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Schiavoni L, Pascarella G, Grande S, Agrò FE. Neuromuscular block monitoring by smartphone application (i-TOF © system): an observational pilot study. NPJ Digit Med 2020; 3:137. [PMID: 33102788 PMCID: PMC7576770 DOI: 10.1038/s41746-020-00344-w] [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: 01/08/2020] [Accepted: 08/31/2020] [Indexed: 11/18/2022] Open
Abstract
Neuromuscular block monitoring is recommended by international guidelines to improve myorelaxation during surgery and reduce the risk of postoperative residual curarization. We conducted a pilot study to verify the efficacy of i-TOF, a wireless neuromuscular monitoring device connectable to a smartphone, comparing it with TOF WATCH SX. We enrolled 53 patients who underwent general anesthesia. For each patient, we recorded by both devices, in different time intervals, train-of-four (TOF) count/ratio after induction to general anesthesia (TI0-TI3) and during recovery (TR0-TR3). Moreover, post-tetanic count (PTC) was evaluated during deep neuromuscular block (TP0-TP2). We noticed no significant differences between the devices in recorded mean values of TOF ratio, TOF count, and PTC analyzed at time intervals for every phase of general anesthesia, although the i-TOF tends to an underestimation compared to TOF WATCH SX. For each patient, data sessions were successfully recorded by a smartphone. This aspect could be relevant for clinicians in order to have a stored proof of good clinical practice to be added on anesthesiologist records. By our results, i-TOF demonstrates a comparable efficacy to TOF WATCH SX, suggesting that it could be a proven alternative to standard devices for neuromuscular block monitoring. Further studies are needed to confirm our findings.
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Affiliation(s)
- Lorenzo Schiavoni
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Stefania Grande
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Felice Eugenio Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
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A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength. Can J Anaesth 2020; 67:959-969. [PMID: 32405975 DOI: 10.1007/s12630-020-01695-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Residual neuromuscular blockade after surgery is associated with airway obstruction, hypoxia, and respiratory complications. Compared with neostigmine, sugammadex reverses neuromuscular blockade to a train-of-four ratio > 0.9 more rapidly. It is unknown, however, whether the superior reversal profile of sugammadex improves clinically relevant measures of strength in the early postoperative period. METHODS Patients undergoing general, gynecological, or urologic surgery were randomized to receive either neostigmine (70 µg·kg-1, maximum 5 mg) or sugammadex (2 or 4 mg·kg-1) to reverse neuromuscular blockade. The primary outcome was the ability to breathe deeply measured by incentive spirometry at 30, 60, and 120 min after reversal. RESULTS We randomized 62 patients to either a neostigmine (n = 31) or sugammadex (n = 31) group. The incentive spirometry volume recovery trajectory was not different between the two groups (P = 0.35). Median spirometry volumes at baseline, 30, 60, and 120 min postoperatively were 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, and 1800 vs 1950 mL for the sugammadex and neostigmine groups, respectively. Postoperative incentive spirometry decrease from baseline was not different between the two groups. Hand grip strength, the ability to sit unaided, train-of-four ratio on postanesthesia care unit (PACU) admission, time to extubation, time to PACU discharge readiness, and Quality of Recovery-15 scores were also not different between the groups. CONCLUSIONS Measures of postoperative strength, such as incentive spirometry, hand group strength, and the ability to sit up in the early postoperative period were not different in patients who received neostigmine or sugammadex for the reversal of neuromuscular blockade. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02909439); registered: 21 September, 2016.
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Domenech G, Kampel MA, García Guzzo ME, Novas DS, Terrasa SA, Fornari GG. Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study. BMC Anesthesiol 2019; 19:143. [PMID: 31390986 PMCID: PMC6686238 DOI: 10.1186/s12871-019-0817-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 07/29/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Complete avoidance of residual neuromuscular blockade (RNMB) during the postoperative period has not yet been achieved in current anesthesia practice. Evidently, compliance with NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. To our knowledge, no publications have reported the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. METHODS This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit (PACU). Scheduled recovery in the intensive care unit was the only exclusion criterion. RESULTS RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P < 0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. CONCLUSIONS The results of the present study suggest that intra-operative quantitative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.
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Affiliation(s)
- Gonzalo Domenech
- Department of Anesthesiology, Italiano de Buenos Aires Hospital, Presidente Teniente General Juan Domingo Perón 4190, Postal Code, 1199, Buenos Aires, Argentina.
| | - Matías A Kampel
- Department of Anesthesiology, Italiano de Buenos Aires Hospital, Presidente Teniente General Juan Domingo Perón 4190, Postal Code, 1199, Buenos Aires, Argentina
| | - María E García Guzzo
- Department of Anesthesiology, Italiano de Buenos Aires Hospital, Presidente Teniente General Juan Domingo Perón 4190, Postal Code, 1199, Buenos Aires, Argentina
| | - Delfina Sánchez Novas
- Department of Anesthesiology, Italiano de Buenos Aires Hospital, Presidente Teniente General Juan Domingo Perón 4190, Postal Code, 1199, Buenos Aires, Argentina
| | - Sergio A Terrasa
- Department of Research, Italiano de Buenos Aires Hospital, Buenos Aires, Argentina
| | - Gustavo Garcia Fornari
- Department of Anesthesiology, Italiano de Buenos Aires Hospital, Presidente Teniente General Juan Domingo Perón 4190, Postal Code, 1199, Buenos Aires, Argentina
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Unterbuchner C, Blobner M, Pühringer F, Janda M, Bischoff S, Bein B, Schmidt A, Ulm K, Pithamitsis V, Fink H. Development of an algorithm using clinical tests to avoid post-operative residual neuromuscular block. BMC Anesthesiol 2017; 17:101. [PMID: 28778151 PMCID: PMC5545011 DOI: 10.1186/s12871-017-0393-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Quantitative neuromuscular monitoring is the gold standard to detect postoperative residual curarization (PORC). Many anesthesiologists, however, use insensitive, qualitative neuromuscular monitoring or unreliable, clinical tests. Goal of this multicentre, prospective, double-blinded, assessor controlled study was to develop an algorithm of muscle function tests to identify PORC. METHODS After extubation a blinded anesthetist performed eight clinical tests in 165 patients. Test results were correlated to calibrated electromyography train-of-four (TOF) ratio and to a postoperatively applied uncalibrated acceleromyography. A classification and regression tree (CART) was calculated developing the algorithm to identify PORC. This was validated against uncalibrated acceleromyography and tactile judgement of TOF fading in separate 100 patients. RESULTS After eliminating three tests with poor correlation, a model with four tests (r = 0.844) and uncalibrated acceleromyography (r = 0.873) were correlated to electromyographical TOF-values without losing quality of prediction. CART analysis showed that three consecutively performed tests (arm lift, head lift and swallowing or eye opening) can predict electromyographical TOF. Prediction coefficients reveal an advantage of the uncalibrated acceleromyography in terms of specificity to identify the EMG measured train-of-four ratio < 0.7 (100% vs. 42.9%) and <0.9 (89.7% vs. 34.5%) compared to the algorithm. However, due to the high sensitivity of the algorithm (100% vs. 94.4%), the risk to overlook an awake patient with a train-of-four ratio < 0.7 was minimal. Tactile judgement of TOF fading showed poorest sensitivity and specifity at train of four ratio < 0.9 (33.7%, 0%) and <0.7 (18.8%, 16.7%). CONCLUSIONS Residual neuromuscular blockade can be detected by uncalibrated acceleromyography and if not available by a pathway of four clinical muscle function tests in awake patients. The algorithm has a discriminative power comparable to uncalibrated AMG within TOF-values >0.7 and <0.3. TRIAL REGISTRATION Clinical Trials.gov (principal investigator's name: CU, and identifier: NCT03219138) on July 8, 2017.
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Affiliation(s)
- Christoph Unterbuchner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany. .,Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauss-Allee, 11 93051, Regensburg, Germany.
| | - Manfred Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Friedrich Pühringer
- Klinik für Anaesthesiologie und operative Intensivmedizin, Klinikum am Steinenberg, Steinenbergstr. 31, 72764, Reutlingen, Germany
| | - Matthias Janda
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universität Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Sebastian Bischoff
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Berthold Bein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Annette Schmidt
- Klinik für Anaesthesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Kurt Ulm
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Viktor Pithamitsis
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Ismaninger Str. 22, 81675, Munich, Germany
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De Robertis E, Zito Marinosci G, Romano GM, Piazza O, Iannuzzi M, Cirillo F, De Simone S, Servillo G. The use of sugammadex for bariatric surgery: analysis of recovery time from neuromuscular blockade and possible economic impact. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:317-22. [PMID: 27418846 PMCID: PMC4934482 DOI: 10.2147/ceor.s109951] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neuromuscular block (NMB) monitoring and use of reversal agents accelerate the recovery time and improve the workflow in the operating room. We aimed to compare recovery times after sugammadex or neostigmine administration, and estimate the time spent in operating theater and the possible economic impact of a faster recovery, in morbidly obese patients undergoing bariatric surgery. METHODS We conducted a retrospective study that analyzed data from records of morbidly obese patients (body mass index >40 kg/m(2)) undergoing elective laparoscopic bariatric surgery in which sugammadex or neostigmine were used to reverse NMB. Patients were divided in two groups: group 1 (sugammadex group [SUG]) received rocuronium and sugammadex for reversal and group 2 (neostigmine group [NEO]) received either rocuronium or cisatracurium and neostigmine. Data are presented as mean (standard deviation). RESULTS Compared with NEO, SUG group showed shorter times to achieve train-of-four ratio of 0.9 (P<0.05) and an Aldrete score of 10 (P<0.05), a higher cost (€146.7 vs €3.6 [P<0.05]), plus a remarkable less duration of operating theater occupancy (P<0.05). Sugammadex cost accounted for 2.58% of the total cost per surgery, while neostigmine cost accounted for 0.06%. Total time saved in SUG group was 19.4 hours, which could be used to perform 12 extra laparoscopic sleeve gastrectomies. CONCLUSION Reversal from NMB was significantly faster with sugammadex than with neostigmine. Although sugammadex was substantially more expensive, duration of operating theater occupancy was reduced with potentially workflow increase or personnel reduced cost.
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Affiliation(s)
- Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
| | - Geremia Zito Marinosci
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
| | - Giovanni Marco Romano
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
| | - Ornella Piazza
- Department of Medicine and Surgery, University of Salerno, Salerno
| | - Michele Iannuzzi
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
| | - Fabrizio Cirillo
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
| | - Stefania De Simone
- Institute for Research on Innovation and Services for Development, National Research Council, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University Federico II, Naples
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Vymazal T, Krecmerova M, Bicek V, Lischke R. Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patients undergoing surgery - a series of 117 cases. Ther Clin Risk Manag 2015; 11:1593-6. [PMID: 26508869 PMCID: PMC4610805 DOI: 10.2147/tcrm.s93009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Myasthenia gravis (MG) is an autoimmune disease interfering with neuromuscular transmission. Patients are at risk of postoperative residual curarization (PORC) if nondepolarizing muscle relaxants are used. Clinically inapparent insufficient muscle strength may result in hypoventilation and postoperative bronchopneumonia. We describe a cohort of 117 cases in which sugammadex was used in MG patients undergoing surgery with muscle relaxation with rocuronium. Methods and patients We anesthetized 117 patients with MG using rocuronium and sugammadex as neuromuscular blockade reversal agent. One hundred five patients underwent surgical thymectomy and 12 underwent cholecystectomy (five laparotomic and seven laparoscopic). We measured time from sugammadex administration to recovery and to extubation, using the TOF-Watch® (series of four consecutive electrical impulses [the train-of-four] >0.9). We tracked peripheral capillary oxygen saturation (SpO2) <95%, elevation of partial pressure of carbon dioxide (pCO2) >10% above baseline, number of reintubations within the first 48 hours, and number of pneumonias within 120 hours, postoperatively. Results were processed as average, minimum, and maximum values. Results The period needed to reach train-of-four of 0.9 following sugammadex administration was on average 117 seconds (minimum of 105 seconds/maximum of 127 seconds) and differed within deviation <10%. The time to extubation following sugammadex administration was on average 276 seconds (minimum of 251 seconds/maximum of 305 seconds) and differed minimally among patients as well. We observed no SpO2 <95%, no pCO2 elevation >10% above a baseline, no emergent reintubation within the first 48 hours, and no pneumonia diagnosed on clinical basis within 120 hours, postoperatively in all 117 patients. Conclusion In this cohort of MG patients undergoing surgery using rocuronium and sugammadex, we did not observe any signs of postoperative residual curarization and respiratory depression. The neuromuscular blockade recovery was reliable, predictable, and rapid.
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Affiliation(s)
- Tomas Vymazal
- Department of Anaesthesiology and ICM, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Martina Krecmerova
- Department of Anaesthesiology and ICM, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Vladimír Bicek
- Department of Anaesthesiology and ICM, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Robert Lischke
- 3rd Surgical Department of 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Sagir O, Yucesoy Noyan F, Koroglu A, Cicek M, Ilksen Toprak H. Comparison between the Effects of Rocuronium, Vecuronium, and Cisatracurium Using Train-of-Four and Clinical Tests in Elderly Patients. Anesth Pain Med 2013; 2:142-8. [PMID: 24223350 PMCID: PMC3821141 DOI: 10.5812/aapm.8406] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 11/01/2012] [Accepted: 11/20/2012] [Indexed: 11/17/2022] Open
Abstract
Background Postoperative residual blockade, longer duration of action for neuromuscular blockade, and slower recovery were relatively common in elderly patients. Objectives We aimed to investigate the safety of train-of-four ratio and clinical tests in the assessment of patient recovery, and to determine the effects of the rocuronium, vecuronium, and cisatracurium on intubation, extubation and recovery times in elderly patients undergoing abdominal surgery. Patients and Methods After obtaining institutional approval and informed consent, 60 patients over 60 years old and undergoing elective abdominal operations were included in this double-blind, randomized clinical trial. Following a standard anesthesia induction, 0.6mg kg-1 rocuronium, 0.1mg kg-1 vecuronium, and 0.1mg kg-1 cisatracurium were administered to the patients in Group R, Group V, and Group C, respectively. Train-of-four (TOF) ratios were recorded at 10-minute intervals during and after the operation. Modified Aldrete Score (MAS) and clinical tests were recorded in the recovery room at 10-minute intervals. In addition, intubation and extubation times, duration of recovery room stay, and any complications were recorded. Results Intubation time was found to be shorter in Group R than that in Groups V and C (P ˂ 0.001). Times to positive visual disturbances and grip strength tests were shorter in Group C than that in Group V (P = 0.016 and P = 0.011, respectively). In Group R and group C, time to TOF ≥ 0.9 was significantly longer than all positive clinical test times except grip strength (P < 0.05). Conclusions We hold the opinion that cisatracurium is safer in elderly patients compared to other drugs. We also concluded that the usage of TOF ratio together with clinical tests is suitable for assessment of neuromuscular recovery in these patients.
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Affiliation(s)
- Ozlem Sagir
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Balikesir University, Balikesir, Turkey
- Corresponding author: Ozlem Sagir, Department of Anesthesiology and Reanimation, Faculty of Medicine, Balikesir University, Balikesir, Turkey. Tel.: +90-5327609927, Fax: +90-2666121294, E-mail:
| | - Funda Yucesoy Noyan
- Department of Anesthesiology and Reanimation, Yeşilyurt State hospital, Malatya, Turkey
| | - Ahmet Koroglu
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Balikesir University, Balikesir, Turkey
| | - Muslum Cicek
- Department of Anesthesiology and Reanimation, Private Gazi Osmanpaşa Hospital, Istanbul, Turkey
| | - Huseyin Ilksen Toprak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Inonu University, Malatya, Turkey
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