Residual neuromuscular block in vulnerable patients: Obesity, obstructive sleep apnea and postoperative pulmonary complications

Deep neuromuscular block with pipecuronium in patients undergoing laparoscopic surgery - A prospective case series

INTRODUCTION

We tested the feasibility of maintaining low intraabdominal pressures during pipecuronium-induced deep block (post-tetanic count ≥1, train-of-four count = 0) in patients undergoing laparoscopic surgery.

METHODS

Ten adult patients awaiting cardiac surgery or heart transplantation and requiring non-elective abdominal surgery were included. Pipecuronium bromide 0.09 mg/kg was used for muscle relaxation and maintenance of deep block. Top-up doses of pipecuronium (0.01-0.02 mg/kg) were administered when post-tetanic count was 4-8. Intraabdominal pressures were kept below 10 mmHg. Mean arterial pressure was measured intra-arterially. Surgical field view was rated on a 5-point scale (1 = extremely poor, 5 = optimal).

RESULTS

Induction dose of 0.09 mg/kg pipecuronium had an onset time of 5.3 (2.3-6.3, 25-75% IQR) min. Deep block was maintained for 51.2 ± 19.7 min. Top-up pipecuronium doses were necessary in 5 patients, 56.0 ± 28.1 min after the first dose. At the end of surgery, neuromuscular block was deep (post-tetanic count 0-6). Administration of 2 mg/kg of sugammadex induced recovery to train-of-four ratio ≥0.9 in 3.5 ± 1.6 min, and to train-of-four ratio = 1.0 in 4.3 ± 1.2 min. Mean intraabdominal pressure was 8.1 ± 1.1 mmHg during pneumoperitoneum. There was no significant change in heart rate (0.0, -2.6 to 0) beats/min.

DISCUSSION

Pipecuronium is a rational alternative when deep neuromuscular block is necessary, because of its long-acting neuromuscular blocking effect that may be antagonized quickly and safely with sugammadex.

REGISTRATION

European Clinical Trials Database registration number: 2022-004114-11, Clinical Trials Database registration number: NCT06517524.

Feasibility of calculating rocuronium dosage by skeletal muscle weight in patients with obesity

This study aimed to investigate the dose-response relationship of rocuronium administered based on skeletal muscle weight and to assess the feasibility of calculating rocuronium dosage by skeletal muscle weight in short surgeries for patients with obesity. This single-center, randomized controlled clinical trial included 71 patients with obesity aged 28-70 years, with body fat percentages (PBF) >20% in men and > 28% in women, ASA status I-III, scheduled for tracheoscopy. Patients were randomly allocated into two groups: skeletal muscle group (SM group) received rocuronium based on the skeletal muscle content (1.0 mg/kg, n = 31), and the conventional administration group (conventional group) received rocuronium based on total body weight (0.45 mg/kg, n = 30). General anesthesia was administered using the same protocol. Parameters recorded included patients' general condition, muscle relaxant usage, onset time of muscle relaxants, non-response time, clinical effect time, 75% recovery time, and recovery index. Additionally, occurrences of body movement, choking, and incomplete muscle relaxation during surgery were recorded. Compared to the conventional group, the SM group required significantly less rocuronium dosage, resulting in significantly lower non-response time, clinical effect time, 75% recovery time, and recovery index (p < 0.05), and the onset time is slightly longer. Neither group experienced body movement, choking, or incomplete muscle relaxation (p > 0.05). Utilizing skeletal muscle weight to calculate rocuronium dosage in short surgeries for patients with obesity can reduce dosage, shorten recovery time, and prevent residual muscle relaxation while achieving satisfactory muscle relaxation to meet surgical requirements.

Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications: a prospective, randomised, double-blind trial in high-risk older patients

BACKGROUND

Residual neuromuscular block is associated with an increased risk of postoperative pulmonary complications in retrospective studies. The aim of our study was to investigate prospectively the incidence of postoperative pulmonary complications after reversal with either sugammadex (SUG) or neostigmine (NEO) in high-risk older patients.

METHODS

We randomly allocated 180 older patients with significant morbidity (ASA physical status 3) ≥75 yr old to reversal of rocuronium with either SUG or NEO. Adverse events in the recovery room and pulmonary complications (defined by a 5-point [0-4; 0=best to 4=worst] outcome score) on postoperative Days 1, 3, and 7 were compared between groups.

RESULTS

Data from 168 patients aged 80 (4) yr were analysed; SUG vs NEO resulted in a reduced probability (0.052 vs 0.122) of increased pulmonary outcome score (impaired outcome) on postoperative Day 7, but not on Days 1 and 3. More patients in the NEO group were diagnosed with radiographically confirmed pneumonia (9.6% vs 2.4%; P=0.046). The NEO group showed a non-significant trend towards longer hospital length of stay across all individual centres (combined 9 vs 7.5 days), with a significant difference in Malaysia (6 vs 4 days; P=0.011).

CONCLUSIONS

Reversal of rocuronium neuromuscular block with SUG resulted in a small, but possibly clinically relevant improvement in pulmonary outcome in a select cohort of high-risk older patients.

CLINICAL TRIAL REGISTRATION

ACTRN12614000108617.