1
|
Voeltzel J, Garnier O, Prades A, Carr J, De Jong A, Molinari N, Jaber S, Chanques G. Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort. Anaesth Crit Care Pain Med 2024; 43:101384. [PMID: 38710326 DOI: 10.1016/j.accpm.2024.101384] [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: 02/02/2024] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population. PATIENTS AND METHODS Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome). RESULTS Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients. CONCLUSIONS ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.
Collapse
Affiliation(s)
- Jules Voeltzel
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Océane Garnier
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Albert Prades
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Julie Carr
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Audrey De Jong
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier La Colombière Hospital, and Institut Montpelliérain Alexander Grothendieck (IMAG), University of Montpellier, CNRS, Montpellier, France
| | - Samir Jaber
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Gerald Chanques
- Department of Anaesthesia & Critical Care Medicine, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France.
| |
Collapse
|
2
|
Lu B, Wei L, Shi G, Du J. Nanotherapeutics for Alleviating Anesthesia-Associated Complications. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2308241. [PMID: 38342603 PMCID: PMC11022745 DOI: 10.1002/advs.202308241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/22/2023] [Indexed: 02/13/2024]
Abstract
Current management of anesthesia-associated complications falls short in terms of both efficacy and safety. Nanomaterials with versatile properties and unique nano-bio interactions hold substantial promise as therapeutics for addressing these complications. This review conducts a thorough examination of the existing nanotherapeutics and highlights the strategies for developing prospective nanomedicines to mitigate anesthetics-related toxicity. Initially, general, regional, and local anesthesia along with the commonly used anesthetics and related prevalent side effects are introduced. Furthermore, employing nanotechnology to prevent and alleviate the complications of anesthetics is systematically demonstrated from three aspects, that is, developing 1) safe nano-formulization for anesthetics; 2) nano-antidotes to sequester overdosed anesthetics and alter their pharmacokinetics; 3) nanomedicines with pharmacodynamic activities to treat anesthetics toxicity. Finally, the prospects and challenges facing the clinical translation of nanotherapeutics for anesthesia-related complications are discussed. This work provides a comprehensive roadmap for developing effective nanotherapeutics to prevent and mitigate anesthesia-associated toxicity, which can potentially revolutionize the management of anesthesia complications.
Collapse
Affiliation(s)
- Bin Lu
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
| | - Ling Wei
- Shanxi Bethune Hospital Center Surgery DepartmentShanxi Academy of Medical SciencesTongji Shanxi HospitalThird Hospital of Shanxi Medical UniversityTaiyuan030032China
| | - Gaoxiang Shi
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
| | - Jiangfeng Du
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
- Department of Medical ImagingShanxi Key Laboratory of Intelligent Imaging and NanomedicineFirst Hospital of Shanxi Medical UniversityTaiyuanShanxi Province030001China
| |
Collapse
|
3
|
Martin-Flores M. Neuromuscular block: Monitoring, reversal, and residual blockade in small animals. Vet Ophthalmol 2023. [PMID: 37248035 DOI: 10.1111/vop.13112] [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: 02/20/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/31/2023]
Abstract
Nondepolarizing neuromuscular blocking agents are used frequently during ophthalmic surgery of dogs and cats. Residual neuromuscular block (NMB)-impaired neuromuscular function at recovery from anesthesia-is a main concern when these agents are used in small animals. In humans, residual NMB reduces the ability to protect the airway (swallow and cough) and increases the incidence of hypoxia and upper airway collapse after recovery from anesthesia. In dogs, impaired neuromuscular function of the larynx can be detected even after common indicators of neuromuscular function suggest that recovery from NMB is complete. Objective monitoring of NMB is a simple, cost-effective strategy to minimize the risk of residual NMB. This review summarizes relevant aspects of monitoring and reversal of NMB, and strategies to minimize the risk of residual NMB in clinical practice of small animals.
Collapse
Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| |
Collapse
|
4
|
Carrillo-Torres O, Pliego-Sánchez MG, Pérez-Muñoz VJ, Sánchez-Jurado J, Camacho-Vacherón V, Carrillo-Ruíz JD. Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study. BMC Anesthesiol 2023; 23:107. [PMID: 37005560 PMCID: PMC10067182 DOI: 10.1186/s12871-023-02027-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/24/2023] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION NMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity. OBJECTIVE To investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00). METHODS We performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old. RESULTS We included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB. CONCLUSIONS The rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.
Collapse
Affiliation(s)
| | | | | | | | | | - José Damián Carrillo-Ruíz
- Research Direction & Neurosurgery Service at Hospital General de México, Mexico City, Mexico.
- Neuroscience Coordination of Psychology Faculty at Mexico Anahuac University, Av. Anahuac 46, Lomas Anahuac, Naucalpan de Juárez, Estado de México, 52786, Mexico.
| |
Collapse
|
5
|
Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13-41. [PMID: 36520073 DOI: 10.1097/aln.0000000000004379] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.
Collapse
|
6
|
Weigel WA, Williams BL, Hanson NA, Blackmore CC, Johnson RL, Nissen GM, James AB, Strodtbeck WM. Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology 2022; 136:901-915. [PMID: 35188958 DOI: 10.1097/aln.0000000000004174] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Wade A Weigel
- Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington
| | - Barbara L Williams
- Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington
| | - Neil A Hanson
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - C Craig Blackmore
- Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington
| | - Randy L Johnson
- Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington
| | - Gary M Nissen
- Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington
| | - Andrew B James
- Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington
| | - Wyndam M Strodtbeck
- Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
7
|
Scherrer NM, Hopster K. Neuromuscular blockade with atracurium for ophthalmic surgery in horses-Effects on surgical and anesthetic characteristics and recovery quality. Vet Ophthalmol 2021; 24:442-446. [PMID: 34402577 DOI: 10.1111/vop.12922] [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: 05/06/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the surgical, anesthetic and recovery qualities of horses receiving either a neuromuscular blocking agent (atracurium) or intravenous lidocaine (treatment groups A and L, respectively). ANIMALS STUDIED A total of thirty horses presented for ocular surgery were used in this study. PROCEDURE Horses were randomly assigned to receive either atracurium (group A) or a lidocaine constant rate infusion (group L). Surgical quality was graded on a scale from 1 (excellent)-5 (poor). While anesthetized, the heart rate, oxygen saturation and mean arterial blood pressure, and end-expiratory carbon dioxide and desflurane concentration were monitored and recorded every 5 minutes. Recovery was scored on a scale from 10 (best)-115 (worst). RESULTS Horses in treatment group A needed significantly less desflurane then horses in treatment group L (p = 0.04). Horses in treatment group A had a significantly better surgery score of 1 (1-2) (median and range) then horses in treatment group L (2.5; 1-5) (p = 0.02). The quality of recovery was significantly better in horses in treatment group A compared with treatment group L, and horses needed significantly less time to reach the standing position. CONCLUSIONS Atracurium and lidocaine CRI are safe methods of anesthesia for equine patients undergoing ocular surgery. Horses receiving atracurium needed less desflurane and had better surgery and recovery scores than horses receiving a lidocaine constant rate infusion.
Collapse
Affiliation(s)
- Nicole M Scherrer
- New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, USA
| | - Klaus Hopster
- New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, USA
| |
Collapse
|
8
|
Azizoğlu M, Özdemir L. Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study. J Patient Saf 2021; 17:352-357. [PMID: 34276037 DOI: 10.1097/pts.0000000000000874] [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: 11/26/2022]
Abstract
OBJECTIVES Postoperative residual neuromuscular block (PRNB) is a serious problem that can cause death after surgery. It was aimed to evaluate the adequacy of neuromuscular block (NMB) during endotracheal intubation and the adequacy of neuromuscular recovery during clinically extubation decision and follow-up with the train-of-four ratio (TOFR) using quantitative monitoring. METHODS This study has a prospective-observational single-blind study design. A total of 205 adult patients who underwent elective surgery, who had American Society of Anesthesiologists physical statuses I to III, and who were intubated with neuromuscular blocking agent under general anesthesia were included in the study. Train-of-four ratio measurements were provided single-blindly by another anesthesiologist outside the team. The TOFRs were measured at the time of intubation (TOFRind), before reversal agent administration (TOFRpre-rev) and after (TOFRpost-rev), at the time of extubation (TOFRext), and on admission to the postoperative care unit (TOFRPACU). If clinical signs of PRNB appeared, the recovery protocol was applied and then TOFRrec was measured. Postoperative respiratory complications were also evaluated for the first 24 hours after surgery. RESULTS Endotracheal intubation was performed in 41.5% of the patients (n = 85) without adequate NMB. In 48.8% (n = 100) of the patients, adequate recovery (TOFRext ˂0.9) was not available at the time of extubation. Adequate TOFRPACU rate was found to be significantly higher in those who did not receive additional neuromuscular blocking agent doses (P < 0.001). In the recovery protocol, low-dose sugammadex administered to patients with clinical signs of PRNB significantly increased the TOFRrec rate compared with neostigmine (P ˂ 0.001). The first 24 hours, postoperative respiratory complication rate was 5.4% (n = 11), and the most common hypoxemia was observed. CONCLUSIONS Approximately half of the patients are intubated without sufficient NMB and extubated without sufficient neuromuscular recovery. This suggests that routine use of quantitative neuromuscular monitoring is necessary for patient safety.
Collapse
Affiliation(s)
- Mustafa Azizoğlu
- From the Department of Anesthesiology and Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
| | | |
Collapse
|
9
|
Martinez-Ubieto J, Aragón-Benedí C, de Pedro J, Cea-Calvo L, Morell A, Jiang Y, Cedillo S, Ramírez-Boix P, Pascual-Bellosta AM. Economic impact of improving patient safety using Sugammadex for routine reversal of neuromuscular blockade in Spain. BMC Anesthesiol 2021; 21:55. [PMID: 33593283 PMCID: PMC7888144 DOI: 10.1186/s12871-021-01248-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background Neuromuscular blocking (NMB) agents are often administered to facilitate tracheal intubation and prevent patient movement during surgical procedures requiring the use of general anesthetics. Incomplete reversal of NMB, can lead to residual NMB, which can increase the risk of post-operative pulmonary complications. Sugammadex is indicated to reverse neuromuscular blockade induced by rocuronium or vecuronium in adults. The aim of this study is to estimate the clinical and economic impact of introducing sugammadex to routine reversal of neuromuscular blockade (NMB) with rocuronium in Spain. Methods A decision analytic model was constructed reflecting a set of procedures using rocuronium that resulted in moderate or deep NMB at the end of the procedure. Two scenarios were considered for 537,931 procedures using NMB agents in Spain in 2015: a scenario without sugammadex versus a scenario with sugammadex. Comparators included neostigmine (plus glycopyrrolate) and no reversal agent. The total costs for the healthcare system were estimated from the net of costs of reversal agents and overall cost offsets via reduction in postoperative pneumonias and atelectasis for which incidence rates were based on a Spanish real-world evidence (RWE) study. The model time horizon was assumed to be one year. Costs were expressed in 2019 euros (€) and estimated from the perspective of a healthcare system. One-way sensitivity analysis was carried out by varying each parameter included in the model within a range of +/− 50%. Results The estimated budget impact of the introduction of sugammadex to the routine reversal of neuromuscular blockade in Spanish hospitals was a net saving of €57.1 million annually. An increase in drug acquisition costs was offset by savings in post-operative pulmonary events, including 4806 post-operative pneumonias and 13,996 cases of atelectasis. The total cost of complications avoided was €70.4 million. All parameters included in the model were tested in sensitivity analysis and were favorable to the scenario with sugammadex. Conclusions This economic analysis shows that sugammadex can potentially lead to cost savings for the reversal of rocuronium-induced moderate or profound NMB compared to no reversal and reversal with neostigmine in the Spanish health care setting. The economic model was based on data obtained from Spain and from assumptions from clinical practice and may not be valid for other countries.
Collapse
Affiliation(s)
| | | | | | | | - A Morell
- Hospital Universitario de la Princesa, Madrid, Spain
| | - Y Jiang
- MSD Ltd., Hoddesdon, Hertfordshire, UK
| | - S Cedillo
- Covance Clinical Development, Madrid, Spain
| | | | | |
Collapse
|
10
|
Carvalho H, Verdonck M, Cools W, Geerts L, Forget P, Poelaert J. Forty years of neuromuscular monitoring and postoperative residual curarisation: a meta-analysis and evaluation of confidence in network meta-analysis. Br J Anaesth 2020; 125:466-482. [DOI: 10.1016/j.bja.2020.05.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 05/06/2020] [Accepted: 05/10/2020] [Indexed: 12/16/2022] Open
|
11
|
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]
|
12
|
Cautionary findings for motor evoked potential monitoring in intracranial aneurysm surgery after a single administration of rocuronium to facilitate tracheal intubation. J Clin Monit Comput 2020; 35:903-911. [PMID: 32617848 DOI: 10.1007/s10877-020-00551-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
Administration of rocuronium to facilitate intubation has traditionally been regarded as acceptable for intraoperative motor evoked potential (MEP) monitoring because of sufficiently rapid spontaneous neuromuscular blockade recovery. We hypothesized that residual neuromuscular blockade, in an amount that could hinder optimal neuromonitoring in patients undergoing intracranial aneurysm clipping, was still present at dural opening. We sought to identify how often this was occurring and to identify factors which may contribute to prolonged blockade. Records of 97 patients were retrospectively analyzed. Rocuronium was administered to facilitate intubation with no additional neuromuscular blockade given. Prolonged spontaneous recovery time to a train-of-four (TOF) ratio of 0.75 after rocuronium administration was defined as 120 min, which was approximately when dural opening and the setting of baseline MEPs were occurring. Logistic regression analysis was used to identify factors related to prolonged spontaneous recovery time. Prolonged spontaneous recovery time to a TOF ratio of 0.75 was observed in 44.3% of patients. Multivariable analysis showed that only the dosage of rocuronium based on ideal body weight had a positive correlation with prolonged spontaneous recovery time (P = 0.01). There was no significant association between dosage of rocuronium based on total body weight, age, sex, or body temperature and prolonged recovery time. This study demonstrates that the duration of relaxation for MEP monitoring purposes is well-beyond the routinely recognized clinical duration of rocuronium. Residual neuromuscular blockade could result in lower amplitude MEP signals and/or lead to higher required MEP stimulus intensities which can both compromise monitoring sensitivity.
Collapse
|
13
|
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: 19] [Impact Index Per Article: 4.8] [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.
Collapse
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.
| |
Collapse
|
14
|
Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
Collapse
Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| |
Collapse
|
15
|
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.
Collapse
|
16
|
Soto R. Incidence and Risk Factors for Postoperative Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
17
|
An J, Lee JH, Kim E, Woo K, Kim H, Lee D. Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: A prospective randomized study. Medicine (Baltimore) 2020; 99:e19130. [PMID: 32049831 PMCID: PMC7035047 DOI: 10.1097/md.0000000000019130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. This study compared efficacy of sugammadex and pyridostigmine for reversal of rocuronium-induced light block or minimal block in children scheduled for elective entropion surgery. METHODS A prospective randomized study was conducted on 60 pediatric patients aged 1 to 11 years and scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using train-of-four (TOF) ulnar nerve stimulation. Patients were randomly assigned to 2 groups receiving sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg plus glycopyrrolate 0.01 mg/kg. Primary outcomes were time from reversal agents administration to TOF ratio 0.9 and time from reversal agent administration to TOF ratio 1.0. Time from TOF ratio 0.9 to extubation, time from TOF ratio 1.0 to extubation, and postoperative adverse events were also recorded. RESULTS There were no substantial differences in demographic variables. Time from reversal agents administration to TOF ratio 0.9 and time from reversal agents to TOF ratio 1.0 were significantly faster in sugammadex group: 1.30 ± 0.84 versus 3.53 ± 2.73 minutes (P < .001) and 2.75 ± 1.00 versus 5.73 ± 2.83 minutes (P < .001). Extubation time was shorter in sugammadex group. Incidence of skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction) was not statistically different between groups. Incidence of patients agitation in recovery room was lower in sugammadex group. CONCLUSION Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery lasting 30 to 60 minutes than did pyridostigmine plus glycopyrrolate, with no differences in incidence of adverse events between groups.
Collapse
|
18
|
Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
Collapse
Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Saager L, Maiese EM, Bash LD, Meyer TA, Minkowitz H, Groudine S, Philip BK, Tanaka P, Gan TJ, Rodriguez-Blanco Y, Soto R, Heisel O. Incidence, risk factors, and consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study. J Clin Anesth 2019; 55:33-41. [DOI: 10.1016/j.jclinane.2018.12.042] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/16/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
|
21
|
Effect of systemic lidocaine infusion on train-of-four ratios during recovery from general anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Differences of Recovery from Rocuronium-induced Deep Paralysis in Response to Small Doses of Sugammadex between Elderly and Nonelderly Patients. Anesthesiology 2018; 129:901-911. [DOI: 10.1097/aln.0000000000002412] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Editor’s Perspective
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.
Collapse
|
24
|
Quantitative Relationships between Pulmonary Function and Residual Neuromuscular Blockade. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9491750. [PMID: 29662906 PMCID: PMC5832181 DOI: 10.1155/2018/9491750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/09/2018] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
Background Neuromuscular blockade is a risk factor for postoperative respiratory weakness during the immediate postoperative period. The quantitative relationships between postoperative pulmonary-function impairment and residual neuromuscular blockade are unknown. Methods 113 patients who underwent elective laparoscopic cholecystectomy were enrolled in this study. They all had a pulmonary-function test (PFT) during the preoperative evaluation. Predictive values based on demographic data were also recorded. The train-of-four ratio (TOFR) was recorded at the same time as the PFT and at every 5 minutes in the qualified 98 patients in the postanesthesia care unit (PACU). We analyzed the degree of PFT recovery when the TOFR had recovered to different degrees. Results There was a significant difference (P < 0.05) between the preoperative baseline value and the postoperative forced vital capacity at each TOFR point, except at a TOFR value of 1.1. There was also a significant difference (P < 0.05) between the preoperative baseline value and the postoperative peak expiratory flow at each TOFR point. Conclusions Postoperative residual neuromuscular blockade was common (75.51%) after tracheal extubation, and pulmonary function could not recover to an acceptable level (85% of baseline value), even if TOFR had recovered to 0.90. Trial Registration Chinese Clinical Trial Register is ChiCTR-OOC-15005838.
Collapse
|
25
|
Adembesa I, Mung'ayi V, Premji Z, Kamya D. A randomized control trial comparing train of four ratio > 0.9 to clinical assessment of return of neuromuscular function before endotracheal extubation on critical respiratory events in adult patients undergoing elective surgery at a tertiary hospital in Nairobi. Afr Health Sci 2018; 18:807-816. [PMID: 30603015 PMCID: PMC6306997 DOI: 10.4314/ahs.v18i3.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is increasing evidence that the incidence of postoperative residual paresis after using neuromuscular blockers ranges from 24 to 50% in post anaesthesia care unit (PACU) and is associated with postoperative complications such as critical respiratory events as evidenced by hypoxia, hypoventilation and upper airway obstruction. Quantitative neuromuscular monitoring (such as the assessment of Train of four (TOF) ratio) and reversal of neuromuscular blockers has been shown to reduce postoperative residual paresis. There are very few outcome studies on effect of residual paresis in PACU. There is a paucity of published randomized controlled trials investigating whether using a TOF ratio ≥0.9 before endotracheal extubation compared to clinical assessment of return of neuromuscular function reduces the incidence of critical respiratory events in PACU. OBJECTIVE To determine whether using TOF ratio ≥ 0.9 compared to clinical assessment of return of neuromuscular function before endotracheal extubation reduces the incidence of critical respiratory events in PACU. METHODS Onehundred sixty eight adult patients in ASA physical status I and II requiring general anaesthesia for elective surgery with cisatracurium as the muscle relaxant were randomized into 2 groups of 84 each. Group 1 were patients who required a TOF ratio of ≥0.9 before extubation. Group 2 patients were extubated based on clinical assessment of return of adequate neuromuscular function by the anaesthetist as is the standard of practice at the Aga Khan University hospital Nairobi. General anaesthesia was standardized in both groups. Both the investigators and patients were blinded during the study.Once the patient was transferred to PACU, oxygen saturation (SP02), respiratory rate and any signs of upper airway obstruction as demonstrated by stridor, laryngospasms or requirement of any airway manipulation was recorded for the first 30 minutes. Duration of anaesthesia and surgery was also recorded. Patient demographics were recorded and analyzed. RESULTS There was no statistical difference between the 2 groups in terms of patient demographics, duration of surgery and anaesthesia and duration since last muscle relaxant was given. In terms of hypoxia on arrival in PACU, the incidence of mild hypoxia (SPO2 90-93%) was 11% in clinical assessment groupversus 5% in TOF group P-value 0.149 while severe hypoxia (SPO2 <90%) was 19% versus 10% P-value 0.078. During the first 30 minutes in PACU, the incidence of mild hypoxia (SPO2 90-93%) was statistically significant between the 2 groups (12% in clinical assessment group versus 1% in TOF group, P-value 0.005) while severe hypoxia (SPO2 <90%) was 7% versus 5%, P-value 0.373. The incidence of upper airway obstruction was statistically significant between the two groups (45% in clinical assessment group versus 14% in TOF group P-value<0.0001 for patients requiring airway maneuver, 21% versus 2% P-value <0.0001 for those who required tactile stimulation and 31% versus 12% were snoring, P-value 0.003. Logistic regression analysis revealed TOF group was less likely associated with mild hypoxia (OR 0.09 95% CI 0.01-0.71 P-value 0.023), tactile stimulation (OR 0.09 95% CI 0.02-0.40 P-value 0.002), airway maneuver (OR 0.20 95% CI 0.10-0.43 P-value <0.001) and snoring (OR 0.30 95% CI 0.13-0.68 P-value 0.04). CONCLUSION Among this population, there is a lower incidence of critical respiratory events in PACU with the use of neuromuscular monitoring using TOF ratio ≥0.9 to assess neuromuscular function before endotracheal extubation compared with the use of clinical assessment methods.
Collapse
Affiliation(s)
- Isaac Adembesa
- Department of Anaesthesia, Aga Khan University, East Africa
| | | | | | - Dorothy Kamya
- Department of Anaesthesia, Aga Khan University, East Africa
| |
Collapse
|
26
|
Thilen S, Ng I, Cain K, Treggiari M, Bhananker S. Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine. Br J Anaesth 2018; 121:367-377. [DOI: 10.1016/j.bja.2018.03.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/29/2018] [Accepted: 03/31/2018] [Indexed: 12/20/2022] Open
|
27
|
Hafeez KR, Tuteja A, Singh M, Wong DT, Nagappa M, Chung F, Wong J. Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnea patients: a systematic review. BMC Anesthesiol 2018; 18:91. [PMID: 30025517 PMCID: PMC6053808 DOI: 10.1186/s12871-018-0549-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/24/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neuromuscular blocking drugs (NMBD) are administered intra-operatively to facilitate intubation and to achieve muscle relaxation for surgical procedures. Incomplete reversal of NMBD can lead to adverse events in the postoperative period. Patients with obstructive sleep apnea (OSA) may be at higher risk of complications related to the use of NMBD. The objectives of this systematic review were to determine whether: 1) OSA patients are at higher risk of postoperative complications from the use of NMBD than non-OSA patients, and 2) the choice of NMBD reversal agent affects the risk of postoperative complications in OSA patients. METHODS A literature search of multiple databases was conducted up to April 2017. The inclusion criteria were: (1) adult surgical patients (≥18 years old) with OSA diagnosed by polysomnography, or history, or suspected by screening questionnaire; (2) patients who were given NMBD and/or NMBD reversal agents intraoperatively; (3) reports on postoperative adverse events, particularly respiratory events were available; (4) published studies were in English; and (5) RCTs or observational cohort studies. The quality of evidence was determined by the Oxford Center for Evidence Based Medicine levels of evidence. RESULTS Out of 4123 studies, five studies (2 RCTs and 3 observational studies) including 1126 patients were deemed eligible. These studies were heterogeneous precluding a meta-analysis of the results. Two of three studies (1 RCT, 2 observational studies) reported that OSA patients given NMBD may be at higher risk of developing postoperative pulmonary complications (PPCs) like hypoxemia, residual neuromuscular blockade or respiratory failure compared to non-OSA patients. Two studies (1 RCT, 1 observational study) reported that OSA patients who were reversed with sugammadex vs. neostigmine had less PPCs and chest radiographic changes, but the quality of the included studies was Oxford level of evidence: low to moderate. CONCLUSIONS OSA patients who receive intraoperative NMBD may be at higher risk for postoperative hypoxemia, respiratory failure and residual neuromuscular blockade compared to non-OSA patients. There is some, albeit very limited evidence that NMBD reversal with sugammadex may be associated with less PPCs than neostigmine in patients with OSA. More high-quality studies are needed.
Collapse
Affiliation(s)
- Khawaja Rashid Hafeez
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
| | - Arvind Tuteja
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
| | - Mandeep Singh
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
- Department of Anesthesia, Women’s College Hospital, Toronto, ON Canada
- Toronto Sleep and Pulmonary Center, Toronto, ON Canada
| | - David T. Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
| | - Mahesh Nagappa
- Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph’s Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph’s Health Care, Western University, London, ON Canada
| | - Frances Chung
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 2-405 McLaughlin Wing, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
- Department of Anesthesia, Women’s College Hospital, Toronto, ON Canada
| |
Collapse
|
28
|
Zafirova Z, Dalton A. Neuromuscular blockers and reversal agents and their impact on anesthesia practice. Best Pract Res Clin Anaesthesiol 2018; 32:203-211. [PMID: 30322460 DOI: 10.1016/j.bpa.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/22/2018] [Indexed: 12/17/2022]
Abstract
Neuromuscular blockers have long been an intricate part of the anesthesia regimen. The scientific progress in pharmacology and physiology has strengthened their clinical relevance, has helped to delineate with precision their medical role, and has enhanced the safety and effectiveness of their use. New frontiers in research will define further the role of these agents in modern anesthesia practice and guide their expanding and discrete clinical applications.
Collapse
Affiliation(s)
- Zdravka Zafirova
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai Hospital System, 321 West 37 St, ap. 5A, New York, NY, 10018, USA.
| | - Allison Dalton
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, USA.
| |
Collapse
|
29
|
Paech MJ, Kaye R, Baber C, Nathan EA. Recovery characteristics of patients receiving either sugammadex or neostigmine and glycopyrrolate for reversal of neuromuscular block: a randomised controlled trial. Anaesthesia 2017; 73:340-347. [PMID: 29214645 DOI: 10.1111/anae.14174] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2017] [Indexed: 11/30/2022]
Abstract
Sugammadex more rapidly and reliably reverses rocuronium-induced neuromuscular block compared with neostigmine, but it is not known if subsequent patient outcomes, including nausea, vomiting and other aspects of recovery are modified. In this study, we compared the recovery characteristics of sugammadex and neostigmine/glycopyrrolate following reversal of neuromuscular block. This was a single-centre, randomised, blinded, parallel-group clinical trial in women undergoing elective day-surgical laparoscopic gynaecological surgery, with a standardised general anaesthesia regimen that included rocuronium. Neuromuscular block was reversed with either sugammadex 2 mg.kg-1 or neostigmine 40 μg.kg-1 and glycopyrrolate 400 μg. The primary outcome was the incidence of nausea and vomiting during the first six postoperative hours. Secondary outcomes included other measures of postoperative recovery such as patient symptoms and recovery scores. Three-hundred and four women were analysed by intention-to-treat (sugammadex n = 151, neostigmine n = 153), which included four major protocol violations. There was no significant difference between sugammadex and neostigmine groups in the incidence of early nausea and vomiting (49.0% vs. 51.0%, respectively; OR 0.92, 95%CI 0.59-1.45; p = 0.731). Double vision (11.5% vs. 20.0%; p = 0.044) and dry mouth (71.6% vs. 85.5%; p = 0.003) were less common after sugammadex. Sedation scores at 2 h were also lower after sugammadex (median (IQR [range]) 0 (0-3 [0-10]) vs. 2 (0-4.[0-10]); p = 0.021). Twenty-four-hour recovery scores were not significantly different between groups. Reversal with sugammadex in this patient population did not reduce postoperative nausea or vomiting compared with neostigmine/glycopyrrolate.
Collapse
Affiliation(s)
- M J Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, Perth, Australia
| | - R Kaye
- Department of Anaesthesia, Stoke Mandeville Hospital, Aylesbury, UK
| | - C Baber
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Australia
| | - E A Nathan
- School of Women's and Infants' Health, University of Western Australia, Perth, Australia
| |
Collapse
|
30
|
Recovery and prediction of postoperative muscle power - is it still a problem? BMC Anesthesiol 2017; 17:108. [PMID: 28830363 PMCID: PMC5568091 DOI: 10.1186/s12871-017-0402-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/14/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the postoperative period, immediate recovery of muscular power is essential for patient safety, but this can be affected by anaesthetic drugs, opioids and neuromuscular blocking agents (NMBA). In this cohort study, we evaluated anaesthetic and patient-related factors contributing to reduced postoperative muscle power and pulse oximetric saturation. METHODS We prospectively observed 615 patients scheduled for minor surgery. Premedication, general anaesthesia and respiratory settings were standardized according to standard operating procedures (SOP). If NMBAs were administered, neuromuscular monitoring was applied to establish a Train of four (TOF)-Ratio of >0.9 before extubation. After achieving a modified fast track score > 10 at 4 time points up to 2 h postoperatively, we measured pulse oximetric saturation and also static and dynamic muscle power, using a high precision digital force gauge. Loss of muscle power in relation to the individual preoperative baseline value was analysed in relation to patient and anaesthesia-related factors using the T-test, simple and multiple stepwise regression analysis. RESULTS Despite having achieved a TOF ratio of >0.9 a decrease in postoperative muscle power was detectable in most patients and correlated with reduced postoperative pulse oximetric saturation. Independent contributing factors were use of neuromuscular blocking agents (p < 0.001), female gender (p = 0.001), TIVA (p = 0.018) and duration of anaesthesia >120 min (p = 0.019). CONCLUSION Significant loss of muscle power and reduced pulse oximetric saturation are often present despite a TOF-Ratio > 0.9. Gender differences are also significant. A modified fast track score > 10 failed to predict recovery of muscle power in most patients. TRIAL REGISTRATION German Clinical Trial Register DRKS-ID DRKS00006032 ; Registered: 2014/04/03.
Collapse
|
31
|
Liu G, Wang R, Yan Y, Fan L, Xue J, Wang T. The efficacy and safety of sugammadex for reversing postoperative residual neuromuscular blockade in pediatric patients: A systematic review. Sci Rep 2017; 7:5724. [PMID: 28720838 PMCID: PMC5515941 DOI: 10.1038/s41598-017-06159-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 05/24/2017] [Indexed: 12/17/2022] Open
Abstract
The aim of this study is to evaluate the efficacy and safety of sugammadex for reversing neuromuscular blockade in pediatric patients. MEDLINE and other three Databases were searched. Randomized clinical trials were included if they compared sugammadex with neostigmine or placebo in pediatric patients undergoing surgery involving the use of rocuronium or vecuronium. The primary outcome was the time interval from administration of reversal agents to train-of-four ratio (TOFr, T4/T1) > 0.9. Incidences of any drug-related adverse events were secondary outcomes. Trial inclusion, data extraction, and risk of bias assessment were performed independently. Mean difference and relative risk were used as summary statistics with random effects models. Statistical heterogeneity was assessed by the I2 statistic. Funnel plot was used to detect publication bias. Ten studies with 580 participants were included. Although considerable heterogeneity (I2 = 98.5%) was detected in primary outcome, the results suggested that, compared with placebo or neostigmine, sugammadex can reverse rocuronium-induced neuromuscular blockade more rapidly with lower incidence of bradycardia. No significant differences were found in the incidences of other adverse events. Compared with neostigmine or placebo, sugammadex may reverse rocuronium-induced neuromuscular blockade in pediatric patients rapidly and safely.
Collapse
Affiliation(s)
- Guangyu Liu
- Department of Anesthesiology, Peking University First Hospital, Beijing, 100035, China
| | - Rui Wang
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yanhong Yan
- Department of Anesthesiology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, 100730, China
| | - Long Fan
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Jixiu Xue
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China.
| |
Collapse
|
32
|
Risk of Postoperative Pneumonia with Neuromuscular Blockade: Keep It Simple! Anesthesiology 2017. [DOI: 10.1097/aln.0000000000001696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Feltracco P, Tonetti T, Barbieri S, Frigo AC, Ori C. Cisatracurium- and rocuronium-associated residual neuromuscular dysfunction under intraoperative neuromuscular monitoring and postoperative neostigmine reversal: a single-blind randomized trial. J Clin Anesth 2016; 35:198-204. [DOI: 10.1016/j.jclinane.2016.07.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/06/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
|
34
|
Insinga RP, Joyal C, Goyette A, Galarneau A. A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada. BMC Anesthesiol 2016; 16:114. [PMID: 27852231 PMCID: PMC5112647 DOI: 10.1186/s12871-016-0281-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/08/2016] [Indexed: 12/18/2022] Open
Abstract
Background The objective of this analysis is to explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex (Bridion™, Merck & Co., Inc., Kenilworth, NJ USA) versus neostigmine for neuromuscular block reversal in Canada. Methods A discrete event simulation (DES) model was developed to compare ORs using either neostigmine or sugammadex for NMB reversal over one month. Selected inputs included OR procedure and turnover times, hospital policies for paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use. Trials show sugammadex’s impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four ratio ≥0.9) is verified prior to extubation in the OR. Scenarios were therefore evaluated reflecting varied assumptions for neuromuscular reversal practices. Results With use of moderate neuromuscular block, when full neuromuscular recovery is verified prior to extubation (93 procedures performed with sugammadex, 91 with neostigmine), use of sugammadex versus neostigmine avoided 2.4 procedural cancellations due to OR time over-run and 33.5 h of paid staff overtime, while saving an average of 62 min per OR day. No difference was observed between comparators for these endpoints in the scenario when full neuromuscular recovery was not verified prior to extubation, however, per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 51 cases prevented), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (23 cases avoided). Sugammadex impact in reversing deep neuromuscular block was evaluated in an exploratory analysis. When it was hypothetically assumed that 30 min of OR time were saved per procedure, the number of paid hours of staff over-time dropped from 84.1 to 32.0, with a 93% reduction in the per patient risk of residual blockade. Conclusions In clinical practice within Canada, for the majority of patients currently managed with moderate neuromuscular block, the principal impact of substituting sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications. For patients maintained at a deep level of block to the end of the procedure, sugammadex is likely to both enhance OR efficiency and reduce residual block complications. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0281-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ralph P Insinga
- Department of Predictive & Economic Modeling, Merck & Co., Inc, PO Box 1000, UG1CD-32, North Wales, PA, 19454-1099, USA.
| | - Cédric Joyal
- Department of Health Economics and Observational Research, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
| | - Alexandra Goyette
- Department of Health Economics and Observational Research, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
| | - André Galarneau
- Department of Medical Affairs, 16750 Transcanada Highway, Merck Canada, Kirkland, Québec, H9H 4M7, Canada
| |
Collapse
|
35
|
Invernizzi JRR, Gopalan PD. Postoperative neuromuscular function following non-depolarising muscle blockade in patients at Inkosi Albert Luthuli Central Hospital, Durban. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2016. [DOI: 10.1080/22201181.2016.1201293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
36
|
Postoperative residual paralysis in patients aged over 65 years old at the Post-Anesthesia Care Unit. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
37
|
González-Cárdenas VH, Salazar-Ramírez KJ, Coral-Sánchez GT. Relajación residual postoperatoria en pacientes mayores de 65 años en la Unidad de Cuidado Postanestésico. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
38
|
Thilen SR, Bhananker SM. Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2016; 6:164-169. [PMID: 27524943 PMCID: PMC4963456 DOI: 10.1007/s40140-016-0155-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review provides recommendations for anesthesia providers who may not yet have quantitative monitoring and sugammadex available and thus are providing care within the limitations of a conventional peripheral nerve stimulator (PNS) and neostigmine. In order to achieve best results, the provider needs to understand the limitations of the PNS. The PNS should be applied properly and early. All overdosing of neuromuscular blocking drugs should be avoided and the intraoperative neuromuscular blockade should be maintained only as deep as necessary. The adductor pollicis is the gold standard site and must be used for the pre-reversal assessment, also when the ulnar nerve and thumb were not accessible intraoperatively. Spontaneous recovery should be maximized and neostigmine should be administered after a TOF count of 4 has been confirmed at the adductor pollicis. Extubation should not occur within 10 min after administration of an appropriate dose of neostigmine.
Collapse
Affiliation(s)
- Stephan R. Thilen
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Ave, Box 359724, Seattle, WA 98104 USA
| | - Sanjay M. Bhananker
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Ave, Box 359724, Seattle, WA 98104 USA
| |
Collapse
|
39
|
Aytac I, Postaci A, Aytac B, Sacan O, Alay GH, Celik B, Kahveci K, Dikmen B. Pesquisa de curarização residual no pós‐operatório, eventos respiratórios agudos e abordagem de anestesiologistas. Braz J Anesthesiol 2016. [DOI: 10.1016/j.bjan.2012.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
40
|
Yu B, Ouyang B, Ge S, Luo Y, Li J, Ni D, Hu S, Xu H, Liu J, Min S, Li L, Ma Z, Xie K, Miao C, Wu X. Incidence of postoperative residual neuromuscular blockade after general anesthesia: a prospective, multicenter, anesthetist-blind, observational study. Curr Med Res Opin 2016; 32:1-9. [PMID: 26452561 DOI: 10.1185/03007995.2015.1103213] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Evidences demonstrate that postoperative residual neuromuscular blockade (rNMB) is a primary and frequent anesthetic risk factor for postoperative complications. This study was designed to mitigate the paucity of data regarding the occurrence and degree of rNMB in a real-life setting. METHODS This prospective, multicenter, anesthetist-blind, observational study enrolled 1571 Chinese adults undergoing elective open or laparoscopic abdominal surgery lasting ≤4 hours from 32 hospitals across China. The patients received anesthesia in accordance with routine practice at the study site. Neuromuscular blockade (NMB) was monitored using acceleromyography, with rNMB defined as a train-of-four (TOF) ratio <0.9. RESULTS The patients' mean age was 46 years and 71% were female. The procedures included laparoscopic (67%), open abdominal (31%), and laparoscopic to open abdominal (2%). NMB was reversed with neostigmine in 78% of patients. The overall incidence of rNMB at extubation was 57.8%, and the proportions of participant with TOF ratios <0.6, 0.6-0.7, 0.7-0.8, 0.8-0.9 were 22.9%, 6.9%, 11.1% and 16.9%, respectively, immediately prior to endotracheal extubation. Age <45 years (OR = 0.630, 95% CI = 0.496-0.801, p = 0.002), use of one neuromuscular blocking agent (NMBA) (OR = 0.387, 95% CI = 0.243-0.618, p < 0.0001), time from neostigmine administration to endotracheal extubation ≥10 min (OR = 0.513, 95% CI = 0.400-0.658, p < 0.0001) and time from last NMBA administration to endotracheal extubation ≥60 min (OR = 0.902, 95% CI = 0.801-0.989, p = 0411) were correlated with non-rNMB at the time of extubation. CONCLUSIONS This observational study demonstrated that the overall incidence of rNMB at the time of endotracheal extubation was high in Chinese patients undergoing abdominal procedures, which necessitates appropriate management in current real-life practice. CLINICAL TRIAL REGISTRY NUMBER NCT01871064.
Collapse
Affiliation(s)
- Buwei Yu
- a a Department of Anesthesiology , Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Baoyi Ouyang
- b b The First Affiliated hospital of Guangzhou Medical University , Guangzhou , China
| | - Shengjin Ge
- c c Zhongshan Hospital of Fudan University , Shanghai , China
| | - Yan Luo
- a a Department of Anesthesiology , Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Jun Li
- d d The Second Affiliated Hospital of Wenzhou Medical College , Wenzhou , China
| | - Dongmei Ni
- e e Peking University First Hospital , Beijing , China
| | - Shuangfei Hu
- f f Zhejiang Provincial People's Hospital , Hangzhou , China
| | - Hui Xu
- g g Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology , Wuhan , China
| | - Jin Liu
- h h West China Hospital, West China School of Medicine, Sichuan University , Chengdu , China
| | - Su Min
- i i The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Longyun Li
- j j China-Japan Union Hospital, Jilin University , Changchun , China
| | - Zhengliang Ma
- k k Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School , Nanjing , China
| | - Kangjie Xie
- l l Zhejiang Cancer Hospital , Hangzhou , China
| | - Changhong Miao
- m m Fudan University Shanghai Cancer Center , Shanghai , China
| | - Xinmin Wu
- e e Peking University First Hospital , Beijing , China
| |
Collapse
|
41
|
Postoperative residual paralysis in patients aged over 65 years old at the Post-Anesthesia Care Unit☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644030-00005] [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] Open
|
42
|
Fortier LP, McKeen D, Turner K, de Médicis É, Warriner B, Jones PM, Chaput A, Pouliot JF, Galarneau A. The RECITE Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade. Anesth Analg 2015; 121:366-72. [PMID: 25902322 DOI: 10.1213/ane.0000000000000757] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade (NMB), defined as a train-of-four (TOF) ratio of <0.9, is an established risk factor for critical postoperative respiratory events and increased morbidity. At present, little is known about the occurrence of residual NMB in Canada. The RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study was a prospective observational study at 8 hospitals in Canada investigating the incidence and severity of residual NMB. METHODS Adult patients undergoing open or laparoscopic abdominal surgery expected to last <4 hours, ASA physical status I-III, and scheduled for general anesthesia with at least 1 dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of neuromuscular relaxation were enrolled in the study. Neuromuscular function was assessed using acceleromyography with the TOF-Watch SX. All reported TOF ratios were normalized to the baseline values. The attending anesthesiologist and all other observers were blinded to the TOF ratio (T4/T1) results. The primary and secondary objectives were to determine the incidence and severity of residual NMB (TOF ratio <0.9) just before tracheal extubation and at arrival at the postanesthesia care unit (PACU). RESULTS Three hundred and two participants were enrolled. Data were available for 241 patients at tracheal extubation and for 207 patients at PACU arrival. Rocuronium was the NMB agent used in 99% of cases. Neostigmine was used for reversal of NMB in 73.9% and 72.0% of patients with TE and PACU data, respectively. The incidence of residual NMB was 63.5% (95% confidence interval, 57.4%-69.6%) at tracheal extubation and 56.5% (95% confidence interval, 49.8%-63.3%) at arrival at the PACU. In an exploratory analysis, no statistically significant differences were observed in the incidence of residual NMB according to gender, age, body mass index, ASA physical status, type of surgery, or comorbidities (all P > 0.13). CONCLUSIONS Residual paralysis is common at tracheal extubation and PACU arrival, despite qualitative neuromuscular monitoring and the use of neostigmine. More effective detection and management of NMB is needed to reduce the risks associated with residual NMB.
Collapse
Affiliation(s)
- Louis-Philippe Fortier
- From the *Département d'Anesthésie, Hôpital Maisonneuve-Rosemont Centre Affilié Université de Montréal, Montréal, Canada; †Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Canada; Department of ‡Anesthesiology and Perioperative Care and §Community Health and Epidemiology, Queen's University, Kingston, Canada; ∥Départment d'Anesthésie, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada; ¶Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada; Departments of #Anesthesia and Perioperative Medicine and **Epidemiology and Biostatistics, University of Western Ontario, London, Canada; ††Department of Anesthesiology, University of Ottawa, Ottawa, Canada; and ‡‡Merck Canada, Kirkland, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
|
44
|
Comparison of train-of-four count by anesthesia providers versus TOF-Watch® SX: a prospective cohort study. Can J Anaesth 2015. [DOI: 10.1007/s12630-015-0433-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
45
|
Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications. Anesthesiology 2015; 122:1201-13. [DOI: 10.1097/aln.0000000000000674] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background:
Duration of action increases with repeated administration of neuromuscular-blocking agents, and intraoperative use of high doses of neuromuscular-blocking agent may affect respiratory safety.
Methods:
In a hospital-based registry study on 48,499 patients who received intermediate-acting neuromuscular-blocking agents, the authors tested the primary hypothesis that neuromuscular-blocking agents are dose dependently associated with the risk of postoperative respiratory complications. In the secondary analysis, the authors evaluated the association between neostigmine dose given for reversal of neuromuscular-blocking agents and respiratory complications. Post hoc, the authors evaluated the effects of appropriate neostigmine reversal (neostigmine ≤60 μg/kg after recovery of train-of-four count of 2) on respiratory complications. The authors controlled for patient-, anesthesia-, and surgical complexity–related risk factors.
Results:
High doses of neuromuscular-blocking agents were associated with an increased risk of postoperative respiratory complications (n = 644) compared with low doses (n = 205) (odds ratio [OR], 1.28; 95% CI, 1.04 to 1.57). Neostigmine was associated with a dose-dependent increase in the risk of postoperative respiratory complications (OR, 1.51; 95% CI, 1.25 to 1.83). Post hoc analysis revealed that appropriate neostigmine reversal eliminated the dose-dependent association between neuromuscular-blocking agents and respiratory complications (for neuromuscular-blocking agent effects with appropriate reversal: OR, 0.98; 95% CI, 0.63 to 1.52).
Conclusions:
The use of neuromuscular-blocking agents was dose dependently associated with increased risk of postoperative respiratory complications. Neostigmine reversal was also associated with a dose-dependent increase in the risk of respiratory complications. However, the exploratory data analysis suggests that the proper use of neostigmine guided by neuromuscular transmission monitoring results can help eliminate postoperative respiratory complications associated with the use of neuromuscular-blocking agents.
Collapse
|
46
|
Martin-Flores M, Sakai DM, Campoy L, Gleed RD. Recovery from neuromuscular block in dogs: restoration of spontaneous ventilation does not exclude residual blockade. Vet Anaesth Analg 2014; 41:269-77. [DOI: 10.1111/vaa.12109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 02/19/2013] [Indexed: 12/01/2022]
|
47
|
Aytac I, Postaci A, Aytac B, Sacan O, Alay GH, Celik B, Kahveci K, Dikmen B. Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists. Braz J Anesthesiol 2014; 66:55-62. [PMID: 26768931 DOI: 10.1016/j.bjane.2012.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 06/19/2012] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate > 20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS The incidence of PORC was 43% (n = 179) for TOFR < 0.9, and 15% (n = 61) for TOFR < 0.7. The incidence of TOFR < 0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR < 0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.
Collapse
Affiliation(s)
- Ismail Aytac
- Department of Anesthesiology and Reanimation, Sami Ulus Children's Hospital, Ankara, Turkey
| | - Aysun Postaci
- Department of Anesthesiology and Reanimation, Numune Education and Research Hospital, Ankara, Turkey.
| | - Betul Aytac
- Department of Anesthesiology and Reanimation, Numune Education and Research Hospital, Ankara, Turkey
| | - Ozlem Sacan
- Department of Anesthesiology and Reanimation, Numune Education and Research Hospital, Ankara, Turkey
| | - Gulcin Hilal Alay
- Department of Anesthesiology and Reanimation, Numune Education and Research Hospital, Ankara, Turkey
| | - Bulent Celik
- Department of Biostatistics, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| | - Kadriye Kahveci
- Department of Anesthesiology and Reanimation, Ministry of Health Etlik Education and Research Hospital, Ankara, Turkey
| | - Bayazit Dikmen
- Department of Anesthesiology and Reanimation, Numune Education and Research Hospital, Ankara, Turkey
| |
Collapse
|
48
|
Kiekkas P, Bakalis N, Stefanopoulos N, Konstantinou E, Aretha D. Residual neuromuscular blockade and postoperative critical respiratory events: literature review. J Clin Nurs 2014; 23:3025-35. [PMID: 24460786 DOI: 10.1111/jocn.12508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2013] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To investigate and synthesise published literature on the associations between residual neuromuscular blockade and critical respiratory events of postoperative adult patients in the postanaesthesia care unit. BACKGROUND Residual neuromuscular blockade continues to be common among patients transferred to the postanaesthesia care unit after general anaesthesia, while negative effects of residual neuromuscular blockade on respiratory function have been demonstrated in laboratory volunteers. DESIGN Literature review. METHODS Using key terms, a search was conducted in Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database and EMBASE (January 1990-May 2013) for clinical trials or observational studies on the associations between residual neuromuscular blockade and critical respiratory events, published in English-language journals. RESULTS Nine articles met the inclusion criteria. Residual neuromuscular blockade definition threshold differed between studies. Among critical respiratory events, only hypoxaemia was investigated in all included studies. Residual neuromuscular blockade was significantly associated with increased incidence of hypoxaemia during postanaesthesia care unit stay in most studies, while associations with the rest of the critical respiratory events were inconclusive. CONCLUSIONS Although limited, existing research has provided evidence that patients with residual neuromuscular blockade are at high risk of early postoperative hypoxaemia. Further studies are needed to investigate independent associations between residual neuromuscular blockade and critical respiratory events, along with causality of these associations. The clinical importance of residual neuromuscular blockade for groups at high risk of critical respiratory events should also be investigated. RELEVANCE TO CLINICAL PRACTICE Healthcare professionals have to be aware of the increased risk of hypoxaemia in patients with residual neuromuscular blockade. Efforts to decrease residual neuromuscular blockade incidence, combined with identification and appropriate evaluation of patients with residual neuromuscular blockade during postanaesthesia care unit stay, are recommended.
Collapse
Affiliation(s)
- Panagiotis Kiekkas
- Nursing Department, Technological Educational Institute of Western Greece, Patras, Greece
| | | | | | | | | |
Collapse
|
49
|
Quillfeldt SV, Föhre B, Andrees N, Spies CD, Galvagni D, Joussen AM, Wernecke KD, Boemke W. Rocuronium reversed by sugammadex versus mivacurium during high-risk eye surgery: An institutional anaesthetic practice evaluation. J Int Med Res 2013; 41:1740-51. [DOI: 10.1177/0300060513489476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective This institutional anaesthetic practice evaluation compared patient safety with respect to residual neuromuscular blockade (NMB) at the time of tracheal extubation in patients undergoing high-risk eye surgery. Methods Two muscle relaxation regimens were compared: rocuronium administered via intravenous (i.v.) bolus dosing combined with reversal through sugammadex at end of surgery (group R/S; 17 patients); mivacurium administered via continuous i.v. infusion without antagonization (group M; 22 patients). Train-of-four (TOF) monitoring determined the depth of NMB. Results The TOF ratio at the time of tracheal extubation was greater in group R/S (median 1.03) than in group M (median 0.62). Time from end of surgery to tracheal extubation was not significantly different. The surgeons were 100% satisfied with the working conditions provided under both relaxation regimens. Conclusions Residual postoperative curarization at the time of extubation was frequently observed in group M, whereas there was complete recovery in group R/S. Reversal of NMB by sugammadex provides an additional safety dimension to patient care and should thus be considered especially for those at risk of airway complications or aspiration, in addition to frail patients.
Collapse
Affiliation(s)
- Susanne von Quillfeldt
- Department of Anesthesiology and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Bettina Föhre
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nicolai Andrees
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Daniele Galvagni
- Department of Anesthesiology and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonia M Joussen
- Department of Ophthalmology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Willehad Boemke
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité – Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
50
|
Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, Nakatsuka I, Takeda J. Reversal with Sugammadex in the Absence of Monitoring Did Not Preclude Residual Neuromuscular Block. Anesth Analg 2013; 117:345-51. [DOI: 10.1213/ane.0b013e3182999672] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|