Current recommendations for monitoring depth of neuromuscular blockade

Effect of coadministration of 10 mg/kg calcium chloride and neostigmine on extubation time: A randomized controlled trial

INTRODUCTION AND OBJECTIVES

Some studies investigating the effect of calcium on neostigmine-induced recovery of neuromuscular blockade have shown that this combination promotes neuromuscular recovery, but does not significantly affect the incidence of postoperative residual curarization and time to extubation. This study aimed to evaluate the effects of 10 mg/kg calcium chloride co-administered with neostigmine on early recovery and time to extubation.

PATIENTS AND METHODS

This prospective, randomized, double-blinded, placebo-controlled study included 88 ASA I-II patients aged between 18 and 65 years who were scheduled for elective surgery lasting at least 1 h under general anaesthesia in which 10 mg/kg of calcium chloride or the same volume of normal saline was co-administered with 5 μg/kg of neostigmine at the end of surgery. Time to extubation (time from neostigmine administration to extubation), time from neostigmine administration to TOF ratio (TOFr) 0.9 (neuromuscular recovery), and the incidence of residual neuromuscular blockade (RNMB) and other adverse effects were recorded.

RESULTS

Median (Q1, Q3) extubation time was significantly shorter in the calcium group vs. the placebo group (6.5 min [5.52-7.43] vs. 9.78 min [8.35-11]), P < .001. Median neuromuscular recovery time in the calcium group was 5 min vs. 7.1 min in the placebo group, P < .001. Patients in the calcium group had significantly higher TOFr and lower incidence of RNMB at 5 and 10 min vs. the placebo group, and no significant side effects.

CONCLUSION

Calcium chloride at a dose of 10 mg/kg co-administered with neostigmine promotes early neuromuscular recovery and reduces time to extubation by about 32%.

Does the objective measurement of muscle strength improve the detection of postoperative residual muscle weakness?

Background and Aims

The postoperative residual neuromuscular block (PRNB) has a significant impact on patient safety and well-being, but continues to remain underestimated. Objective evaluation of handgrip strength using a force dynamometer can be useful to identify postoperative muscle weakness.

Material and Methods

Thirty-two American Society of Anesthesiologists (ASA) class I and II patients who received general anesthesia were included. Patients were extubated after the train-of-four (TOR) ratio (TOFR) was >0.90 and the clinical criteria for motor power recovery were judged as adequate. The measurements of handgrip strength and peak expiratory flow rate (PEFR) were obtained at baseline, 15 min after extubation, and 1, 2, and 4 h postoperatively. The incidence of significant decline from baseline (>25%) was determined. The correlation between handgrip strength and PEFR was assessed using Spearman correlation. The time to return to baseline for muscle grip strength and PEFR was performed using Kaplan-Meier survival analysis. A P value of 0.05 was considered significant for all tests.

Results

The incidence of the significant decline in handgrip strength from baseline was 100% at 15 and 60 min, 76% at 2 h, and 9.4% at 4 h. There was a strong correlation between muscle grip strength and PEFR (0.89, P < 0.001). None of the patients exhibited the potential complications of PRNB. (PRMB in abstract. It should be uniform) The mean time to return to the baseline value of muscle grip strength was 3.8 h (95% confidence interval [CI] 3.6-3.9), and the mean time to return to baseline for PEFR was 3.2 h (95% CI 2.9-3.4 h).

Conclusion

Objective assessment of muscle grip strength using a force dynamometer has the potential to be a new objective metric to monitor postoperative muscle weakness.

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION

In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities.

EVIDENCE ACQUISITION

A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence.

EVIDENCE SYNTHESIS

The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions.

CONCLUSIONS

The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

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.

Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis

BACKGROUND

We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS).

METHODS

This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery.

RESULTS

Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005).

CONCLUSIONS

During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

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

Vigilance: the behavioral impact of quantitative monitoring on administration and antagonism of neuromuscular blocking agents

PURPOSE

The aim of this study was to determine whether use of acceleromyography (1) changes dosing of neuromuscular blocking agents (NMBAs), and (2) increases the time between neostigmine administration and extubation, when compared with subjective assessment of neuromuscular blockade.

METHODS

For this retrospective study, data were collected from patient electronic medical records. Patients were included if they had received an NMBA as part of a general anesthetic in 2013 and 2014. Data were analyzed by category of monitoring device: quantitative monitor (acceleromyograph [AMG]) or subjective device (peripheral nerve stimulator [PNS]). Outcomes measured were the total dose of NMBA administered and, the timing of the last dose of NMBA and anticholinesterase relative to tracheal extubation.

RESULTS

Results from multivariate models showed that use of acceleromyography was not associated with a change in the total dose of NMBA administered. In contrast, the number of times any monitor was used, as determined by the frequency with which the train-of-four count (TOFC) was recorded, correlated with the administration of greater amounts of rocuronium (P < 0.01) and vecuronium (P < 0.01). The use of acceleromyography did not prolong the time interval between neostigmine administration and tracheal extubation. The number of times any monitor was used during an anesthetic was associated with a decrease in this time interval. The interval decreased an average of 2.7 min each successive time the TOFC was recorded (P < 0.01).

CONCLUSIONS

The data presented provides insight about the behavioral engineering inherent to the practice of anesthesiology. Introduction of neuromuscular blockade assessment appeared to increase provider vigilance in dosing of NMBAs-regardless of assessment method. The frequency of intraoperative monitoring (quantitative or subjective) was associated with an increased total dose of NMBA administered and decreased time interval between the last dose of neostigmine and extubation.

Comparison of neuromuscular blockade recovery co-administered with neostigmine and different doses of calcium gluconate: a randomized control trial

BACKGROUND

Calcium increases the probability of transmitter release at the neuromuscular junction. It is not known whether there is a dose-dependent relationship between the dosage of calcium gluconate and the probability of transmitter release for non-depolarizing neuromuscular blockade (NMB) recovery by acetylcholinesterase inhibitors (AchEIs). This study compared the neuromuscular recovery time and the incidence of postoperative residual curarization (PORC) according to the dosage of calcium gluconate co-administered with neostigmine in three patient groups.

METHODS

Patients were randomly allocated to a control group, a 5 mg/kg calcium gluconate group (calcium 5 group), or a 10 mg/kg calcium gluconate group (calcium 10 group). In patients with a TOF ratio (TOFr) between 0.2-0.7, 0.04 mg/kg of neostigmine was administered and both 0.2 mg of glycopyrrolate and 0.4 mg of atropine per 1 mg of neostigmine were administered. And additional 5 or 10 mg/kg of calcium gluconate were administrated to the calcium 5 and 10 groups. The primary endpoint was neuromuscular recovery time (the time between reversal and TOFr≥0.9). The secondary endpoints were the incidence of PORC at 5, 10, and 20 min after reversal administration and the train-of-four ratio (TOFr) at each time point.

RESULTS

The neuromuscular recovery time was 5.3 min in the control group, 3.9 min in the calcium 5 group, and 4.1 min in the calcium 10 group, respectively (P = 0.004). The incidence of PORC at 5 min after neostigmine administration was 12 in the control group, 4 in the calcium 5 group, and 4 in the calcium 10 group, respectively, with statistical significance (P = 0.014).

CONCLUSIONS

The co-administration of calcium gluconate with neostigmine safely promoted early NMB recovery, and the neuromuscular recovery time of the calcium 10 group tended to be more evenly distributed than that of the calcium 5 group.

TRIAL REGISTRATION

https://cris.nih.go.kr/cris/index.jsp(KCT0004182 ). Date of registration: August 122,019.

Laryngeal mask airway for general anesthesia in interventional neuroradiology procedures

Objectives:

To evaluate whether using laryngeal mask airway (LMA) made a difference in terms of airway security, hemodynamic changes, complications, and recovery times compared to tracheal intubation during the procedure in patients undergoing general anesthesia for endovascular treatments of unruptured cerebrovascular aneurysms.

Methods:

The electronic medical records database, patient files, and anesthesia charts were examined between May 2008 and September 2016 to identify patients with the following inclusion criteria: 1) aged 18-70 years; 2) American Society of Anesthesiologists (ASA) classification I-III; 3) diagnosis of unruptured CVA; 4) Glasgow coma scale of 15 without neurological deficit; and 5) underwent elective EVT under general anesthesia.

Results:

Tracheal tube (TT) was used in 46 patients (group TT, n=46) and LMA in 42 patients (group LMA, n=42). Mean arterial pressure (MAP) levels were increased to >20% of baseline in 14 patients (30.4%) after intubation and in 6 (13%) after extubation in group TT. All LMA patients remained within normal MAP limits (p<0.05). Six patients (13%) displayed coughing or straining at extubation in group TT whereas none in group LMA (p<0.05). Recovery and discharge times were similar (p>0.05).

Conclusion:

Laryngeal mask airway and TT provided comparable airway security during procedure. Laryngeal mask airway attenuated stress response in hemodynamic parameters at intubation and extubation and smoother emergence compared to TT without delay in recovery.

Effects of calcium chloride coadministered with neostigmine on neuromuscular blockade recovery: A double-blind randomised study

BACKGROUND

Ionised calcium plays an important role in neuromuscular transmission, but its effects on the reversal of nondepolarising neuromuscular blockade have not been fully evaluated.

OBJECTIVE

We examined whether calcium chloride coadministered with neostigmine could enhance the rate of neuromuscular recovery.

DESIGN

Randomised double-blind trial.

SETTING

A tertiary teaching hospital.

PATIENTS

In total, 53 patients undergoing elective surgery under general anaesthesia with neuromuscular monitoring by acceleromyography using a TOF-Watch SX monitor.

INTERVENTIONS

Patients were randomly allocated to receive either 5 mg kg of calcium chloride (calcium group, n = 26) or the same volume of normal saline (control group, n = 27) coadministered with 25 μg kg of neostigmine and 15 μg kg of atropine at the end of surgery.

MAIN OUTCOME MEASURES

The primary end point was the neuromuscular recovery time [time from neostigmine administration to recovery of the TOF ratio (TOFr) to 0.9]. Secondary end points included the TOFr at 5, 10 and 20 min after neostigmine administration and the incidence of postoperative residual curarisation (PORC), defined as a TOFr less than 0.9 at each time point.

RESULTS

The neuromuscular recovery time was significantly faster in the calcium group than in the control group (median [Q1 to Q3]; 5.0 [3.0 to 7.0] vs. 6.7 [5.7 to 10.0] min, respectively; P = 0.007). At 5 min after neostigmine administration, the TOFr was higher [87 (74 to 100) vs. 68 (51 to 81)%, respectively; P = 0.002] and the incidence of PORC was lower (50.0 vs. 81.5%, respectively; P = 0.016) in the calcium group than in the control group. There were no differences between the two groups with respect to the TOFr or incidence of PORC at 10 and 20 min after neostigmine administration.

CONCLUSION

Calcium chloride coadministered with neostigmine enhanced neuromuscular recovery in the early period of nondepolarising neuromuscular blockade reversal.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Method for Prediction of Efficacy of Sugammadex Administered to Recover from Rocuronium-Induced Neuromuscular Blockade in Gynecological Laparoscopic Surgery Cases

Sugammadex (SDX), a neuromuscular blocking-reversal agent, quickly reverses neuromuscular blockade induced by rocuronium (RCR). SDX dosage is set according to the state of neuromuscular blockade determined with a neuromuscular monitoring device. However, in clinical situations, such a devise is not frequently used. Here, we report construction of a method for theoretically setting SDX dose by which the optimum reverse time (RT) can be obtained for individual patients even when the device is not available. The subjects were 42 adult female patients who underwent laparoscopic surgery from 1 August 2015 to 31 March 2016, during which RCR and SDX were administered. We formulated an equation for theoretically calculating the RCR residual ratio (RR) in blood after SDX administration. Furthermore, we examined the relationship between RR and RT. Based on the results obtained, we developed a method for predicting RT using RR. We excluded 1 subject as the RT value was detected as an outlier in our analysis. Multiple regression analysis was performed using standard body weight, serum creatinine, total bilirubin, and RR as explanatory variables. The number of subjects with a prediction error of RT within ±1 min was 36 (87.8%) of 41 in multiple regression analysis. We could predict RT following SDX administration by using the RT prediction expression with RR obtained for subjects administered RCR during the surgery. Furthermore, our results suggest that the SDX dose able to achieve optimum RT may be set prior to surgery on the basis of the present methodology.

Monitoring intraoperative neuromuscular blockade and blood pressure with one device (TOF-Cuff): A comparative study with mechanomyography and invasive blood pressure

OBJECTIVE

The overall objective of the study is to determine the ability of TOF-Cuff device (blood-pressure modified cuff, including stimulation electrodes) to monitor with the same device the non-invasive blood pressure (NIBP) and the depth of a neuromuscular blockade (NMB) induced pharmacologically, by stimulation of the brachial plexus at the humeral level and recording evoked changes in arterial pressure.

MATERIAL AND METHOD

Clinical, single-centre, open-controlled study with 32 adult patients ASA I-III for scheduled elective surgery under general anaesthesia in supine position, for the validation of neuromuscular monitoring, comparing the values obtained from neuromuscular relaxation TOF-Cuff with those obtained by mechanomyography (MMG) (control method) during the recovery phase of NMB, when a TOF ratio>0.7 and>0.9 (primary endpoint) were reached respectively. And an additional consecutive study of 17 patients for validation of NIBP monitoring with TOF-Cuff device vs invasive blood pressure measured by an intra-arterial catheter. All data were analyzed using the Bland-Altman method.

RESULTS

Recovery from NMB measured with the TOF-Cuff was earlier compared to MMG. Comparing TOF-ratio>0.9 measured with TOF-Cuff vs TOF-ratio>0.7 with MMG, a specificity of 91% and a positive predictive value of 84% were obtained. In NIBP measurement, the mean error and standard deviation of both systolic blood pressure (1.6±7mmHg) and diastolic blood pressure (-3.4±6.3) were within the European accuracy requirements for medical devices.

CONCLUSIONS

The TOF-Cuff device has been shown to be valid and safe in the monitoring of NMB and in the measurement of NIBP, with no patient presenting any adverse events, skin-level lesions or residual pain. It is not interchangeable with MMG, having a TOF-ratio>0.9 quantified by the TOF-Cuff device, a good correlation with a TOF-ratio>0.7 on MMG.

A reduced gastric corpus microvascular blood flow during Ivor-Lewis esophagectomy detected by laser speckle contrast imaging technique

BACKGROUND

Reduced microvascular blood flow is related to anastomotic insufficiency following esophagectomy, emphasizing a need for intraoperative monitoring of the microcirculation. This study evaluated if laser speckle contrast imaging (LSCI) was able to detect intraoperative changes in gastric microcirculation.

METHODS

Gastric microcirculation was assessed prior to and after reconstruction of gastric continuity in 25 consecutive patients operated for adenocarcinoma with open Ivor-Lewis esophagectomy while hemodynamic variables were recorded.

RESULTS

During upper laparotomy, microcirculation at the corpus decreased by 25% from baseline to mobilization of the stomach (p = .008) and decreased further (to a total decrease of 40%) following gastric pull to the thorax (p = .013). On the other hand, microcirculation at the antrum did not change significantly after gastric mobilization (p = .091). The decrease in corpus microcirculation took place unrelated to central cardiovascular variables.

CONCLUSION

Using LSCI technique, we identified a reduced microcirculation at the corpus area during open Ivor-Lewis esophagectomy. LSCI provides an option for real-time assessment of gastric microcirculation and could form basis for intraoperative stabilization of the microcirculation.

Current Status of Neuromuscular Reversal and Monitoring

Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.

To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.

Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus

INTRODUCTION

Neuromuscular blockade enables airway management, ventilation and surgical procedures. However there is no national consensus on its routine clinical use. The objective was to establish the degree of agreement among anaesthesiologists and general surgeons on the clinical use of neuromuscular blockade in order to make recommendations to improve its use during surgical procedures.

METHODS

Multidisciplinary consensus study in Spain. Anaesthesiologists experts in neuromuscular blockade management (n=65) and general surgeons (n=36) were included. Delphi methodology was selected. A survey with 17 final questions developed by a dedicated scientific committee was designed. The experts answered the successive questions in two waves. The survey included questions on: type of surgery, type of patient, benefits/harm during and after surgery, impact of objective neuromuscular monitoring and use of reversal drugs, viability of a multidisciplinary and efficient approach to the whole surgical procedure, focussing on the level of neuromuscular blockade.

RESULTS

Five recommendations were agreed: 1) deep neuromuscular blockade is very appropriate for abdominal surgery (degree of agreement 94.1%), 2) and in obese patients (76.2%); 3) deep neuromuscular blockade maintenance until end of surgery might be beneficial in terms of clinical aspects, such as as immobility or better surgical access (86.1 to 72.3%); 4) quantitative monitoring and reversal drugs availability is recommended (89.1%); finally 5) anaesthesiologists/surgeons joint protocols are recommended.

CONCLUSIONS

Collaboration among anaesthesiologists and surgeons has enabled some general recommendations to be established on deep neuromuscular blockade use during abdominal surgery.

Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion

INTRODUCTION

Acetylcholinesterase inhibitors (neostigmine, edrophonium) and encapsulating agents (sugammadex and calabadion) can be used to reverse residual neuromuscular blockade (NMB).

AREAS COVERED

This review provides information about efficacy, effectiveness, and side effects of drugs (acetylcholinesterase inhibitors and encapsulating agents) used to reverse neuromuscular blocking agents (NMBAs).

EXPERT OPINION

The therapeutic range of acetylcholinesterase-inhibitors is narrow and effectiveness studies demonstrate clinicians don't use these unspecific reversal agents effectively to increase postoperative respiratory safety. The encapsulating drugs sugammadex and calabadion reverse all levels of NMB, and complete recovery of muscle strength can be achieved almost immediately after administration. For this reason encapsulating agents can be used as a solution for "cannot intubate cannot ventilate"- situations. Poor binding selectivity of encapsulating agents carries the risk of displacement of the NMBA by a competitively binding drug, which may lead to recurarization. In order to avoid side-effects, related to unspecific binding of endogenous proteins and drugs administered perioperatively it is prudent to titrate the dose of reversal agents to the minimal effective dose, depending on the depth of neuromuscular transmission block identified by neuromuscular transmission monitoring. Calabadions provide a diversified (increased binding selectivity) and expanded (reversal of benzylisoquinolines) spectrum of possible indications.