and 13.5 minutes [11.0-18.3] in the neostigmine group (P = .27). The treatment effect estimate with a bootstrapped 95% confidence interval [CI] for time from admission to discharge from OR was -0.5 [-2.5 to 3]. No differences were observed in postoperative complications and other secondary outcomes. CONCLUSIONS No difference was observed in OR discharge time in morbidly obese patients with OSA when sugammadex was administered instead of neostigmine.
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Affiliation(s)
- Olawale Ajetunmobi
- From the Department of Anesthesiology, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - David Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anahi Perlas
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Wesley Rajaleelan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stella Wang
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Jackson
- Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
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25
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Obara S, Suhara R, Murakawa M. Pharmacokinetic simulation can detect erroneous TOF counts. J Anesth 2024; 38:414-416. [PMID: 38430259 DOI: 10.1007/s00540-024-03328-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Center for Pain Management, Surgical Operation Department, Fukushima Medical University, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
| | - Ryota Suhara
- Iwase General Hospital, 20 Kitamachi, Sukagawa, Fukushima, 962-8503, Japan
| | - Masahiro Murakawa
- Department of Anesthesiology, Center for Pain Management, Surgical Operation Department, Fukushima Medical University, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
- Iwase General Hospital, 20 Kitamachi, Sukagawa, Fukushima, 962-8503, Japan
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26
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Obiyo LT, Tobes D, Cole NM. Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act. Curr Opin Anaesthesiol 2024; 37:285-291. [PMID: 38390901 DOI: 10.1097/aco.0000000000001363] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.
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Affiliation(s)
- Leziga T Obiyo
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois, USA
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Wedemeyer Z, Bowdle A, Jelacic S, Lopez A, Silliman W, Michaelsen KE. Evolution of a laboratory mechanomyograph. J Clin Monit Comput 2024:10.1007/s10877-024-01175-w. [PMID: 38758405 DOI: 10.1007/s10877-024-01175-w] [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: 02/26/2024] [Accepted: 05/04/2024] [Indexed: 05/18/2024]
Abstract
Mechanomyography is currently the accepted laboratory reference standard for quantitative neuromuscular blockade monitoring. Mechanomyographs are not commercially available. Previously, a mechanomyograph was built by our laboratory and used in several clinical studies. It was subsequently redesigned to improve its usability and functionality and to accommodate a wider range of hand sizes and shapes using an iterative design process. Each version of the redesigned device was initially tested for usability and functionality in the lab with the investigators as subjects without electrical stimulation. The redesigned devices were then assessed on patients undergoing elective surgery under general anesthesia without neuromuscular blocking drugs. Since the patients were not paralyzed, the expected train-of-four ratio was 1.0. The device accuracy and precision were represented by the train-of-four ratio mean and standard deviation. If issues with the device's useability or functionality were discovered, changes were made, and the redesign processes repeated. The final mechanomyograph design was used to collect 2,362 train-of-four ratios from 21 patients. The mean and standard deviation of the train-of-four ratios were 0.99 ± 0.030. Additionally, the final mechanomyograph design was easier to use and adjust than the original design and fit a wider range of hand sizes. The final design also reduced the frequency of adjustments and the time needed for adjustments, facilitating data collection during a surgical procedure.
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Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Aidan Lopez
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Kelly E Michaelsen
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA.
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28
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Dong Y, Guo W, Yang Y, Li Q. The Effect of Phonomyography Prototype for Intraoperative Neuromuscular Monitoring: A Preliminary Study. Bioengineering (Basel) 2024; 11:486. [PMID: 38790354 PMCID: PMC11117765 DOI: 10.3390/bioengineering11050486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 04/29/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Quantitative neuromuscular monitoring, as extolled by clinical guidelines, is advocated to circumvent the complications associated with neuromuscular blockers (NMBs), such as residual neuromuscular block (rNMB). Nonetheless, the worldwide utilization of such methods remains undesirable. Phonomyography (PMG) boasts the advantages of convenience, stability, and multi-muscle recording which may be a promising monitoring method. The purpose of this preliminary study is conducting a feasibility analysis and an effectiveness evaluation of a PMG prototype under general anesthesia. A prospective observational preliminary study was conducted. Twenty-five adults who had undergone none-cardiac elective surgery were enrolled. The PMG prototype and TOF-Watch SX simultaneously recorded the pharmacodynamic properties of single bolus rocuronium at the ipsilateral adductor pollicis for each patient. For the primary outcome, the time duration to 0.9 TOF ratio of the two devices reached no statistical significance (p > 0.05). For secondary outcomes, the multi-temporal neuromuscular-monitoring measurements between the two devices also reached no statistical significance (p > 0.05). What is more, both the Spearman's and Pearson's correlation tests revealed a strong correlation across all monitoring periods between the PMG prototype and TOF-Watch SX. Additionally, Bland-Altman plots demonstrated a good agreement between the two devices. Thus, the PMG prototype was a feasible, secure, and effective neuromuscular-monitoring technique during general anesthesia and was interchangeable with TOF-Watch SX.
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Affiliation(s)
- Yanjie Dong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Weichao Guo
- Meta Robotics Institute, Shanghai Jiao Tong University, Shanghai 200240, China;
| | - Yi Yang
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, Chengdu 610072, China;
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China;
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Oh MW, Mohapatra SG, Pak T, Hermawan A, Chen CA, Thota B, Chen J, Siu E, Park J, Moon TS. Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study. Anesth Analg 2024; 138:1043-1051. [PMID: 38190344 DOI: 10.1213/ane.0000000000006807] [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: 01/10/2024]
Abstract
BACKGROUND Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.
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Affiliation(s)
- Matthew W Oh
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shweta G Mohapatra
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taylor Pak
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aundree Hermawan
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chieh-An Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhavana Thota
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joy Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Siu
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Park
- Department of Biostatistics, Southern Methodist University, Dallas, Texas
| | - Tiffany S Moon
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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30
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Verdonck M, Carvalho H, Fuchs-Buder T, Brull SJ, Poelaert J. Machine learning based analysis and detection of trend outliers for electromyographic neuromuscular monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01141-6. [PMID: 38573367 DOI: 10.1007/s10877-024-01141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/09/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Neuromuscular monitoring is frequently plagued by artefacts, which along with the frequent unawareness of the principles of this subtype of monitoring by many clinicians, tends to lead to a cynical attitute by clinicians towards these monitors. As such, the present study aims to derive a feature set and evaluate its discriminative performance for the purpose of Train-of-Four Ratio (TOF-R) outlier analysis during continuous intraoperative EMG-based neuromuscular monitoring. METHODS Patient data was sourced from two devices: (1) Datex-Ohmeda Electromyography (EMG) E-NMT: a dataset derived from a prospective observational trial including 136 patients (21,891 TOF-R observations), further subdivided in two based on the type of features included; and (2) TetraGraph: a clinical case repository dataset of 388 patients (97,838 TOF-R observations). The two datasets were combined to create a synthetic set, which included shared features across the two. This process led to the training of four distinct models. RESULTS The models showed an adequate bias/variance balance, suggesting no overfitting or underfitting. Models 1 and 2 consistently outperformed the others, with the former achieving an F1 score of 0.41 (0.31, 0.50) and an average precision score (95% CI) of 0.48 (0.35, 0.60). A random forest model analysis indicated that engineered TOF-R features were proportionally more influential in model performance than basic features. CONCLUSIONS Engineered TOF-R trend features and the resulting Cost-Sensitive Logistic Regression (CSLR) models provide useful insights and serve as a potential first step towards the automated removal of outliers for neuromuscular monitoring devices. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
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Affiliation(s)
- Michaël Verdonck
- Department of Business Informatics and Operations Management, University Ghent, Tweekerkenstraat 2, Ghent, 9000, Belgium.
| | - Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
- Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Oostende, Belgium
| | - Thomas Fuchs-Buder
- University of Lorraine, Centre Hospitalier Universitaire de Nancy/Hôpitaux de Brabois, Lorraine, France
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
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31
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Wang Y, Ren L, Li Y, Zhou Y, Yang J. The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial. BMC Anesthesiol 2024; 24:123. [PMID: 38561654 PMCID: PMC10983731 DOI: 10.1186/s12871-024-02512-x] [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: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Glycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly patients. Therefore, this study aimed to compare the cardiovascular effects of G/N and A/N for the reversal of NMB in elderly patients. METHODS Elderly patients aged 65-80 years who were scheduled for elective non-cardiac surgery under general anesthesia were randomly assigned to the glycopyrrolate group (group G) or the atropine group (group A). Following the last administration of muscle relaxants for more than 30 min, group G received 4 ug/kg glycopyrrolate and 20 ug/kg neostigmine, while group A received 10 ug/kg atropine and 20 ug/kg neostigmine. HR, mean arterial pressure (MAP), and ST segment in lead II (ST-II) were measured 1 min before administration and 1-15 min after administration. RESULTS HR was significantly lower in group G compared to group A at 2-8 min after administration (P < 0.05). MAP was significantly lower in group G compared to group A at 1-4 min after administration (P < 0.05). ST-II was significantly depressed in group A compared to group G at 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, and 15 min after administration (P < 0.05). CONCLUSIONS In comparison to A/N, G/N for reversing residual NMB in the elderly has a more stable HR, MAP, and ST-II within 15 min after administration.
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Affiliation(s)
- Yanping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China.
| | - Liyuan Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yanshuang Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yinhui Zhou
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
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32
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Nhan HN, Terada R, Butt AL, de Armendi A. Sugammadex dosing challenges in pediatric neuromuscular reversal-Comments on Cates et al. Paediatr Anaesth 2024; 34:379-380. [PMID: 38078502 DOI: 10.1111/pan.14821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Huy N Nhan
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rui Terada
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Alberto de Armendi
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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33
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Rodney G, Raju PKBC, Brull SJ. Residual neuromuscular block: time to consign it to history. Anaesthesia 2024; 79:344-348. [PMID: 38282525 DOI: 10.1111/anae.16238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Affiliation(s)
- G Rodney
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - P K B C Raju
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - S J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
- Mayo Clinic Florida, Jacksonville, FL, 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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Chen W, Chen Z, Cheng F, Wang Z, Li J, Li S, Xie H. The feasibility of the posterior tibial nerve-flexor hallucis brevis pathway applied in neuromuscular monitoring: a multicentric, controlled, and prospective clinical trial. PeerJ 2024; 12:e17154. [PMID: 38560472 PMCID: PMC10979752 DOI: 10.7717/peerj.17154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
This study aimed to investigate the clinical viability of utilizing the flexor hallucis brevis as an alternative site for neuromuscular monitoring compared to the conventional adductor pollicis. Patients were recruited from three medical centers. Cis-atracurium was administered, and two monitors were employed independently to assess neuromuscular blockade of the adductor pollicis and the ipsilateral flexor hallucis brevis, following a train of four (TOF) pattern until TOF ratios exceeded 0.9 or until the conclusion of surgery. Statistical analysis revealed significant differences in onset time, duration of no-twitch response, spontaneous recovery time, and total monitoring time between the two sites, with mean differences of -53.54 s, -2.49, 3.22, and 5.89 min, respectively (P < 0.001).The posterior tibial nerve-flexor hallucis brevis pathway presents a promising alternative for neuromuscular monitoring during anesthesia maintenance. Further investigation is warranted to explore its utility in anesthesia induction and recovery. Trial registration: The trial was registered at www.chictr.org.cn (20/11/2018, ChiCTR1800019651).
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Affiliation(s)
- Weiqiang Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhijian Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fang Cheng
- Department of Anesthesiology, Jiangmen Central Hospital, Jiangmen, China
| | - Zhuodan Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Juan Li
- GCP ClinPlus Co., Ltd, Guangzhou, China
| | - Shangrong Li
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hanbin Xie
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Hunter JM, Blobner M. Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents: beware of the risks. Br J Anaesth 2024; 132:461-465. [PMID: 38135525 DOI: 10.1016/j.bja.2023.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
The phenomena of residual curarisation and recurarisation after the use of long-acting non-depolarising neuromuscular blocking drugs such as tubocurarine and pancuronium were well recognised 60 years ago. But the incidence seemed to decline with the introduction of atracurium and vecuronium. However, recently there have been an increasing number of reports of residual and recurrent neuromuscular block. Some of these reports are a result of inappropriate doses of rocuronium, sugammadex or both, together with inadequate neuromuscular monitoring. We urge clinicians to review their practice to ensure the highest standards of clinical care when using neuromuscular blocking drugs and reversal agents. This includes the use of quantitative neuromuscular monitoring whenever neuromuscular blocking drugs are administered.
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Affiliation(s)
- Jennifer M Hunter
- Department of Musculoskeletal and Ageing Science, University of Liverpool, Liverpool, UK.
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
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Carr SG, Clifton JC, Freundlich RE, Fowler LC, Sherwood ER, McEvoy MD, Robertson A, Dunworth B, McCarthy KY, Shotwell MS, Kertai MD. Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study. Anesth Analg 2024; 138:517-529. [PMID: 38364243 PMCID: PMC10878712 DOI: 10.1213/ane.0000000000006722] [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: 02/18/2024]
Abstract
BACKGROUND We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.
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Affiliation(s)
- Shane G. Carr
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob C. Clifton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brent Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen Y. McCarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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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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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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40
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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Phoowanakulchai S, Kawaguchi M. Updated review on the use of neuromuscular blockade during intraoperative motor-evoked potential monitoring in the modern anesthesia era. J Anesth 2024; 38:114-124. [PMID: 37843561 DOI: 10.1007/s00540-023-03265-6] [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: 05/23/2023] [Accepted: 09/23/2023] [Indexed: 10/17/2023]
Abstract
Transcranial electrical stimulation motor-evoked potentials (Tc-MEP) monitoring is a common practice in neurosurgery to prevent postoperative neurological damage. However, the use of neuromuscular blocking agents (NMBAs) during Tc-MEP monitoring is a subject of controversy. In addition, the effectiveness of sugammadex, a selective reversal agent, in the context of Tc-MEP monitoring requires further investigation. This review aimed to clarify the considerations involved in achieving optimal Tc-MEP monitoring while ensuring patient safety. Preoperative patient selection, comorbidity assessment, motor power evaluation, and the nature of the planned surgery are critical factors. Accurate paralysis assessment, continuous NMBA infusion, and post-tetanic stimulation techniques are essential for achieving optimal partial NMB. The decision to administer an NMB during Tc-MEP monitoring necessitates a careful evaluation of the balance between accuracy and potential complications. This review emphasizes the challenges associated with NMB administration during Tc-MEP monitoring and highlights the need for personalized patient assessment.
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Affiliation(s)
- Sirima Phoowanakulchai
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Anesthesiology, Nara Medical University, Shijo 840, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Shijo 840, Kashihara, Nara, 634-8522, Japan.
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Salaün JP, Décary E, Veyckemans F. Recurarisation after sugammadex in children: review of case reports and recommendations. Br J Anaesth 2024; 132:410-414. [PMID: 38170632 DOI: 10.1016/j.bja.2023.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Jean-Philippe Salaün
- Normandie Univ, UNICAEN, INSERM UMR- S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institut Blood and Brain @ Caen- Normandie (BB@C), GIP Cyceron, Caen, France; Department of Anesthesiology and Critical Care Medicine, CHU Caen Normandie, Caen University Hospital, 14000 Caen, France; Department of Pediatric Anesthesiology, Sainte-Justine Mother and Child University Hospital, University of Montreal, Montreal, Quebec, Canada.
| | - Elizabeth Décary
- Department of Pediatric Anesthesiology, Sainte-Justine Mother and Child University Hospital, University of Montreal, Montreal, Quebec, Canada
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43
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Lin CJ, Eikermann M, Mahajan A, Smith KJ. Restrictive versus unrestrictive use of sugammadex for reversal of rocuronium: a decision analysis. Br J Anaesth 2024; 132:415-417. [PMID: 38104004 DOI: 10.1016/j.bja.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Charles J Lin
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Matthias Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jelacic S, Bowdle A, Bussey L, Nguyen S, Ocol JM, Togashi K. Should respiratory therapists routinely monitor neuromuscular blockade in the intensive care unit? J Clin Anesth 2024; 92:111310. [PMID: 37918081 DOI: 10.1016/j.jclinane.2023.111310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Logan Bussey
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Sharon Nguyen
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Jay M Ocol
- Respiratory Care Services, University of Washington Medical Center, Seattle, WA, USA.
| | - Kei Togashi
- University of California Irvine, Department of Anesthesiology and Perioperative Care, Orange, CA, USA.
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Ward B. The Sub-Post-Tetanic "Bergin Zone" of Paralysis and its Impact on Neuromuscular Monitoring and Reversal. J Perianesth Nurs 2024; 39:161-164. [PMID: 38307696 DOI: 10.1016/j.jopan.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 02/04/2024]
Affiliation(s)
- Blake Ward
- Associate Chief CRNA - Quality and Education, Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS.
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Blum FE, Locke AR, Nathan N, Katz J, Bissing D, Minhaj M, Greenberg SB. Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review. J Clin Med 2024; 13:861. [PMID: 38337560 PMCID: PMC10856567 DOI: 10.3390/jcm13030861] [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: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.
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Affiliation(s)
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Naveen Nathan
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Jeffrey Katz
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - David Bissing
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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Wedemeyer Z, Jelacic S, Michaelsen K, Silliman W, Togashi K, Bowdle A. Comparative performance of stimpod electromyography with mechanomyography for quantitative neuromuscular blockade monitoring. J Clin Monit Comput 2024; 38:205-212. [PMID: 37831378 DOI: 10.1007/s10877-023-01087-1] [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: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The purpose of this study was to compare the Stimpod electromyograph neuromuscular blockade monitor to mechanomyography, which is widely considered to be the reference standard. METHODS The Stimpod electromyograph was used with its designated electrode array on the same hand as the mechanomyograph. Pairs of train-of-four measurements were recorded every 0.5-2 min. When the train-of-four count was zero on the electromyograph monitor, pairs of post tetanic count measurements were recorded every 2.5 min, instead of train-of-four measurements. Measurements were recorded from immediately after induction of anesthesia until just before emergence. Stimulation current was set to 60 mA with a duration of 200 microsec. The mechanomyography recording system recorded each twitch waveform for analysis. High resolution electromyograph waveforms were also recorded using a datalogger accessory provided by the manufacturer, facilitating inspection of individual waveforms. The administration of neuromuscular blocking drugs was left up to the discretion of the anesthesia care team. RESULTS Twenty-three patients contributed 1,088 data pairs suitable for analysis. Bland-Altman analysis of 415 pairs of train-of-four ratios showed a bias of 0.028 and limits of agreement of -0.18 and 0.24. Two hundred seventy-three train-of-four count data pairs were compared by Cohen's quadratically weighted kappa which was calculated to be 0.44, indicating moderate agreement. Three hundred thirty-eight post tetanic count data pairs were compared by Cohen's quadradically weighted kappa which was calculated to be 0.80, indicating substantial agreement. CONCLUSION The electromyograph produced results that were comparable to the mechanomyograph.
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Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kelly Michaelsen
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kei Togashi
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA.
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48
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Martin-Flores M, Sakai DM, Araos J, Campoy L. Low-dose sugammadex reverses moderate rocuronium-induced neuromuscular block in horses. Equine Vet J 2024. [PMID: 38281489 DOI: 10.1111/evj.14066] [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: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Neuromuscular block (NMB) during general anaesthesia has an implicit risk of inadvertent residual NMB during recovery. Reversal of NMB is commonly encouraged to decrease this risk, and has historically been performed with neostigmine/atropine, two agents with important cardiac and gastrointestinal side effects. Sugammadex is a new selective relaxant binding agent that can reverse rocuronium-induced NMB efficiently and without these complications. Recommended doses are possibly cost-prohibitive. OBJECTIVES To measure the recovery time from rocuronium-NMB after administration of low-dose sugammadex, compared with spontaneous recovery. STUDY DESIGN Nonrandomised in vivo experiments. METHODS Fourteen adult horses undergoing different research procedures were anaesthetised with detomidine and isoflurane. All horses received NMB with rocuronium 0.3 mg/kg IV. Neuromuscular function was measured with acceleromyographic train-of-four (TOF) ratio. Recovery occurred spontaneously in five horses weighing (median [range]) 548 (413-594) kg and was enhanced with sugammadex 200 mg (total dose) in nine horses (433 [362-515]) kg. Recovery time from moderate NMB to a TOF ratio 1.0, and total duration of NMB were compared between groups. Cases of recurarisation (decrease in the TOF ratio <0.9 after recovery) were identified within 30 min after sugammadex. RESULTS The dose of sugammadex was 0.46 (0.39-0.55) mg/kg. The recovery period lasted 21 (17-39) minutes for spontaneous and 4 (3-7) minutes for sugammadex. Total duration of NMB was 58 (41-70) minutes for spontaneous and 36 (21-43) for sugammadex (both p ≤ 0.003). There were no instances of recurarisation. MAIN LIMITATIONS Small sample size. CONCLUSIONS A dose of sugammadex of approximately 0.5 mg/kg substantially shortened the recovery period from rocuronium-induced NMB from a median of 21 to 4 min, when given at a moderate depth of NMB. No recurarisation was observed within the next 30 min.
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Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Daniel M Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
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49
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Baba H, Wakabayashi R, Ichiyanagi H, Suzuki A, Sato N. Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle. Cureus 2024; 16:e52456. [PMID: 38371001 PMCID: PMC10872652 DOI: 10.7759/cureus.52456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.
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Affiliation(s)
- Hiroko Baba
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Ryo Wakabayashi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Hiroki Ichiyanagi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Aki Suzuki
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Nobukazu Sato
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
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50
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Rodney G, Raju P, Brull S. Neuromuscular block management: evidence-based principles and practice. BJA Educ 2024; 24:13-22. [PMID: 38495745 PMCID: PMC10941205 DOI: 10.1016/j.bjae.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
| | - P. Raju
- Ninewells Hospital, Dundee, UK
| | - S.J. Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
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