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El Mously DA, Mostafa NM, Hassan NY, El-Sayed GM. Development of Different Separation Techniques for Impurity Profiling of Neostigmine Methylsulfate: A Comparative Study. J Chromatogr Sci 2023; 61:963-971. [PMID: 37032123 DOI: 10.1093/chromsci/bmad029] [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: 03/18/2022] [Revised: 02/15/2023] [Indexed: 04/11/2023]
Abstract
Different separation techniques have been employed to resolve mixtures of multicomponent preparations over the last few decades. They could be efficiently applied for impurity profiling of active drug substances. Impurity profiling has become a critical procedure in pharmaceutical companies to comply with numerous regulatory standards. Isolation and characterization of impurities are crucial for obtaining data that proves biological safety and efficacy. In this contribution, different HPLC, capillary electrophoresis (CE) and TLC-densitometric methods were developed for the determination of neostigmine methylsulfate (NEO) along with 3-hydroxyphenyltrimethyl ammonium methylsulfate (3-HPA) and 3-dimethylaminophenol (DAP) as its impurities in the presence of citric acid. The linearity for NEO was attained in the range of 5-120 μg/mL and 10-60 μg/mL for the HPLC and CE methods, respectively. Regarding the impurities, linearity was obtained over the range of 10-30 μg/mL for 3-HPA and 5-30 μg/mL for DAP in the two proposed methods. For the TLC method, NEO and DAP were determined within the range of 1-11 μg/band, whereas 3-HPA was assayed over the range of 2-12 μg/band. The suggested methods can be securely utilized for routine analysis of the cited components in quality control laboratories.
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Affiliation(s)
- Dina A El Mously
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El-Aini, 11562 Cairo, Egypt
| | - Nadia M Mostafa
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El-Aini, 11562 Cairo, Egypt
| | - Nagiba Y Hassan
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El-Aini, 11562 Cairo, Egypt
| | - Ghada M El-Sayed
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El-Aini, 11562 Cairo, Egypt
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2
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Si S, Zhao X, Su F, Lu H, Zhang D, Sun L, Wang F, Xu L. New advances in clinical application of neostigmine: no longer focusing solely on increasing skeletal muscle strength. Front Pharmacol 2023; 14:1227496. [PMID: 37601044 PMCID: PMC10436336 DOI: 10.3389/fphar.2023.1227496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Neostigmine is a clinical cholinesterase inhibitor, that is, commonly used to enhance the function of the cholinergic neuromuscular junction. Recent studies have shown that neostigmine regulates the immune-inflammatory response through the cholinergic anti-inflammatory pathway, affecting perioperative neurocognitive function. This article reviews the relevant research evidence over the past 20 years, intending to provide new perspectives and strategies for the clinical application of neostigmine.
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Affiliation(s)
- Shangkun Si
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaohu Zhao
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fan Su
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hongxiu Lu
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dongbin Zhang
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Li Sun
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Fulei Wang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Li Xu
- Shandong University of Traditional Chinese Medicine, Jinan, China
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Díaz-Cambronero O, Serrano A, Abad-Gurumeta A, Garutti Martinez I, Esteve N, Alday E, Ferrando C, Mazzinari G, Vila-Caral P, Errando Oyonarte CL. Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:37-50. [PMID: 36621572 DOI: 10.1016/j.redare.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.
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Affiliation(s)
- O Díaz-Cambronero
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - A Serrano
- Hospital Ramón y Cajal, Madrid, Spain.
| | | | | | - N Esteve
- Hospital Son Espases, Palma de Mallorca, Mallorca, Spain.
| | - E Alday
- Hospital de La Princesa, Madrid, Spain.
| | | | - G Mazzinari
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - P Vila-Caral
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - C L Errando Oyonarte
- Hospital Can Misses, Ibiza, Islas Baleares, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
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Liu F, Lin X, Lin Y, Deng X, Guo Y, Wang B, Dong R, Bi Y. The effect of neostigmine on postoperative delirium after colon carcinoma surgery: a randomized, double-blind, controlled trial. BMC Anesthesiol 2022; 22:267. [PMID: 35996073 PMCID: PMC9394039 DOI: 10.1186/s12871-022-01804-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022] Open
Abstract
Background Postoperative delirium (POD) is a critical complication in patients accepting colon carcinoma surgery. Neostigmine, as a cholinesterase inhibitor, can enhance the transmission of cholinergic transmitters in synaptic space, and play an important role in maintaining the normal level of cognition, attention and consciousness. The objective of this study was to investigate the effect of neostigmine on POD and clinical prognosis. Methods A randomized, double-blind controlled trial was implemented in Qingdao Municipal Hospital Affiliated to Qingdao University. A total of 454 patients aged 40 to 90 years old accepted colon carcinoma surgery were enrolled between June 7, 2020, and June 7, 2021, with final follow-up on December 8, 2021. Patients were randomly assigned to two groups: the neostigmine group (group N) and the placebo group (group P), the patients in group N were injected with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine intravenously. The primary endpoint was the incidence of POD, researchers evaluated the occurrence of POD by the Confusion Assessment Method (CAM) twice daily (at 10 a.m. and 2 p.m.) during the first 7 postoperative days, POD severity was assessed by the Memorial Delirium Assessment Scale (MDAS). The secondary endpoints were the extubating time, postanesthesia care unit (PACU) time, the incidence of various postoperative complications, length of hospital stays, and 6 months postoperative mortality. Results The incidence of POD was 20.20% (81/401), including 19.39% (38/196) in group N and 20.98% (43/205) in group P. There was no significant statistical significance in the incidence of POD between group N and group P (P > 0.05); Compared to group P, the extubating time and PACU time in group N were significantly reduced (P < 0.001), the incidence of postoperative pulmonary complications (POPCs) decreased significantly in group N (P < 0.05), while no significant differences were observed in postoperative hospital stay and mortality in 6 months between the two groups (P > 0.05). Conclusion For patients accepted colon carcinoma surgery, neostigmine did not significantly reduce the incidence of POD, postoperative mortality and postoperative hospital stay, while it indeed reduced the extubating time, PACU time and the incidence of POPCs. Trial registration The randomized, double-blind, controlled trial was registered retrospectively at www.chictr.org.cn on 07/06/2020 (ChiCTR2000033639).
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Affiliation(s)
- Fanghao Liu
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xu Lin
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Yanan Lin
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Xiyuan Deng
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Yuwei Guo
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Bin Wang
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China.
| | - Rui Dong
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yanlin Bi
- Department of Anesthesiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China.
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Schmartz D, Sghaier R, Bernard P, Fils JF, Fuchs-Buder T. Neuromuscular block in patients 80 years and older: a prospective, controlled study. BMC Anesthesiol 2021; 21:225. [PMID: 34517841 PMCID: PMC8436544 DOI: 10.1186/s12871-021-01443-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background An increasing number of patients older than 80 years are undergoing anesthesia, but little information is available regarding pharmacodynamic effects of myorelaxants in this population. This study aims to compare the time course of rocuronium neuromuscular block in patients ≥ 80 years with those of younger adults. Methods Under total intravenous anesthesia with propofol and sufentanil, time course of a bolus of rocuronium 0.6 mg/kg neuromuscular block was assessed with acceleromyography in patients ≥ 80 and in patients 20–50 years old. Onset time, clinical duration, duration until 90% and 100% recovery of baseline were determined. Results Data from 32 patients were analyzed, 16 were ≥ 80 years and 16 were 20–50 years old. Demographic data are shown in Table 1. In the group ≥ 80, onset time was 190 s ± 46 s compared to 123 s ± 40 s in the group 20–50, P < 0.001 and the clinical duration was 52 [48–69.5] min and 36 [34–41] min, respectively, P < 0.001. Duration to 90% recovery of baseline was 77.5 [71–88.5] min and duration to 100% recovery of baseline was 91.2 [82.2–98] min in patients ≥ 80 years and the corresponding values in the patients 20–50 years old were 53.5 [49–55.5] min and 59.5 [56.5–70.25] min, respectively, P < 0.001. Conclusion Compared to younger adults rocuronium shifted in patients ≥ 80 years from a rapid onset, intermediate acting compound to a slower onset, long-acting compound. Trial registration ClinicalTrials.gov identifier: NCT03551652 (29/05/2018).
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Affiliation(s)
- Denis Schmartz
- CHU Brugmann, Université Libre de Bruxelles, 4 Place Van Gehuchten, 1020, Bruxelles, Belgium.
| | - Raouf Sghaier
- CHRU de Nancy, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
| | - Paul Bernard
- CHRU de Nancy, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
| | | | - Thomas Fuchs-Buder
- CHRU de Nancy, Université de Lorraine, Rue du Morvan, 54511, Vandœuvre-lès-Nancy, France
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Chou WY, Hsu CJ. A118G polymorphism of OPRM1 gene caused different morphine consumption in female patients after total knee replacement. J Orthop Sci 2021; 26:629-635. [PMID: 32800527 DOI: 10.1016/j.jos.2020.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/15/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND We intended to clarify the effect of gender and A118G polymorphism of Opioid Receptor μ1 (OPRM1) on the required morphine for patients to maintain Visual Analogue Scale ≦ 3 for post-operative pain control after total knee replacement (TKR). METHODS With approval from Institutional Review Board (IRB) and obtainment of informed consents, 111 patients undergoing primary TKR were enrolled without violating the exclusion criteria, including previous history of allergy to morphine, alcohol or substance abuse, use of psychotropic medications, morbid obesity of body mass index (BMI) > 40 kg/m2, chronic pain with evidence of central sensitization, and uncooperative use of patient controlled analgesia (PCA) device. The amount of PCA-delivered morphine for pain control and the 'demand' (the count of button pushing for requiring pain medication from PCA) were recorded at 3, 6, 12, 24, 36, 48 and 72 h after the operation. One-way ANOVA with post-hoc test by Scheffe's method was adopted for statistical analysis of each variant (AA, AG, GG). The side-effects (nausea, vomiting and sedation) from morphine were recorded. P < 0.05 was considered to be statistically significant. RESULTS With sequencing by ABI PRISM 310 Genetic Analyser, we disclosed that the allele frequency was 75.5% for the A allele (female: 77.5%, male: 69.6%) and 24.5% for the G allele (female: 22.5%, male: 30.4%). The frequency of genotype occurrence was 61.3% for AA, 24.3% for AG and 14.4% for GG. Female patients of homozygous G118G of OPRMI required more morphine from PCA device for post-operative pain control than patients of AA and AG genotypes. No significant difference in morphine consumption for post-operative pain control was disclosed among three genotypes for male patients. CONCLUSIONS The impact caused by G118G polymorphism of OPRM1 on requirement of morphine consumption for post-operative pain control is potentially gender-linked.
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Affiliation(s)
- Wen-Ying Chou
- Department of Anesthesiology, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Pharmacy and Pharmaceutical Science, National Cheng Kung University, Taiwan.
| | - Chien-Jen Hsu
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Taiwan; Nursing College, Fooyin University, Kaohsiung, Taiwan.
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Gilbertson LE, Fiedorek MC, Fiedorek CS, Trinh TA, Lam H, Austin TM. Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective bayesian regression analysis. Paediatr Anaesth 2021; 31:290-297. [PMID: 33382505 DOI: 10.1111/pan.14118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Infants undergoing pyloromyotomy are at a high risk of aspiration, making rapid sequence induction the preferred method of induction. Since succinylcholine use in infants can be associated with complications, rocuronium is frequently substituted despite its prolonged duration of action. AIMS To examine the likelihood of non-reversibility to neostigmine at the end of surgery in laparoscopic pyloromyotomies and its correlation to both rocuronium dose and out of operating room time. METHODS Patients who underwent laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, received rocuronium, and were reversed with neostigmine were included. Bayesian multivariable logistic regression was utilized to determine the probability of non-reversibility, and Bayesian multivariable median regression was performed to ascertain the correlation between out of operating room time and non-reversibility. RESULTS 306 patients were analyzed with a median surgical duration of 19 min (interquartile range 16 to 23). 74% received succinylcholine for intubation followed by rocuronium, and the remaining received rocuronium alone. The median rocuronium dose was 0.41 mg/kg (interquartile range 0.27 - 0.56 mg/kg). Prolonged block occurred in 68 (22.2%) patients. There was a non-trivial probability of prolonged block with low rocuronium doses, and each 0.1 mg/kg increase in total rocuronium dose was associated with an odds ratio of 1.36 (95% credible interval: 1.17-1.58) of neostigmine non-reversibility at the end of surgery. Non-reversibility was correlated with a substantial increase in median out of operating room time (13.4 min, 95% credible interval: 5.5-20.8 min), which was compounded by high rocuronium dosing (2.2 min increase per 0.1 mg/kg for doses greater than 0.5 mg/kg, 95% credible interval: 0.7-3.6 min). CONCLUSION Prolonged blockade can occur from rocuronium administration in infants undergoing pyloromyotomy even at low doses. Therefore, consideration of appropriate rocuronium dosing or the use of sugammadex should be considered.
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Affiliation(s)
- Laura E Gilbertson
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael C Fiedorek
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher S Fiedorek
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Tuan A Trinh
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Humphrey Lam
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas M Austin
- Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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El‐Sayed GM, El Mously DA, Mostafa NM, Hassan NY, Mahmoud AM. Design of Copper Microfabricated Potentiometric Sensor for
in‐line
Monitoring of Neostigmine Degradation Kinetics. ELECTROANAL 2021. [DOI: 10.1002/elan.202060536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ghada M. El‐Sayed
- Analytical Chemistry Department Faculty of Pharmacy Cairo University Kasr-El-Aini 11562 Cairo Egypt
| | - Dina A. El Mously
- Analytical Chemistry Department Faculty of Pharmacy Cairo University Kasr-El-Aini 11562 Cairo Egypt
| | - Nadia M. Mostafa
- Analytical Chemistry Department Faculty of Pharmacy Cairo University Kasr-El-Aini 11562 Cairo Egypt
| | - Nagiba Y. Hassan
- Analytical Chemistry Department Faculty of Pharmacy Cairo University Kasr-El-Aini 11562 Cairo Egypt
| | - Amr M. Mahmoud
- Analytical Chemistry Department Faculty of Pharmacy Cairo University Kasr-El-Aini 11562 Cairo Egypt
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Abstract
PURPOSE OF REVIEW The present review provides a summary of the literature on recent development of new neuromuscular blocking agents and presents clinically well established and new reversal agents. RECENT FINDINGS Anesthesiologists are still waiting for the ideal neuromuscular blocking agent with a succinylcholine-like rapid onset and offset without side effects. Recent drug development led to a new series of neuromuscular compounds, called the chlorofumarates such as gantacurium, CW002, and CW011. These drugs have a promising pharmacodynamic profile; importantly, they can rapidly be reversed by L-cysteine adduction without relevant side effects. In addition, a new spectrum of reversal agents are currently examined in preclinical studies: adamgammadex sodium, a modified γ-cyclodextrin derivate that forms an inactive tight inclusion complex with rocuronium or vecuronium and calabadions, capable of reversing both benzylisoquinolines and steroidal neuromuscular blocking agents. SUMMARY Although the recent advancements in neuromuscular research are very promising, to date, the presented drugs are currently not available for clinical use. Clinical studies will determine the role of these developments in anesthesia practice. Therefore, well established combinations such as rocuronium-sugammadex are popular in clinical practice to offer quick paralysis for intubation and to optimize surgical conditions, while providing a fast neuromuscular recovery at the end of surgery.
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Affiliation(s)
- Christiane G Stäuble
- Klinik für Anaesthesiologie und Intensivmedizin, Technische Universität München, Klinikum Rechts der Isar, Ismaninger Straße, München, Germany
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Luthe SK, Iwasaki H. The Financial and Humanistic Costs Associated with Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00402-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Raval AD, Anupindi VR, Ferrufino CP, Arper DL, Bash LD, Brull SJ. Epidemiology and outcomes of residual neuromuscular blockade: A systematic review of observational studies. J Clin Anesth 2020; 66:109962. [PMID: 32585565 DOI: 10.1016/j.jclinane.2020.109962] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/31/2020] [Accepted: 06/14/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Complete reversal of neuromuscular blockade (NMB) is important for patient safety and prognosis following surgical procedures involving NMB agents (NMBAs). Published evidence on the epidemiology and consequences of residual neuromuscular blockade (rNMB; incomplete neuromuscular recovery) in real-world clinical settings is lacking with advances in NMB management. Therefore, we aimed to examine the burden of rNMB and its associated clinical, economic and humanistic outcomes using a systematic review framework. REVIEW METHODS Electronic and conference database searches were performed to include observational studies examining rNMB or related outcomes in adults undergoing surgery and receiving NMBAs with or without NMBA antagonists. RESULTS Of 1438 screened abstracts, 58 studies with 25,277 total patients were included. Inconsistent definitions of rNMB were reported across studies with 44 (76%) and 29 (50%) studies utilizing quantitative and qualitative measures to detect rNMB, respectively. The most common definition of rNMB was train-of-four ratio (TOFR) <0.9 (29 studies) and TOFR <0.7 (16 studies) measured at post-anesthesia care unit (PACU) entry. For TOFR <0.9 at PACU entry, rNMB incidence ranged from 0% to 90.5% (median 30%) overall; 0% to 16.0% in the sugammadex (SUG) group; 3.5% to 90.5% in the neostigmine (NEO) group; and 15% to 89% in the spontaneous recovery (SR) group. Twenty-one studies reported clinical outcomes (reintubation, mild hypoxemia, or a respiratory event) or resource utilization outcomes (hospital/PACU length of stay [LOS]) by presence/absence of rNMB. Patients with rNMB had higher rates of acute respiratory events compared to those without rNMB. CONCLUSIONS Real-world observational studies show a significant burden of rNMB and associated health sequelae, though rNMB measures were not reported consistently across studies. Appropriate quantitative measurement is needed to accurately identify rNMB, and interventions are needed to reduce its burden and associated adverse outcomes.
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Affiliation(s)
- Amit D Raval
- Merck & Co., Inc., Center for Observational and Real-World Evidence, 2000 Galloping Hill Rd., Kenilworth, NJ 07033, USA
| | | | - Cheryl P Ferrufino
- IQVIA, Inc., 3110 Fairview Park Drive, Suite 400, Falls Church, VA 22042, USA
| | - Diana L Arper
- IQVIA, Inc., 3110 Fairview Park Drive, Suite 400, Falls Church, VA 22042, USA
| | - Lori D Bash
- Merck & Co., Inc., Center for Observational and Real-World Evidence, 2000 Galloping Hill Rd., Kenilworth, NJ 07033, USA
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Schmartz D, Bernard P, Sghaier R, Fuchs-Buder T. Evaluation of the Efficacy and Safety of Neostigmine in Reversing Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Firde M, Yetneberk T, Adem S, Fitiwi G, Belayneh T. Preventive strategies of residual neuromuscular blockade in resource-limited settings: Systematic review and guideline. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fuchs-Buder T. Neuromuskuläre Restblockaden. Anaesthesist 2019; 68:742-743. [DOI: 10.1007/s00101-019-00687-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Algorithmusbasierte Präventionsstrategien zur Vermeidung neuromuskulärer Restblockaden. Anaesthesist 2019; 68:744-754. [DOI: 10.1007/s00101-019-00677-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Deep neuromuscular blockade improves surgical conditions during gastric bypass surgery for morbid obesity. Eur J Anaesthesiol 2019; 36:486-493. [DOI: 10.1097/eja.0000000000000996] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Wardhana A, Kurniawaty J, Uyun Y. Optimised reversal without train-of-four monitoring versus reversal using quantitative train-of-four monitoring: An equivalence study. Indian J Anaesth 2019; 63:361-367. [PMID: 31142879 PMCID: PMC6530284 DOI: 10.4103/ija.ija_94_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Less residual paralysis in recovery room was demonstrated when train-of-four (TOF) monitoring was applied. The aim of this study was to know whether optimisation of neostigmine reversal without TOF monitoring was equivalent to reversal using TOF monitoring. Methods: Seventy two patients, aged 18–60 years, undergoing elective surgery under general anaesthesia (sevoflurane and rocuronium) with intubation were randomised into two interventions: an optimised neostigmine reversal strategy without TOF monitoring (group A, n = 36) and a neostigmine reversal strategy using quantitative TOF monitoring (group B, n = 36). Per-protocol analysis was performed to compare incidence of residual paralysis in the recovery room between the two groups. Results: Six residual paralyses occurred in group A in the recovery room, whereas one case occurred in group B. The equivalence test showed that the 95% confidence interval of this study was outside the range of equivalence margin (15%). The absolute difference was 13.9%: standard error (SE) =0.068 (P = 0.107; 95% confidence interval (CI): 1%, 27.2%). No subjects had TOF ratio <0.70 in the recovery room. The TOF ratio in the recovery room did not differ between the two groups (mean difference: −2.58; P = 0.05; 95% CI: −5.20, 0.29). One respiratory adverse event occurred in this study. Conclusion: An optimised reversal strategy without TOF monitoring is not equivalent to a reversal strategy based on quantitative TOF monitoring. TOF monitoring should be used whenever applicable, although neostigmine is optimised.
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Affiliation(s)
- Ardyan Wardhana
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medical, Public Health and Nursing, University of Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Juni Kurniawaty
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medical, Public Health and Nursing, University of Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Yusmein Uyun
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medical, Public Health and Nursing, University of Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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Luo J, Chen S, Min S, Peng L. Reevaluation and update on efficacy and safety of neostigmine for reversal of neuromuscular blockade. Ther Clin Risk Manag 2018; 14:2397-2406. [PMID: 30573962 PMCID: PMC6292224 DOI: 10.2147/tcrm.s179420] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Postoperative residual neuromuscular block is a serious threat which endangers the patient safety. Neostigmine has been the most commonly used anticholinesterase for the pharmacological reversal of neuromuscular blockade. Although newer agents have been introduced recently, neostigmine has some irreplaceable advantages, including broad-spectrum reversal of all nondepolarizing neuromuscular blocking drugs, low cost, and availability of more related data for clinical practice to refer to. Neostigmine is also noticed to have some drawbacks, such as the inability to reverse profound and deep blockade, potential induction of muscle weakness, cardiovascular adverse effects, and so on. Data on the usage of neostigmine in the geriatric and the pediatric population are still insufficient. Some discrepancies are observed in the results from previous studies which need further investigation. However, recent studies offer some renewed information. Regarding both efficacy and safety, the key for successful reversal of neuromuscular blockade is to use neostigmine “appropriately,” optimizing the dosage and timing of administration under close monitoring.
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Affiliation(s)
- Jie Luo
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Shuting Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Lihua Peng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
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Yazar MA, Balaban O, Yoldaş TK, Sarıkuş Z. EFFECT OF SUGAMMADEX AND NEOSTIGMINE ON BLOOD GLUCOSE LEVEL:A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL. SANAMED 2018. [DOI: 10.24125/sanamed.v13i3.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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20
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Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record. Eur J Anaesthesiol 2018; 35:883-892. [DOI: 10.1097/eja.0000000000000861] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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21
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Lorrain PE, Schmartz D, Fuchs-Buder T. Neostigmine: Mechanism of Action, Dosing, and Factors Determining Adequacy of Recovery Following Administration. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0278-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Affiliation(s)
- Christoph Unterbuchner
- Department of Anesthesiology, University Medical Centre Regensburg Franz-Josef-Strauss-Allee 11 93053 Regensburg, Germany
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23
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