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

Study of 60 Adult Patients to Compare Standard Postoperative Clinical Assessment with Train-of-Four Ratio ≥0.9 on Patient Outcomes Using Postoperative Spirometry and Neuromuscular Function Measurements Following Extubation

BACKGROUND Postoperative tracheal extubation requires optimal timing to ensure patient safety and normal muscle function. The train-of-four ratio (TOFR) of the fourth muscle response compared with the first indicates a non-depolarizing neuromuscular block, and a ratio ≥0.9 can be used as an objective measurement of neuromuscular reversal. This study of 60 adult patients who underwent elective surgery with general anesthesia that included the neuromuscular blocking agent cisatracurium aimed to compare standard postoperative clinical assessment with the TOFR ≥0.9 on patient outcomes using postoperative neuromuscular function assessed by grip strength and ability to sit up unaided and spirometry measurements following extubation. MATERIAL AND METHODS The 30 patients extubated postoperatively in the TOF group were required to have a TOFR ≥0.9, while the 30 patients in the clinical assessment group were awake and following simple commands and had a 5-second head lift and spontaneous breathing with acceptable oxygenation. The main outcomes were the incentive spirometry and grip strength and ability to sit up unaided measured at 10, 30, 50 min and 24 h after extubation. RESULTS The groups had no difference in recovery path of incentive spirometry volume (P=0.072) and no difference in postoperative incentive spirometry decrease from baseline except at 10 min after extubation (P=0.005). There was no difference in handgrip strength and independent sitting between groups. CONCLUSIONS The findings showed that using the TOF ratio ≥0.9 before extubation did not improve early postoperative strength quantified by spirometry volume, handgrip strength, and proportion of unaided sitting.

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

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.

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

Neuromuscular Blockade Agents Reversal with Sugammadex Compared to Neostigmine in the Living Kidney Donors

BACKROUND

The reversation of NMBA (neuromuscular blocking agents) prevents numerous postoperative complications, increases quality of recovery and decreases the time, expenditure spending in hospital. The choice of medicine used to reverse NMBA depends considered as a key fators to gain the best outcome and to avoid the side effects.

AIM

To evaluate the postoperative effect on muscle relaxation reversal and side effects of sugammadex 2 mg/kg versus the combination of neostigmine and atropine sulfate in the living kidney donors.

METHODS

A randomised controlled trial on 70 patients undergoing living kidney donation surgery were allocated to 2 groups. Patients in group I (SUGA) were reversed with sugammadex 2 mg/kg and in group II (NEO/ATR) with the combination of neostigmine and atropine sulfat.

RESULTS

With 35 patients in each group, the study results showed that after 3 mintutes of reversal patients reaching TOF value ≥ 0.9 in group SUGA is 91.4%, after 5 minutes 100% of patients in group SUGA reached TOF value ≥ 0.9 . In group NEO/ATR after 3 minutes 28.6% patients reached TOF ≥ 0.9 and 40% patients reached TOF≥ 0.9 after 5 minutes. The difference in percentage of patients reaching TOF ≥ 0.9 after 3 minutes, 5 minutes of reversal between two groups is significant (p<0.05). After 10 minutes, 100% patients in both group got TOF ≥ 0.9. Time to exutubation of group SUGA was 249.43 ± 81.75 seconds and it was 456.29 ± 146.45 seconds in group NEO/ATR. Nausea, bradycardia, and increased phlegm production in group NEO/ATR was 22.9%; 28.5%; 25.7% respectively; while those side effects were not met in group SUGA, the difference was significant (p<0.05).

CONCLUSION

The muscle relaxation reversal effect of sugammadex was faster than that of neostigmine, the duration TOF ≥ 0.9 and the time to extubation was significantly faster. Sugammadex did not cause hemodynamic changes before and after muscle relaxation reversal, neostigmine resulted in the bradycardia, increased phlegm secreting and other side effects. The renal function after 24 hours postoperatively of two groups was similar.