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An G, Qiu Y, Zhou Z, Ding X, Li C. Effects of a single dose of rocuronium in patients with different body fat percentages: A randomised controlled trial. Clin Exp Pharmacol Physiol 2024; 51:e13836. [PMID: 38302078 DOI: 10.1111/1440-1681.13836] [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: 06/14/2023] [Revised: 11/20/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
The pharmacodynamics in patients with high body fat percentage might be similar to those in obese patients. This randomised controlled clinical trial observed the effects of rocuronium in patients with different percent body fats (PBFs). Fifty-four patients who underwent elective urological or pelvic surgery under general anaesthesia at Shanghai General Hospital were included in the present study; 51 patients were included for data analysis. Patients with normal PBF (<25%) were given a single dose of rocuronium calculated based on total body weight (N-TBW, control group). Patients with a higher PBF (≥25%) were given a single dose of rocuronium calculated based on total body weight (H-TBW). Patients with higher PBF and rocuronium were dosed based on fat-free mass (H-FFM). A train of four (TOF)-Watch acceleromyography monitor was used to measure the effects of the rocuronium. H-TBW (91.9 ± 28.8 s) had significantly shorter onset time than N-TBW and H-FFM (p = 0.003). H-TBW had significantly longer clinical duration time and pharmacological duration time than the other groups (p = 0.000 and 0.000, respectively); the TOF ratio0.25-0.9 time was significantly different among the three groups (p = 0.005). There were no significant differences in the recovery time (p = 0.103) or recovery index (p = 0.159) among the three groups. The effects of rocuronium dosed based on FFM in patients with high PBFs are similar to those in normal patients. A single dose of rocuronium calculated based on TBW might shorten the onset time, prolong the clinical and pharmacological duration times, and prolong the recovery time.
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Affiliation(s)
- Guanghui An
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University Affiliated Shanghai General Hospital, Shanghai, China
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yan Qiu
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiaotong University Affiliated Shanghai General Hospital, Shanghai, China
| | - Zheliang Zhou
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiaotong University Affiliated Shanghai General Hospital, Shanghai, China
| | - Xueying Ding
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiaotong University Affiliated Shanghai General Hospital, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
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Padmaja D, Singam G, Tappa R, Maremanda K, Kabra N, Barada A. Does the objective measurement of muscle strength improve the detection of postoperative residual muscle weakness? J Anaesthesiol Clin Pharmacol 2024; 40:29-36. [PMID: 38666160 PMCID: PMC11042092 DOI: 10.4103/joacp.joacp_186_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/30/2022] [Accepted: 07/02/2022] [Indexed: 04/28/2024] Open
Abstract
Background and Aims The postoperative residual neuromuscular block (PRNB) has a significant impact on patient safety and well-being, but continues to remain underestimated. Objective evaluation of handgrip strength using a force dynamometer can be useful to identify postoperative muscle weakness. Material and Methods Thirty-two American Society of Anesthesiologists (ASA) class I and II patients who received general anesthesia were included. Patients were extubated after the train-of-four (TOR) ratio (TOFR) was >0.90 and the clinical criteria for motor power recovery were judged as adequate. The measurements of handgrip strength and peak expiratory flow rate (PEFR) were obtained at baseline, 15 min after extubation, and 1, 2, and 4 h postoperatively. The incidence of significant decline from baseline (>25%) was determined. The correlation between handgrip strength and PEFR was assessed using Spearman correlation. The time to return to baseline for muscle grip strength and PEFR was performed using Kaplan-Meier survival analysis. A P value of 0.05 was considered significant for all tests. Results The incidence of the significant decline in handgrip strength from baseline was 100% at 15 and 60 min, 76% at 2 h, and 9.4% at 4 h. There was a strong correlation between muscle grip strength and PEFR (0.89, P < 0.001). None of the patients exhibited the potential complications of PRNB. (PRMB in abstract. It should be uniform) The mean time to return to the baseline value of muscle grip strength was 3.8 h (95% confidence interval [CI] 3.6-3.9), and the mean time to return to baseline for PEFR was 3.2 h (95% CI 2.9-3.4 h). Conclusion Objective assessment of muscle grip strength using a force dynamometer has the potential to be a new objective metric to monitor postoperative muscle weakness.
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Affiliation(s)
- Durga Padmaja
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Geetha Singam
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rabbani Tappa
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Krishnarao Maremanda
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Nitesh Kabra
- Department of Anaesthesiology and Intensive Care, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Anupama Barada
- Medical Student and Research Assistant, China Medical University, Shenyang, China
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Bucheery BA, Isa HM, Rafiq O, Almansoori NA, Razaq ZAA, Gawe ZA, Almoosawi JA. Residual Neuromuscular Blockade and Postoperative Pulmonary Complications in the Post-anesthesia Care Unit: A Prospective Observational Study. Cureus 2023; 15:e51013. [PMID: 38264400 PMCID: PMC10803948 DOI: 10.7759/cureus.51013] [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: 12/23/2023] [Indexed: 01/25/2024] Open
Abstract
Background Neuromuscular blocking agents (NMBAs) are employed during general anesthesia induction for endotracheal intubation and to facilitate specific surgeries requiring muscle relaxation. However, residual neuromuscular blockade (RNMB) can lead to respiratory complications in post-anesthesia care units (PACUs). This study investigates RNMB incidence in PACUs and its association with postoperative airway and respiratory issues. Methods A prospective observational study on patients undergoing general anesthesia with NMBAs was conducted at the Department of Anesthesia, Salmaniya Medical Complex, Bahrain, over six months (April to September 2023). Train-of-four (TOF) ratios were calculated using an acceleromyograph upon PACU arrival. Data on demographics, perioperative variables, and postoperative complications were recorded. Results Among 82 patients, 30 (36.6%) had RNMB upon PACU arrival. RNMB incidence declined: 17.1% at 10 minutes, 6.1% at 20 minutes, and 2.4% at 30 minutes, resolving by 40 minutes. Demographics and procedure duration showed no correlation with RNMB. Postoperative respiratory complications affected 23.2% of patients, notably higher in those with RNMB (p = 0.001). Among patients with TOF <90% at PACU arrival, 46.7% experienced complications compared to 9.6% with TOF ≥90% (p<0.001). Participants without RNMB had a significantly higher weight (p = 0.046). Airway support was required for 30% of patients, all with TOF <90% (p<0.001). Conclusion This study emphasizes the importance of assessing and monitoring neuromuscular function to detect and prevent RNMB in PACUs. RNMB presence correlated with an increased susceptibility to postoperative respiratory complications. Regular quantitative neuromuscular monitoring is advisable in clinical practice to proactively mitigate RNMB incidence and its complications.
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Affiliation(s)
| | - Hasan M Isa
- Department of Pediatrics, Arabian Gulf University, Manama, BHR
- Department of Pediatrics, Salmaniya Medical Complex, Manama, BHR
| | - Owais Rafiq
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
| | | | | | - Zeana A Gawe
- Department of Anesthesia, Salmaniya Medical Complex, Manama, BHR
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Thilen SR, Liang T, Kruse TN, Cain KC, Treggiari MM, Bhananker SM. Evaluation of a Protocol for the Management of Maintenance and Reversal of Rocuronium Block Using Neostigmine or Sugammadex. Anesth Analg 2023; 136:1143-1153. [PMID: 37205804 DOI: 10.1213/ane.0000000000006510] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade (PRNB) is defined as an adductor pollicis train-of-four ratio (TOFR) <0.9. It is a common postoperative complication when nondepolarizing muscle relaxants are either not reversed or reversed with neostigmine. PRNB has been reported in 25% to 58% of patients who receive intermediate-acting nondepolarizing muscle relaxants, and it is associated with increased morbidity and decreased patient satisfaction. We conducted a prospective descriptive cohort study during the implementation of a practice guideline that included the selective use of sugammadex or neostigmine. The primary study aim of this pragmatic study was to estimate the incidence of PRNB at arrival to the postanesthesia care unit (PACU) when the practice guideline is followed. METHODS We enrolled patients undergoing orthopedic or abdominal surgery requiring neuromuscular blockade. Rocuronium administration was guided by surgical requirements and based on ideal body weight, with dose reductions for women and/or age >55 years. Only qualitative monitoring was available to the anesthesia providers, and selection of sugammadex or neostigmine was guided by tactile assessments of the response to train-of-four (TOF) stimulation by a peripheral nerve stimulator. Neostigmine was administered if no fade was detected in the TOF response at the thumb. Deeper blocks were reversed with sugammadex. The prespecified primary and secondary end points were the incidence of PRNB at arrival to the PACU, defined as a normalized TOFR (nTOFR) < 0.9, and severe PRNB, defined as nTOFR <0.7 on arrival to the PACU. Anesthesia providers were blinded to all quantitative measurements made by research staff. RESULTS Analysis included 163 patients, and 145 underwent orthopedic and 18 abdominal surgeries. Of the 163 patients, 92 (56%) were reversed with neostigmine and 71 (44%) with sugammadex. The overall incidence of PRNB at PACU arrival was 5 of 163 or 3% (95% confidence interval [CI], 1-7). The incidence of severe PRNB in PACU was 1% (95% CI, 0-4). Three of the 5 subjects with PRNB had TOFR <0.4 at time of reversal but were given neostigmine since anesthesia providers detected no fade by qualitative assessment. CONCLUSIONS The use of a protocol that specifies rocuronium dosing and selective use of sugammadex versus neostigmine based on qualitative assessment of TOF count and fade allowed us to achieve an incidence of PRNB of 3% (95% CI, 1-7) at PACU arrival. Quantitative monitoring may be needed to further reduce this incidence.
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Affiliation(s)
| | - Tinny Liang
- Medicine, University of Washington, Seattle, Washington
| | | | - Kevin C Cain
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
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Lwin NS, Leslie K. Neuromuscular monitoring during general anaesthesia: a review of current national and international guidelines. BJA OPEN 2022; 3:100028. [PMID: 37588583 PMCID: PMC10430869 DOI: 10.1016/j.bjao.2022.100028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/29/2022] [Indexed: 08/18/2023]
Abstract
Background The extent to which neuromuscular monitoring is included in professional anaesthesia society guidelines is unclear. Our aim was to comprehensively review neuromuscular monitoring guidelines published by these societies. Methods National societies were identified using the World Federation of Societies of Anaesthesiologists' member list and further manual searches were undertaken to identify multinational societies and specialist medical colleges. A web search and secondary literature search were conducted to locate guidelines for monitoring during anaesthesia. The income of each nation or group of nations was determined using the World Bank classification. Results Forty guidelines were identified. Of 38 nations or classifiable groups of nations, 25 (66%) were high-income nations and 13 (34%) were middle-income nations. Neuromuscular monitoring was mentioned in 36 (90%) of the 40 guidelines. Availability of neuromuscular monitoring was mentioned in 17 (47%) guidelines (mandated in eight [47%] and recommended in nine [53%]). Use of neuromuscular monitoring was mentioned in 26 (72%) guidelines (mandated in three [12%] and recommended in 23 [88%]). Quantitative neuromuscular monitoring was specified in nine (25%) of the guidelines, with the type of monitoring unspecified in the remaining 27 (75%) of the 36 guidelines. Quantitative monitoring was only mandated in one guideline, and this was only when monitoring equipment was available. Conclusions We identified a gap in the availability of professional anaesthesia society neuromuscular monitoring guidelines, particularly in middle- and low-income nations. Recommendations about availability, use and type of monitoring varied among guidelines. An effort to improve the availability and consistency of guidelines is required.
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Affiliation(s)
- Nyan S. Lwin
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
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Pratyusha AC. Abstract No.: ABS3480 : Dynamometer based hand grip strength as a clinical tool for objective assessment of post-operative residual muscle weakness. Indian J Anaesth 2022. [PMCID: PMC9116797 DOI: 10.4103/0019-5049.340789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background and Aims: Residual neuromuscular block is a known postoperative complication. Even after train of four (TOF) ratio of >0.9, there is a possibility of neuromuscular blockade causing respiratory dysfunction. Primary objective was assessment of postoperative residual muscle weakness with dynamometer. Secondary objective was time of recovery to baseline strength. Methods: This was a single centre, prospective, observational study. We enroled 50 patients undergoing surgery under general anesthesia. The patients of Americal Society of Anesthesiologists physical status I-II, aged 18-60 years and undergoing surgery under general anaesthesia were included. The patients with surgery including fracture, deformity involving dominant upper limb and pre-existing neuromuscular diseases were excluded from the study. Baseline handgrip strength with dynamometer and peak expiratory flow rate (PEFR) were observed before induction of anaesthesia. Trachea was extubated with TOF ratio >0.9. Values monitored at 15 minutes after extubation,at regular intervals of 15 minutes until 1 hour, 30 minutes until 4 hours and hourly until 6 hours. Results: Muscle strength remained 50 to 60% of baseline at 15 minutes, 75% at 45 minutes and reached 100% of baseline at 210 minutes after endotracheal extubation. PEFR remained 50 - 60 % of baseline at 15minutes, 75% of baseline at 60 minutes and reached 100% of baseline at 180 minutes after endotracheal extubation (Table 1). Conclusion: A significant reduction in the postoperative muscle strength was detected using objective force dynamometer to measure handgrip strength even when TOF ratio had returned to 1 with no clinical signs of muscle weakness.
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Reply to: should we use earlier and lower dose administration of sugammadex? Eur J Anaesthesiol 2022; 39:294. [PMID: 35115465 DOI: 10.1097/eja.0000000000001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pratyusha AC, Krishna Prasad C, Sharmila C, Durga P, Sowjanya K, Harika K. Dynamometer based hand grip strength as a clinical tool for objective assessment of post-operative residual muscle weakness. Indian J Anaesth 2022; 66:707-711. [PMID: 36437981 PMCID: PMC9698293 DOI: 10.4103/ija.ija_442_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Background and Aims: Residual neuromuscular block continues to be a significant postoperative complication despite neuromuscular monitoring. This study aims to determine the applicability of a hand-held forced dynamometer for hand grip strength assessment as an objective measure of residual muscle weakness. Methods: The study included patients undergoing surgery under general anaesthesia. A demonstration was given to the patient on the usage of a dynamometer for handgrip strength and a peak expiratory flow meter for peak expiratory flow rate (PEFR) and baseline values were recorded. The parameters were monitored at 15 minutes post-extubation and again at intervals of 15 minutes until one hour, half-hourly until four hours, and hourly until six hours post-operatively. Paired t-test was used for comparison of baseline muscle strength and PEFR with the parameters at different time points. Association between muscle strength and PEFR was tested with the Pearson-correlation test. Results: Muscle strength was 50 to 60%, 75% and 100% of baseline at 15, 45 and 210 minutes after extubation, respectively. PEFR was 50 to 60%, 75% and 100% of baseline at 15, 60 and 180 minutes after extubation. The Pearson-correlation test established a positive correlation between handgrip strength and PEFR (correlation-coefficient 0.86). Conclusion: A significant reduction in the postoperative muscle strength can be detected using an objective forced dynamometer to measure handgrip strength even when train of four count has returned to unity and even when there are no clinical signs of muscle weakness. The residual muscle weakness is significant enough to affect the PEFR in the postoperative period.
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Wong P, Seet E, Kumar CM, Koh KF, Pan TLT, Quah T, Chua NPP. Recommendations for standards of neuromuscular monitoring during anaesthesia. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:852-855. [PMID: 34877589 DOI: 10.47102/annals-acadmedsg.2021159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Patrick Wong
- Department of Anaesthesia, Waikato District Health Board, Hamilton, New Zealand
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