Delayed recurarisation after sugammadex reversal:

Is quantitative neuromuscular monitoring mandatory after administration of the recommended dose of sugammadex? A prospective observational study

BACKGROUND

Some anaesthetists wonder whether confirming a train-of-four ratio (TOFR) ≥0.9 is necessary when using sugammadex to antagonise neuromuscular blockade (NMB). In this study, we aimed to determine whether using sugammadex at the recommended dose under neuromuscular monitoring (NMM) would ensure complete recovery, even without further NMM.

METHODS

This prospective observational study included 51 patients who underwent robot-assisted surgery under general anaesthesia between March and May 2023. At the end of surgery, sugammadex was administered (2 mg/kg for a train-of-four (TOF) count ≥1 and 4 mg/kg for a TOF count = 0 and a post-tetanic count ≥1). NMM was discontinued, and subsequent recovery was completed at the discretion of the attending anaesthetist. TOFR was measured twice immediately upon admission to the post-anaesthesia care unit (PACU). The primary outcome was the incidence of a non-normalised TOFR (nTOFR) <0.9 upon arrival in PACU. The secondary outcomes were the incidences of a nTOFR <0.7 or 1.0, symptoms/signs of residual NMB (diplopia, dyspnoea, and desaturation) and recovery profiles in PACU.

RESULTS

The incidence of a nTOFR <0.9 upon arrival in PACU was 5.9% (3/51 patients). No patient had a nTOFR <0.7, and 47.1% (24 patients) had a nTOFR <1.0, but no patients showed clinical symptoms/signs of residual NMB.

CONCLUSIONS

When the recommended dose of sugammadex was administered under qualitative NMM, residual NMB at the time of PACU arrival occurred frequently, indicating that quantitative NMM is necessary to ensure adequate recovery.

REGISTRATION

ClinicalTrials, NCT05760560.

Prolonged Neuromuscular Blockade From Continuous Vecuronium in an Infant With Renal Failure Being Treated With Dialysis

Neuromuscular blockade may be required in critically ill pediatric patients to facilitate ventilator synchrony or maintain safety during high-risk procedures. Vecuronium is one neuromuscular blocking agent used for this purpose; however, there are limited data regarding its use in pediatric patients with renal failure. Although predominantly considered to be metabolized by the liver, there are numerous adult cases and 1 pediatric case report that have described extended paralysis from vecuronium due to renal failure. The proposed mechanism is accumulation of renally cleared active metabolites. This case report describes an infant with vecuronium exposure during continuous renal replacement therapy who experienced prolonged neuromuscular blockade for several days after the agent was stopped. This highlights the importance of considering renal function when selecting neuromuscular blocking agent.

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

Purpose of Review

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

Recent Findings

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

Summary

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

Failure of reversion of neuromuscular block with sugammadex in patient with myasthenia gravis: case report and brief review of literature

Background

Myasthenia gravis (MG) is a challenge for anesthesia management. This report shows that the use of rocuronium-sugammadex is not free from flaws and highlights the importance of cholinesterase inhibitors management and neuromuscular block monitoring in the perioperative period of myasthenic patients.

Case presentation

Myasthenic female patient submitted to general balanced anesthesia using 25 mg of rocuronium. Under train-of-four (TOF) monitoring, repeated doses of sugammadex was used in a total of 800 mg without recovery of neuromuscular blockade, but TOF ratio (TOFR) was stabilized at 60%. Neostigmine administration led to the improvement of TOFR.

Conclusions

Although the use of rocuronium-sugammadex seems safe, we should consider their unpredictability in myasthenic patients. This report supports the monitoring of neuromuscular blockade as mandatory in every patient, especially the myasthenic ones.

Differences of Recovery from Rocuronium-induced Deep Paralysis in Response to Small Doses of Sugammadex between Elderly and Nonelderly Patients

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What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Complete recovery from rocuronium-induced muscle paralysis with sugammadex is reported to be delayed in elderly patients. The authors tested a hypothesis that recovery from deep neuromuscular block with low-dose sugammadex is slower (primary hypothesis) and incidence of recurarization is higher (secondary hypothesis) in elderly patients than in nonelderly patients.

Methods

In anesthetized elderly (n = 20; 76.9 ± 5.0 yr of age) and nonelderly patients (n = 20; 53.7 ± 12.8 yr of age) under deep paralysis with rocuronium, change of train-of-four ratio per minute (primary outcome variable) was measured with an acceleromyograph neuromuscular monitor during spontaneous recovery from rocuronium-induced muscle paralysis (0.6 mg/kg) and after infusion of low-dose sugammadex (50 µg · kg-1 · min-1). Recurarization was defined as the negative change of train-of-four ratio.

Results

Spontaneous train-of-four ratio recovery rate was significantly slower in the elderly group (median [25th percentile, 75th percentile]: 1.89 [1.22, 2.90] %/min) than in the nonelderly group (3.45 [1.96, 4.25] %/min, P = 0.024). Train-of-four ratio change rate in response to low-dose sugammadex was significantly slower in elderly (0.55 [–0.29, 1.54] %/min) than in the nonelderly group (1.68 [0.73, 3.13] %/min, P = 0.024). Incidence of recurarization was significantly higher in the elderly group than in the nonelderly group (35% vs. 5%, P = 0.044). Multiple linear regression analyses indicate that slower spontaneous train-of-four ratio recovery rate and impaired renal function are two major contributing factors that decrease train-of-four ratio change rate in response to low-dose sugammadex.

Conclusions

Elderly patients are at greater risk for recurarization and residual muscle paralysis when low-dose sugammadex is administered.

A comparison of sugammadex and neostigmine for reversal of rocuronium-induced neuromuscular blockade in children

BACKGROUND

Sugammadex is designed to be a reversal agent for steroidal muscle relaxants. The current trial was aimed to compare between sugammadex and neostigmine concerning the recovery time from neuromuscular blockade. We hypothesised that sugammadex might have shorter recovery time than neostigmine.

METHODS

Sixty paediatric patients aged 2-10 years scheduled for lower abdominal surgeries were randomly assigned into two equal groups to receive 4 mg/kg sugammadex (Group S) or 0.35 mg/kg neostigmine and 0.02 mg/kg atropine (Group N) as a reversal agent for rocuronium at the end of surgery. Primary outcome was the recovery time [time from starting of sugammadex or neostigmine till reaching train of four (TOF) ratio> 0.9] whereas secondary outcomes included number of patients who needed another dose of sugammadex or neostigmine to reach TOF ratio> 0.9, extubation time (time from stoppage of anaesthetic inhalation until the patient fulfilled criteria for safe extubation, post-anaesthesia care unit (PACU) discharge time and post-operative adverse effects.

RESULTS

The mean recovery and extubation times were significantly shorter (P = 0.002 and 0.005) in Group S compared with Group N (2.5 and 2.0 min vs. 12.6 min and 4.3 min respectively). In the Group N, eight patients needed another reversal dose compared with one patient in Group S (P = 0.035). PACU discharge time showed no significant difference between both groups. Incidence of nausea, vomiting, tachycardia, and dry mouth were significantly higher in Group N.

CONCLUSION

Sugammadex administration in children resulted in faster recovery and extubation times and lower incidence of adverse events compared with neostigmine.