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Ji Y, Yuan H, Chen Y, Zhang X, Wu F, Tang W, Lu Z, Huang C. Sugammadex Is Associated With Reduced Pulmonary Complications in Patients With Respiratory Dysfunction. J Surg Res 2023; 290:133-140. [PMID: 37267702 DOI: 10.1016/j.jss.2023.04.023] [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: 12/01/2022] [Revised: 04/12/2023] [Accepted: 04/30/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Use of sugammadex is associated with fewer postoperative pulmonary complications (PPCs). This study investigated the relationship between sugammadex and PPCs in specific patients with respiratory dysfunction. MATERIALS AND METHODS We reviewed the electronic medical and anesthesia records of patients with respiratory dysfunction who underwent laparoscopic gastric or intestinal surgery at a single center between May 1, 2018 and December 31, 2019. The patients were divided into the sugammadex group and the nonsugammadex group, based on whether they received sugammadex or neostigmine. Binary logistic regression analyses were used to characterize the differences in incidence of PPC. RESULTS A total of 112 patients were included, of which 46 patients (41.1%) received sugammadex. In the logistic regression analysis, the incidences of PPC were fewer in the sugammadex group. Postoperative fever (odds ratio [OR] 0.330; 95% confidence interval [CI] 0.137-0.793, P = 0.0213), postoperative intensive care unit admission (OR 0.204; 95% CI 0.065-0.644, P = 0.007), cough (OR 0.143; 95% CI 0.061- 0.333, P < 0.001), pleural effusion (all) (OR: 0.280; 95% CI 0.104- 0.759, P = 0.012), pleural effusion (massive) (OR: 0.142; 95% CI 0.031- 0.653, P = 0.012), and difficulty in breathing (OR: 0.111; 95% CI 0.014-0.849, P = 0.039) showed significant differences between the two groups. CONCLUSIONS Sugammadex is associated with a reduction in PPC in patients with respiratory dysfunction.
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Affiliation(s)
- Yiqin Ji
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Hui Yuan
- Department of Anesthesiology, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Yijun Chen
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China.
| | - Xincai Zhang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Fan Wu
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Wan Tang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Zihui Lu
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
| | - Changshun Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo, Zhejiang, China
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Bruceta M, Singh PM, Bonavia A, Carr ZJ, Karamchandani K. Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study. J Anaesthesiol Clin Pharmacol 2023; 39:232-238. [PMID: 37564851 PMCID: PMC10410049 DOI: 10.4103/joacp.joacp_289_21] [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: 06/08/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 08/12/2023] Open
Abstract
Background and Aims The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. Material and Methods This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. Results A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). Conclusion The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.
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Affiliation(s)
- Melanio Bruceta
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State University College of Medicine, Hershey, PA, USA
| | - Preet M. Singh
- Department of Anesthesiology, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State University College of Medicine, Hershey, PA, USA
| | - Zyad J. Carr
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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Ho AMH, Klar G, Mizubuti GB. A simple technique for dosing neostigmine and glycopyrrolate in children. Can J Anaesth 2023; 70:282-283. [PMID: 36447091 DOI: 10.1007/s12630-022-02369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/11/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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Tan J, He J, Wang L, Fang J, Li P, Song Z, Bian Q. Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study. BMC Anesthesiol 2023; 23:32. [PMID: 36698080 PMCID: PMC9875499 DOI: 10.1186/s12871-023-01979-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Sugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery. METHODS This single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes. RESULTS Of the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (β = 0.29 95% confidence interval {CI}: [- 1.13, - 0.54], P = 0.4912). However, it was associated with shorter PACU stay (β = - 20.30 95% CI: [- 24.48, - 17.11], P < 0.0001), shorter time to postoperative ambulation movement (β = - 0.43 95% CI: [- 0.62, - 0.23], P < 0.0001), and reduced time-to-first-defecation (β = - 2.25 95% CI: [- 0.45, - 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05). CONCLUSIONS Neuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.
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Affiliation(s)
- Jing Tan
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
| | - Jianhua He
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
| | - Lijun Wang
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
| | - Jia Fang
- grid.428392.60000 0004 1800 1685Department of Endocrine, Nanjing Hospital of Traditional Chinese Medicine, 157 Daming Road, Nanjing, Jiangsu Province China
| | - Pengyi Li
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
| | - Zhenghuan Song
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
| | - Qingming Bian
- grid.452509.f0000 0004 1764 4566Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, 42 Baizi Pavilion, Nanjing, Jiangsu Province China
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Beltran RJ, Mpody C, Nafiu OO, Tobias JD. Association of Sugammadex or Neostigmine With Major Postoperative Pulmonary Complications in Children. Anesth Analg 2022; 135:1041-1047. [PMID: 35020682 DOI: 10.1213/ane.0000000000005872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent data in adult patients indicate that the use of sugammadex compared to neostigmine for reversal of neuromuscular block (NMB) was associated with a significant reduction in the risk of composite postoperative pulmonary complications. Despite the clinical significance of pulmonary complications in children, studies exploring the role of NMB reversal in the risk of these complications are currently unavailable. METHOD We performed a propensity score-matched retrospective study using the Pediatric Health Information System (PHIS) dataset spanning the years 2016 and 2020. We studied children <18 years who underwent elective, inpatient, noncardiac surgical procedures and received either neostigmine or sugammadex for reversal of NMB. Our primary outcome was major postoperative pulmonary complication, which we defined as the occurrence of either postoperative pneumonia or respiratory failure. RESULTS Our study included a study population of 33,819 children, of whom 23,312 (68.9%) received neostigmine and 10,507 (31.1%) received sugammadex. After propensity score matching (10,361 matched from each group), we found no evidence of a statistically significant association between the NMB reversal agent and the incidence of pulmonary complications (3.1% vs 3.1%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.05; P = .19). The components of pulmonary complications, including respiratory failure and pneumonia, were not statistically associated with the choice of NMB reversal agent. CONCLUSIONS Choice of NMB reversal agent does not appear to impact the incidence of major postoperative pulmonary complications. Further research is needed to determine whether our results carry forth across subpopulations defined by surgical specialty, the presence of complex chronic conditions, and anesthesia technique.
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Affiliation(s)
- Ralph J Beltran
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Aragón-Benedí C, Pascual-Bellosta A, Ortega-Lucea S, Visiedo-Sánchez S, Martínez-Ubieto J. Predictive study of pharmacological reversal for residual neuromuscular blockade and postoperative pulmonary complications: a prospective, observational, cohort study. Sci Rep 2022; 12:14955. [PMID: 36056061 PMCID: PMC9440015 DOI: 10.1038/s41598-022-18917-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
In recent years, some studies have generated controversy since they conclude that intraoperatively pharmacological reversal of neuromuscular blockade does not contribute to the reduction of postoperative residual neuromuscular blockade or pulmonary complications. Therefore, the main objective of this study was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal. The secondary aim was to present a prognostic model to predict the probability of having postoperative residual neuromuscular blockade depending on a patient's comorbidities and intraoperative neuromuscular blocking agents management. A single-center, prospective, observational cohort study including patients undergoing surgical procedures with general anesthesia was designed. A total of 714 patients were analyzed. Patients were divided into four groups: cisatracurium with spontaneous reversal, cisatracurium with neostigmine antagonism, rocuronium with spontaneous reversal, and rocuronium with sugammadex antagonism. According to our binomial generalized linear model, none of the studied comorbidities was a predisposing factor for an increase in the residual neuromuscular blockade. However, in our study, pharmacological reversal of rocuronium with sugammadex and, particularly, neuromuscular monitoring during surgery were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early and late postoperative pulmonary complications.
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Affiliation(s)
- Cristian Aragón-Benedí
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain.
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.
| | - Ana Pascual-Bellosta
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Sonia Ortega-Lucea
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Sara Visiedo-Sánchez
- Department of Anaesthesia, Resuscitation and Pain Therapy, University Clinical Hospital Lozano Blesa, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Javier Martínez-Ubieto
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009, Zaragoza, Spain
- Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
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7
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Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology 2022; 136:901-915. [PMID: 35188958 DOI: 10.1097/aln.0000000000004174] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes. EDITOR’S PERSPECTIVE
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Khanna S, Sreedharan R. Con: Sugammadex Should Not Be Used Routinely for Reversal of Neuromuscular Blockade in Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth 2022; 36:1792-1797. [PMID: 35027298 DOI: 10.1053/j.jvca.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sandeep Khanna
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH.
| | - Roshni Sreedharan
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH; Department of Intensive Care Resuscitation, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
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Pulmonary Risk Assessment. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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10
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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11
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Weigel WA, Thilen SR. Neuromuscular Blockade Monitoring and Reversal: A Clinical and Pharmacoeconomic Update. Adv Anesth 2021; 39:169-188. [PMID: 34715973 DOI: 10.1016/j.aan.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Wade A Weigel
- Department of Anesthesiology, Virginia Mason Franciscan Health, mailstop B2-AN, 1100 9th Avenue, Seattle, WA 98101, USA.
| | - Stephan R Thilen
- Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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Echeverry G, Polskin L, Tollinche LE, Seier K, Tan KS, McCormick PJ, Fischer GW, Grant FM. ROUTINE USE OF SUGAMMADEX DOES NOT SHORTEN PACU LENGTH OF STAY: A PROSPECTIVE DOUBLE-BLINDED RANDOMIZED CONTROLLED TRIAL. ACTA ACUST UNITED AC 2021; 24. [PMID: 34504958 DOI: 10.1016/j.pcorm.2021.100199] [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] [Indexed: 11/27/2022]
Abstract
Background The reversal agent sugammadex has been shown to be more efficacious at reversal from neuromuscular blockade (NMB) induced by the aminosteroid class of non-depolarizing muscle relaxants than the traditionally used medication neostigmine. However, whether these differences lead to significantly faster PACU discharge readiness remains unknown. Given the increased acquisition cost of sugammadex as compared to neostigmine we compared these two reversal agents in our surgical population to determine if its pharmacokinetic superiority warranted a change in current practice. Methods We conducted a single-center randomized patient and assessor blinded clinical trial. A total of 201 patients presenting for surgery requiring NMB with an estimated duration of ≤ 6 hours were included in the intention-to-treat (ITT) analysis. The primary outcome was time from reversal agent administration to PACU discharge readiness, measured by either the institutional discharge scoring tool or bedside clinical assessment by a PACU physician or advanced practice provider. Secondary outcomes included subjective assessment of recovery by the patient (pain, visual changes, speaking difficulty, swallowing difficulty, PONV, anxiety) and a simple strength assessment. Results Median time from reversal administration to PACU discharge readiness was 3.59 hours (IQR 2.49-5.09) in the neostigmine group and 3.62 hours (IQR 2.70-5.87) in the sugammadex group. Patients who received sugammadex had 8% longer reversal to PACU discharge times (exp(estimate) 1.08, 95% CI [0.87-1.34], p=0.499). Patients age 70 or older had 28% longer reversal to PACU discharge times (exp(estimate) of 1.28, 95% CI [0.91-1.80], P=0.158). In the a modified ITT analysis, sugammadex patients were estimated to be in PACU 13% longer than neostigmine arm patients (exp(estimate) 1.13, 95% CI [0.91-1.40], p=0.265) and patients older than or equal to 70 years 31% longer than patients less than 70 years old (exp(estimate) 1.31, 95% CI [0.93-1.84], p=0.121). Treatment arm was not associated with any of the secondary outcomes. Conclusion There was no significant difference in time to readiness to discharge from PACU, and there were no subjective or objective clinically relevant differences in recovery from neuromuscular blockade between the groups. Findings of this study support continued use of either agent at the anesthesiologist's discretion.
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Affiliation(s)
- Germán Echeverry
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Lily Polskin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Luis E Tollinche
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10056
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10056
| | - Patrick J McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Florence M Grant
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065
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13
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He J, He H, Li X, Sun M, Lai Z, Xu B. Required dose of sugammadex or neostigmine for reversal of vecuronium-induced shallow residual neuromuscular block at a train-of-four ratio of 0.3. Clin Transl Sci 2021; 15:234-243. [PMID: 34435439 PMCID: PMC8742655 DOI: 10.1111/cts.13143] [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: 03/24/2021] [Revised: 05/14/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022] Open
Abstract
Residual shallow neuromuscular block (NMB) is potentially harmful and contributes to critical respiratory events. Evidence for the optimal dose of sugammadex required to reverse vecuronium‐induced shallow NMB is scarce. The aims of the present study were to find suitable doses of sugammadex and neostigmine to reverse a residual vecuronium‐induced NMB from a time of flight (TOF) ratio of 0.3–0.9 and evaluate their safety and efficacy. In total, 121 patients aged 18–65 years were randomly assigned to 11 groups to receive placebo, sugammadex (doses of 0.125, 0.25, 0.5, 1.0, or 2.0 mg/kg), or neostigmine (doses of 10, 25, 40, 55, or 70 μg/kg). The reversal time of sugammadex and neostigmine to antagonize a vecuronium‐induced shallow residual NMB (i.e., TOF ratio of 0.3) and related adverse reactions were recorded. Several statistical models were tested to find an appropriate statistical model to explore the suitable doses of sugammadex and neostigmine required to reverse a residual vecuronium‐induced NMB. Based on a monoexponential model with the response variable on a logarithmic scale, sugammadex 0.56 mg/kg may be sufficient to reverse vecuronium‐induced shallow residual NMB at a TOF ratio of 0.3 under anesthesia maintained with propofol. Neostigmine may not provide prompt and satisfactory antagonism as sugammadex, even in shallow NMB.
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Affiliation(s)
- Jing He
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Huan He
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xing Li
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Mei Sun
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Zhihao Lai
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Bo Xu
- Department of Anesthesiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
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The association of nitrous oxide on length of stay in the postanesthesia care unit: a retrospective observational study. Can J Anaesth 2021; 68:1630-1640. [PMID: 34406608 DOI: 10.1007/s12630-021-02067-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess whether intraoperative use of nitrous oxide (N2O) as an adjunct to general anesthesia is associated with a shorter length of stay in the postanesthesia care unit (PACU). METHODS We analyzed data from adult patients who underwent non-cardiothoracic surgery under general anesthesia between May 2008 and December 2018. We assessed the association between intraoperative low- and high-dose N2O and PACU length of stay. RESULTS A total of 148,284 patients were included in the primary analysis. After adjusting for a priori defined confounders, a high dose of N2O significantly decreased PACU length of stay, with a calculated difference of -9.1 min (95% confidence interval [CI], -10.5 to -7.7; P < 0.001). Patients who received high-dose N2O had a lower incidence of both short- and prolonged-duration of intraoperative hypotension (adjusted odds ratio [aOR], 0.85; 95% CI, 0.83 to 0.88; P < 0.001 and aOR, 0.76; 95% CI, 0.73 to 0.80; P < 0.001, respectively) and received a lower total intraoperative vasopressor dose (-0.04 mg of norepinephrine equivalents; 95% CI, -0.06 to -0.01; P = 0.01). The effect of high-dose N2O on PACU length of stay was modified by surgical complexity (adjusted absolute difference: -26.1 min; 95% CI, -29.2 to -23.1; P < 0.001; P for interaction < 0.001), and most pronounced in patients who underwent complex surgery and received intraoperative antiemetic therapy (adjusted absolute difference: -38.9 min; 95% CI, -43.1 to -34.6; P < 0.001; P for interaction < 0.001). CONCLUSIONS Nitrous oxide was dose-dependently associated with a decreased PACU length of stay. The effect was clinically relevant (> 30 min difference) in patients who underwent complex surgical procedures and received intraoperative antiemetic therapy.
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Recovery of lower oesophageal barrier function: a pilot study comparing a mixture of atropine and neostigmine and sugammadex: A randomised controlled pilot study. Eur J Anaesthesiol 2021; 38:856-864. [PMID: 34226418 DOI: 10.1097/eja.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lower oesophageal sphincter (LOS) barrier serves to prevent regurgitation of gastric contents. Although general anaesthesia depresses its function, its recovery process during emergence from anaesthesia has not been systematically examined. OBJECTIVE To explore whether recovery of lower oesophageal barrier function differed between patients receiving a mixture of 1 mg atropine and 2 mg neostigmine and those receiving 2 mg kg-1 sugammadex during emergence from anaesthesia. DESIGN An unblinded randomised controlled pilot study. SETTING A single university hospital from January 2016 to December 2018. PATIENTS A total of 20 non-obese adult females undergoing minor surgery. INTERVENTION The patients were randomly assigned to a group either receiving atropine and neostigmine or sugammadex for reversal of rocuronium. MAIN OUTCOME MEASURES Through use of the high-resolution manometry technique, the lower oesophageal barrier pressure (PBAR: primary variable) defined as a pressure difference between pressures at the LOS and the stomach was measured at five distinguishable time points during emergence from total intravenous anaesthesia. A mixed effects model for repeated measures was used to test the hypothesis. RESULTS In all patients baseline PBAR values were positive even under muscle paralysis and general anaesthesia before administration of reversal agents, and did not differ between the groups (P = 0.299). During recovery from muscle paralysis and general anaesthesia, PBAR (mean ± SD) significantly increased (P = 0.004) from 17.0 ± 2.9 to 21.0 ± 5.0 mmHg in the atropine and neostigmine group (n = 8) and from 19.1 ± 9.0 to 24.5 ± 12.7 mmHg in the sugammadex group (n = 11). PBAR significantly increased immediately after return of consciousness in both groups, whereas return of muscle tone, lightening of anaesthesia and tracheal extubation did not change it. CONCLUSION Recovery of the lower oesophageal barrier function does not differ between patients receiving either atropine and neostigmine or sugammadex and is completed after recovery of consciousness from general anaesthesia. TRIAL REGISTRATION UMIN Clinical Trials Registry: UMIN000020500: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000023594&type=summary&language=E.
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Azizoğlu M, Özdemir L. Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study. J Patient Saf 2021; 17:352-357. [PMID: 34276037 DOI: 10.1097/pts.0000000000000874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Postoperative residual neuromuscular block (PRNB) is a serious problem that can cause death after surgery. It was aimed to evaluate the adequacy of neuromuscular block (NMB) during endotracheal intubation and the adequacy of neuromuscular recovery during clinically extubation decision and follow-up with the train-of-four ratio (TOFR) using quantitative monitoring. METHODS This study has a prospective-observational single-blind study design. A total of 205 adult patients who underwent elective surgery, who had American Society of Anesthesiologists physical statuses I to III, and who were intubated with neuromuscular blocking agent under general anesthesia were included in the study. Train-of-four ratio measurements were provided single-blindly by another anesthesiologist outside the team. The TOFRs were measured at the time of intubation (TOFRind), before reversal agent administration (TOFRpre-rev) and after (TOFRpost-rev), at the time of extubation (TOFRext), and on admission to the postoperative care unit (TOFRPACU). If clinical signs of PRNB appeared, the recovery protocol was applied and then TOFRrec was measured. Postoperative respiratory complications were also evaluated for the first 24 hours after surgery. RESULTS Endotracheal intubation was performed in 41.5% of the patients (n = 85) without adequate NMB. In 48.8% (n = 100) of the patients, adequate recovery (TOFRext ˂0.9) was not available at the time of extubation. Adequate TOFRPACU rate was found to be significantly higher in those who did not receive additional neuromuscular blocking agent doses (P < 0.001). In the recovery protocol, low-dose sugammadex administered to patients with clinical signs of PRNB significantly increased the TOFRrec rate compared with neostigmine (P ˂ 0.001). The first 24 hours, postoperative respiratory complication rate was 5.4% (n = 11), and the most common hypoxemia was observed. CONCLUSIONS Approximately half of the patients are intubated without sufficient NMB and extubated without sufficient neuromuscular recovery. This suggests that routine use of quantitative neuromuscular monitoring is necessary for patient safety.
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Affiliation(s)
- Mustafa Azizoğlu
- From the Department of Anesthesiology and Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
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Garutti I, Errando CL, Mazzinari G, Bellón JM, Díaz-Cambronero O, Ferrando C. Spontaneous recovery of neuromuscular blockade is an independent risk factor for postoperative pulmonary complications after abdominal surgery: A secondary analysis. Eur J Anaesthesiol 2021; 37:203-211. [PMID: 32028288 DOI: 10.1097/eja.0000000000001128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven. OBJECTIVE To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs). DESIGN The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data. SETTING Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016. PATIENTS Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases. INTERVENTIONS The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery. MAIN OUTCOME MEASURES The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed. RESULTS From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82). CONCLUSION Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02158923.
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Affiliation(s)
- Ignacio Garutti
- From the Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid (IG), Department of Anaesthesiology, Consorcio Hospital General Universitario de Valencia (CLE), Department of Anaesthesiology, Hospital de Manises, Valencia (GM), Department of Biostatistics, Hospital General Universitario Gregorio Marañón, Madrid (JMB), Department of Anaesthesiology, Hospital Universitari i Politécnic La Fe (OD-C), Perioperative Medicine Research Group Instituto de Investigación Sanitaria La Fe (IIS laFe), Valencia (GM, OD-C) and Pharmacology and Toxicology Department, School of Medicine, Complutense University of Madrid, Madrid, Spain (IG) the Department of Anaesthesiology and Critical Care, Hospital Clinic i Provincial, Barcelona, Spain (CF), CIBER de Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid, Spain (CF)
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18
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Pulmonary function decline in immediate postoperative period is not necessarily related to residual neuromuscular block: An observational study. Eur J Anaesthesiol 2021; 37:1008-1013. [PMID: 32412987 DOI: 10.1097/eja.0000000000001221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have reported an association between the use of neuromuscular blocking (NMB) agents and postoperative pulmonary complications. Postoperative pulmonary function is a key indicator for postoperative pulmonary complications. Several sites can be used to assess depth and recovery from NMB. OBJECTIVES To investigate postoperative pulmonary function change in relation to train-of-four measurements at the adductor pollicis and corrugator supercilii muscles, and anaesthesia-related variables in orthopaedic patients undergoing hip or knee arthroplasty. DESIGN Observational study. SETTING University hospital. PATIENTS Orthopaedic patients undergoing hip or knee arthroplasty. MAIN OUTCOME MEASURES Postoperative pulmonary function tests in the postanaesthesia care unit. METHODS Patients scheduled for elective hip or knee arthroplasty received simultaneous corrugator supercilii and adductor pollicis measurements during anaesthesia conducted according to clinical standards. Forced expiratory volume in 1 s and forced vital capacity (FVC) were measured at the time of inclusion and postoperatively on the postanaesthesia care unit. Linear regression analysis was performed for association between risk factors and pulmonary function change. RESULTS A total of 35 patients were included. After exclusions, 20 patients remained for final analysis. Corrugator supercilii showed earlier NMB recovery than adductor pollicis. FVC decreased significantly after surgery from 2.9 ± 1.0 to 2.3 ± 1.0 (P < 0.01) and forced expiratory volume in 1 s decreased from 2.3 ± 0.9 to 1.6 ± 0.8 l (P < 0.01). Patient age was the only factor significantly related to FVC decrease after surgery (P = 0.019) with a cut-off value of 65 years. CONCLUSION Both corrugator supercilii and adductor pollicis failed to indicate recovery of pulmonary function after NMB. Age seems to be a risk factor for postoperative decline in pulmonary function. TRIAL REGISTRATION German Clinical Trials registry, DRKS-ID: DRKS00014305.
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Yu J, Park JY, Lee Y, Hwang JH, Kim YK. Sugammadex versus neostigmine on postoperative pulmonary complications after robot-assisted laparoscopic prostatectomy: a propensity score-matched analysis. J Anesth 2021; 35:262-269. [PMID: 33683444 DOI: 10.1007/s00540-021-02910-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/14/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Robot-assisted laparoscopic prostatectomy (RALP) requires particular surgical conditions, such as carbon dioxide pneumoperitoneum and steep Trendelenburg positioning, which may have adverse effects on the respiratory system. The effect of sugammadex on postoperative pulmonary complications (PPCs) is controversial. Therefore, we evaluated the incidence of PPCs according to the type of neuromuscular blockade reversal agents in RALP. METHODS We retrospectively analyzed RALP patients. We compared the incidence of PPCs between patients receiving neostigmine (neostigmine group) and those receiving sugammadex (sugammadex group) as a neuromuscular blockade reversal agent. Propensity score-matched analysis was performed. Other postoperative outcomes, such as duration of hospital stays, major adverse cardiac events during hospital stays, and death during hospital stays, were also compared between the two groups. RESULTS The incidence of PPCs was 28.9% (137/474) in RALP. The incidence of PPCs was significantly lower in the sugammadex group than in the neostigmine group (18.6% [44/237] vs. 39.2% [93/237], p < 0.001). The incidence of atelectasis was significantly lower in the sugammadex group than in the neostigmine group (18.6% vs. 39.2%, p < 0.001). The incidence of pneumonia was not significantly different between the sugammadex and neostigmine groups after RALP (0.0% vs. 0.4%, p > 0.999). Besides these, other postoperative outcomes were not significantly different between the two groups. CONCLUSIONS The incidence of PPCs after RALP was significantly lower in patients receiving sugammadex than in those receiving neostigmine. These results can provide useful information on the appropriate selection of neuromuscular blockade reversal agents in RALP.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yongsoo Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Serrano AB, DÍaz-Cambronero Ó, Melchor-RipollÉs J, Abad-Gurumeta A, Ramirez-Rodriguez JM, MartÍnez-Ubieto J, SÁnchez-Merchante M, Rodriguez R, JordÁ L, Gil-Trujillo S, Cabellos-Olivares M, Bordonaba-Bosque D, Aldecoa C. Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial. Minerva Anestesiol 2021; 87:13-25. [PMID: 33538417 DOI: 10.23736/s0375-9393.20.14589-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program. METHODS We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated. RESULTS Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048). CONCLUSIONS Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.
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Affiliation(s)
- Ana B Serrano
- Department of Anesthesiology, Ramón y Cajal University Hospital, Madrid, Spain - .,Instituto de Investigación Sanitaria Hospital Ramón y Cajal (IRYCIS), Madrid, Spain -
| | - Óscar DÍaz-Cambronero
- Department of Anesthesiology, The University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
| | | | | | | | | | | | - Rita Rodriguez
- Department of Anesthesiology, University Clinical Hospital of Valladolid, Valladolid, Spain
| | - Laura JordÁ
- Department of Anesthesiology, University General Hospital of Castellón, Castellón, Spain
| | - Silvia Gil-Trujillo
- Department of Anesthesiology, Hospital General Universitario de Ciudad Real (HGUCR), Ciudad Real, Spain
| | | | - Daniel Bordonaba-Bosque
- Institute for Health Sciences in Aragon (IACS), Centro de Investigación Biomédica de Aragón (CIBA), Zaragoza, Spain
| | - César Aldecoa
- Department of Anesthesiology, University General Hospital of Castellón, Castellón, Spain
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21
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Lee TY, Jeong SY, Jeong JH, Kim JH, Choi SR. Comparison of postoperative pulmonary complications between sugammadex and neostigmine in lung cancer patients undergoing video-assisted thoracoscopic lobectomy: a prospective double-blinded randomized trial. Anesth Pain Med (Seoul) 2021; 16:60-67. [PMID: 33486942 PMCID: PMC7861896 DOI: 10.17085/apm.20056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/07/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Reversal of neuromuscular blockade (NMB) at the end of surgery is important for reducing postoperative residual NMB; this is associated with an increased risk of postoperative pulmonary complications (PPCs). Moreover, PPCs are associated with poor prognosis after video-assisted thoracoscopic surgery (VATS) for lobectomy. We compared the effects of two reversal agents, sugammadex and neostigmine, on the incidence of PPCs and duration of hospital stay in patients undergoing VATS lobectomy. METHODS After VATS lobectomy was completed under neuromuscular monitoring, the sugammadex group (n = 46) received sugammadex 2 mg/kg, while the neostigmine group (n = 47) received neostigmine 0.05 mg/kg with atropine 0.02 mg/kg after at least the third twitch in response to the train of four stimulation. The primary outcome was incidence of PPCs. The secondary outcomes were duration of hospital stay and intensive care unit (ICU) admission. RESULTS There was no significant difference in the incidence of PPCs for both the sugammadex and neostigmine groups (32.6% and 40.4%, respectively; risk difference = 0.08; 95% confidence interval = [-0.12, 0.27]; P = 0.434). The lengths of hospital (P = 0.431) and ICU (P = 0.964) stays were not significantly different between the two groups. CONCLUSIONS The clinical use of sugammadex and neostigmine in NMB reversal for patients undergoing VATS lobectomy was not significantly different in the incidence of PPCs and duration of hospital and ICU stay.
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Affiliation(s)
- Tae Young Lee
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Seong Yeop Jeong
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Joon Ho Jeong
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jeong Ho Kim
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - So Ron Choi
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
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Polshin V, Petro J, Wachtendorf LJ, Hammer M, Simopoulos T, Eikermann M, Santer P. Effect of peripheral nerve blocks on postanesthesia care unit length of stay in patients undergoing ambulatory surgery: a retrospective cohort study. Reg Anesth Pain Med 2021; 46:233-239. [PMID: 33452202 DOI: 10.1136/rapm-2020-102231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Peripheral regional anesthesia and analgesia may increase the efficiency of ambulatory surgical centers by reducing pain and preventing nausea and vomiting, which are important modifiable causes of prolonged postanesthesia care unit (PACU) length of stay. We hypothesized that the use of peripheral nerve blocks (PNB) was associated with shorter PACU length of stay in ambulatory surgery. METHODS In this retrospective cohort study, we analyzed data from adult ambulatory surgical cases, in which PNB was a viable anesthetic option (ie, was routinely performed for these procedures), at an academic medical center between 2008 and 2018. We assessed the association between the use of PNB and the primary endpoint of PACU length of stay. As key secondary endpoint, we compared intraoperative opioid doses. Analyses were adjusted for patient demographics, comorbidities and intraoperative factors. RESULTS A total of 57 040 cases were analyzed, of whom 13 648 (23.9%) received a PNB. The use of PNB was associated with shorter PACU length of stay (a decrease of 7.3 min, 95% CI 6.1 to 8.6, p<0.001). This association was most pronounced in surgeries of long duration (decrease of 11.2 min, 95% CI 9.0 to 13.4) and in patients undergoing leg and ankle procedures (decrease of 15.1 min, 95% CI 5.5 to 24.6). Intraoperative opioid doses were significantly lower in patients receiving a nerve block (decrease of 9.40 mg oral morphine equivalents, 95% CI 8.34 to 10.46, p<0.001). CONCLUSION The use of PNB significantly reduced PACU length of stay in ambulatory surgical patients, which may in part be attributed to lower intraoperative opioid requirements.
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Affiliation(s)
- Victor Polshin
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Petro
- Department of Anesthesiology and Perioperative Medicine, Veterans Administration Hospital of Boston, West Roxbury, Massachusetts, USA
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maximilian Hammer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Simopoulos
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA .,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lai CJ, Chen JS, Ho SI, Lu ZY, Huang YJ, Cheng YJ. Detecting Oropharyngeal and Esophageal Emptying by Submental Ultrasonography and High-Resolution Impedance Manometry: Intubated vs. Non-Intubated Video-Assisted Thoracoscopic Surgery. Diagnostics (Basel) 2020; 10:diagnostics10121079. [PMID: 33322685 PMCID: PMC7763338 DOI: 10.3390/diagnostics10121079] [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: 10/23/2020] [Revised: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 12/04/2022] Open
Abstract
Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.
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Affiliation(s)
- Chih-Jun Lai
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 100025, Taiwan;
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 106037, Taiwan;
| | - Shih-I Ho
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Zhi-Yin Lu
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Yi-Ju Huang
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Ya-Jung Cheng
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei 100233, Taiwan
- Department of Anesthesiology, National Taiwan University Cancer Center, Taipei 106037, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456 (ext. 65517)
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Niu L, Wang Y, Yao C, Sun Y, Yao S, Lin Y. Efficacy and Safety of Neuromuscular Blockade in Overweight Patients Undergoing Nasopharyngeal Surgery. Med Sci Monit 2020; 26:e926452. [PMID: 32936790 PMCID: PMC7519943 DOI: 10.12659/msm.926452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Adequate muscle relaxation and rapid recovery of neuromuscular function are essential in the perioperative period. We therefore compared various anesthetic regimens of neuromuscular blockers and antagonists administered to overweight patients undergoing nasopharyngeal surgery. MATERIAL AND METHODS This prospective, randomized, double-blind study was conducted in overweight patients undergoing nasopharyngeal surgery. We randomly assigned 102 patients into 3 groups (each n=34) treated with various muscle relaxant agents and antagonists: rocuronium and sugammadex (Group RS), rocuronium and neostigmine (Group RN), and cisatracurium and neostigmine (Group CN). Then, we compared the efficacy and safety indexes of the 3 groups. RESULTS Onset times of muscular relaxation in Group RS and Group RN (110 s and 120 s) were shorter than in Group CN (183 s). Time from administration of antagonist to recovery of the TOF ratio to 0.9 was shorter in Group RS (3.3 min) than in other groups (20.7 min and 19.1 min, respectively). The incidence of postoperative residual curarization (PORC) was significantly lower in Group RS (5.9%) than in the other 2 groups (both 41.2%). The hemodynamic parameter changes before extubation were significantly higher in Group RN and Group CN than in Group RS. The postoperative pain scores were lowest in Group RS. CONCLUSIONS For overweight patients undergoing nasopharyngeal surgery, the use of rocuronium with sugammadex had the shortest onset time of neuromuscular relaxation, accelerated the reversion of neuromuscular blockade, effectively reduced the occurrence of PORC, relieved postoperative pain, and maintained hemodynamic stability before extubation. The combination of rocuronium and sugammadex may be the best anesthetic regimen for overweight patients undergoing nasopharyngeal surgery.
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Affiliation(s)
- Lingxia Niu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Chunlin Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yan Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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Appropriate Use of Neuromuscular Blocking Agents and Reversal Drugs to Enhance Recovery Following Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Suzuki K, Takazawa T, Saito S. History of the development of antagonists for neuromuscular blocking agents. J Anesth 2020; 34:723-728. [PMID: 32766960 DOI: 10.1007/s00540-020-02836-1] [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: 03/25/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Abstract
Muscle relaxation induced by neuromuscular blocking agents (NMBAs) is necessary for tracheal intubation and immobilization during surgery. Although acetylcholinesterase inhibitors have been successfully used as antagonists for NMBAs, they have their limitations; their effects are transient and ineffective against profound neuromuscular blockade. In the past, alternative antagonists were developed, such as germine and 4-aminopyridine, which are effective for the treatment of diseases causing muscle weakness and could potentially be used as antagonists for NMBAs. Unfortunately, these drugs did not come into practical use due to unwanted side-effects. Sugammadex is an almost ideal antagonist because it rapidly forms a rigid complex with rocuronium and produces less adverse effects. The development of novel NMBAs and antagonists, especially sugammadex, has revolutionized anesthesia practice. Recently, novel short-acting NMBAs, such as gantacurium and CW002 have been developed. Their effects can be reversed by the amino-acid L-cysteine. More recently, calabadions have been developed, which can form complexes with both steroidal and bisbenzyl-isoquinolinium NMBAs, in a similar fashion as sugammadex. Understanding the history of the NMBA antagonist's development is interesting and useful for modern anesthesiologists since it enhances their knowledge about the mechanisms involved in neuromuscular transmission and might lead to the development of ideal NMBA antagonists.
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Affiliation(s)
- Keiko Suzuki
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Shigeru Saito
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan.,Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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Egbuta C, Mason KP. Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient. J Clin Med 2020; 9:jcm9061942. [PMID: 32580323 PMCID: PMC7355459 DOI: 10.3390/jcm9061942] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022] Open
Abstract
There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.
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Shaydenfish D, Wongtangman K, Eikermann M, Schaefer MS. The effects of acetylcholinesterase inhibitors on morbidity after general anesthesia and surgery. Neuropharmacology 2020; 173:108134. [PMID: 32416089 DOI: 10.1016/j.neuropharm.2020.108134] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/24/2020] [Accepted: 05/08/2020] [Indexed: 12/20/2022]
Abstract
Non-depolarizing neuromuscular blocking agents are used during general anesthesia to facilitate intubation and optimize surgical conditions. When patients leave the operating room after surgery, postoperative residual neuromuscular block occurs frequently, increasing vulnerability to respiratory complications such as hypoxemia and unplanned postoperative mechanical ventilation. To restore neuromuscular transmission and skeletal muscle strength, anesthesiologists typically administer peripherally acting acetylcholinesterase inhibitors such as neostigmine. However, neostigmine's desirable effects have a narrow therapeutic range. Even at recommended dose (15-50 μg/kg), neostigmine induces nicotinic (upper airway muscle weakness leading to dysphagia and upper airway obstruction, and decreased maximum inspiratory airflow) and muscarinic (blurred vision, bronchial constriction, abdominal cramping and nausea) side effects. Recent data have questioned as to whether neostigmine reversal of neuromuscular blockade improves relevant patient outcomes such as postoperative respiratory and perioperative cardiovascular complications. A central strategy to avoid side effects of neuromuscular blocking agents is their judicious use based on quantitative monitoring of neuromuscular transmission using repetitive peripheral nerve stimulation (train-of-four ratio). Peripherally acting acetylcholinesterase inhibitors such as neostigmine should then only be administered when indicated and dosed based on results of the train-of-four ratio.
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Affiliation(s)
- Denys Shaydenfish
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA
| | - Karuna Wongtangman
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA; Department of Anaesthesiology & Intensive Care Medicine, University of Duisburg-Essen, Essen, Germany.
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA; Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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Neostigmine versus sugammadex: the tide may be turning, but we still need to navigate the winds. Br J Anaesth 2020; 124:504-507. [DOI: 10.1016/j.bja.2020.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 02/22/2020] [Accepted: 02/27/2020] [Indexed: 12/15/2022] Open
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Ventilatory frequency during intraoperative mechanical ventilation and postoperative pulmonary complications: a hospital registry study. Br J Anaesth 2020; 125:e130-e139. [PMID: 32223967 DOI: 10.1016/j.bja.2020.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/03/2020] [Accepted: 02/24/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High ventilatory frequencies increase static lung strain and possibly lung stress by shortening expiratory time, increasing intrathoracic pressure, and causing dynamic hyperinflation. We hypothesised that high intraoperative ventilatory frequencies were associated with postoperative respiratory complications. METHODS In this retrospective hospital registry study, we analysed data from adult non-cardiothoracic surgical cases performed under general anaesthesia with mechanical ventilation at a single centre between 2005 and 2017. We assessed the association between intraoperative ventilatory frequency (categorised into four groups) and postoperative respiratory complications, defined as composite of invasive mechanical ventilation within 7 days after surgery or peripheral oxygen desaturation after extubation, using multivariable logistic regression. In a subgroup, we adjusted analyses for arterial blood gas parameters. RESULTS A total of 102 632 cases were analysed. Intraoperative ventilatory frequencies ranged from a median (inter-quartile range [IQR]) of 8 (8-9) breaths min-1 (Group 1) to 15 (14-18) breaths min-1 (Group 4). High ventilatory frequencies were associated with higher odds of postoperative respiratory complications (adjusted odds ratio=1.26; 95% confidence interval, 1.14-1.38; P<0.001), which was confirmed in a subgroup after adjusting for arterial partial pressure of carbon dioxide and the ratio of arterial oxygen partial pressure to fractional inspired oxygen. We identified considerable variability in the use of high ventilatory frequencies attributable to individual provider preference (ranging from 22% to 88%) and temporal change; however, the association with postoperative respiratory complications remained unaffected. CONCLUSIONS High intraoperative ventilatory frequency was associated with increased risk of postoperative respiratory complications, and increased postoperative healthcare utilisation.
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Shay D, Scheffenbichler FT, Kelly BJ, Lihn AL, Deng H, Nourmahnad A, Xu X, Houle TT, Eikermann M, Forman SA. Effects of Anticholinesterase Reversal Under General Anesthesia on Postoperative Cardiovascular Complications: A Retrospective Cohort Study. Anesth Analg 2020; 130:685-695. [PMID: 30896593 DOI: 10.1213/ane.0000000000004099] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The anticholinesterase neostigmine and the muscarinic inhibitor glycopyrrolate are frequently coadministered for the reversal of neuromuscular blockade. This practice can precipitate severe bradycardia or tachycardia, but whether it affects the incidence of cardiovascular complications remains unclear. We hypothesized that anticholinesterase reversal with neostigmine and glycopyrrolate versus no anticholinesterase reversal increases the risk of postoperative cardiovascular complications among adult patients undergoing noncardiac surgery with general anesthesia. METHODS We conducted a prespecified retrospective analysis of hospital registry data from a major health care network for patients undergoing surgery with general anesthesia from January 2007 to December 2015. The primary outcome was a composite of cardiac dysrhythmia, acute heart failure, transient ischemic attack, ischemic stroke, and acute myocardial infarction within 30 days after surgery. We performed sensitivity analyses in subgroups and propensity score adjustment and explored the association between exposure and outcome in subgroups of patients with high risk of cardiovascular complications. RESULTS Of the 98,147 cases receiving neuromuscular blockade, 73,181 (74.6%) received neostigmine and glycopyrrolate, while 24,966 (25.4%) did not. A total of 5612 patients (7.7%) in the anticholinesterase reversal group and 1651 (6.6%) in the control group (P < .001) experienced the primary outcome. After adjustment for clinical covariates, neostigmine and glycopyrrolate exposure was significantly associated in a dose-dependent fashion (P for trend <.001, respectively) with tachycardia (adjusted odds ratio = 2.1 [95% CI, 1.97-2.23]; P < .001) and bradycardia (adjusted odds ratio = 2.84 [95% CI, 2.49-3.24]; P < .001) but not with postoperative cardiovascular complications (adjusted odds ratio = 1.03 [95% CI, 0.97-1.1]; P = .33). We identified a significant effect modification of anticholinesterase reversal by high age, high-risk surgery, and history of atrial fibrillation (P for interaction = .002, .001, and .02, respectively). By using linear combinations of main effect and exposure-risk interaction terms, we detected significant associations between anticholinesterase reversal and cardiovascular complications toward a higher vulnerability in these patient subgroups. CONCLUSIONS Neuromuscular blockade reversal with neostigmine and glycopyrrolate was associated with an increased incidence of intraoperative tachycardia and bradycardia but not with 30-day postoperative cardiovascular complications. Exploratory analyses suggest that a high postoperative cardiovascular complication risk profile may modify the effects of anticholinesterase reversal toward clinical relevance.
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Affiliation(s)
- Denys Shay
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Flora T Scheffenbichler
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Barry J Kelly
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Anne-Louise Lihn
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hao Deng
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anahita Nourmahnad
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Timothy T Houle
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany
| | - Stuart A Forman
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Oh TK, Ryu JH, Nam S, Oh AY. Association of neuromuscular reversal by sugammadex and neostigmine with 90-day mortality after non-cardiac surgery. BMC Anesthesiol 2020; 20:41. [PMID: 32079528 PMCID: PMC7033926 DOI: 10.1186/s12871-020-00962-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/17/2020] [Indexed: 12/18/2022] Open
Abstract
Background Reversing a neuromuscular blockade agent with sugammadex is known to lessen postoperative complications by reducing postoperative residual curarization. However, its effects on 90-day mortality are unknown. Therefore, this study aimed to compare the effects of sugammadex and neostigmine in terms of 90-day mortality after non-cardiac surgery. Methods This retrospective cohort study analyzed the medical records of adult patients aged 18 years or older who underwent non-cardiac surgery at a single tertiary care hospital between 2011 and 2016. Propensity score matching and Cox regression analysis were used to investigate the effectiveness of sugammadex and neostigmine in lowering 90-day mortality after non-cardiac surgery. Results A total of 65,702 patients were included in the analysis (mean age: 52.3 years, standard deviation: 15.7), and 23,532 of these patients (35.8%) received general surgery. After propensity score matching, 14,179 patients (3906 patients from the sugammadex group and 10,273 patients from the neostigmine group) were included in the final analysis. Cox regression analysis in the propensity score-matched cohort showed that the risk of 90-day mortality was 40% lower in the sugammadex group than in the neostigmine group (hazard ratio: 0.60, 95% confidence interval: 0.37, 0.98; P = 0.042). These results were similar in the multivariable Cox regression analysis of the entire cohort (hazard ratio: 0.62, 95% confidence interval: 0.39, 0.96; P = 0.036). Conclusions This retrospective cohort study suggested that reversing rocuronium with sugammadex might be associated with lower 90-day mortality after non-cardiac surgery compared to neostigmine. However, since this study did not evaluate quantitative neuromuscular function in the postoperative period due to its retrospective design, the results should be interpreted carefully. Future prospective studies with quantitative neuromuscular monitoring in the postoperative period should be performed to confirm these results.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sunwoo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea. .,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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Comparison of neostigmine vs. sugammadex for recovery of muscle function after neuromuscular block by means of diaphragm ultrasonography in microlaryngeal surgery. Eur J Anaesthesiol 2020; 37:44-51. [DOI: 10.1097/eja.0000000000001055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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How to optimize neuromuscular blockade in ambulatory setting? Curr Opin Anaesthesiol 2019; 32:714-719. [PMID: 31689267 DOI: 10.1097/aco.0000000000000798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the optimal use of neuromuscular blocking agents (NMBA) during ambulatory surgery, and to provide an update on the routine use of neuromuscular monitoring and the prevention of residual paralysis. RECENT FINDINGS The number of major surgical procedures performed in ambulatory patients is likely to increase in the coming years, following the development of laparoscopic and thoracoscopic procedures. To successfully complete these procedures, the proper use of NMBA is mandatory. The use of NMBA not only improves intubating conditions but also ventilation. Recent studies demonstrate that NMBA are much more the solution rather than the cause of airway problems. There is growing evidence that the paralysis of the diaphragm and the abdominal wall muscles, which are resistant to NMBA is of importance during laparoscopic surgery. Further studies are still required to determine when deep neuromuscular block [posttetanic count (PTC) < 5] is required perioperatively. There is now a consensus to use perioperatively neuromuscular monitoring and particularly objective neuromuscular monitoring in combination with reversal agents to avoid residual paralysis and its related morbidity (e.g. respiratory complications in the PACU). SUMMARY Recent data suggest that it is now possible to obtain a tight control of neuromuscular block to maintain optimal relaxation tailored to the surgical requirements and to obtain a rapid and reliable recovery at the end of the procedure.
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Algorithmusbasierte Präventionsstrategien zur Vermeidung neuromuskulärer Restblockaden. Anaesthesist 2019; 68:744-754. [DOI: 10.1007/s00101-019-00677-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Schepens T, Janssens K, Maes S, Wildemeersch D, Vellinga J, Jorens PG, Saldien V. Respiratory muscle activity after spontaneous, neostigmine- or sugammadex-enhanced recovery of neuromuscular blockade: a double blind prospective randomized controlled trial. BMC Anesthesiol 2019; 19:187. [PMID: 31629404 PMCID: PMC6800991 DOI: 10.1186/s12871-019-0863-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background The use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. In previous studies, we found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex. It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. In this study, we wanted to assess the effect of commonly used degrees of NMB and their possible reversal strategies on respiratory muscle activity after the return of normal neuromuscular transmission. Methods This is a randomized, controlled, parallel-group, single-centre, double-blind study in patients scheduled for intracranial surgery at a tertiary academic hospital in Belgium. All participants received target controlled propofol/remifentanil anesthesia and were randomized into one of five groups, receiving either a shallow NMB with no reversal (shallow/saline), a shallow NMB with sugammadex reversal (shallow/sugammadex), a moderate NMB with neostigmine reversal (moderate/neostigmine), a moderate NMB with sugammadex reversal (moderate/sugammadex), or a deep NMB with sugammadex reversal (deep/sugammadex). Primary and secondary outcome parameters were diaphragm and intercostal electromyographic (EMG) activity at the moment of resumed spontaneous breathing activity, defined as a maximal interval of 10 min after the first spontaneous breath. Results For the five groups, a total of 55 patients could be included in the final analysis. Median time of spontaneous breathing analyzed was 5 min (IQR 3–9.5 min). Both the moderate/sugammadex and the moderate/neostigmine groups had lower levels of diaphragm EMG compared to the shallow/sugammadex group. The moderate/neostigmine group had lower levels of intercostal EMG activity compared to the shallow/saline group. Conclusions In this study, the depth of neuromuscular blockade and type of reversal strategy impacts respiratory muscle activity at the moment of resumed spontaneous breathing and recovery of neuromuscular blockade. Both groups that received moderate NMB had lower levels of diaphragm EMG, compared to the shallow NMB group with sugammadex reversal. Compared to the shallow NMB group with no reversal, the moderate NMB with neostigmine reversal group had lower intercostal EMG activity. Trial registration Clinicaltrials.gov NCT01962298 on October 9, 2013 and EudraCT 2013–001926-25 on October 10, 2013.
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Affiliation(s)
- Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium.
| | - Koen Janssens
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - Sabine Maes
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | | | | | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Vera Saldien
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
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Honing G, Martini CH, Bom A, van Velzen M, Niesters M, Aarts L, Dahan A, Boon M. Safety of sugammadex for reversal of neuromuscular block. Expert Opin Drug Saf 2019; 18:883-891. [PMID: 31359807 DOI: 10.1080/14740338.2019.1649393] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Sugammadex is a modified cyclodextrin that is able to reverse neuromuscular block induced by aminosteroidal neuromuscular blocking drugs. Compared to reversal with neostigmine, it reverses neuromuscular block quicker and more predictable and without cholinergic side effects. However, there have been concerns about sugammadex ability to bind other drugs and its effects on QT interval and clotting times. In addition, sugammadex might induce hypersensitivity reactions more frequently than initially anticipated. This review summarizes current evidence with regard to these and other safety aspects of sugammadex. Areas covered: This review provides an overview of the efficacy of sugammadex in various patient populations, evaluates potential interactions with other drugs and discusses adverse effects and reactions that have been reported in the literature. Expert opinion: Sugammadex quickly reverses aminosteroid neuromuscular block with less side effects compared to neostigmine. As such, it has the potential to significantly reduce the incidence of residual neuromuscular block and to improve postoperative pulmonary outcome. Current safety concerns mainly focus on hypersensitivity reactions and cardiac arrhythmias. Although the absolute risk for these events is low, ongoing vigilance and research in this area are needed.
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Affiliation(s)
- Ghm Honing
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - C H Martini
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | | | - M van Velzen
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - M Niesters
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - Lphj Aarts
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - M Boon
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
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Xia R, Kachru N, Tuazon DM, Bostan F, Fuentes A. Evaluation of Neuromuscular Blockade Reversal on Postoperative Mechanical Ventilation Time in a Cardiovascular Surgery Population. J Cardiothorac Vasc Anesth 2019; 33:3348-3357. [PMID: 31350144 DOI: 10.1053/j.jvca.2019.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To report on postoperative outcomes related to the administration of neostigmine for reversal of nondepolarizing neuromuscular blocking agents in cardiovascular surgery patients, with a specific focus on the duration of postoperative mechanical ventilation as the primary endpoint. DESIGN A retrospective cohort study design was followed to achieve the study objectives. SETTING This was a single-center, chart review study conducted at a large academic medical center of adult patients post-cardiovascular surgery. PARTICIPANTS Patients were included if they had received a bolus dose of perioperative nondepolarizing neuromuscular blocking agent and underwent one of the targeted cardiovascular surgeries. INTERVENTIONS Final analysis comprised of 175 patients, 95 of whom received neostigmine and 80 who did not receive neostigmine. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the duration of postoperative mechanical ventilation. When controlling for all covariates, neostigmine use was associated with a 0.34-hour reduction (∼20.4 min) in duration of mechanical ventilation (parameter estimate: 0.66, 95% confidence interval 0.49-0.89; p = 0.0071). More patients who received neostigmine met the early extubation benchmark of less than 6 hours (55 v 34 patients; p = 0.04). Finally, neostigmine use was not found to be associated with increased risk of respiratory complications or postoperative nausea and/or vomiting. CONCLUSIONS The use of neostigmine was found to have a protective effect on the duration of postoperative mechanical ventilation without increasing the risk of adverse complications.
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Affiliation(s)
| | - Nandita Kachru
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX
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Grabitz SD, Rajaratnam N, Chhagani K, Thevathasan T, Teja BJ, Deng H, Eikermann M, Kelly BJ. The Effects of Postoperative Residual Neuromuscular Blockade on Hospital Costs and Intensive Care Unit Admission: A Population-Based Cohort Study. Anesth Analg 2019; 128:1129-1136. [PMID: 31094777 DOI: 10.1213/ane.0000000000004028] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade continues to be a frequent occurrence with a reported incidence rate of up to 64%. However, the effect of postoperative residual neuromuscular blockade on health care utilization remains unclear. We conducted a retrospective cohort study to investigate the effects of postoperative residual neuromuscular blockade on hospital costs (primary outcome), intensive care unit admission rate, and hospital length of stay (secondary outcomes). METHODS We performed a prespecified secondary analysis of data obtained in 2233 adult patients undergoing surgery under general anesthesia. Postoperative residual neuromuscular blockade was defined as a train-of-four ratio <0.9 in the postanesthesia care unit (PACU). Our confounder model adjusted for a variety of patient, surgical, and anesthesia-related factors. We fitted truncated negative binomial regression models for hospital cost and hospital length of stay analyses and a logistic regression model for our intensive care unit admission analysis. RESULTS Overall, 457 (20.5%) patients in our cohort had residual neuromuscular blockade on admission to the PACU. Postoperative residual neuromuscular blockade was not independently associated with increased hospital costs (adjusted incidence rate ratio, 1.04, CI, 0.98-1.11; P = .22). There were significantly higher odds of intensive care unit admission in those with postoperative residual neuromuscular blockade compared to those without (adjusted odds ratio, 3.03, CI, 1.33-6.87; P < .01). Further, we found a trend toward increased hospital length of stay in patients with postoperative residual neuromuscular blockade (adjusted incidence rate ratio, 1.09; P = .06). Sensitivity analysis using the same model in the day of surgery admissions and ambulatory surgery confirmed our findings. CONCLUSIONS Postoperative residual neuromuscular blockade at PACU admission was not significantly associated with increased hospital costs, but was associated with higher rates of intensive care unit admission. These findings support the view that clinicians should continue to work to reduce the rate of postoperative residual neuromuscular blockade.
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Affiliation(s)
- Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nishan Rajaratnam
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Khushi Chhagani
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tharusan Thevathasan
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bijan J Teja
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hao Deng
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Barry J Kelly
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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On-demand versus continuous rocuronium infusion for deep neuromuscular relaxation in patients undergoing thoraco-laparoscopic esophagectomy: a randomized-controlled clinical trial (DEPTH). Can J Anaesth 2019; 66:1062-1074. [DOI: 10.1007/s12630-019-01373-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 12/17/2022] Open
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Kent NB, Liang SS, Phillips S, Smith NA, Khandkar C, Eikermann M, Stewart PA. Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double-blind, placebo-controlled, randomised volunteer study. Anaesthesia 2019; 73:1079-1089. [PMID: 30132821 DOI: 10.1111/anae.14386] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Neostigmine reverses non-depolarising neuromuscular blockade, but may cause muscle weakness when administered after full recovery of neuromuscular function. We hypothesised that neostigmine in therapeutic doses impairs muscle strength and respiratory function in awake healthy volunteers. Twenty-one volunteers were randomised to receive two doses of either intravenous (i.v.) neostigmine 2.5 mg with glycopyrrolate 450 μg (neostigmine group, n = 14) or normal saline 0.9% (placebo group, n = 7). The first dose was administered immediately after obtaining baseline measurements, and the second dose was administered 15 min later. All 14 volunteers in the neostigmine group received the first dose, mean (SD) 35 (5.8) μg.kg-1 , but only nine of these volunteers agreed to receive the second dose, 34 (3.5) ?g.kg-1 . The primary outcome was hand grip strength. Secondary outcomes were train-of-four ratio, single twitch height, forced expiratory volume in 1 s, forced vital capacity, forced expiratory volume in 1 s/forced vital capacity ratio, oxygen saturation, heart rate and mean arterial pressure. The first dose of intravenous neostigmine with glycopyrrolate resulted in reduced grip strength compared with placebo, -20 (20) % vs. +4.3 (9.9) %, p = 0.0016; depolarising neuromuscular blockade with decreased single twitch height, -14 (11) % vs. -3.8 (5.6) %, p = 0.0077; a restrictive spirometry pattern with decreased predicted forced expiratory volume in 1 s, -15 (12) % vs. -0.47 (3.4) %, p = 0.0011; and predicted forced vital capacity, -20 (12) % vs. -0.59 (3.2) %, p < 0.0001 at 5 min after administration. The second dose of neostigmine with glycopyrrolate further decreased grip strength mean (SD) -41 (23) % vs. +1.0 (15) %, p = 0.0004; single twitch height -25 (15) % vs. -2.5 (6.6) %, p = 0.0030; predicted forced expiratory volume in 1 s -23 (24) % vs. -0.7 (4.4) %, p = 0.0063; and predicted forced vital capacity, -27.1 (22.0) % vs. -0.66 (3.9) %, p = 0.0010. Train-of-four ratio remained unchanged (p = 0.22). In healthy volunteers, therapeutic doses of neostigmine induced significant and dose-dependent muscle weakness, demonstrated by a decrease in maximum voluntary hand grip strength and a restrictive spirometry pattern secondary to depolarising neuromuscular blockade.
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Affiliation(s)
- N B Kent
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - S S Liang
- Department of Anaesthesia, Westmead Hospital, Westmead, NSW, Australia
| | - S Phillips
- Department of Anaesthesia, The University of Sydney, Sydney Adventist Hospital Clinical School, Sydney, NSW, Australia
| | - N A Smith
- Department of Anaesthesia, Wollongong Hospital, Wollongong, NSW, Australia
| | - C Khandkar
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - M Eikermann
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.,Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - P A Stewart
- Department of Anaesthesia, The University of Sydney, Sydney Adventist Hospital Clinical School, Sydney, NSW, Australia
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Bose S, Xu X, Eikermann M. Does reversal of neuromuscular block with sugammadex reduce readmission rate after surgery? Br J Anaesth 2019; 122:294-298. [PMID: 30770044 DOI: 10.1016/j.bja.2018.12.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 12/23/2018] [Accepted: 12/23/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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45
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Hunter JM. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation. Br J Anaesth 2019; 119:i53-i62. [PMID: 29161387 DOI: 10.1093/bja/aex318] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The use of anticholinesterases to reverse residual neuromuscular block at the end of surgery became routine practice in the 1950s. These drugs could only be used when recovery from block was established [two twitches of the train-of-four (TOF) count detectable] and concern was expressed about their cholinergic side-effects. By the 1990s, it was recognized that failure to reverse residual block adequately to a TOF ratio (TOFR) >0.7 was associated with increased risk of postoperative pulmonary complications (POPCs) following the long-acting non-depolarizing neuromuscular blocking drug (NDNMBD) pancuronium. By 2003, and the introduction of acceleromyography, a TOFR ≥0.9 was considered necessary to protect the airway from aspiration before tracheal extubation. It was also considered that four, not two, twitches of the TOF should be detectable before neostigmine was given. Use of any NDNMBD was subsequently shown to be associated with increased risk of POPCs, but it was thought that neostigmine reduced that risk. Recently, there has been conflicting evidence that use of neostigmine might increase the incidence of POPCs. Although sugammadex has been shown to rapidly reverse profound neuromuscular block from aminosteroidal agents, there is currently no evidence that sugammadex is superior to neostigmine in its effect on POPCs. Other new antagonists, including cysteine to degrade CW002 and calabadion 1 and 2 to antagonize aminosteroidal and benzylisoquinolium NDNMBDs, are being studied in preclinical and clinical trials. Quantitative neuromuscular monitoring is essential whenever a NDNMBD is used to ensure full recovery from neuromuscular block.
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Affiliation(s)
- J M Hunter
- University of Liverpool, Institute of Ageing and Chronic Disease, Liverpool L69 3GA, UK
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Luo J, Chen S, Min S, Peng L. Reevaluation and update on efficacy and safety of neostigmine for reversal of neuromuscular blockade. Ther Clin Risk Manag 2018; 14:2397-2406. [PMID: 30573962 PMCID: PMC6292224 DOI: 10.2147/tcrm.s179420] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Postoperative residual neuromuscular block is a serious threat which endangers the patient safety. Neostigmine has been the most commonly used anticholinesterase for the pharmacological reversal of neuromuscular blockade. Although newer agents have been introduced recently, neostigmine has some irreplaceable advantages, including broad-spectrum reversal of all nondepolarizing neuromuscular blocking drugs, low cost, and availability of more related data for clinical practice to refer to. Neostigmine is also noticed to have some drawbacks, such as the inability to reverse profound and deep blockade, potential induction of muscle weakness, cardiovascular adverse effects, and so on. Data on the usage of neostigmine in the geriatric and the pediatric population are still insufficient. Some discrepancies are observed in the results from previous studies which need further investigation. However, recent studies offer some renewed information. Regarding both efficacy and safety, the key for successful reversal of neuromuscular blockade is to use neostigmine “appropriately,” optimizing the dosage and timing of administration under close monitoring.
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Affiliation(s)
- Jie Luo
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Shuting Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
| | - Lihua Peng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China,
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Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record. Eur J Anaesthesiol 2018; 35:883-892. [DOI: 10.1097/eja.0000000000000861] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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48
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Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann M, Meistelman C, Hunter JM, Ulm K, Blobner M. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. THE LANCET RESPIRATORY MEDICINE 2018; 7:129-140. [PMID: 30224322 DOI: 10.1016/s2213-2600(18)30294-7] [Citation(s) in RCA: 198] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. METHODS We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients' preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. FINDINGS Between June 16, 2014, and April 29, 2015, data from 22 803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21 694); ORadj 1·86, 95% CI 1·53-2·26; ARRadj -4·4%, 95% CI -5·5 to -3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15-1·49; ARRadj -2·6%, 95% CI -3·9 to -1·4) and the administration of reversal agents (1·23, 1·07-1·41; -1·9%, -3·2 to -0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85-1·25; ARRadj -0·3%, 95% CI -2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82-1·31; -0·4%, -3·5 to 2·2) was associated with better pulmonary outcomes. INTERPRETATION We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications. FUNDING European Society of Anaesthesiology.
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Affiliation(s)
- Eva Kirmeier
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Lars I Eriksson
- Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Heidrun Lewald
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Malin Jonsson Fagerlund
- Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Andreas Hoeft
- Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Markus Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam University, Amsterdam, Netherlands
| | | | - Jennifer M Hunter
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, Liverpool University, Liverpool, UK
| | - Kurt Ulm
- Department of Medical Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology, Technical University of Munich, Munich, Germany.
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Thilen S, Ng I, Cain K, Treggiari M, Bhananker S. Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine. Br J Anaesth 2018; 121:367-377. [DOI: 10.1016/j.bja.2018.03.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/29/2018] [Accepted: 03/31/2018] [Indexed: 12/20/2022] Open
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50
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Hamel AG, Recker MW. Neostigmine Hyperinflation. J Pharm Pract 2018. [DOI: 10.1177/0897190018762884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Mark W. Recker
- Lima Memorial Health System, Lima, OH, USA. Recker is now with the Vizient, Inc, Irving, TX, USA
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