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Yang S, Sun Z, Zhou C, Wei W, Qu N, Shi R, Ma B, Xu W, Ji Q, Zhang J, Wang Y. Feasibility of the enhanced neuromuscular blockade recovery protocol with selective use of sugammadex in thyroid surgery with intraoperative neuromonitoring. Head Neck 2024. [PMID: 38877778 DOI: 10.1002/hed.27826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/31/2024] [Accepted: 05/20/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND To investigate feasibility of utilizing enhanced neuromuscular blocking agents with selective recovery protocol during thyroid surgery with intraoperative neuromonitoring (IONM). METHODS Two-hundred and ninety patients were randomized into two groups: group A 0.3 mg/kg rocuronium and group B 0.6 mg/kg. Sugammadex 2 mg/kg was injected if needed followed initial vagal stimulation (V0). Electromyography signals from vagus and recurrent laryngeal nerves before and after resection were recorded as V1, V2, R1, and R2. RESULTS In group B, 30 patients (20.7%) had V0 signals <100 μV, compared to 9 (6.2%) in group A. After sugammadex administration, 144 patients (99.3%) in both groups achieved positive V1 signals. Group B demonstrated a shorter surgical time from rocuronium injection to V2 stimulation compared to group A, accompanied by a significantly lower incidence of intraoperative body movement (0 vs. 16 patients). CONCLUSIONS 0.6 mg/kg rocuronium with selective use 2 mg/kg sugammadex for IONM in thyroid surgery can meet both anesthesia and surgery demands.
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Affiliation(s)
- Shuwen Yang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhirong Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Changming Zhou
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Wenjun Wei
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ning Qu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Rongliang Shi
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ben Ma
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Weibo Xu
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qinhai Ji
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Wang
- Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, China
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Guzzi G, Ricciuti RA, Della Torre A, Lo Turco E, Lavano A, Longhini F, La Torre D. Intraoperative Neurophysiological Monitoring in Neurosurgery. J Clin Med 2024; 13:2966. [PMID: 38792507 PMCID: PMC11122101 DOI: 10.3390/jcm13102966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Intraoperative neurophysiological monitoring (IONM) is a crucial advancement in neurosurgery, enhancing procedural safety and precision. This technique involves continuous real-time assessment of neurophysiological signals, aiding surgeons in timely interventions to protect neural structures. In addition to inherent limitations, IONM necessitates a detailed anesthetic plan for accurate signal recording. Given the growing importance of IONM in neurosurgery, we conducted a narrative review including the most relevant studies about the modalities and their application in different fields of neurosurgery. In particular, this review provides insights for all physicians and healthcare professionals unfamiliar with IONM, elucidating commonly used techniques in neurosurgery. In particular, it discusses the roles of IONM in various neurosurgical settings such as tumoral brain resection, neurovascular surgery, epilepsy surgery, spinal surgery, and peripheral nerve surgery. Furthermore, it offers an overview of the anesthesiologic strategies and limitations of techniques essential for the effective implementation of IONM.
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Affiliation(s)
- Giusy Guzzi
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | | | - Attilio Della Torre
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Erica Lo Turco
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Angelo Lavano
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
| | - Domenico La Torre
- Neurosurgery Department, “R. Dulbecco” Hospital, 88100 Catanzaro, Italy
- Department of Medical and Surgical Sciences, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy
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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] [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).
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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
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Marquet Y, Philippe A, Toussaint S, Abdallah SB, Morel-Fatio E, Baillard C. Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study. Anaesth Crit Care Pain Med 2023; 42:101214. [PMID: 36889437 DOI: 10.1016/j.accpm.2023.101214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION For thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. PATIENTS AND METHODS In this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg-1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 μV. If not, sugammadex (2 mg.kg-1) was administered. The dissection began when the signal was positive. RESULTS From January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/- 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DISCUSSION This prospective study shows that the use of 0.5 mg.kg-1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.
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Affiliation(s)
- Yann Marquet
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Axel Philippe
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Toussaint
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Samia Ben Abdallah
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Elsa Morel-Fatio
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Baillard
- Department of Anesthesiology and Critical Care Medicine, Cochin University Hospital, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Oh MY, Chai YJ, Huang TY, Wu CW, Dionigi G, Kim HY, Kim C, Won D, Lee JM. Administration of neostigmine after tracheal intubation shortens time to successful intraoperative neuromonitoring during thyroid surgery: a randomized controlled trial. Sci Rep 2022; 12:16797. [PMID: 36207389 PMCID: PMC9546920 DOI: 10.1038/s41598-022-21282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
This prospective, randomized controlled trial evaluated the effect of neostigmine for intraoperative neuromonitoring (IONM) during thyroid surgery. Forty subjects undergoing thyroidectomy with IONM, randomized into neostigmine administration after tracheal intubation (Group N, n = 20) or control treatment with normal saline (Group C, n = 20), completed the trial. Electromyography amplitudes of the vagus nerve (V1) were recorded before thyroid dissection. The time from the initial V1 signal check to successful V1 stimulation was recorded. In Group N, all the patients had a successful V1 signal at the first check, whereas ten (50%) patients in Group C had a time delay between the initial V1 check and successful V1 (p < 0.001). The mean delay time among the delayed patients in Group C was 11.2 ± 1.4 min. The mean time from skin incision to successful V1 stimulation was significantly shorter in Group N than in Group C (15.4 ± 2.4 min vs. 19.9 ± 5.7 min, p = 0.003). In Groups N and C, the mean V1 amplitudes were 962.2 ± 434.5 μV vs. 802.3 ± 382.7 μV (p = 0.225), respectively, and the mean R1 amplitudes were 1240.0 ± 836.5 μV vs. 1023.4 ± 455.8 μV (p = 0.316), respectively. There was one bucking event in Group N. In conclusion, neostigmine administration immediately after tracheal intubation can be useful to reverse neuromuscular blockade for successful IONM in thyroid surgeries.
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Affiliation(s)
- Moon Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Republic of Korea.,Transdisciplinary Department of Medicine and Advanced Technology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Division of Surgery, Istituto Auxologico Italiano Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chanho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dongwook Won
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea.
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Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery. Medicina (B Aires) 2022; 58:medicina58040495. [PMID: 35454334 PMCID: PMC9028259 DOI: 10.3390/medicina58040495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.
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Lu IC, Hsu CD, Chang PY, Wu SH, Huang TY, Lin YC, Ko HY, Dionigi G, Chai YJ, Chiang FY, Kuo YW, Wu CW. A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery. Front Endocrinol (Lausanne) 2022; 13:817476. [PMID: 35222277 PMCID: PMC8867063 DOI: 10.3389/fendo.2022.817476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Neuromuscular blocking agents provide muscular relaxation for tracheal intubation and surgery. However, the degree of neuromuscular block may disturb neuromuscular transmission and lead to weak electromyography during intraoperative neuromonitoring. This study aimed to investigate a surgeon-friendly neuromuscular block degree titrated sugammadex protocol to maintain both intraoperative neuromonitoring quality and surgical relaxation during thyroid surgery. METHODS A total of 116 patients were enrolled into two groups and underwent elective thyroid surgery with intraoperative neuromonitoring. All patients followed a standardized intraoperative neuromonitoring protocol with continuous neuromuscular transmission monitoring and received 0.6 mg/kg rocuronium for tracheal intubation. Patients were allocated into two groups according to the degree of neuromuscular block when the anterior surface of the thyroid gland was exposed. The neuromuscular block degree was assessed by the train-of-four (TOF) count and ratio. Patients in group I received sugammadex 0.25 mg/kg for non-deep neuromuscular block degree (TOF count = 1~4). Patients in group II were administered sugammadex 0.5 mg/kg for deep neuromuscular block degree (TOF count = 0). The quality of the intraoperative neuromonitoring was measured using the V1 electromyography (EMG) amplitude. An amplitude less than 500 μV and greater than 500 μV was defined as weak and satisfactory, respectively. RESULTS The quality of the intraoperative neuromonitoring was not different between groups I and II (satisfactory/weak: 75/1 vs. 38/2, P = 0.14). The quality of surgical relaxation was acceptable after sugammadex injection and showed no difference between groups [55/76 (72.3%) in group I vs. 33/40 (82.5%) in group II, P = 0.23]. CONCLUSIONS This surgeon-centered sugammadex protocol guided by neuromuscular block degree (0.5 mg/kg for deep block and 0.25 mg/kg for others) showed comparably high intraoperative neuromonitoring quality and adequate surgical relaxation. The results expanded the practicality of sugammadex for precise neuromuscular block management during monitored thyroidectomy.
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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
| | - Chiung-Dan Hsu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Ta-Tung 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
| | - Yi-Chu Lin
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - How-Yun Ko
- Department of Otorhinolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS (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
| | - Yi-Wei Kuo
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Yi-Wei Kuo, ; Che-Wei Wu,
| | - 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
- *Correspondence: Yi-Wei Kuo, ; Che-Wei Wu,
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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] [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.
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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
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Oh MY, Lee JM, Won D, Huang TY, Wu CW, Dionigi G, Kim HY, Seo M, Choi HS, Chai YJ. Investigation of potential neuropharmacological activity of neostigmine-glycopyrrolate for intraoperative neural monitoring in thyroid surgery. Kaohsiung J Med Sci 2021; 38:59-64. [PMID: 34562340 DOI: 10.1002/kjm2.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022] Open
Abstract
Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine-glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle-twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine-glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine-glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine-glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine-glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.
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Affiliation(s)
- Moon Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Dongwook Won
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Miyeon Seo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyun Suk Choi
- Department of Nursing, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - 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
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10
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de Vendin OE, Fuchs-Buder T, Schmartz D, Nguyen DT, Gallet P, Bihain F, Nomine-Criqui C, Brunaud L. Impact of rocuronium on intraoperative neuromonitoring vagal amplitudes during thyroidectomy. Langenbecks Arch Surg 2021; 406:2019-2025. [PMID: 34120194 DOI: 10.1007/s00423-021-02234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Neuromuscular blocking agents (NMBA) facilitate endotracheal intubation and reduce related laryngeal morbidity. However, NMBA interfere with intraoperative neuromonitoring amplitudes during thyroidectomy. The goal of this study was to evaluate the impact of rocuronium used for tracheal intubation on early intraoperative neuromonitoring vagal amplitudes observed during first thyroid lobe dissection. METHODS This is an observational pharmacoepidemiological study with prospective data collection and retrospective analysis. During the study period, all consecutive patients who underwent thyroid surgery with neuromonitoring were included. Patients underwent endotracheal intubation either using a single dose of rocuronium (NMBA group) or without NMBA (NMBA-free group) according to the anesthesiologist's preference. RESULTS Six hundred six patients were included (213 NMBA and 393 NMBA-free group patients). At V1, 39 patients (18%) in the NMBA group had an amplitude < 100 µV (need for curarization reversal in 30 patients) and 13 patients (3.3%) in the NMBA-free group (p < 0.001). In the remaining 554 patients, the mean V1 amplitude was significantly decreased in the NMBA group (544 versus 685 µV; p < 0.001). After exclusion of 25 patients with loss of signal types 1 and 2 during dissection, the difference between mean V1 and mean V2 was significantly lower in NMBA group patients (- 22 versus - 86 µV; p = 0.016). CONCLUSION This study provides new data showing how NMBA used for tracheal intubation significantly decrease V1 amplitude baseline and modify amplitude variations from V1 to V2 values during the first thyroid lobe dissection. LEVEL OF EVIDENCE Pharmacoepidemiological study.
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Affiliation(s)
- Ombeline Empis de Vendin
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Thomas Fuchs-Buder
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Denis Schmartz
- Department, of Anesthesiology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France.,Department of Anesthesiology, Université Libre de Bruxelles, Brussels, Belgium
| | - Duc-Trung Nguyen
- Department of Oto-Rhino-Laryngology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Patrice Gallet
- Department of Oto-Rhino-Laryngology, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Florence Bihain
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France
| | - Claire Nomine-Criqui
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France
| | - Laurent Brunaud
- Department of Surgery (CVMC), Unit of Metabolic, Endocrine, and Thyroid Surgery, Université de Lorraine, CHRU Nancy-Brabois (7Eme Étage), Vandœuvre-lès-Nancy, France. .,INSERM U1256, Faculty of Medicine, Université de Lorraine, CHRU Nancy-Brabois, Vandœuvre-lès-Nancy, France.
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11
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Garofalo E, Bruni A, Scalzi G, Curto LS, Rovida S, Brescia V, Gervasi R, Navalesi P, Innaro N, Longhini F. Low-Dose of Rocuronium During Thyroid Surgery: Effects on Intraoperative Nerve-Monitoring and Intubation. J Surg Res 2021; 265:131-138. [PMID: 33940235 DOI: 10.1016/j.jss.2021.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/04/2021] [Accepted: 03/25/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intraoperative Neurophysiological Monitoring (IONM) reduces the incidence of Recurrent Laryngeal Nerve (RLN) injuries during thyroid surgery. To preserve nerve function, long acting neuromuscular blocking agents (NMBA) should be avoided. However, NMBA are necessary for laryngoscopy and endotracheal intubation. We designed this double-blinded, randomized, placebo-controlled trial to assess if a low-dose of rocuronium given at intubation would affect the IONM data recorded before the thyroid dissection. METHODS Hundred patients undergoing elective thyroid surgery were randomized to receive either 0.3 mg kg-1 of low dose rocuronium (intervention) or no-NMBA (control). Intubation was performed with video-laryngoscopy. IONM was placed on RLN and nerve stimulation was performed before and after thyroid dissection. The presence of a valid amplitude prior to dissection was defined when the IONM signal was >100 μV. Occurrence of difficult laryngoscopy was reported together with intubation details including time, difficulty and failure. The lowest peripheral saturation (SpO2) and the number of desaturation episodes during the intubation were also registered. RESULTS No patients showed impaired IONM signal before dissection in both groups. Cormack-Lehane grade was higher in the intervention group (11;2) compared to control one (11;1; P = 0.046). No-NMBA patients had increased number of difficult laryngoscopies (21% versus 6%, P = 0.041) and intubations (34% versus 8%; P = 0.003) as well as a longer time to intubation (78 [55; 175] versus 55 [31; 110] sec; P = 0.006). Lower values of peripheral SpO2 during intubation attempt were registered in the no NMBA group (99 [97; 100] versus 99 [99; 100] %; P = 0.020). However, the number of intubation failure was similar between groups (p=0.495). CONCLUSIONS Low-dose of rocuronium does not compromise pre-dissection IONM signal and improves intubation condition when compared to a relaxant free strategy.
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Affiliation(s)
- Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Giuseppe Scalzi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Lucia Stella Curto
- Endocrine Surgery Unit, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Serena Rovida
- Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Vincenzo Brescia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Rita Gervasi
- Endocrine Surgery Unit, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Padua Hospital, Department of Medicine - DIMED, University of Padua, Italy
| | - Nadia Innaro
- Endocrine Surgery Unit, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy.
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12
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Chai YJ, Lee JM, Won D, Lee J, Hwang JY, Kim TK, Chang JE, Kim H, Yang HJ, Min SW. Comparison of Sugammadex Dose for Intraoperative Neuromonitoring in Thyroid Surgery: A Randomized Controlled Trial. Laryngoscope 2021; 131:2154-2159. [PMID: 33720388 DOI: 10.1002/lary.29515] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/10/2021] [Accepted: 03/06/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare effect of 1 and 2 mg/kg of sugammadex on the incidence of intraoperative bucking and intraoperative neuromonitoring (IONM) quality in thyroid surgery. STUDY DESIGN Randomized controlled trial. METHODS Patients qualified for thyroid surgery with IONM were eligible for this double-blind, randomized, controlled trial. After tracheal intubation with 0.6 mg/kg rocuronium, 1 or 2 mg/kg of sugammadex was administered to patients in group I or II, respectively. The quality of the IONM for the external branch of the superior laryngeal nerve (EBSLN) was evaluated (strong/intermediate/weak). The initial amplitude of electromyography for the vagus nerve (V1) and the recurrent laryngeal nerve (R1) were recorded. Intraoperative bucking movements was recorded. RESULTS A total of 102 patients (51 in each group) completed the study. Time from sugammadex administration to initial checking for the EBSLN was not different between group I and II (25.0 ± 7.9 vs. 25.5 ± 9.0 minutes, P = .788). There was no difference in the neuromonitoring quality for the EBSLN between group I and II (strong/intermediate/weak: 46/5/0 vs. 50/1/0, P = .205). The amplitudes of V1 (1,086.3 ± 673.3 μV vs. 1,161.8 ± 727.5 μV, P = .588) and R1 (1,328.2 ± 934.1 μV vs. 1,410.5 ± 919.6 μV, P = .655) were comparable between the groups. Patients who experienced bucking were significantly fewer in the group I than the group II (13.7% vs. 35.3%, P = .020). CONCLUSION A dose of 1 mg/kg sugammadex induced less bucking than 2 m/kg while providing comparable IONM quality during thyroid surgery. LEVEL OF EVIDENCE 2 Laryngoscope, 131:2154-2159, 2021.
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Affiliation(s)
- Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dongwook Won
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jee-Eun Chang
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyerim Kim
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo Jun Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong-Won Min
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
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13
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Influence of rocuronium on achieving optimal vagal stimulation during intraoperative nerve monitoring in thyroid surgery. Asian J Surg 2020; 44:527-530. [PMID: 33262046 DOI: 10.1016/j.asjsur.2020.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/06/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection. METHODS Included in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11-25%, (3) 26-50%, (4) 51-75% and (5) >75%. RESULTS The average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 μV, 463 μV, 543 μV, 513 μV and 551 μV, respectively. No difference between the groups was observed in this regard (p > 0.05). CONCLUSION It can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve.
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14
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Vilallonga R. Are We Ready for an Optimal Neuromuscular Block Management for Neural Monitoring during Thyroid Surgery? J INVEST SURG 2020; 34:1397-1398. [PMID: 32892664 DOI: 10.1080/08941939.2020.1817638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Center of Excellence for the EAC-BC, Barcelona, Spain.,ELSAN, Clinique St-Michel, Toulon, France
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15
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Lu IC, Wu SH, Chang PY, Ho PY, Huang TY, Lin YC, Kamani D, Randolph GW, Dionigi G, Chiang FY, Wu CW. Precision Neuromuscular Block Management for Neural Monitoring During Thyroid Surgery. J INVEST SURG 2020; 34:1389-1396. [PMID: 32791867 DOI: 10.1080/08941939.2020.1805055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Titration of neuromuscular block (NMB) plays a key role in intraoperative recurrent laryngeal nerve monitoring during thyroid surgery. The combination of neuromuscular blocking agent and timely partial reversal of NMB was investigated in both animal experiments and clinical neuro-monitored thyroidectomy. METHODS In animal experiments, 8 piglets received sugammadex to assess the laryngeal EMG recovery after rocuronium-induced NMB. In clinical monitored thyroidectomy, 40 patients each were allocated to conventional group and sugammadex group. Conventional group received rocuronium 0.3 mg/kg at anesthesia induction, while sugammadex group received partial NMB recovery protocol- 0.6 mg/kg of rocuronium at anesthesia induction and 0.5 mg/kg of sugammadex. Main outcome was assessed by first (V1) and final (V2) EMG signal induced by vagal stimulation. RESULTS In the porcine model, 50% recovery of laryngeal EMG amplitude was achieved at 16.8 ± 1.9 and 6 ± 2.7 minutes respectively after 0.5 and 1 mg/kg of sugammadex (p < 0.01). In monitored thyroidectomy, EMG amplitudes at V1 in group S and group C were 1214 ± 623 and 915 ± 476 μV, respectively (p = 0.02). Positive and adequately high EMG amplitudes were observed at the early surgical stage for all patients. Sugammadex groups were superior to conventional group in EMG tube placement (p < 0.001). CONCLUSION Both porcine model and clinical application showed that precise NMB management by low-dose sugammadex was effective for intraoperative neural monitoring (IONM). The regimen ensured optimal conditions for tracheal intubation and timely neuromuscular function restoration for high-quality EMG signal.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Yang Ho
- Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology- Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, and Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otorhinolaryngology- Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, and Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Child-hood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Sicily, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology- Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, and Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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16
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Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
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Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
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17
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Sung ES, Kwon HK, Shin SC, Cheon YI, Lee JW, Park DH, Choi SW, Kim HB, Park HJ, Lee JC, Ro JH, Lee BJ. Application of an Intraoperative Neuromonitoring System Using a Surface Pressure Sensor in Parotid Surgery: A Rabbit Model Study. Clin Exp Otorhinolaryngol 2020; 14:131-136. [PMID: 32623851 PMCID: PMC7904436 DOI: 10.21053/ceo.2019.01900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 03/31/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives Facial nerve monitoring (FNM) can be used to identify the facial nerve, to obtain information regarding its course, and to evaluate its status during parotidectomy. However, there has been disagreement regarding the efficacy of FNM in reducing the incidence of facial nerve palsy during parotid surgery. Therefore, instead of using electromyography (EMG) to identify the location and state of the facial nerve, we applied an intraoperative neuromonitoring (IONM) system using a surface pressure sensor to detect facial muscle twitching. The objective of this study was to investigate the feasibility of using the IONM system with a surface pressure sensor to detect facial muscle twitching during parotidectomy. Methods We evaluated the stimulus thresholds for the detection of muscle twitching in the orbicularis oris and orbicularis oculi, as well as the amplitude and latency of EMG and the surface pressure sensor in 13 facial nerves of seven rabbits, using the same stimulus intensity. Results The surface pressure sensor detected muscle twitching in the orbicularis oris and orbicularis oculi in response to a stimulation of 0.1 mA in all 13 facial nerves. The stimulus threshold did not differ between the surface pressure sensor and EMG. Conclusion The application of IONM using a surface pressure sensor during parotidectomy is noninvasive, reliable, and feasible. Therefore, the IONM system with a surface pressure sensor to measure facial muscle twitching may be an alternative to EMG for verifying the status of the facial nerve.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Hyun-Keun Kwon
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Young-Il Cheon
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Jung-Woo Lee
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Da-Hee Park
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Seong-Wook Choi
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Hwa-Bin Kim
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Hye-Jin Park
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Jung-Hoon Ro
- Department of Biomedical Engineering, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
| | - Byung-Joo Lee
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University Hospital, College of Medicine and Medical Research Institute, Busan, Korea
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18
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What is the impact of continuous neuromonitoring on the incidence of injury to the recurrent laryngeal nerve during total thyroidectomy? Surgery 2020; 169:63-69. [PMID: 32409167 DOI: 10.1016/j.surg.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Continuous intraoperative neuromonitoring may facilitate reversal of intraoperative injurious operative maneuvers in comparison with intermittent intraoperative neuromonitoring. The aim of this study was to evaluate the impact of the routine use of continuous intraoperative neuromonitoring on intraoperative injuries to the recurrent laryngeal nerve. METHOD This study was a prospective case series with retrospective analysis of consecutive patients undergoing total thyroidectomy from August 2013 to August 2019. During this period, intermittent intraoperative neuromonitoring (before Mar 2016) and continuous intraoperative neuromonitoring (after Mar 2016) were used in all patients. RESULTS We reviewed the outcomes of 603 patients (466 female patients) comprising 236 who underwent intermittent intraoperative neuromonitoring and 367 who underwent continuous intraoperative neuromonitoring. Intraoperative adverse electromyography events (>50% decrease in amplitude between VN1 and VN2) were observed in 87 patients (14.5%) and were less frequent in the continuous intraoperative neuromonitoring group (10.6 vs 20.3%, P = .001). Intraoperative loss of signal (electromyography events with VN2 ≤100μV) were observed in 35 patients (5.8%) without any difference between the 2 groups of patients (5.2 vs 6.8%, P = .415). Postoperative recurrent laryngeal nerve palsies were observed in 36 patients (5.9%) without any difference between the 2 groups of patients (4.9 vs 7.6%, P = .168). CONCLUSION The routine use of continuous intraoperative neuromonitoring improves the rate of intraoperative adverse electromyography events but does not impact significantly the rates of loss of signal and recurrent laryngeal nerve palsy.
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Gunes ME, Dural AC, Akarsu C, Guzey D, Sahbaz NA, Tulubas EK, Bulut S, Donmez T. Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial. Ann Surg Treat Res 2019; 97:282-290. [PMID: 31824882 PMCID: PMC6893217 DOI: 10.4174/astr.2019.97.6.282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/09/2019] [Accepted: 10/23/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery. Methods The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission. Results In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups. Conclusion Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.
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Affiliation(s)
- Mehmet Emin Gunes
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Cem Dural
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Cevher Akarsu
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Deniz Guzey
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Nuri Alper Sahbaz
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Evrim Kucur Tulubas
- Department of Anesthesiology, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Sezer Bulut
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Turgut Donmez
- Department of General Surgery, Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Lu IC, Wu SH, Wu CW. Neuromuscular blockade management for intraoperative neural monitoring. Kaohsiung J Med Sci 2019; 36:230-235. [PMID: 31713975 DOI: 10.1002/kjm2.12153] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022] Open
Abstract
This article reviews the literature on development of neuromuscular blockade management in thyroid surgery with intraoperative neural monitoring (IONM) in the past decade. Neuromuscular blockade management includes the choice of neuromuscular blocking agents (NMBAs) and reversal of neuromuscular blockade by sugammadex. A series of animal study and clinical trials showed NMBAs effect on IONM in thyroid surgery. We summarized five NMBA regimens for IONM: (a) relaxant-free regimen, (b) depolarizing NMBA-succinylcholine, (c) titration of nondepolarizing NMBA, and (d) rocuronium combined with sugammadex. The proper management of neuromuscular blockade during IONM has greatly developed over the past decade. The misuse of NMBAs is associated with false IONM interpretations to surgeons. A detailed understanding of NMBAs and neuromuscular blockade management by sugammadex may optimize IONM quality in patients receiving monitored thyroid surgery.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
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Sung ES, Lee JC, Shin SC, Kwon HG, Kim MS, Kim DJ, Ro JH, Lee BJ. Development of a Novel Intraoperative Neuromonitoring System Using a Surface Pressure Sensor to Detect Muscle Movement: A Rabbit Model Study. Clin Exp Otorhinolaryngol 2018; 12:217-223. [PMID: 30531650 PMCID: PMC6453788 DOI: 10.21053/ceo.2018.01207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/18/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES False-negative or false-positive responses in intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroid surgery pose a challenge. Therefore, we developed a novel IONM system that uses a surface pressure sensor instead of EMG to detect muscle twitching. This study aimed to investigate the feasibility and safety of a new IONM system using a piezo-electric surface pressure sensor in an experimental animal model. METHODS We developed the surface pressure sensor by modifying a commercial piezo-electric sensor. We evaluated the stimulus thresholds to detect muscle movement, as well as the amplitude and latency of the EMG and surface pressure sensor in six sciatic nerves of three rabbits, according to the stimulus intensity. RESULTS The surface pressure sensor detected the muscle movements in response to a 0.1 mA stimulation of all six sciatic nerves. There were no differences in the thresholds of stimulus intensity between the surface pressure sensor and EMG recordings to detect muscle movements. CONCLUSION It is possible to measure the change in surface pressure by using a piezo-electric surface pressure sensor instead of EMG to detect muscle movement induced by nerve stimulation. The application of IONM using a piezo-electric surface pressure sensor during surgery is noninvasive, safe, and feasible. Measuring muscle twitching to identify the state of the nerves using the novel IONM system can be an alternative to recording of EMG responses.
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Affiliation(s)
- Eui-Suk Sung
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Jin-Choon Lee
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
| | - Hyun-Geun Kwon
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
| | - Min-Sik Kim
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Dong-Jo Kim
- Department of Otolaryngology, Head and Neck Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University College of Medicine, Yangsan, Korea
| | - Jung-Hoon Ro
- Department of Biomedical Engineering, Pusan National University Hospital, Busan, Korea
| | - Byung-Joo Lee
- Department of Otolaryngology, Head and Neck Surgery and Medical Research Institute, Pusan National University College of Medicine, Busan, Korea
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