1
|
Bash LD, Turzhitsky V, Mark RJ, Hofer IS, Weingarten TN. Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting. J Clin Anesth 2024; 93:111344. [PMID: 38007845 DOI: 10.1016/j.jclinane.2023.111344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023]
Abstract
STUDY OBJECTIVE Perioperative neuromuscular blocking agents are pharmacologically reversed to minimize complications associated with residual neuromuscular block. Neuromuscular block reversal with anticholinesterases (e.g., neostigmine) require coadministration of an anticholinergic agent (e.g., glycopyrrolate) to mitigate muscarinic activity; however, sugammadex, devoid of cholinergic activity, does not require anticholinergic coadministration. Single-institution studies have found decreased incidence of post-operative urinary retention associated with sugammadex reversal. This study used a multicenter database to better understand the association between neuromuscular block reversal technique and post-operative urinary retention. DESIGN Retrospective cohort study utilizing large healthcare database. SETTING Non-profit, non-governmental and community and teaching hospitals and health systems from rural and urban areas. PATIENTS 61,898 matched adult inpatients and 95,500 matched adult outpatients. INTERVENTIONS Neuromuscular block reversal with sugammadex or neostigmine plus glycopyrrolate. MEASUREMENTS Incidence of post-operative urinary retention by neuromuscular block reversal agent and the independent association of neuromuscular block reversal technique and risk of post-operative urinary retention. MAIN RESULTS The incidence of post-operative urinary retention was 2-fold greater among neostigmine with glycopyrrolate compared to sugammadex patients (5.0% vs 2.4% inpatients; 0.9% vs 0.4% outpatients; both p < 0.0001). Multivariable logistic regression identified reversal with neostigmine to be independently associated with greater risk of post-operative urinary retention (inpatients: odds ratio, 2.20; 95% confidence interval, 2.00 to 2.41; p < 0.001; outpatients: odds ratio, 2.57; 95% confidence interval, 2.13 to 3.10; p < 0.001). Post-operative urinary retention-related visits within 2 days following discharge were five-fold higher among those reversed with neostigmine than sugammadex among inpatients (0.05% vs. 0.01%, respectively; p = 0.018) and outpatients (0.5% vs. 0.1%; p < 0.0001). CONCLUSION Though this study suggests that neuromuscular block reversal with neostigmine can increase post-operative urinary retention risk, additional studies are needed to fully understand the association.
Collapse
Affiliation(s)
- Lori D Bash
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Vladimir Turzhitsky
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Robert J Mark
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Ira S Hofer
- Department of Anesthesiology, Pain and Perioperative Medicine; Department of Medicine, Division of Data Driven Medicine; Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Toby N Weingarten
- Mayo Clinic College of Medicine, Department of Anesthesiology and Perioperative Medicine, Rochester, MN, United States.
| |
Collapse
|
2
|
Oh MW, Mohapatra SG, Pak T, Hermawan A, Chen CA, Thota B, Chen J, Siu E, Park J, Moon TS. Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study. Anesth Analg 2024; 138:1043-1051. [PMID: 38190344 DOI: 10.1213/ane.0000000000006807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.
Collapse
Affiliation(s)
- Matthew W Oh
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shweta G Mohapatra
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taylor Pak
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aundree Hermawan
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chieh-An Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhavana Thota
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joy Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Siu
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Park
- Department of Biostatistics, Southern Methodist University, Dallas, Texas
| | - Tiffany S Moon
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
3
|
Huang S, Pan Y, Wang Y, Pei S, Wang X, Sun S, Yao S, Chen X, Xia H. Muscular Function Recovery from General Anesthesia in 132 Patients Undergoing Surgery with Acceleromyography, Combined Acceleromyography, and Ultrasonography, and without Monitoring Muscular Function. Med Sci Monit 2024; 30:e942780. [PMID: 38627942 PMCID: PMC11034390 DOI: 10.12659/msm.942780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/08/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Diaphragmatic thickness fraction (DTF), measured by ultrasound, can predict the occurrence of postoperative residual neuromuscular blockade (RNMB). We hypothesized that the utilization of diaphragmatic ultrasound during the postoperative awakening phase of anesthesia in patients offers a successful means of avoiding RNMB in a notably comfortable manner, as compared to the use of acceleromyograph. MATERIAL AND METHODS Patients who underwent elective thyroid cancer radical surgery were enrolled in this prospective clinical study. Eligible participants were randomly assigned to 1 of 3 groups: 1) combined ultrasonography with acceleromyography group (the US+AMG group), 2) the AMG group, or 3) the usual clinical practice group (the UCP group). The primary outcomes of the study were the incidence of RNMB and hypoxemia after tracheal extubation. RESULTS The study included a total of 127 patients (43 in the US+AMG group, 44 in the AMG group, and 40 in the UCP group). The incidence of RNMB and hypoxemia was higher in the UCP group than in the US+AMG and AMG groups at 15 and 30 min after extubation, respectively. The mean area under the receiver operating characteristic curve, and the decision curve of the recovery rate of DTF (DTF) was greater than that of DTF. CONCLUSIONS The use of diaphragm ultrasound during the postoperative awakening phase of anesthesia can significantly reduce the incidence of RNMB. This method was non-inferior to the use of AMG during the entire perioperative period.
Collapse
Affiliation(s)
- Shiqian Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Yu Pan
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Yu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Shuaijie Pei
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Xiang Wang
- Department of Anesthesiology, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| | - Haifa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, Wuhan, Hubei, PR China
| |
Collapse
|
4
|
Li HX, Xu X, Tan PX, Wang TH, Li BL, Zheng H, Yan T. [The effect of deep neuromuscular block combined with low pneumoperitoneum pressure on postoperative pain in patients undergoing laparoscopic radical colorectal surgery]. Zhonghua Yi Xue Za Zhi 2024; 104:1057-1063. [PMID: 38561301 DOI: 10.3760/cma.j.cn112137-20231011-00704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Objective: To investigate the effect of deep neuromuscular blockade (DNMB) combined with low pneumoperitoneum pressure anesthesia strategy on postoperative pain in patients undergoing laparoscopic colorectal surgery. Methods: This study was a randomized controlled trial. One hundred and twenty patients who underwent laparoscopic colorectal surgery at Cancer Hospital of Chinese Academy of Medical Sciences from December 1, 2022 to May 31, 2023 were selected and randomly divided into two groups by random number table method. Moderate neuromuscular blockade [train of four stimulations count (TOFC)=1-2] was maintained in patients of the control group (group C, n=60) and pneumoperitoneum pressure level was set at 15 mmHg(1 mmHg=0.133 kPa). DNMB [post-tonic stimulation count (PTC)=1-2] was maintained in patients of the DNMB combined with low pneumoperitoneum pressuregroup (group D, n=60) and pneumoperitoneum pressure level was set at 10 mmHg. The primary measurement was incidence of moderate to severe pain at 1 h after surgery. The secondary measurements the included incidence of moderate to severe pain at 1, 2, 3, 5 d and 3 months after surgery, the incidence of rescue analgesic drug use, the doses of sufentanil in analgesic pumps, surgical rating scale (SRS) score, the incidence of postoperative residual neuromuscular block, postoperative recovery [evaluated with length of post anesthesia care unit (PACU) stay, time of first exhaust and defecation after surgery and length of hospital stay] and postoperative inflammation conditions [evaluated with serum concentration of interleukin (IL)-1β and IL-6 at 1 d and 3 d after surgery]. Results: The incidence of moderate to severe pain in group D 1 h after surgery was 13.3% (8/60), lower than 30.0% (18/60) of group C (P<0.05). The incidence of rescue analgesia in group D at 1 h and 1 d after surgery were 13.3% (8/60) and 4.2% (5/120), respectively, lower than 30.0% (18/60) and 12.5% (15/120) of group C (both P<0.05). The IL-1β level in group D was (4.1±1.8)ng/L at 1 d after surgery, which was lower than (4.9±2.6) ng/L of group C (P=0.048). The IL-6 level in group D was (2.0±0.7)ng/L at 3 d after surgery, which was lower than (2.4±1.1) ng/L of group C (P=0.018). There was no significant difference in the doses of sufentanil in analgesic pumps, intraoperative SRS score, incidence of neuromuscular block residue, time spent in PACU, time of first exhaust and defecation after surgery, incidence of nausea and vomiting, and length of hospitalization between the two groups (all P>0.05). Conclusion: DNMB combined with low pneumoperitoneum pressure anesthesia strategy alleviates the early-stage pain in patients after laparoscopic colorectal surgery.
Collapse
Affiliation(s)
- H X Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - X Xu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - P X Tan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - T H Wang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - B L Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - H Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - T Yan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
5
|
Wedemeyer Z, Jelacic S, Michaelsen K, Silliman W, Togashi K, Bowdle A. Comparative performance of stimpod electromyography with mechanomyography for quantitative neuromuscular blockade monitoring. J Clin Monit Comput 2024; 38:205-212. [PMID: 37831378 DOI: 10.1007/s10877-023-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The purpose of this study was to compare the Stimpod electromyograph neuromuscular blockade monitor to mechanomyography, which is widely considered to be the reference standard. METHODS The Stimpod electromyograph was used with its designated electrode array on the same hand as the mechanomyograph. Pairs of train-of-four measurements were recorded every 0.5-2 min. When the train-of-four count was zero on the electromyograph monitor, pairs of post tetanic count measurements were recorded every 2.5 min, instead of train-of-four measurements. Measurements were recorded from immediately after induction of anesthesia until just before emergence. Stimulation current was set to 60 mA with a duration of 200 microsec. The mechanomyography recording system recorded each twitch waveform for analysis. High resolution electromyograph waveforms were also recorded using a datalogger accessory provided by the manufacturer, facilitating inspection of individual waveforms. The administration of neuromuscular blocking drugs was left up to the discretion of the anesthesia care team. RESULTS Twenty-three patients contributed 1,088 data pairs suitable for analysis. Bland-Altman analysis of 415 pairs of train-of-four ratios showed a bias of 0.028 and limits of agreement of -0.18 and 0.24. Two hundred seventy-three train-of-four count data pairs were compared by Cohen's quadratically weighted kappa which was calculated to be 0.44, indicating moderate agreement. Three hundred thirty-eight post tetanic count data pairs were compared by Cohen's quadradically weighted kappa which was calculated to be 0.80, indicating substantial agreement. CONCLUSION The electromyograph produced results that were comparable to the mechanomyograph.
Collapse
Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kelly Michaelsen
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kei Togashi
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA.
| |
Collapse
|
6
|
Zhang Y, Jiang Y, Lei Q, Li C, Jin S, Wang Q, Huang Y, Li Y, Hong Y, Wang S, Lin H, Li H, Ou Y, Zou X, Sun Q, Guo Q, Chen Z, Min S, Qi Y, Jie Q, Liu J, Liu B, Zhang W. Phase III clinical trial comparing the efficacy and safety of adamgammadex with sugammadex for reversal of rocuronium-induced neuromuscular block. Br J Anaesth 2024; 132:45-52. [PMID: 38007377 DOI: 10.1016/j.bja.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Preliminary clinical trials of adamgammadex, a new cyclodextrin-based selective reversal agent, have demonstrated its efficacy in reversing neuromuscular block by rocuronium. METHODS This multicentre, randomised, double-blind, positive-controlled, non-inferiority phase III clinical trial compared the efficacy and safety of adamgammadex and sugammadex. We randomised 310 subjects to receive adamgammadex (4 mg kg-1) or sugammadex (2 mg kg-1) at reappearance of the second twitch of the train-of-four (TOF), and standard safety data were collected. RESULTS For the primary outcome, the proportion of patients with TOF ratio ≥0.9 within 5 min was 98.7% in the adamgammadex group vs 100% in the sugammadex group, with a point estimate and 95% confidence interval (CI) of 1.3% (-4.6%, +1.3%); the lower limit was greater than the non-inferiority margin of -10%. For the key secondary outcome, the median (inter quartile range) time from the start of administration of adamgammadex or sugammadex to recovery of TOF ratio to 0.9 was 2.25 (1.75, 2.75) min and 1.75 (1.50, 2.00) min, respectively. The difference was 0.50 (95% CI: 0.25, 0.50); the upper limit was lower than the non-inferiority margin of 5 min. In addition, there were no inferior results observed in secondary outcomes. Adamgammadex had a lower incidence of adverse drug reactions compared with sugammadex (anaphylactic reaction, recurarisation, decreased heart rate, and laryngospasm; P=0.047). CONCLUSIONS Adamgammadex was non-inferior to sugammadex with a possible lower incidence of adverse drug reactions compared with sugammadex. Adamgammadex may have a potential advantage in terms of its overall risk-benefit profile. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2000039525. Registered October 30, 2020. https://www.chictr.org.cn/showproj.html?proj=56825.
Collapse
Affiliation(s)
- Yujun Zhang
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yingying Jiang
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Lei
- Department of Anaesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Chaoyu Li
- Department of Anaesthesiology, Second People's Hospital of Neijiang, Neijiang, China
| | - Shu'an Jin
- Department of Anaesthesiology, Central Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Ji'nan, China
| | - Qin Wang
- Department of Anaesthesiology, Central Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Ji'nan, China
| | - Yidan Huang
- Department of Anaesthesiology, Liuzhou People's Hospital, Liuzhou, China
| | - Yalan Li
- Department of Anaesthesiology, First Affiliated Hospital of Jinan University (Guangzhou Overseas Chinese Hospital), Jinan University, Guangzhou, China
| | - Yi Hong
- Department of Anaesthesiology, First Affiliated Hospital of Xinjiang Medical University, Xinjiang Medical University, Urumqi, China
| | - Shoushi Wang
- Department of Anaesthesiology, Qingdao Central Hospital Group, Qingdao, China
| | - Han Lin
- Department of Anaesthesiology, Second Affiliated Hospital of WMU, Wenzhou Medical University, Wenzhou, China
| | - Hong Li
- Department of Anaesthesiology, Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yangwen Ou
- Department of Anaesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaohua Zou
- Department of Anaesthesiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Qiang Sun
- Department of Anaesthesiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Qulian Guo
- Department of Anaesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhigang Chen
- Department of Anaesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Su Min
- Department of Anaesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Youmao Qi
- Hangzhou Adamerck Pharmlabs Inc. Hangzhou, China
| | - Qing Jie
- Hangzhou Adamerck Pharmlabs Inc. Hangzhou, China
| | - Jin Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Wensheng Zhang
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China; Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
7
|
Arumugaswamy PR, Chumber S, Rathore YS, Maitra S, Bhattacharjee HK, Bansal VK, Aggarwal S, Dhar A, Asuri K, Kataria K, Ranjan P. Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial. Surg Endosc 2024; 38:449-459. [PMID: 38012441 DOI: 10.1007/s00464-023-10558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
Collapse
Affiliation(s)
- Prasanna Ramana Arumugaswamy
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Souvik Maitra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Hemanga Kumar Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Krishna Asuri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| |
Collapse
|
8
|
Cates AC, Freundlich RE, Clifton JC, Lorinc AN. Analysis of the factors contributing to residual weakness after sugammadex administration in pediatric patients under 2 years of age. Paediatr Anaesth 2024; 34:28-34. [PMID: 37792601 PMCID: PMC10872520 DOI: 10.1111/pan.14773] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Sugammadex reverses the neuromuscular blockade induced by rocuronium and vecuronium and is approved by the U.S. Food and Drug Administration for use in patients aged over 2 years. There is, however, a paucity of data regarding its dosing profile in infants and children younger than 2 years. AIMS The aim of this study was to assess the risk of recurarization, or re-paralysis, in children under 2 years of age to increase awareness on the importance of appropriate neuromuscular blocked monitoring and reversal. METHODS All patients aged ≤24 months who underwent an operative procedure at a tertiary medical center between January 1, 2018, and December 31, 2021, and received both rocuronium for neuromuscular blockade and sugammadex for neuromuscular blockade reversal, were identified in the electronic medical record. Patients were excluded from analysis if they (1) received vecuronium, cisatracurium, atracurium, or succinylcholine for neuromuscular blockade, (2) received neostigmine for reversal, or (3) underwent more than one operation within 24 h. We performed a survival analysis of sugammadex redose using a Cox proportional hazards model. RESULTS We reviewed 2923 records. Sugammadex was redosed in 123 (4.2%) cases. The median [IQR] time to redose was 7 [4-17] min, and the median [IQR] amount of redose administered was 2.74 [1.96-3.99] mg/kg. Increasing patient age (p < .01) and weight (p < .01) were associated with reduced hazard rate of sugammadex redose. For a patient of median weight, increasing age from 3 to 13 months was associated with a 53% risk reduction (HR: 0.47; 95% CI: 0.24-0.91). For a patient of median age, increasing weight from 4.7 to 9.2 kg was associated with 41% risk reduction (HR: 0.59; 95% CI: 0.32-1.07). We failed to detect any other associations. CONCLUSIONS In this single-center, retrospective cohort study of pediatric surgery patients, there was an association between the hazard of sugammadex redose with both increased age and weight.
Collapse
Affiliation(s)
- Alexandra C. Cates
- Department of Anesthesiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacob C. Clifton
- Department of Anesthesiology & Perioperative Informatics Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda N. Lorinc
- Department of Anesthesiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| |
Collapse
|
9
|
Wu L, Wei S, Xiang Z, Yu E, Chen Z, Qu S, Du Z. Effect of neuromuscular block on surgical conditions during laparoscopic surgery in neonates and small infants: A randomised controlled trial. Eur J Anaesthesiol 2023; 40:928-935. [PMID: 37611024 DOI: 10.1097/eja.0000000000001898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Neuromuscular block (NMB) is routinely used in paediatric and adult anaesthesia to facilitate endotracheal intubation and optimise surgical conditions. However, there are limited data regarding NMB and optimising the conditions for laparoscopic surgery in neonates and small infants. OBJECTIVE The goal of this study was to determine the effect of NMB on the conditions for laparoscopic surgery in neonates and small infants. DESIGN A randomised controlled trial. SETTING Single-centre Children's Hospital, conducted from November 2021 to December 2022. PATIENTS One hundred and two ASA I-II neonates and small infants aged up to 60 weeks postmenstrual age who were scheduled to undergo an elective laparoscopic Ladd's procedure were included in the study. INTERVENTIONS Patients were randomised into three groups: no NMB group, shallow NMB group and moderate NMB group. Each group was given different doses of rocuronium to achieve the target depth of NMB. MAIN OUTCOME MEASURES The primary outcome was the quality of the surgical conditions evaluated with the Leiden-Surgical Rating Scale (L-SRS) by a blinded surgeon. Secondary outcomes included tracheal intubating conditions and adverse events. RESULTS The percentage of L-SRS scores of 4 or 5 was similar among the three groups at all the assessment times ( P > 0.05 for each time interval). The distribution of L-SRS scores was also similar among the three groups. There were no significant differences in operating condition scores between the groups at any time interval ( P > 0.05 for each time interval). The incidence of adverse events during anaesthesia induction was significantly higher in the no NMB group (51.4%) than in the other two groups (13.6% and 14.7%) (adjusted P = 0.012 and adjusted P = 0.003). In particular, clinically unacceptable intubation conditions occurred in 12 patients (34.3%) in the no NMB group, significantly more than in the shallow NMB group (6.1%, adjusted P = 0.012) and moderate NMB group (2.9%, adjusted P = 0.003). There was no statistically significant difference in the incidence of adverse events in the PACU among the three groups ( P = 0.103). CONCLUSIONS The depth of NMB was not associated with superior surgical conditions during laparoscopic surgery, but it was associated with a reduction in adverse events during induction and maintenance of anaesthesia in neonates and small infants. TRIAL REGISTRATION Registered at www.chictr.org.cn (ChiCTR2100052296).
Collapse
Affiliation(s)
- Lei Wu
- From the Department of Anaesthesiology, Hunan Children's Hospital, Changsha, China
| | | | | | | | | | | | | |
Collapse
|
10
|
Yamamoto M, Takagi S, Kijima M, Sato H, Doshu-Kajiura A, Kitajima O, Suzuki T. Influence of the Pringle maneuver during partial hepatectomy on the neuromuscular block induced by intermittent and continuous dosing of rocuronium. J Anesth 2023; 37:828-834. [PMID: 37548656 DOI: 10.1007/s00540-023-03239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE The Pringle maneuver (PM) is a common procedure in hepatectomy that is known to interrupt drug elimination. The purpose of this study was to examine the influence of PM on the duration of action of rocuronium administered by intermittent bolus dosing, the continuous rocuronium infusion dose required for maintenance of a moderate neuromuscular block, and changes in plasma concentrations of rocuronium. METHODS Twenty-seven adult patients undergoing partial hepatectomy with PM were enrolled in this study. The duration of action of 0.2 mg/kg rocuronium boluses (DUR), and the continuous rocuronium infusion dose required for maintenance of the height of the first twitch of the train-of-four (T1) at 10-20% of the control value (%T1), respectively, were electromyographically monitored on the adductor digiti minimi muscle. The effects of PM on DUR, %T1, and the plasma concentration of rocuronium were measured. RESULTS The DUR was significantly prolonged during PM [mean: 42.2 (SD: 8.0) min, P < 0.001] compared to baseline [29.7 (6.3) min]. It was prolonged even after completion of the PM [46.2 (10.5) min, P < 0.001]. The plasma concentration of rocuronium measured at every reappearance of T1 was comparable between before and during PM. %T1 [15.5 (5.6)%] was significantly depressed after the start of PM [6.5 (3.9)%, P < 0.001], with persistence of the depression even after completion of PM. However, there were no significant changes in the plasma concentration of rocuronium. CONCLUSIONS Rocuronium-induced neuromuscular block is significantly augmented during PM. However, the augmentation is not associated with an increase in plasma rocuronium concentration.
Collapse
Affiliation(s)
- Mai Yamamoto
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shunichi Takagi
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Miho Kijima
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hanae Sato
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Akira Doshu-Kajiura
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Osamu Kitajima
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Takahiro Suzuki
- Department of Anesthesiology, Nihon University School of Medicine, 30-1, Oyaguchi-Kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| |
Collapse
|
11
|
Kim J, Kim JA, Jang JN, Yang M, Ahn HJ, Choi J, Jo S. The arousal effect of sugammadex reversal of neuromuscular blockade differs with anesthetic depth in propofol-remifentanil anesthesia: a randomized controlled trial. Sci Rep 2023; 13:20776. [PMID: 38012277 PMCID: PMC10682451 DOI: 10.1038/s41598-023-48031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
Sugammadex reverses neuromuscular blockade by encapsulating steroidal neuromuscular blockers; therefore, it does not pharmacologically affect sedation levels. However, some clinicians avoid using it because of sudden unwanted acting out or patient arousal. Previous studies suggested sugammadex-induced awakening, but frontal muscle contraction after sugammadex administration compromised reliability of results obtained from EEG-based anesthesia depth monitoring tools like bispectral index (BIS). We hypothesized that sugammadex would affect patients' arousal depending on their baseline levels of sedation. We evaluated arousal signs after sugammadex administration with BIS between 25 - 35 and 45 - 55 under steady-state propofol-remifentanil anesthesia at the end of a surgery (n = 33 in each group). After sugammadex administration, twelve patients with a BIS of 45 - 55 showed clinical signs of awakening but none with a BIS of 25 - 35 (36.4% vs. 0%, P = 0.001). The distribution of the modified observer's assessment of alertness/sedation scale scores was also significantly different between the two groups (P < 0.001). Changes in the BIS were significantly greater in the BIS 45 - 55 than in the 25 - 35 group (median difference, 7; 95% CI 2 - 19, P = 0.002). Arousal after sugammadex was affected by patient sedation levels, and clinical signs of awakening appeared only in those with BIS 45 - 55. Unwanted arousal of the patient should be considered when using sugammadex under shallow anesthesia.Clinical trial registry number: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ; Principal investigator: Jieae Kim; Registration number: KCT0006248; Date of first registration: 11/06/2021).
Collapse
Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea.
| | - Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University School of Medicine, Incheon, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Jiwon Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Sungwoo Jo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| |
Collapse
|
12
|
Yoon JJ, Anderson AL, Niesen AD. Undiagnosed Lambert-Eaton Myasthenic Syndrome in the Era of Sugammadex: A Case Report. Clin Neuropharmacol 2023; 46:205-208. [PMID: 37962306 DOI: 10.1097/wnf.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. METHODS We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. RESULTS Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. CONCLUSIONS Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.
Collapse
Affiliation(s)
| | - Alexandra L Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam D Niesen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
13
|
Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
Collapse
Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
14
|
Poelaert J, Hunter JM. Educating anaesthetists on neuromuscular monitoring: the challenges continue. Br J Anaesth 2023; 131:429-431. [PMID: 37380566 DOI: 10.1016/j.bja.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023] Open
Abstract
The need to introduce guidelines on neuromuscular monitoring emphasising the use of quantitative techniques that record the train-of-four ratio is now recognised by an increasing number of national anaesthetic societies in the Western world. But the challenge of convincing individual anaesthetists to adopt and use this practice routinely remains. For >10 yr, it has been recognised that all staff in anaesthetic departments need to have regular training in modern neuromuscular monitoring techniques. We discuss a publication in this journal that describes the challenges of setting up multicentre training in Spain to expand the use of quantitative neuromuscular monitoring and their short-term results.
Collapse
Affiliation(s)
- Jan Poelaert
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Anaesthesia, ICU and Chronic Pain Therapy, Hospital Maria Middelares, Ghent, Belgium.
| | - Jennifer M Hunter
- Department of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
| |
Collapse
|
15
|
Li HX, Zheng H, Tang W, Sun YK, Zhang L, Kong XY, Yan T. Postoperative recurarization after sugammadex administration in two patients who received neoadjuvant chemotherapy: case reports and literature review. Can J Anaesth 2023; 70:1529-1538. [PMID: 37407856 DOI: 10.1007/s12630-023-02527-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Preoperative neoadjuvant chemotherapy plays a critical role in multidisciplinary therapy for a variety of malignant tumours. Although oncologists consider myocardial injury to be the most concerning side effect of chemotherapy, unique chemotherapy-mediated skeletal muscular damage has received attention recently. CLINICAL FEATURES We report two unusual cases of postoperative delayed respiratory failure following administration of the recommended sugammadex dosage for patients undergoing lengthy operations with deep neuromuscular blockade (NMB) after neoadjuvant chemotherapy. Based on clinical outcomes, especially the comparison of muscle imaging results in patients at different treatment time points, we concluded that NMB recurrence had a possible correlation with neoadjuvant chemotherapy-induced muscular damage. CONCLUSION The early identification of neoadjuvant chemotherapeutic side effects on NMB could be instrumental for clinical safety, especially in cases of major surgery requiring deep NMB. Thus, the timing of NMB antagonism and the recommended dosage of sugammadex warrant special consideration in these patients. In addition to neuromuscular monitoring during the operation, a more extended and closer observation period in the postanesthesia care unit is warranted.
Collapse
Affiliation(s)
- Hui-Xian Li
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hui Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wei Tang
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Kun Sun
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Zhang
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
- Centre of Cancer Research, Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
| | - Xiang-Yi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yan
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| |
Collapse
|
16
|
Zheng J, Du L, Zhang L, Du B, Zhang W, Chen G. Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta-Analysis. Laryngoscope 2023; 133:2055-2065. [PMID: 36625304 DOI: 10.1002/lary.30561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/17/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery. DATA SOURCES PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database. METHODS Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no-deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions. SECONDARY OUTCOME the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications [including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV)]. Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded. RESULTS Four articles with 242 patients were identified for analysis. The results indicated that compared with no-deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio [RR] = 1.29, 95% CI: 1.07-1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR = 0.32; 95% CI: 0.21-0.49) (lower incidence of vocal fold movement [1.85% vs. 34%; RR = 0.08, 95% CI: 0.02-0.41] and coughing [15.53% vs. 38.78%; RR = 0.42, 95% CI: 0.27-0.66]). There were no differences in the overall incidence of postoperative complications (RR = 2.10, 95% CI: 0.12-36.40). CONCLUSIONS Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications. LEVEL OF EVIDENCE 1 Laryngoscope, 133:2055-2065, 2023.
Collapse
Affiliation(s)
- Jianqiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lu Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
17
|
Cao M, Huang H, Tong J, Ou Y, Liao Y. Optimal dose of neostigmine antagonizing cisatracurium-induced shallow neuromuscular block in elderly patients: a randomized control study. BMC Anesthesiol 2023; 23:269. [PMID: 37563623 PMCID: PMC10413529 DOI: 10.1186/s12871-023-02233-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Residual neuromuscular block after using neuromuscular blocking agents is a common and potentially harmful complication of general anesthesia. Neostigmine is a widely used antagonist, but its optimal dose for elderly patients is unclear. OBJECTIVES To compare the optimal dosage and safety of neostigmine for reversing shallow residual block in elderly patients after cisatracurium-induced neuromuscular block. METHODS A randomized controlled trial was conducted in 196 elderly patients undergoing non-cardiac surgery under general anesthesia with cisatracurium. Patients were assigned to receive either no neostigmine (control group) or neostigmine at 20 µg/kg, 40 µg/kg or 50 µg/kg when train-of-four (TOF) ratio reached 0.2 at the end of surgery. The primary outcome was the time to reach TOF ratio of 0.9 after administration. Secondary outcomes included TOF ratio at 10 min after administration, postoperative nausea and vomiting, postoperative cognitive impairment and post-anesthesia care unit (PACU) stay time. RESULTS The time to reach TOF ratio of 0.9 in the 20 µg/kg, 40 µg/kg and 50 µg/kg groups was significantly shorter than the control group (H = 104.257, P < 0.01), and the time of 40 µg/kg group and 50 µg/kg group was significantly shorter than the 20 µg/kg group (P < 0.001). There was no significant difference between 40 µg/kg and 50 µg/kg groups (P = 0.249). The TOF ratio at 10 min after administration showed similar results. There were no significant differences among groups in postoperative nausea and vomiting, postoperative cognitive impairment or post-operation hospital stay. CONCLUSIONS Timely use of neostigmine after general anesthesia in elderly patients can significantly shorten time of TOF value reaching 0.9, among which 40 µg/kg dosage may be a more optimized choice. TRIAL REGISTRATION this study was registered on chictr.org.cn (ChiCTR2100054685, 24/12/2021).
Collapse
Affiliation(s)
- Mengya Cao
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Huifan Huang
- Department of Anesthesiology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, P.R. China
| | - Jianbin Tong
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
- Hunan Province Key Laboratory of Brain Homeostasis, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Yangwen Ou
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Yan Liao
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China.
| |
Collapse
|
18
|
Krijtenburg P, Bruintjes MHD, Fütterer JJ, van de Steeg G, d'Ancona F, Scheffer GJ, Keijzer C, Warlé MC. MRI measurement of the effects of moderate and deep neuromuscular blockade on the abdominal working space during laparoscopic surgery, a clinical study. BMC Anesthesiol 2023; 23:238. [PMID: 37452279 PMCID: PMC10347813 DOI: 10.1186/s12871-023-02201-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Conflicting data exist regarding the effects of deep neuromuscular blockade (NMB) on abdominal dimensions during laparoscopic procedures. We performed a clinical study to establish the influence of moderate and deep neuromuscular blockade (NMB) on the abdominal working space, measured by Magnetic Resonance Imaging (MRI), during laparoscopic donor nephrectomy with standard pressure (12 mmHg) pneumoperitoneum under sevoflurane anaesthesia. METHODS Ten patients were intraoperatively scanned three times in the lateral decubitus position, with pneumoperitoneum maintained by a mobile insufflator. The first scan without NMB (T1) was followed by scans with moderate (T2) and deep NMB (T3). The skin-sacral promontory (S-SP) distance was measured, and 3D pneumoperitoneum volumes were reconstructed. RESULTS The mean difference in the S-SP distance was -0.32 cm between T2 and T3 (95% CI -1.06 - 0.42 cm; p = 0.344) and + 2.1 cm between T1 and T2 (95% CI 0.81 - 3.39 cm; p = 0.006). The mean differences in pneumoperitoneum volume were 166 mL between T2 and T3 (95% CI, 5 - 327 mL; p = 0.044) and 108 mL between T1 and T2 (95% CI, -273 - 488 mL; p = 0.525). The pneumoperitoneum volume showed high inter-individual variability and no increase in three patients with a high volume at T1. CONCLUSIONS During laparoscopic surgery in the lateral decubitus position with standard pressure under sevoflurane anaesthesia, deep NMB did not increase the S-SP distance compared to moderate NMB. Moderate NMB increased the S-SP distance by a mean of 2.1 cm (15.2%) compared with no NMB. The mean pneumoperitoneum volume increased slightly from moderate to deep NMB, with high inter-individual variability. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03287388.
Collapse
Affiliation(s)
- Piet Krijtenburg
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands.
| | | | - Jurgen J Fütterer
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | | | - Frank d'Ancona
- Department of Urology, Radboudumc, Nijmegen, the Netherlands
| | - Gert Jan Scheffer
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Christiaan Keijzer
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboudumc, Nijmegen, the Netherlands
| |
Collapse
|
19
|
Blum LV, Steeger E, Iken S, Lotz G, Zinn S, Piekarski F, Zacharowski K, Raimann FJ. Effect of quantitative versus qualitative neuromuscular blockade monitoring on rocuronium consumption in patients undergoing abdominal and gynecological surgery: a retrospective cohort study. J Clin Monit Comput 2023; 37:509-516. [PMID: 35986228 PMCID: PMC10068638 DOI: 10.1007/s10877-022-00909-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 08/09/2022] [Indexed: 10/15/2022]
Abstract
The level of neuromuscular blockade can be assessed by subjective (qualitative) and objective (quantitative) methods. This study aims to compare the dosage of the neuromuscular blocking agents (NMBA) rocuronium and the need for reversion by sugammadex between those methods. A retrospective, observational analysis was conducted. In the tactile qualitative-neuromuscular monitoring-group (tactile NMM) (n = 244), muscle contractions were assessed tactilely. In the quantitative neuromuscular monitoring-group (n = 295), contractions were accessed using an acceleromyograph. Primary endpoints were dosage of rocuronium per minute operation-time (milligram per kilogram bodyweight per minute (mg/kgBW/min)), count of repeated rocuronium administrations and use of sugammadex. Secondary endpoints were: NMM use before repeated NMBA application or extubation, time to extubation, post-operative oxygen demand. A total of n = 539 patients were included. n = 244 patients were examined with tactile NMM and 295 patients by quantitative NMM. Quantitative NMM use resulted in significantly lower rocuronium dosing (tactile NMM: 0.01 (± 0.007) mg/kgBW/min vs. quantitative NMM: 0.008 (± 0.006) mg/kgBW/min (p < 0.001)). In quantitative NMM use fewer repetitions of rocuronium application were necessary (tactile NMM: 83% (n = 202) vs. quantitative NMM: 71% (n = 208) p = 0.007). Overall, 24% (n = 58) in the tactile NMM-group, and 20% (n = 60) in the quantitative NMM-group received sugammadex ((p = 0.3), OR: 1.21 (0.81-1.82)). Significantly fewer patients in the quantitative NMM-group required oxygen-supply postoperative (quantitative NMM: 43% (n = 120)) vs. tactile NMM: 57% (n = 128)) (p = 0.002). The use of quantitative assessment of NMBA results in a lower overall dosage and requires fewer repetitions of rocuronium application. Therefore, quantitative monitoring systems should be used to monitor NMBA intraoperatively to reduce NMBA dosing, while achieving continuous neuromuscular blockade.
Collapse
Affiliation(s)
- Lea Valeska Blum
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Ellen Steeger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sonja Iken
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Gösta Lotz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sebastian Zinn
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Florian Piekarski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Florian Jürgen Raimann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| |
Collapse
|
20
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|
21
|
Joo H, Cho S, Lee JW, Kim WJ, Lee HJ, Woo JH, Lee G, Baik HJ. Comparison of Contralateral Acceleromyography and Electromyography for Posttetanic Count Measurement. Anesthesiology 2023; 138:241-248. [PMID: 36520831 DOI: 10.1097/aln.0000000000004466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Electromyography has advantages over mechanomyography and acceleromyography. Previously, agreement of the train-of-four counts between acceleromyography and electromyography was found to be fair. The objective of this study was to assess the agreement of posttetanic count including agreement of neuromuscular blockade status (intense block, posttetanic count equal to 0; or deep block, posttetanic count 1 or greater and train-of-four count equal to 0) between acceleromyography and electromyography. METHODS Thirty-six patients, aged 20 to 65 yr, participated in this study. A dose of 0.6 mg/kg rocuronium, with additional dose of 0.3 mg/kg if required, was administered to the patients. The train-of-four and posttetanic counts were monitored in the contralateral arm using electromyography at the first dorsal interosseus or adductor pollicis, and acceleromyography at the adductor pollicis. Posttetanic count measurements were performed at 6-min intervals; the responses were recorded until the train-of-four count reached 1. The authors evaluated the agreement of degree of neuromuscular blockade (intense or deep block) and that of posttetanic count between acceleromyography and electromyography. RESULTS The authors analyzed 226 pairs of measurements. The percentage agreement indicating the same neuromuscular blockade status (intense or deep block) between acceleromyography and electromyography was 73%. Cohen's kappa coefficient value was 0.26. After excluding data with acceleromyography-posttetanic counts greater than 15, a total of 184 pairs of posttetanic counts were used to evaluate the agreement between the two monitoring methods. For acceleromyography-posttetanic count, 42 (23%) pairs had the same electromyography-posttetanic count, and 93 (50%) pairs had more than the electromyography-posttetanic count. The mean posttetanic count on electromyography was 38% (95% CI, 20 to 51%) lower than that on acceleromyography (P = 0.0002). CONCLUSIONS Acceleromyography frequently counted more twitches than electromyography in posttetanic count monitoring. Acceleromyography- and electromyography-posttetanic counts cannot be used interchangeably to assess the degree of neuromuscular blockade. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Hyunyoung Joo
- Department of Anesthesiology and Pain Medicine, Daniel Hospital, Bucheon, Republic of Korea
| | - Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Won Joong Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Giyear Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| |
Collapse
|
22
|
Hirsch JG, Chia PA, Jahr JS. Sugammadex: A Review of the Considerations for Women of Childbearing Age. Am J Ther 2023; 30:e146-e150. [PMID: 36892560 DOI: 10.1097/mjt.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 03/10/2023]
Affiliation(s)
- Jason G Hirsch
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | |
Collapse
|
23
|
Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, de Boer HD, Sorbello M, Jankovic R, Kranke P. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2023; 40:82-94. [PMID: 36377554 DOI: 10.1097/eja.0000000000001769] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n = 24 000) to the finally relevant clinical studies ( n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).
Collapse
Affiliation(s)
- Thomas Fuchs-Buder
- From the Department of Anaesthesiology, Intensive Care and Peri-operative Medicine, CHRU de Nancy, Nancy, France (TF-B), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (C-S.R), Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany (HL), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AA), Department of Anaesthesiology & Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (A-MH), Department of Anesthesiology, CUB Hôpital Erasme, Bruxelles, Belgium (DS), Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany (JH), Department of Anesthesia and Intensive Care, Hôpital Bichat-Claude Bernard, Université de Paris, Paris, France (DL), Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospitals of Wuerzburg, Wuerzburg, Germany (MP, PK), Department of Anesthesiology Pain Medicine & Procedural Sedation and Analgesia Martini General Hospital Groningen, Groningen, The Netherlands (HDDB), Anesthesia and Intensive Care, AOU Policlinico - San Marco, Catania, Italy (MS), Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia (RJ)
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Bickler PE, Abouyannis M, Bhalla A, Lewin MR. Neuromuscular Weakness and Paralysis Produced by Snakebite Envenoming: Mechanisms and Proposed Standards for Clinical Assessment. Toxins (Basel) 2023; 15:49. [PMID: 36668869 PMCID: PMC9861841 DOI: 10.3390/toxins15010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/23/2022] [Accepted: 12/10/2022] [Indexed: 01/11/2023] Open
Abstract
Respiratory and airway-protective muscle weakness caused by the blockade of neuromuscular transmission is a major cause of early mortality from snakebite envenoming (SBE). Once weakness is manifest, antivenom appears to be of limited effectiveness in improving neuromuscular function. Herein, we review the topic of venom-induced neuromuscular blockade and consider the utility of adopting clinical management methods originally developed for the safe use of neuromuscular blocking agents by anesthesiologists in operating rooms and critical care units. Failure to quantify neuromuscular weakness in SBE is predicted to cause the same significant morbidity that is associated with failure to do so in the context of using a clinical neuromuscular block in surgery and critical care. The quantitative monitoring of a neuromuscular block, and an understanding of its neurophysiological characteristics, enables an objective measurement of weakness that may otherwise be overlooked by traditional clinical examination at the bedside. This is important for the initial assessment and the monitoring of recovery from neurotoxic envenoming. Adopting these methods will also be critical to the conduct of future clinical trials of toxin-inhibiting drugs and antivenoms being tested for the reversal of venom-induced neuromuscular block.
Collapse
Affiliation(s)
- Philip E. Bickler
- Center for Exploration and Travel Health, California Academy of Science, San Francisco, CA 94118, USA
- Anesthesia and Perioperative Care, University of California at San Francisco, 513 Parnassus Ave, Medical Science Room S-257, San Francisco, CA 94143-0542, USA
| | - Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Matthew R. Lewin
- Center for Exploration and Travel Health, California Academy of Science, San Francisco, CA 94118, USA
- Ophirex, Inc., Corte Madera, CA 94925, USA
| |
Collapse
|
25
|
Díaz-Cambronero O, Serrano A, Abad-Gurumeta A, Garutti Martinez I, Esteve N, Alday E, Ferrando C, Mazzinari G, Vila-Caral P, Errando Oyonarte CL. Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations. Rev Esp Anestesiol Reanim (Engl Ed) 2023; 70:37-50. [PMID: 36621572 DOI: 10.1016/j.redare.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.
Collapse
Affiliation(s)
- O Díaz-Cambronero
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - A Serrano
- Hospital Ramón y Cajal, Madrid, Spain.
| | | | | | - N Esteve
- Hospital Son Espases, Palma de Mallorca, Mallorca, Spain.
| | - E Alday
- Hospital de La Princesa, Madrid, Spain.
| | | | - G Mazzinari
- Hospital Universitari Politécnic La Fe, Grupo de Investigación Medicina Perioperatoria, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.
| | - P Vila-Caral
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - C L Errando Oyonarte
- Hospital Can Misses, Ibiza, Islas Baleares, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.
| |
Collapse
|
26
|
Ozmete O, Dardag E, Civi S. Reversal of rocuronium induced neuromuscular block with sugammadex in patients under 2 years of age. A series of 280 cases. Ann Ital Chir 2023; 94:612-616. [PMID: 38131376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
AIM Neuromuscular muscle relaxants are still indispensable for surgical procedures requiring general anesthesia, and the use of these agents may result in postoperative residual curarization. Sugammadex may offer a distinct advantage to pediatric patients where residual neuromuscular blockade may be poorly tolerated. Sugammadex is approved for use in adults and children over two years. This is the main reason why large-scale studies could not be conducted in the group of patients younger than two years old. This study aimed to evaluate the efficacy and safety of sugammadex for reversing deep rocuronium-induced neuromuscular blockade in children under two years of age. METHODS Pediatric patients younger than two years of age who underwent neurosurgery under sevoflurane anesthesia were included in the study. Neuromuscular block was achieved by the administration of rocuronium. It was antagonized by the administration of 5 mg/kg sugammadex and evaluated using train-of-four (TOF). Primary outcome measure was the time from sugammadex administration to return of the TOF ratio to 0,9. Postoperative adverse events were also recorded. RESULTS Two hundred eighty patients (10 day-24 months of age; 3-18 kg) were included in this study. Reversal of deep rocuronium-induced neuromuscular block with sugammadex was rapid in all patients. No residual curarization or recurarization was observed. No adverse events or hypersensitivity reactions were observed after administration of sugammadex. CONCLUSİON: Reversal of rocuronium-induced deep neuromuscular block in infants was rapid and safe. Sugammadex provided safe extubation in patients younger than two years of age who had undergone neurosurgery. Research Fund. KEY WORDS Neuromuscular blockade, Neuromuscular monitoring, Pediatrics, Sugammadex.
Collapse
|
27
|
Colquhoun DA, Vaughn MT, Bash LD, Janda A, Shah N, Ghaferi A, Sjoding M, Mentz G, Kheterpal S. Association between choice of reversal agent for neuromuscular block and postoperative pulmonary complications in patients at increased risk undergoing non-emergency surgery: STIL-STRONGER, a multicentre matched cohort study. Br J Anaesth 2023; 130:e148-e159. [PMID: 35691703 PMCID: PMC9875908 DOI: 10.1016/j.bja.2022.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Postoperative pulmonary complications are a source of morbidity after major surgery. In patients at increased risk of postoperative pulmonary complications we sought to assess the association between neuromuscular blocking agent reversal agent and development of postoperative pulmonary complications. METHODS We conducted a retrospective matched cohort study, a secondary analysis of data collected in the prior STRONGER study. Data were obtained from the Multicenter Perioperative Outcomes Group. Included patients were aged 18 yr and older undergoing non-emergency surgery under general anaesthesia with tracheal intubation with neuromuscular block and reversal, who were predicted to be at elevated risk of postoperative pulmonary complications. This risk was defined as American Society of Anesthesiologists Physical Status 3 or 4 in patients undergoing either intrathoracic or intra-abdominal surgery who were either aged >80 yr or underwent a procedure lasting >2 h. Cohorts were defined by reversal with neostigmine or sugammadex. The primary composite outcome was the occurrence of pneumonia or respiratory failure. RESULTS After matching by institution, sex, age (within 5 yr), body mass index, anatomic region of surgery, comorbidities, and neuromuscular blocking agent, 3817 matched pairs remained. The primary postoperative pulmonary complications outcome occurred in 224 neostigmine cases vs 100 sugammadex cases (5.9% vs 2.6%, odds ratio 0.41, P<0.01). After adjustment for unbalanced covariates, the adjusted odds ratio for the association between sugammadex use and the primary outcome was 0.39 (P<0.0001). CONCLUSIONS In a cohort of patients at increased risk for pulmonary complications compared with neostigmine, use of sugammadex was independently associated with reduced risk of subsequent development of pneumonia or respiratory failure.
Collapse
Affiliation(s)
| | - Michelle T Vaughn
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Allison Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Amir Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
28
|
Elsherbini N, Weingartshofer A, Backman SB. Postoperative hypotonia in a patient with stiff person syndrome: a case report and literature review. Can J Anaesth 2022; 69:1419-1425. [PMID: 35986141 DOI: 10.1007/s12630-022-02306-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Stiff person syndrome (SPS), an autoimmune disease that manifests with episodic muscle rigidity and spasms, has anesthetic considerations because postoperative hypotonia may occur. This hypotonia has been linked to muscle relaxants and volatile anesthetics and may persist in spite of neostigmine administration and train-of-four (TOF) monitoring suggesting full reversal. We present a patient with SPS who experienced hypotonia following total intravenous anesthesia (TIVA), which was promptly reversed with sugammadex. These observations are considered in light of the relevant medical literature. CLINICAL FEATURES A 46-yr-old female patient with SPS underwent breast lumpectomy and sentinel node biopsy. Anesthesia consisted of TIVA (propofol/remifentanil) with adjunctive administration of rocuronium 20 mg to obtain adequate intubating conditions. Despite return of the TOF ratio to 100% within 30 min, hypotonia was clinically evident at conclusion of surgery two hours later. Sugammadex 250 mg reversed residual muscle relaxation permitting uneventful extubation. A literature review identified six instances of postoperative hypotonia (TIVA, n = 3; volatile anesthetics, n = 3) in spite of neostigmine administration (n = 2) and TOF monitoring suggesting full reversal (n = 4). CONCLUSIONS Patients with SPS may show hypotonia regardless of general anesthetic technique (TIVA vs inhalational anesthesia), which can persist despite recovery of the TOF ratio and may be more effectively reversed by a chelating agent than with an anticholinesterase. If general anesthesia is required, we suggest a cautious approach to administering muscle relaxants including using the smallest dose necessary, considering the importance of clinical assessment of muscle strength recovery in addition to TOF monitoring, and discussing postoperative ventilation risk with the patient prior to surgery.
Collapse
Affiliation(s)
- Noha Elsherbini
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | | | - Steven B Backman
- MUHC Department of Anesthesia, Royal Victoria Hospital, 1001 Boulevard Décarie, Rm C05.2653, Montreal, QC, H4A 3J1, Canada.
| |
Collapse
|
29
|
Lee J, An J, Lee DH, Lee J, Kim E, Woo K, Kim KH. Cortisol secretory patterns in deep and moderate neuromuscular blockades in laparoscopic surgery under total intravenous anesthesia: A prospective, single-blinded, randomized controlled trial. Medicine (Baltimore) 2022; 101:e30702. [PMID: 36181085 PMCID: PMC9524859 DOI: 10.1097/md.0000000000030702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Neuroendocrine stress response induces physiological changes depending on the type of surgery and anesthesia. Although the optimal depth of neuromuscular blockade for reducing this response remains unknown, deep neuromuscular blockade is known to improve the surgical environment. Therefore, we hypothesized that a patient's stress response would be lower in surgical procedures under deep neuromuscular blockade than under moderate neuromuscular blockade. METHODS This prospective, randomized, single-blind study enrolled 72 patients who underwent laparoscopic gynecological surgery under general anesthesia and were assigned to group D (deep blockade: target train-of-four 0 and posttetanic count ≥ 1) or group M (moderate blockade: target train-of-four count 1-3). The primary endpoints were changing patterns in cortisol and adrenocorticotrophic hormone levels; the secondary endpoints were patient outcomes, such as hemodynamic variables, serum glucose level, postoperative pain in the postanesthesia care unit, and hospital stay. RESULTS The baseline characteristics were comparable between the 67 patients included in the 2 groups (34 in group M and 33 in group D). Cortisol and adrenocorticotrophic hormone levels increased perioperatively in both groups but without significant intergroup differences. Serum glucose level increased perioperatively and decreased postoperatively, but without a significant intergroup difference. Postoperative pain, fentanyl requirement in the postanesthesia care unit, and hospital stay were also comparable. CONCLUSIONS Compared with moderate neuromuscular blockade, deep neuromuscular blockade improved the surgical environment without significant intergroup differences in the hormonal stress response.
Collapse
Affiliation(s)
- Jeongyoon Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| | - Jihyun An
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
- *Correspondence: Jihyun An, Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, 99 Ayang-ro, Daegu 41199, Korea (e-mail: )
| | - Dong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| | - Jihyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| | - Eunju Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| | - Kyeongyoon Woo
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| | - Kyeong Hyo Kim
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, DaeguKorea
| |
Collapse
|
30
|
Aragón-Benedí C, Pascual-Bellosta A, Ortega-Lucea S, Visiedo-Sánchez S, Martínez-Ubieto J. Predictive study of pharmacological reversal for residual neuromuscular blockade and postoperative pulmonary complications: a prospective, observational, cohort study. Sci Rep 2022; 12:14955. [PMID: 36056061 PMCID: PMC9440015 DOI: 10.1038/s41598-022-18917-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
In recent years, some studies have generated controversy since they conclude that intraoperatively pharmacological reversal of neuromuscular blockade does not contribute to the reduction of postoperative residual neuromuscular blockade or pulmonary complications. Therefore, the main objective of this study was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal. The secondary aim was to present a prognostic model to predict the probability of having postoperative residual neuromuscular blockade depending on a patient's comorbidities and intraoperative neuromuscular blocking agents management. A single-center, prospective, observational cohort study including patients undergoing surgical procedures with general anesthesia was designed. A total of 714 patients were analyzed. Patients were divided into four groups: cisatracurium with spontaneous reversal, cisatracurium with neostigmine antagonism, rocuronium with spontaneous reversal, and rocuronium with sugammadex antagonism. According to our binomial generalized linear model, none of the studied comorbidities was a predisposing factor for an increase in the residual neuromuscular blockade. However, in our study, pharmacological reversal of rocuronium with sugammadex and, particularly, neuromuscular monitoring during surgery were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early and late postoperative pulmonary complications.
Collapse
Affiliation(s)
- Cristian Aragón-Benedí
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain.
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.
| | - Ana Pascual-Bellosta
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Sonia Ortega-Lucea
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Sara Visiedo-Sánchez
- Department of Anaesthesia, Resuscitation and Pain Therapy, University Clinical Hospital Lozano Blesa, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Javier Martínez-Ubieto
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| |
Collapse
|
31
|
Christodoulides A, Palma S, Zaazoue MA, Huh A, Tobin MK, Dine SA, Huh M, Bradbury JL. Utility of neuromuscular blockade reversal in the evaluation of acute neurosurgical patients: A retrospective case-series. J Clin Neurosci 2022; 104:82-87. [PMID: 35981464 DOI: 10.1016/j.jocn.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Sugammadex reversal of neuromuscular blocking agents (NMBAs) is usually performed postoperatively. A scarcity of literature exists exploring sugammadex use for timely neurological examination of neurosurgical patients. NMBAs, like rocuronium, are used in the Emergency Department during intubation and their unpredictable duration of action often impedes timely and accurate assessment of patient neurological status. We aim to explore the role of sugammadex in evaluating patients in need of acute neurosurgical care. METHODS Retrospective assessment of patients presenting with traumatic brain injury or intracranial hemorrhage was conducted at our level 1 trauma center. Patients of interest were those for whom sugammadex reversal of rocuronium neuromuscular blockade, from intubating doses, was pursued to ensure timely neurologic assessment. Nine patients were identified for whom GCS pre-/post-sugammadex, rocuronium dosing, elapsed time between rocuronium administration and reversal, and clinical course data were retrieved. RESULTS Arrival GCS was 5.2 ± 3.2, with intubation accomplished within 10 ± 2.5 min of presentation. Rocuronium dosing was consistent between patients, average single dose of 1.2 ± 0.3 mg/kg. Lingering neuromuscular blockade ranged from 28 to 132 min (87.3 ± 34.3 min). All patients exhibited a GCS of 3 T upon initial neurosurgical evaluation, prior to reversal. Post-reversal GCS rose to 6.0 T ± 2.2. Sugammadex facilitated more accurate clinical decision making in 8 of 9 patients, including prevention of unnecessary invasive procedures. Two of 9 patients were eventually discharged home or to a rehabilitation facility. CONCLUSIONS Rocuronium neuromuscular blockade can linger beyond pharmacokinetic predictions, thus delaying timely and precise neurologic assessment. Our data suggests sugammadex may be a useful addition to the clinician's armamentarium for acute neurologic assessment in the neurosurgical population. Sugammadex may impact clinical decision-making in certain patients and allow for more informed decision-making by families and physicians alike. Prospective studies are needed to definitively assess the impact of sugammadex on outcomes in acute neurosurgical settings.
Collapse
Affiliation(s)
- Alexei Christodoulides
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA.
| | - Samantha Palma
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA
| | - Mohamed A Zaazoue
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA
| | - Andrew Huh
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA
| | - Matthew K Tobin
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA
| | - Serena A Dine
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Morgan Huh
- Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - Jamie L Bradbury
- Indiana University School of Medicine, Department of Neurological Surgery, Indianapolis, IN, USA
| |
Collapse
|
32
|
Lang B, Han L, Zeng L, Zhang Q, Chen S, Huang L, Jia Z, Yu Q, Zhang L. Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis. BMC Pediatr 2022; 22:295. [PMID: 35590273 PMCID: PMC9118813 DOI: 10.1186/s12887-022-03288-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 04/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent survey revealed that extensive off-label use of sugammadex in pediatric anesthesia deserved particular attention. The present study with trial sequential analysis (TSA) aimed to evaluate the effects of sugammadex for antagonizing neuromuscular blockade (NMB) in pediatric patients, and to investigate whether the findings achieved the required information size to draw conclusions. METHODS PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to April 2021. All randomized controlled trials used sugammadex as reversal agent in pediatric patients were enrolled. Time from NMB reversal to recovery of the train-of-four ratio (TOFr) to 0.9 and extubation time were considered as co-primary outcomes, and incidences of adverse events were considered as secondary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of evidences. RESULTS Data from 18 studies involving 1,065 pediatric patients were acquired. The results revealed that use of sugammadex was associated with shorter duration from administration of reversal agents to TOFr > 0.9 (MD = -14.42, with 95% CI [-17.08, -11.75]) and shorter interval from reversal from NMB to extubation (MD = -13.98, with 95% CI [-16.70, -11.26]) compared to control groups. TSA also indicated that the current sample sizes were sufficient with unnecessary further trials. Analysis of secondary outcomes indicated that administration of sugammadex was associated with less incidence of postoperative nausea and vomiting (PONV), bradycardia, and dry mouth compared to control groups. CONCLUSION Considering of satisfactory and rapid neuromuscular blockade reversal with low incidences of adverse events, sugammadex might be considered as the preferred option for children in clinical anesthesia practice compared to acetylcholinesterase inhibitors. However, overall low-quality evidences in present study rated by GRADE system indicated that superiority of sugammadex employed in pediatric patients needs to be confirmed by more studies with high quality and large sample size in future.
Collapse
Affiliation(s)
- Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Lu Han
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Qianqian Zhang
- Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Zhijun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Biopharmaceutics, West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
| |
Collapse
|
33
|
Dong Y, Li Q. Phonomyography on Perioperative Neuromuscular Monitoring: An Overview. Sensors (Basel) 2022; 22:s22072448. [PMID: 35408063 PMCID: PMC9003319 DOI: 10.3390/s22072448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/15/2022] [Accepted: 03/20/2022] [Indexed: 02/05/2023]
Abstract
Complications related to neuromuscular blockade (NMB) could occur during anesthesia induction, maintenance, and emergency. It is recommended that neuromuscular monitoring techniques be utilized perioperatively to avoid adverse outcomes. However, current neuromuscular monitoring methods possess different shortcomings. They are cumbersome to use, susceptible to disturbances, and have limited alternative monitoring sites. Phonomyography (PMG) monitoring based on the acoustic signals yielded by skeletal muscle contraction is emerging as an interesting and innovative method. This technique is characterized by its convenience, stable signal quality, and multimuscle recording ability and shows great potential in the application field. This review summarizes the progression of PMG on perioperative neuromuscular monitoring chronologically and presents the merits, demerits, and challenges of PMG-based equipment, aiming at underscoring the potential of PMG-based apparatuses for neuromuscular monitoring.
Collapse
Affiliation(s)
| | - Qian Li
- Correspondence: ; Tel.: +86-18980601635
| |
Collapse
|
34
|
Park SH, Huh H, Choi SI, Kim JH, Jang YJ, Park JM, Kwon OK, Jung MR, Jeong O, Lee CM, Min JS, Kim JJ, An L, Yang KS, Park S, Lee IO. Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial. J Am Coll Surg 2022; 234:326-339. [PMID: 35213496 DOI: 10.1097/xcs.0000000000000061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients. STUDY DESIGN We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events. RESULTS Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth. CONCLUSION Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.
Collapse
Affiliation(s)
- Shin-Hoo Park
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Anam Hospital, Seoul, Republic of Korea (SH Park, S Park)
| | - Hyub Huh
- Department of Anesthesiology and Pain Medicine (Huh), Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Sung Il Choi
- Department of Surgery (Choi), Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Jong-Han Kim
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea (JH Kim, Jang)
| | - You-Jin Jang
- Division of Foregut Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea (JH Kim, Jang)
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Republic of Korea (JM Park)
| | - Oh Kyoung Kwon
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea (Kyoung Kwon)
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Jeollanam-do, Republic of Korea (Ran Jung, Jeong)
| | - Oh Jeong
- Department of Surgery, Chonnam National University Medical School, Jeollanam-do, Republic of Korea (Ran Jung, Jeong)
| | - Chang Min Lee
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Ansan Hospital, Seoul, Republic of Korea (CM Lee)
| | - Jae Seok Min
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Cancer Center, Busan, Republic of Korea (Seok Min)
| | - Jin-Jo Kim
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Republic of Korea (JJ Kim)
| | - Liang An
- Shaoxing Hospital Zhejiang University School of Medicine, Shaoxing, China (An)
| | - Kyung Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (Sook Yang)
| | - Sungsoo Park
- From the Division of Foregut Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea (SH Park, JH Kim, CM Lee, S Park)
- Division of Foregut Surgery, Korea University Anam Hospital, Seoul, Republic of Korea (SH Park, S Park)
| | - Il Ok Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Seoul, Republic of Korea (IO Lee)
| |
Collapse
|
35
|
Sun S, Sun Y, Chen R, Yao C, Xia H, Chen X, Lin Y, Yao S. Diaphragm ultrasound to evaluate the antagonistic effect of sugammadex on rocuronium after liver surgery in patients with different liver Child-Pugh grades: study protocol for a prospective, double-blind, non-randomised controlled trial. BMJ Open 2022; 12:e052279. [PMID: 35105573 PMCID: PMC8808392 DOI: 10.1136/bmjopen-2021-052279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The use of muscle relaxants is an indispensable in the general anaesthesia but is prone to accidents, which are often related to residual muscle relaxant. Therefore, how to timely and effectively eliminate the residual effect of muscle relaxants after surgery has become an urgent clinical problem. Rocuronium is a non-depolarising muscle relaxant that is primarily metabolised by the liver. Patients with liver dysfunction can affect the metabolic process of rocuronium, thereby delaying the recovery of muscle relaxation. Sugammadex (SUG) is a novel-specific antagonist of aminosteroidal muscle relaxants, which can effectively antagonise muscle relaxants at different depths. However, whether liver dysfunction affects the antagonistic effect of SUG against rocuronium has not been reported. Therefore, we hypothesise that with the increase of patients' liver Child-Pugh grade, the recovery time of rocuronium antagonised by the same dose of SUG after surgery will be prolonged, and the incidence of muscle relaxation residual will be increased in the short term. METHODS AND ANALYSIS This study is a prospective, double-blind, low-intervention, non-randomised controlled clinical trial involving 99 patients with American Society of Anesthesiologists (ASA) Ⅰ-Ⅲ, body mass index 18.5-24.9 kg/m2, who will undergo laparoscopic radical resection of liver cancer under general anaesthesia in the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. Ultrasonography will be applied to monitor the change rate of diaphragm thickness at different time after extubation to evaluate the occurrence of residual muscle relaxant, which indirectly reflects the dose-effect relationship of SUG antagonising against rocuronium in patients with different liver Child-Pugh grades preoperatively. ETHICS AND DISSEMINATION The protocol was reviewed and approved by the Medical Ethics Committee of Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology (UHCT21012). The findings will be disseminated to the public through peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT05028088.
Collapse
Affiliation(s)
- Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rui Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chunlin Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Haifa Xia
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| |
Collapse
|
36
|
Putz L, Lovqvist L, Bachy V, Van der Vorst S, Jamart J, Dubois PE. Evaluation of the impact of deep neuromuscular blockade on surgical conditions for laryngeal microsurgery with High Frequency Jet Ventilation. A comparison with no block during intravenous general anesthesia with topical lidocaine. Am J Otolaryngol 2022; 43:103187. [PMID: 34536915 DOI: 10.1016/j.amjoto.2021.103187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Laryngeal transoral surgery classically requires a neuromuscular block (NMB) to facilitate tracheal intubation and to improve surgical conditions. However, the short duration of most procedures and the potential complications of residual NMB lead to consider a no block approach. The hypothesis that intravenous anesthesia (remifentanil and propofol infusions) without NMB but including glottis topical lidocaine anesthesia would allow clinically acceptable laryngeal exposure and good surgical conditions was tested in the specific context of procedures undergone with High Frequency Jet Ventilation (HFJV). STUDY DESIGN A prospective randomized clinical comparison. METHODS 66 consenting patients were planned to receive 0.6 mg·kg-1 rocuronium or saline at random. The outcome measurements included the time and conditions to complete suspended laryngoscopy, and the surgical conditions rated by the surgeon. Any vocal cord movement or coughing was recorded. Data were compared using a Wilcoxon rank-sum test for numerical variables and chi-square test for categorical ones. Treatment failure was defined as an impossible laryngoscopy or a grade 4 surgical field occurring at any time during surgery and was compared to its null theoretical value by a general z-test. An interim analysis after completion of 50% patients was performed using Pocock boundaries at 0.0294 significance levels. RESULTS A significant failure rate occurred in the non paralysed group (27%, p < 0.001). No coughing and no vocal cords movement occurred in the NMB group. Poorer surgical conditions were obtained without NMB (p = 0.011). CONCLUSION Inducing a deep NMB ensured improved conditions during direct laryngeal microsurgery with HFJV.
Collapse
Affiliation(s)
- Laurie Putz
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium.
| | - Linda Lovqvist
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium
| | - Vincent Bachy
- Université catholique de Louvain, CHU UCL Namur, Department of Oto-rhino-laryngology, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium
| | - Sébastien Van der Vorst
- Université catholique de Louvain, CHU UCL Namur, Department of Oto-rhino-laryngology, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium
| | - Jacques Jamart
- Université catholique de Louvain, CHU UCL Namur, Scientific Support Unit, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium
| | - Philippe E Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Avenue Dr G Thérasse 1, 5530 Yvoir, Belgium
| |
Collapse
|
37
|
Lu IC, Tan H, Wu SH, Huang TY, Tseng HY, Wang JJ, Dionigi G, Chai YJ, Chiang FY, Chang PY, Wu CW. A comparison between cisatracurium and rocuronium-induced neuromuscular block on laryngeal electromyography recovery after neostigmine reversal in a porcine model. Front Endocrinol (Lausanne) 2022; 13:875597. [PMID: 36004347 PMCID: PMC9393356 DOI: 10.3389/fendo.2022.875597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Inducing and reversing neuromuscular block is essential to a positive outcome of thyroid surgery, with intraoperative neuromonitoring (IONM) being used to decrease recurrent and superior laryngeal nerve injuries and improve vocal outcome. Neostigmine is a non-specific broad-spectrum and inexpensive reversal agent for neuromuscular blocking agents (NMBAs). The aim of this porcine study was to explore the effect of neostigmine on electromyography (EMG) signal recovery profile following the commonly used NMBAs, cisatracurium and rocuronium. METHODS Twelve piglets were allocated into two groups with six piglets in each group. When stable baseline EMG signals were obtained, a neuromuscular block was induced by intravenous cisatracurium 0.2 mg/kg (group C) or rocuronium 0.6 mg/kg (group R) for each piglet. We compared laryngeal EMG tracing with spontaneous recovery (control) and neostigmine (0.04 mg/kg) reversal for each group. The time course of real-time laryngeal EMG signals was observed for 30 min from NMBA injection. Effects of neostigmine on EMG signal were assessed at 50% EMG recovery and by the maximum neuromuscular block recovery degree from the baseline value. RESULTS Neostigmine shortened the recovery time to 50% EMG amplitude in both group C (16.5 [2.5] vs. 29.0 [2.0] min, P<0.01) and group R (16.5[2.5] vs. 26.5 [1.5] min, P<0.05) compared to spontaneous recovery, respectively. Neostigmine reversal also enhanced the maximum degree of EMG amplitude recovery in both group C (83.6 [5.1] vs. 47.2 [6.1] %, P<0.01) and group R (85.6 [18.2]vs. 57.1 [6.3] %, P<0.05) compared to spontaneous recovery, respectively. The reversal effect of neostigmine did not differ significantly between cisatracurium and rocuronium. CONCLUSIONS This porcine model demonstrated that neostigmine provides an adequate and timely IONM signal suppressed by both cisatracurium and rocuronium. These results can potentially expand the options for precision neuromuscular block management during IONM to improve vocal outcomes in thyroid surgery patients.
Collapse
Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hao Tan
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Tseng
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia-Joanna Wang
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano, Istituto di ricovero e cura a carattere scientifico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
38
|
Jin S, Baik HJ, Cho S, Chung RK, Kong KA, Kim YJ. The influence of neuromuscular blockade on phase lag entropy and bispectral index: A randomized, controlled trial. PLoS One 2021; 16:e0257467. [PMID: 34520506 PMCID: PMC8439464 DOI: 10.1371/journal.pone.0257467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this study is to compare the effects of neuromuscular blockade (NMB) on phase lag entropy (PLE) and the bispectral index (BIS). We recorded the BIS, electromyograph (EMG) activity on a BIS monitor (EMG_BIS), PLE, and EMG activity on a PLE monitor (EMG_PLE) in 40 patients receiving general anesthesia. During the awake state, we analyzed the changes in parameters before and 2 min after the eyes were closed. During sedation, we compared the changes in the parameters before and at 4 min after injecting rocuronium (group R) or normal saline (group C) between the two groups. During anesthesia, we compared the changes in parameters before and at 4 min after injecting sugammadex (group B) or normal saline (group D) between the two groups. During the awake state, the BIS, EMG_BIS, and EMG_PLE, but not PLE, decreased significantly with closed eyes. An effect of EMG on the BIS was evident, but not on PLE. During sedation, the BIS decreased with the decrease in EMG_BIS regardless of NMB caused by rocuronium, but NMB decreased PLE, although the degree of the decrease in EMG_PLE after NMB was similar to that after placebo. To determine the effect of NMB on electroencephalograms (EEGs) in groups R and C, we plotted the power spectra before and at 4 min after injecting rocuronium or normal saline. Changes in slow and delta frequency bands were observed at 4 min after injecting rocuronium relative to before injecting rocuronium. There was no effect of EMG on either the BIS or PLE during anesthesia. In conclusion, the effect of electromyograph activity and/or neuromuscular blockade on BIS or PLE depends on the level of consciousness.
Collapse
Affiliation(s)
- Sohee Jin
- Department of Anesthesiology and Pain Medicine, Yonsei Barun Hospital, Seoul, Republic of Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Kyoung Ae Kong
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| |
Collapse
|
39
|
Nam SW, Oh AY, Koo BW, Kim BY, Han J, Chung SH. Effects of depth of neuromuscular blockade on the BIS-guided propofol requirement: A randomized controlled trial. Medicine (Baltimore) 2021; 100:e26576. [PMID: 34398011 PMCID: PMC8294904 DOI: 10.1097/md.0000000000026576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/10/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Deep neuromuscular blockade is considered beneficial for improving the surgical space condition during laparoscopic surgery. Adequacy of the surgical space condition may affect the anesthetists' decision regarding titration of depth of anesthesia. We investigated whether deep neuromuscular blockade reduces the propofol requirement under bispectral index monitoring compared to moderate neuromuscular blockade. METHODS Adult patients undergoing elective laparoscopic colorectal surgery were randomly allocated to a moderate or deep group. A train-of-four count of 1-2 in the moderate group, and a post-tetanic count of 1-2 in the deep group, were maintained by continuous infusion of rocuronium. The induction and maintenance of anesthesia were achieved by target-controlled infusion of propofol and remifentanil. The dose of propofol was adjusted to maintain the bispectral index in the range of 40-50. The remifentanil dose was titrated to maintain the systolic blood pressure to within 20% of the ward values. RESULTS A total of 82 patients were included in the analyses. The mean±SD dose of propofol was 7.54 ± 1.66 and 7.42 ± 1.01 mg·kg-1·h-1 in the moderate and deep groups, respectively (P = .104). The mean±SD dose of remifentanil was 4.84 ± 1.74 and 4.79 ± 1.77 μg kg-1 h-1 in the moderate and deep groups, respectively (P = .688). In comparison to the moderate group, the deep group showed significantly lower rates of intraoperative patient movement (42.9% vs 22.5%, respectively, P = .050) and additional neuromuscular blocking agent administration (76% vs 53%, respectively, P = .007). Postoperative complications, including pulmonary complications, wound problems and reoperation, were not different between the two groups. CONCLUSION Deep neuromuscular blockade did not reduce the bispectral index-guided propofol requirement compared to moderate neuromuscular blockade during laparoscopic colon surgery, despite reducing movement of the patient and the requirement for a rescue neuromuscular blocking agent. TRIAL REGISTRATION Clinicaltrials.gov (NCT03890406).
Collapse
Affiliation(s)
- Sun Woo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Bo Young Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Jiwon Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Sung Hoon Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| |
Collapse
|
40
|
Kressin C, Thompson Bastin M, Ather A, Gopinath A, Srour H, Schadler A, Pandya K. Cisatracurium Continuous Infusion Versus No Neuromuscular Blockade for Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation. J Clin Pharmacol 2021; 61:1415-1420. [PMID: 34180067 DOI: 10.1002/jcph.1933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/22/2021] [Indexed: 01/24/2023]
Abstract
The benefit of continuous infusion neuromuscular blockade concurrently with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome who are receiving mechanical ventilation remains unclear. Adult patients with severe acute respiratory distress syndrome requiring VV ECMO were analyzed in 2 groups: continuous infusion neuromuscular blockade with cisatracurium vs no neuromuscular blockade. Similar mechanical ventilation strategies were used. The primary end point was duration of VV ECMO. This single-center, retrospective observational cohort included a total of 47 patients, 28 of whom received continuous infusion cisatracurium and 19 patients who did not receive neuromuscular blockade. There was no difference in the duration of VV ECMO in patients who received cisatracurium, 226.5 hours (interquartile range, 119-362.3) vs 187.0 hours (interquartile range, 108-374) in the group who did not receive a paralytic (P = .64). There were no differences in secondary outcomes of days in the hospital, days free of organ dysfunction, ECMO survival, or discharged alive. Among patients with severe ARDS who were managed with VV ECMO, patients who received continuous infusion cisatracurium had no difference in the duration of VV ECMO compared to the nonparalytic comparator group.
Collapse
Affiliation(s)
- Christian Kressin
- Acute Care Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | | | - Ayesha Ather
- Acute Care Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Anil Gopinath
- Pulmonary Critical Care and Sleep Medicine, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Habib Srour
- Critical Care Anesthesiology, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Aric Schadler
- College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
- Kentucky Children's Hospital, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Komal Pandya
- Acute Care Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| |
Collapse
|
41
|
Yuan L, Zhang Y, Xu C, Wu A. Postoperative analgesia and opioid use following hip arthroscopy with ultrasound-guided quadratus lumborum block: a randomized controlled double-blind trial. J Int Med Res 2021; 48:300060520920996. [PMID: 32356470 PMCID: PMC7221222 DOI: 10.1177/0300060520920996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the postoperative analgesic effect of ultrasound-guided
quadratus lumborum block (QLB) in patients undergoing arthroscopic hip
surgery. Methods Patients who were scheduled to undergo elective arthroscopic hip surgery were
randomly assigned to the QLB (Q) or control (C) group (n = 40 each). After
general anesthesia induction, unilateral QLB was performed under ultrasound
guidance in the Q group. The amount of opioid use via patient-controlled
analgesia (PCA) and the resting and movement pain visual analog scale (VAS)
scores when the patient left the postanesthesia care unit (PACU) and 4, 8,
12, and 24 hours after surgery were recorded. Postoperative complications
were recorded for both groups. Results At 24 hours post-surgery, opioid consumption amounts via PCA (48.4
[48.1–48.6] mL) in the Q group were significantly lower compared with the C
group (52.0 [51.0–53.8] mL). A significant reduction in opioid consumption
was observed between the two groups at each time point. Resting and movement
VAS scores at each time point were significantly lower in the Q compared
with the C group. Conclusions Hip arthroscopy patients who received QLB and general anesthesia in
combination had less pain and a lower opioid requirement within 24 hours
postoperatively.
Collapse
MESH Headings
- Abdominal Muscles
- Adult
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anesthesia, General
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Female
- Humans
- Male
- Middle Aged
- Neuromuscular Blockade/methods
- Neuromuscular Blocking Agents
- Pain Measurement
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Pain, Postoperative/etiology
- Therapy, Computer-Assisted
- Time Factors
- Ultrasonography
Collapse
Affiliation(s)
- Liangjing Yuan
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital
Medical University, Beijing, China
- Department of Anesthesiology, Beijing Jishuitan Hospital,
Beijing, China
| | - Ye Zhang
- Department of Anesthesiology, Beijing Jishuitan Hospital,
Beijing, China
| | - Chengshi Xu
- Department of Anesthesiology, Beijing Jishuitan Hospital,
Beijing, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital
Medical University, Beijing, China
- Anshi Wu, Department of Anesthesiology,
Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
42
|
Lim BG, Won YJ, Kim H. The effect of dexamethasone on sugammadex reversal of rocuronium-induced neuromuscular blockade in surgical patients undergoing general anesthesia: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23992. [PMID: 33592855 PMCID: PMC7870250 DOI: 10.1097/md.0000000000023992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/27/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There have been conflicting results regarding clinical dexamethasone-sugammadex interactions in adults and pediatric patients under general anesthesia. METHODS This study used a systematic review with meta-analysis of randomized controlled trials and non-randomized studies based on the Cochrane Review Methods. A comprehensive literature search was conducted to identify clinical trials that investigated the effect of dexamethasone on sugammadex reversal of rocuronium-induced neuromuscular blockade in surgical patients undergoing general anesthesia. RESULTS Among the 314 patients in the 6 studies, 147 received intravenous dexamethasone (dexamethasone group), and 167 received intravenous saline or other antiemetics (control group). The primary outcome, the time to recovery after sugammadex administration (the time to recovery of the train-of-four ratio to 0.9 after sugammadex administration; s) was comparable between the 2 groups, the weighted mean difference (95% confidence interval [CI]) being -2.93 (-36.19, 30.33) (I2 = 94%). The time to extubation after sugammadex administration (s) and incidence of postoperative nausea and vomiting was not different between the 2 groups, the weighted mean difference (95% CI) being 23.31 (-2.26, 48.88) (I2 = 86%) and the pooled risk ratio (95% CI) being 0.25 (0.03, 2.11), respectively. The time to recovery after sugammadex administration might be different according to the study design or study region. CONCLUSION This meta-analysis showed that use of dexamethasone in the perioperative period neither delayed nor facilitated the reversal of rocuronium-induced neuromuscular blockade with sugammadex in patients undergoing elective surgery with general anesthesia. However, given that the results showed high heterogeneity, further randomized controlled trials are needed to confirm these findings.
Collapse
|
43
|
Dubovoy TZ, Saager L, Shah NJ, Colquhoun DA, Mathis MR, Kapeles S, Mentz G, Kheterpal S, Vaughn MT. Utilization Patterns of Perioperative Neuromuscular Blockade Reversal in the United States: A Retrospective Observational Study From the Multicenter Perioperative Outcomes Group. Anesth Analg 2020; 131:1510-1519. [PMID: 33079874 PMCID: PMC7593983 DOI: 10.1213/ane.0000000000005080] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Following the introduction of sugammadex to the US clinical practice, scarce data are available to understand its utilization patterns. This study aimed to characterize patient, procedure, and provider factors associated with sugammadex administration in US patients. METHODS This retrospective observational study was conducted across 24 Multicenter Perioperative Outcomes Group institutions in the United States with sugammadex on formulary at the time of the study. All American Society of Anesthesiologists (ASA) physical status I-IV adults undergoing noncardiac surgery from 2014 to 2018 receiving neuromuscular blockade (NMB) were eligible. The study established 3 periods based on the date of first documented sugammadex use at each institution: the presugammadex period, 0- to 6-month transitional period, and 6+ months postsugammadex period. The primary outcome was reversal using sugammadex during the postsugammadex period-defined as 6 months after sugammadex was first utilized at each institution. A multivariable mixed-effects logistic regression model controlling for institution was developed to assess patient, procedure, and provider factors associated with sugammadex administration. RESULTS A total of 934,798 cases met inclusion criteria. Following the 6-month transitional period, sugammadex was used on average in 40.0% (95% confidence interval [CI], 39.8-40.2) of cases receiving NMB. Multivariable analysis demonstrated sugammadex use to be associated with train-of-four count of 0-1 (adjusted odds ratio = 4.06; 95% CI, 33.83-4.31) or 2 (2.45; 2.29-2.62) vs 3-4 twitches before reversal; the amount of NMB administered (3.01; 2.88-3.16) for the highest effective dose 95 quartile compared to the lowest quartile; advanced age (1.83; 1.71-1.95) compared to age <41; male sex (1.36; 1.32-1.39) compared to female sex; major thoracic surgery (1.26; 1.13-1.39); congestive heart failure (1.17, 1.07-1.28); and ASA III or IV (1.13; 1.10-1.16) versus ASA I or II. CONCLUSIONS Our data demonstrate broad early clinical adoption of sugammadex following Food and Drug Administration approval. Sugammadex is used preferentially in cases with higher degrees of NMB before reversal and in patients with greater burden of comorbidities and known risk factors for residual blockade or pulmonary complications.
Collapse
Affiliation(s)
- Timur Z Dubovoy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Leif Saager
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Nirav J Shah
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Douglas A Colquhoun
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michael R Mathis
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven Kapeles
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Graciela Mentz
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michelle T Vaughn
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
44
|
Abstract
The management of Acute Respiratory Distress Syndrome (ARDS) secondary to the novel Coronavirus Disease 2019 (COVID-19) proves to be challenging and controversial. Multiple studies have suggested the likelihood of an atypical pathophysiology to explain the spectrum of pulmonary and systemic manifestations caused by the virus. The principal paradox of COVID-19 pneumonia is the presence of severe hypoxemia with preserved pulmonary mechanics. Data derived from the experience of multiple centers around the world have demonstrated that initial clinical efforts should be focused into avoid intubation and mechanical ventilation in hypoxemic COVID-19 patients. On the other hand, COVID-19 patients progressing or presenting into frank ARDS with typical decreased pulmonary compliance, represents another clinical enigma to many clinicians, since routine therapeutic interventions for ARDS are still a subject of debate.
Collapse
Affiliation(s)
- Jose R Navas-Blanco
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1800 NW 10 Avenue (M-820), Miami, FL, 33136, USA.
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1800 NW 10 Avenue (M-820), Miami, FL, 33136, USA
| |
Collapse
|
45
|
Albers KI, Polat F, Panhuizen IF, Snoeck MMJ, Scheffer GJ, de Boer HD, Warlé MC. The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): study protocol for a randomized controlled study. Trials 2020; 21:541. [PMID: 32552782 PMCID: PMC7301516 DOI: 10.1186/s13063-020-04496-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/10/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND There is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery. Deep neuromuscular blockade allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. While there is considerable evidence to support superior surgical conditions during deep neuromuscular blockade, there is only a limited amount of studies investigating patient outcomes. Moreover, results are not always consistent between studies and vary between different types of laparoscopic surgery. This study will investigate the effect of low-pressure pneumoperitoneum facilitated by deep NMB on quality of recovery after laparoscopic colorectal surgery. METHODS The RECOVER study is a multicenter double-blinded randomized controlled trial consisting of 204 patients who will be randomized in a 1:1 fashion to group A, low-pressure pneumoperitoneum (8 mmHg) facilitated by deep neuromuscular blockade (post tetanic count of 1-2), or group B, normal-pressure pneumoperitoneum (12 mmHg) with moderate neuromuscular blockade (train-of-four response of 1-2). The primary outcome is quality of recovery on postoperative day 1, quantified by the Quality of Recovery-40 questionnaire. DISCUSSION Few studies have investigated the effect of lower insufflation pressures facilitated by deep neuromuscular blockade on patient outcomes after laparoscopic colorectal procedures. This study will identify whether low pressure pneumoperitoneum and deep neuromuscular blockade will enhance recovery after colorectal laparoscopic surgery and, moreover, if this could be a valuable addition to the Enhanced Recovery After Surgery guidelines. TRIAL REGISTRATION EudraCT 2018-001485-42. Registered on April 9, 2018. Clinicaltrials.govNCT03608436. Registered on July 30, 2018.
Collapse
Affiliation(s)
- Kim I. Albers
- Department of Surgery and Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Ivo F. Panhuizen
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Marc M. J. Snoeck
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Hans D. de Boer
- Department of Anesthesiology, Martini General Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Michiel C. Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| |
Collapse
|
46
|
Raval AD, Deshpande S, Rabar S, Koufopoulou M, Neupane B, Iheanacho I, Bash LD, Horrow J, Fuchs-Buder T. Does deep neuromuscular blockade during laparoscopy procedures change patient, surgical, and healthcare resource outcomes? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0231452. [PMID: 32298304 PMCID: PMC7161978 DOI: 10.1371/journal.pone.0231452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/24/2020] [Indexed: 01/02/2023] Open
Abstract
Background Deep neuromuscular blockade may facilitate the use of reduced insufflation pressure without compromising the surgical field of vision. The current evidence, which suggests improved surgical conditions compared with other levels of block during laparoscopic surgery, features significant heterogeneity. We examined surgical patient- and healthcare resource use-related outcomes of deep neuromuscular blockade compared with moderate neuromuscular blockade in adults undergoing laparoscopic surgery. Methods We conducted a systematic literature review according to the quality standards recommended by the Cochrane Handbook for Systematic Reviews. Randomized controlled trials comparing outcomes of deep neuromuscular blockade and moderate neuromuscular blockade among adults undergoing laparoscopic surgeries were included. A random-effects model was used to conduct pair-wise meta-analyses. Results The systematic literature review included 15 studies—only 13 were analyzable in the meta-analysis and none were judged to be at high risk of bias. Compared with moderate neuromuscular blockade, deep neuromuscular blockade was associated with improved surgical field of vision and higher vision quality scores. Also, deep neuromuscular blockade was associated with a reduction in the post-operative pain scores in the post-anesthesia care unit compared with moderate neuromuscular blockade, and there was no need for an increase in intra-abdominal pressure during the surgical procedures. There were minor savings on resource utilization, but no differences were seen in recovery in the post-anesthesia care unit or overall length of hospital stay with deep neuromuscular blockade. Conclusions Deep neuromuscular blockade may aid the patient and physician surgical experience by improving certain patient outcomes, such as post-operative pain and improved surgical ratings, compared with moderate neuromuscular blockade. Heterogeneity in the pooled estimates suggests the need for better designed randomized controlled trials.
Collapse
Affiliation(s)
- Amit D. Raval
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Sohan Deshpande
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Silvia Rabar
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Maria Koufopoulou
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Binod Neupane
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Ike Iheanacho
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Lori D. Bash
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Jay Horrow
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Thomas Fuchs-Buder
- Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy, Vandoeuvre-les-Nancy, France
- * E-mail: ,
| |
Collapse
|
47
|
Affiliation(s)
- Ivan Co
- Both authors: Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | | |
Collapse
|
48
|
Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
49
|
Wei Y, Li J, Sun F, Zhang D, Li M, Zuo Y. Low intra-abdominal pressure and deep neuromuscular blockade laparoscopic surgery and surgical space conditions: A meta-analysis. Medicine (Baltimore) 2020; 99:e19323. [PMID: 32118762 PMCID: PMC7478474 DOI: 10.1097/md.0000000000019323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/13/2020] [Accepted: 01/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Low intra-abdominal pressure (IAP) and deep neuromuscular blockade (NMB) are frequently used in laparoscopic abdominal surgery to improve surgical space conditions and decrease postoperative pain. The evidence supporting operations using low IAP and deep NMB is open to debate. METHODS The feasibility of the routine use of low IAP +deep NMB during laparoscopic surgery was examined. A meta-analysis is conducted with randomized controlled trials (RCTs) to compare the influence of low IAP + deep NMB vs. low IAP + moderate NMB, standard IAP +deep NMB, and standard IAP + moderate NMB during laparoscopic procedures on surgical space conditions, the duration of surgery and postoperative pain. RCTs were identified using the Cochrane, Embase, PubMed, and Web of Science databases from initiation to June 2019. Our search identified 9 eligible studies on the use of low IAP + deep NMB and surgical space conditions. RESULTS Low IAP + deep NMB during laparoscopic surgery did not improve the surgical space conditions when compared with the use of moderate NMB, with a mean difference (MD) of -0.09 (95% confidence interval (CI): -0.55-0.37). Subgroup analyses showed improved surgical space conditions with the use of low IAP + deep NMB compared with low IAP + moderate NMB, (MD = 0.63 [95% CI:0.06-1.19]), and slightly worse conditions compared with the use of standard IAP + deep NMB and standard IAP + moderate NMB, with MDs of -1.13(95% CI:-1.47 to 0.79) and -0.87(95% CI:-1.30 to 0.43), respectively. The duration of surgery did not improve with low IAP + deep NMB, (MD = 1.72 [95% CI: -1.69 to 5.14]), and no significant reduction in early postoperative pain was found in the deep-NMB group (MD = -0.14 [95% CI: -0.51 to 0.23]). CONCLUSION Low IAP +deep NMB is not significantly more effective than other IAP +NMB combinations for optimizing surgical space conditions, duration of surgery, or postoperative pain in this meta-analysis. Whether the use of low IAP + deep NMB results in fewer intraoperative complications, enhanced quality of recovery or both after laparoscopic surgery should be studied in the future.
Collapse
Affiliation(s)
- Yiyong Wei
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan
- The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu
| | - Jia Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan
- The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu
| | - Fude Sun
- Department of Anesthesiology, Penglai Traditional Chinese Medicine Hospital, Penglai, Shandong, China
| | - Donghang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan
- The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu
| | - Ming Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan
- The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan
- The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu
| |
Collapse
|
50
|
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: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
|