1
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Obara S, Suhara R, Murakawa M. Pharmacokinetic simulation can detect erroneous TOF counts. J Anesth 2024; 38:414-416. [PMID: 38430259 DOI: 10.1007/s00540-024-03328-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Shinju Obara
- Department of Anesthesiology, Center for Pain Management, Surgical Operation Department, Fukushima Medical University, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
| | - Ryota Suhara
- Iwase General Hospital, 20 Kitamachi, Sukagawa, Fukushima, 962-8503, Japan
| | - Masahiro Murakawa
- Department of Anesthesiology, Center for Pain Management, Surgical Operation Department, Fukushima Medical University, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
- Iwase General Hospital, 20 Kitamachi, Sukagawa, Fukushima, 962-8503, Japan
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2
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Obiyo LT, Tobes D, Cole NM. Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act. Curr Opin Anaesthesiol 2024; 37:285-291. [PMID: 38390901 DOI: 10.1097/aco.0000000000001363] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.
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Affiliation(s)
- Leziga T Obiyo
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois, USA
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3
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Wedemeyer Z, Bowdle A, Jelacic S, Lopez A, Silliman W, Michaelsen KE. Evolution of a laboratory mechanomyograph. J Clin Monit Comput 2024:10.1007/s10877-024-01175-w. [PMID: 38758405 DOI: 10.1007/s10877-024-01175-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/04/2024] [Indexed: 05/18/2024]
Abstract
Mechanomyography is currently the accepted laboratory reference standard for quantitative neuromuscular blockade monitoring. Mechanomyographs are not commercially available. Previously, a mechanomyograph was built by our laboratory and used in several clinical studies. It was subsequently redesigned to improve its usability and functionality and to accommodate a wider range of hand sizes and shapes using an iterative design process. Each version of the redesigned device was initially tested for usability and functionality in the lab with the investigators as subjects without electrical stimulation. The redesigned devices were then assessed on patients undergoing elective surgery under general anesthesia without neuromuscular blocking drugs. Since the patients were not paralyzed, the expected train-of-four ratio was 1.0. The device accuracy and precision were represented by the train-of-four ratio mean and standard deviation. If issues with the device's useability or functionality were discovered, changes were made, and the redesign processes repeated. The final mechanomyograph design was used to collect 2,362 train-of-four ratios from 21 patients. The mean and standard deviation of the train-of-four ratios were 0.99 ± 0.030. Additionally, the final mechanomyograph design was easier to use and adjust than the original design and fit a wider range of hand sizes. The final design also reduced the frequency of adjustments and the time needed for adjustments, facilitating data collection during a surgical procedure.
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Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Aidan Lopez
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Kelly E Michaelsen
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA.
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4
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Dong Y, Guo W, Yang Y, Li Q. The Effect of Phonomyography Prototype for Intraoperative Neuromuscular Monitoring: A Preliminary Study. Bioengineering (Basel) 2024; 11:486. [PMID: 38790354 PMCID: PMC11117765 DOI: 10.3390/bioengineering11050486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 04/29/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Quantitative neuromuscular monitoring, as extolled by clinical guidelines, is advocated to circumvent the complications associated with neuromuscular blockers (NMBs), such as residual neuromuscular block (rNMB). Nonetheless, the worldwide utilization of such methods remains undesirable. Phonomyography (PMG) boasts the advantages of convenience, stability, and multi-muscle recording which may be a promising monitoring method. The purpose of this preliminary study is conducting a feasibility analysis and an effectiveness evaluation of a PMG prototype under general anesthesia. A prospective observational preliminary study was conducted. Twenty-five adults who had undergone none-cardiac elective surgery were enrolled. The PMG prototype and TOF-Watch SX simultaneously recorded the pharmacodynamic properties of single bolus rocuronium at the ipsilateral adductor pollicis for each patient. For the primary outcome, the time duration to 0.9 TOF ratio of the two devices reached no statistical significance (p > 0.05). For secondary outcomes, the multi-temporal neuromuscular-monitoring measurements between the two devices also reached no statistical significance (p > 0.05). What is more, both the Spearman's and Pearson's correlation tests revealed a strong correlation across all monitoring periods between the PMG prototype and TOF-Watch SX. Additionally, Bland-Altman plots demonstrated a good agreement between the two devices. Thus, the PMG prototype was a feasible, secure, and effective neuromuscular-monitoring technique during general anesthesia and was interchangeable with TOF-Watch SX.
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Affiliation(s)
- Yanjie Dong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Weichao Guo
- Meta Robotics Institute, Shanghai Jiao Tong University, Shanghai 200240, China;
| | - Yi Yang
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, Chengdu 610072, China;
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China;
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5
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Oh MW, Mohapatra SG, Pak T, Hermawan A, Chen CA, Thota B, Chen J, Siu E, Park J, Moon TS. Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study. Anesth Analg 2024; 138:1043-1051. [PMID: 38190344 DOI: 10.1213/ane.0000000000006807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.
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Affiliation(s)
- Matthew W Oh
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shweta G Mohapatra
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taylor Pak
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aundree Hermawan
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chieh-An Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhavana Thota
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joy Chen
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Siu
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Park
- Department of Biostatistics, Southern Methodist University, Dallas, Texas
| | - Tiffany S Moon
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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6
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Vanlinthout LE, Driessen JJ, Stolker RJ, Lesaffre EM, Berghmans JM, Staals LM. Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach. Paediatr Anaesth 2024. [PMID: 38676354 DOI: 10.1111/pan.14908] [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: 01/23/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. METHOD We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results. RESULTS We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. CONCLUSIONS The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.
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Affiliation(s)
- Luc E Vanlinthout
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jacques J Driessen
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Emmanuel M Lesaffre
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Universities of Leuven-Hasselt, Hasselt, Belgium
| | - Johan M Berghmans
- Department of Anesthesiology and Perioperative medicine, University of Ghent, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, University of Ghent, Ghent, Belgium
| | - Lonneke M Staals
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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7
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Verdonck M, Carvalho H, Fuchs-Buder T, Brull SJ, Poelaert J. Machine learning based analysis and detection of trend outliers for electromyographic neuromuscular monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01141-6. [PMID: 38573367 DOI: 10.1007/s10877-024-01141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/09/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Neuromuscular monitoring is frequently plagued by artefacts, which along with the frequent unawareness of the principles of this subtype of monitoring by many clinicians, tends to lead to a cynical attitute by clinicians towards these monitors. As such, the present study aims to derive a feature set and evaluate its discriminative performance for the purpose of Train-of-Four Ratio (TOF-R) outlier analysis during continuous intraoperative EMG-based neuromuscular monitoring. METHODS Patient data was sourced from two devices: (1) Datex-Ohmeda Electromyography (EMG) E-NMT: a dataset derived from a prospective observational trial including 136 patients (21,891 TOF-R observations), further subdivided in two based on the type of features included; and (2) TetraGraph: a clinical case repository dataset of 388 patients (97,838 TOF-R observations). The two datasets were combined to create a synthetic set, which included shared features across the two. This process led to the training of four distinct models. RESULTS The models showed an adequate bias/variance balance, suggesting no overfitting or underfitting. Models 1 and 2 consistently outperformed the others, with the former achieving an F1 score of 0.41 (0.31, 0.50) and an average precision score (95% CI) of 0.48 (0.35, 0.60). A random forest model analysis indicated that engineered TOF-R features were proportionally more influential in model performance than basic features. CONCLUSIONS Engineered TOF-R trend features and the resulting Cost-Sensitive Logistic Regression (CSLR) models provide useful insights and serve as a potential first step towards the automated removal of outliers for neuromuscular monitoring devices. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
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Affiliation(s)
- Michaël Verdonck
- Department of Business Informatics and Operations Management, University Ghent, Tweekerkenstraat 2, Ghent, 9000, Belgium.
| | - Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
- Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Oostende, Belgium
| | - Thomas Fuchs-Buder
- University of Lorraine, Centre Hospitalier Universitaire de Nancy/Hôpitaux de Brabois, Lorraine, France
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
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8
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Grillot N, Roquilly A. Tracheal intubation without neuromuscular blocking drugs: isn't it an illusion? Anaesthesia 2024. [PMID: 38563134 DOI: 10.1111/anae.16287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Nicolas Grillot
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
| | - Antoine Roquilly
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
- Nantes Université, CHU Nantes, Service d'Anesthésie Réanimation Chirurgicale, Nantes, France
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9
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Wang Y, Ren L, Li Y, Zhou Y, Yang J. The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial. BMC Anesthesiol 2024; 24:123. [PMID: 38561654 PMCID: PMC10983731 DOI: 10.1186/s12871-024-02512-x] [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: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Glycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly patients. Therefore, this study aimed to compare the cardiovascular effects of G/N and A/N for the reversal of NMB in elderly patients. METHODS Elderly patients aged 65-80 years who were scheduled for elective non-cardiac surgery under general anesthesia were randomly assigned to the glycopyrrolate group (group G) or the atropine group (group A). Following the last administration of muscle relaxants for more than 30 min, group G received 4 ug/kg glycopyrrolate and 20 ug/kg neostigmine, while group A received 10 ug/kg atropine and 20 ug/kg neostigmine. HR, mean arterial pressure (MAP), and ST segment in lead II (ST-II) were measured 1 min before administration and 1-15 min after administration. RESULTS HR was significantly lower in group G compared to group A at 2-8 min after administration (P < 0.05). MAP was significantly lower in group G compared to group A at 1-4 min after administration (P < 0.05). ST-II was significantly depressed in group A compared to group G at 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, and 15 min after administration (P < 0.05). CONCLUSIONS In comparison to A/N, G/N for reversing residual NMB in the elderly has a more stable HR, MAP, and ST-II within 15 min after administration.
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Affiliation(s)
- Yanping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China.
| | - Liyuan Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yanshuang Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Yinhui Zhou
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No.1 East Jianshe Road, 450052, Zhengzhou, China
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10
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Nhan HN, Terada R, Butt AL, de Armendi A. Sugammadex dosing challenges in pediatric neuromuscular reversal-Comments on Cates et al. Paediatr Anaesth 2024; 34:379-380. [PMID: 38078502 DOI: 10.1111/pan.14821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Huy N Nhan
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rui Terada
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Alberto de Armendi
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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11
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Rodney G, Raju PKBC, Brull SJ. Residual neuromuscular block: time to consign it to history. Anaesthesia 2024; 79:344-348. [PMID: 38282525 DOI: 10.1111/anae.16238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Affiliation(s)
- G Rodney
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - P K B C Raju
- Department of Anaesthetics, Ninewells Hospital, Dundee, UK
| | - S J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
- Mayo Clinic Florida, Jacksonville, FL, USA
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12
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Kosciuczuk U, Dardzinska A, Kasperczuk A, Dzienis P, Tomaszuk A, Tarnowska K, Rynkiewicz-Szczepanska E, Kossakowska A, Pryzmont M. Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method. J Clin Med 2024; 13:1976. [PMID: 38610741 PMCID: PMC11012245 DOI: 10.3390/jcm13071976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.
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Affiliation(s)
- Urszula Kosciuczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Agnieszka Dardzinska
- Faculty of Biocybernetics and Biomedical Engineering, Bialystok University of Technology, 15-276 Bialystok, Poland;
| | - Anna Kasperczuk
- Faculty of Mechanical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland; (A.K.); (P.D.)
| | - Paweł Dzienis
- Faculty of Mechanical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland; (A.K.); (P.D.)
| | - Adam Tomaszuk
- Faculty of Electrical Engineering, Bialystok University of Technology, 15-351 Bialystok, Poland;
| | - Katarzyna Tarnowska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Ewa Rynkiewicz-Szczepanska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Agnieszka Kossakowska
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
| | - Marta Pryzmont
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Kilinskiego Street 1, 15-276 Bialystok, Poland; (K.T.); (E.R.-S.); (A.K.); (M.P.)
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13
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Chen W, Chen Z, Cheng F, Wang Z, Li J, Li S, Xie H. The feasibility of the posterior tibial nerve-flexor hallucis brevis pathway applied in neuromuscular monitoring: a multicentric, controlled, and prospective clinical trial. PeerJ 2024; 12:e17154. [PMID: 38560472 PMCID: PMC10979752 DOI: 10.7717/peerj.17154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
This study aimed to investigate the clinical viability of utilizing the flexor hallucis brevis as an alternative site for neuromuscular monitoring compared to the conventional adductor pollicis. Patients were recruited from three medical centers. Cis-atracurium was administered, and two monitors were employed independently to assess neuromuscular blockade of the adductor pollicis and the ipsilateral flexor hallucis brevis, following a train of four (TOF) pattern until TOF ratios exceeded 0.9 or until the conclusion of surgery. Statistical analysis revealed significant differences in onset time, duration of no-twitch response, spontaneous recovery time, and total monitoring time between the two sites, with mean differences of -53.54 s, -2.49, 3.22, and 5.89 min, respectively (P < 0.001).The posterior tibial nerve-flexor hallucis brevis pathway presents a promising alternative for neuromuscular monitoring during anesthesia maintenance. Further investigation is warranted to explore its utility in anesthesia induction and recovery. Trial registration: The trial was registered at www.chictr.org.cn (20/11/2018, ChiCTR1800019651).
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Affiliation(s)
- Weiqiang Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhijian Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fang Cheng
- Department of Anesthesiology, Jiangmen Central Hospital, Jiangmen, China
| | - Zhuodan Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Juan Li
- GCP ClinPlus Co., Ltd, Guangzhou, China
| | - Shangrong Li
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hanbin Xie
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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14
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Hunter JM, Blobner M. Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents: beware of the risks. Br J Anaesth 2024; 132:461-465. [PMID: 38135525 DOI: 10.1016/j.bja.2023.12.001] [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: 10/30/2023] [Revised: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
The phenomena of residual curarisation and recurarisation after the use of long-acting non-depolarising neuromuscular blocking drugs such as tubocurarine and pancuronium were well recognised 60 years ago. But the incidence seemed to decline with the introduction of atracurium and vecuronium. However, recently there have been an increasing number of reports of residual and recurrent neuromuscular block. Some of these reports are a result of inappropriate doses of rocuronium, sugammadex or both, together with inadequate neuromuscular monitoring. We urge clinicians to review their practice to ensure the highest standards of clinical care when using neuromuscular blocking drugs and reversal agents. This includes the use of quantitative neuromuscular monitoring whenever neuromuscular blocking drugs are administered.
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Affiliation(s)
- Jennifer M Hunter
- Department of Musculoskeletal and Ageing Science, University of Liverpool, Liverpool, UK.
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
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15
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Carr SG, Clifton JC, Freundlich RE, Fowler LC, Sherwood ER, McEvoy MD, Robertson A, Dunworth B, McCarthy KY, Shotwell MS, Kertai MD. Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study. Anesth Analg 2024; 138:517-529. [PMID: 38364243 PMCID: PMC10878712 DOI: 10.1213/ane.0000000000006722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.
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Affiliation(s)
- Shane G. Carr
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob C. Clifton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brent Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen Y. McCarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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16
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Guo S, Moore J, Moradi L, Rosero E, Sabuncu AC. A compressomyograph train of four monitoring device. Med Eng Phys 2024; 125:104127. [PMID: 38508804 DOI: 10.1016/j.medengphy.2024.104127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/16/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
The monitoring of the neuromuscular blockade is critical for patient's safety during and after surgery. The monitoring of neuromuscular blockade often requires the use of Train of Four (TOF) technique. During a TOF test two electrodes are attached to the ulnar nerve, and a series of four electric pulses are applied. The electrical stimulation causes the thumb to twitch, and the amount of twitch varies depending on the amount of neuromuscular blockade in patient's system. Current medical devices used to assist anesthesiologists to perform TOF monitoring often require free hand movement and do not provide accurate or reliable results. The goal of this work is to design, prototype and test a new medical device that provides reliable TOF results when thumb movement is restricted. A medical device that uses a pressurized catheter balloon to detect the response thumb twitch of the TOF test is created. An analytical model, numerical study, and mechanical finger testing were employed to create an optimum design. The design is tested through a pilot human subjects study. No significant correlation is reported with subjects' properties, including hand size.
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Affiliation(s)
- Shu Guo
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Joe Moore
- Worcester Polytechnic Institute, 2808 Matsu Ln, Opelika, AL 36804, USA
| | - Lee Moradi
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Eric Rosero
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Ahmet C Sabuncu
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA.
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17
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Faulk DJ, Karlik JB, Strupp KM, Tran SM, Twite M, Brull SJ, Yaster M, Austin TM. The Incidence of Residual Neuromuscular Block in Pediatrics: A Prospective, Pragmatic, Multi-institutional Cohort Study. Cureus 2024; 16:e56408. [PMID: 38638790 PMCID: PMC11024486 DOI: 10.7759/cureus.56408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Residual neuromuscular block, defined as a quantitatively measured train-of-four ratio (TOFr) <0.9, is common postoperatively. Using a pragmatic trial design, we hypothesized that qualitative and/or clinical assessment of neuromuscular block would inadequately detect residual block following antagonism with neostigmine or sugammadex. Method After IRB approval and written informed consent, 74 children (aged 2-17 years), undergoing elective surgery and receiving rocuronium, were prospectively enrolled in the study at Children's Hospital Colorado and Children's Healthcare of Atlanta. Routine clinical practice at both institutions consisted of clinical signs and/or qualitative assessment with peripheral nerve stimulators. Children at the Colorado hospital routinely received sugammadex antagonism; whereas children at the Atlanta hospital received neostigmine. Residual neuromuscular block was assessed postoperatively using quantitative electromyography. If TOFr was <0.9, patients received sugammadex until TOFr ≥0.9. Result Qualitative and clinical assessment failed to detect residual block in 29.7% of patients in the neostigmine reversal cohort (adjusted odds ratio (aOR) 29.8, 95% confidence interval (CI): 2.7 to 5,559.5, p-value = 0.002). No residual block was detected in the sugammadex reversal cohort. A correlation between increasing patient weight and incidence of postoperative residual block was observed in the neostigmine cohort (aOR 1.05, 95% CI: 1.02 to 1.10, p-value = 0.002). Conclusion Qualitative and/or clinical assessment of neuromuscular block inadequately detects residual block following neostigmine antagonism.
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Affiliation(s)
- Debra J Faulk
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Joelle B Karlik
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Kim M Strupp
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Stephanie M Tran
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Mark Twite
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Sorin J Brull
- Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, USA
| | - Myron Yaster
- Anesthesiology, Children's Hospital Colorado, Denver, USA
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18
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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19
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Phoowanakulchai S, Kawaguchi M. Updated review on the use of neuromuscular blockade during intraoperative motor-evoked potential monitoring in the modern anesthesia era. J Anesth 2024; 38:114-124. [PMID: 37843561 DOI: 10.1007/s00540-023-03265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/23/2023] [Indexed: 10/17/2023]
Abstract
Transcranial electrical stimulation motor-evoked potentials (Tc-MEP) monitoring is a common practice in neurosurgery to prevent postoperative neurological damage. However, the use of neuromuscular blocking agents (NMBAs) during Tc-MEP monitoring is a subject of controversy. In addition, the effectiveness of sugammadex, a selective reversal agent, in the context of Tc-MEP monitoring requires further investigation. This review aimed to clarify the considerations involved in achieving optimal Tc-MEP monitoring while ensuring patient safety. Preoperative patient selection, comorbidity assessment, motor power evaluation, and the nature of the planned surgery are critical factors. Accurate paralysis assessment, continuous NMBA infusion, and post-tetanic stimulation techniques are essential for achieving optimal partial NMB. The decision to administer an NMB during Tc-MEP monitoring necessitates a careful evaluation of the balance between accuracy and potential complications. This review emphasizes the challenges associated with NMB administration during Tc-MEP monitoring and highlights the need for personalized patient assessment.
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Affiliation(s)
- Sirima Phoowanakulchai
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Anesthesiology, Nara Medical University, Shijo 840, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Shijo 840, Kashihara, Nara, 634-8522, Japan.
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20
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Salaün JP, Décary E, Veyckemans F. Recurarisation after sugammadex in children: review of case reports and recommendations. Br J Anaesth 2024; 132:410-414. [PMID: 38170632 DOI: 10.1016/j.bja.2023.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Jean-Philippe Salaün
- Normandie Univ, UNICAEN, INSERM UMR- S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institut Blood and Brain @ Caen- Normandie (BB@C), GIP Cyceron, Caen, France; Department of Anesthesiology and Critical Care Medicine, CHU Caen Normandie, Caen University Hospital, 14000 Caen, France; Department of Pediatric Anesthesiology, Sainte-Justine Mother and Child University Hospital, University of Montreal, Montreal, Quebec, Canada.
| | - Elizabeth Décary
- Department of Pediatric Anesthesiology, Sainte-Justine Mother and Child University Hospital, University of Montreal, Montreal, Quebec, Canada
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21
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Lin CJ, Eikermann M, Mahajan A, Smith KJ. Restrictive versus unrestrictive use of sugammadex for reversal of rocuronium: a decision analysis. Br J Anaesth 2024; 132:415-417. [PMID: 38104004 DOI: 10.1016/j.bja.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Charles J Lin
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Matthias Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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22
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Jelacic S, Bowdle A, Bussey L, Nguyen S, Ocol JM, Togashi K. Should respiratory therapists routinely monitor neuromuscular blockade in the intensive care unit? J Clin Anesth 2024; 92:111310. [PMID: 37918081 DOI: 10.1016/j.jclinane.2023.111310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Logan Bussey
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Sharon Nguyen
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
| | - Jay M Ocol
- Respiratory Care Services, University of Washington Medical Center, Seattle, WA, USA.
| | - Kei Togashi
- University of California Irvine, Department of Anesthesiology and Perioperative Care, Orange, CA, USA.
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23
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Ward B. The Sub-Post-Tetanic "Bergin Zone" of Paralysis and its Impact on Neuromuscular Monitoring and Reversal. J Perianesth Nurs 2024; 39:161-164. [PMID: 38307696 DOI: 10.1016/j.jopan.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 02/04/2024]
Affiliation(s)
- Blake Ward
- Associate Chief CRNA - Quality and Education, Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS.
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24
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Blum FE, Locke AR, Nathan N, Katz J, Bissing D, Minhaj M, Greenberg SB. Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review. J Clin Med 2024; 13:861. [PMID: 38337560 PMCID: PMC10856567 DOI: 10.3390/jcm13030861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.
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Affiliation(s)
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Naveen Nathan
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Jeffrey Katz
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - David Bissing
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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25
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Wedemeyer Z, Jelacic S, Michaelsen K, Silliman W, Togashi K, Bowdle A. Comparative performance of stimpod electromyography with mechanomyography for quantitative neuromuscular blockade monitoring. J Clin Monit Comput 2024; 38:205-212. [PMID: 37831378 DOI: 10.1007/s10877-023-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The purpose of this study was to compare the Stimpod electromyograph neuromuscular blockade monitor to mechanomyography, which is widely considered to be the reference standard. METHODS The Stimpod electromyograph was used with its designated electrode array on the same hand as the mechanomyograph. Pairs of train-of-four measurements were recorded every 0.5-2 min. When the train-of-four count was zero on the electromyograph monitor, pairs of post tetanic count measurements were recorded every 2.5 min, instead of train-of-four measurements. Measurements were recorded from immediately after induction of anesthesia until just before emergence. Stimulation current was set to 60 mA with a duration of 200 microsec. The mechanomyography recording system recorded each twitch waveform for analysis. High resolution electromyograph waveforms were also recorded using a datalogger accessory provided by the manufacturer, facilitating inspection of individual waveforms. The administration of neuromuscular blocking drugs was left up to the discretion of the anesthesia care team. RESULTS Twenty-three patients contributed 1,088 data pairs suitable for analysis. Bland-Altman analysis of 415 pairs of train-of-four ratios showed a bias of 0.028 and limits of agreement of -0.18 and 0.24. Two hundred seventy-three train-of-four count data pairs were compared by Cohen's quadratically weighted kappa which was calculated to be 0.44, indicating moderate agreement. Three hundred thirty-eight post tetanic count data pairs were compared by Cohen's quadradically weighted kappa which was calculated to be 0.80, indicating substantial agreement. CONCLUSION The electromyograph produced results that were comparable to the mechanomyograph.
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Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kelly Michaelsen
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kei Togashi
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA.
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26
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Martin-Flores M, Sakai DM, Araos J, Campoy L. Low-dose sugammadex reverses moderate rocuronium-induced neuromuscular block in horses. Equine Vet J 2024. [PMID: 38281489 DOI: 10.1111/evj.14066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Neuromuscular block (NMB) during general anaesthesia has an implicit risk of inadvertent residual NMB during recovery. Reversal of NMB is commonly encouraged to decrease this risk, and has historically been performed with neostigmine/atropine, two agents with important cardiac and gastrointestinal side effects. Sugammadex is a new selective relaxant binding agent that can reverse rocuronium-induced NMB efficiently and without these complications. Recommended doses are possibly cost-prohibitive. OBJECTIVES To measure the recovery time from rocuronium-NMB after administration of low-dose sugammadex, compared with spontaneous recovery. STUDY DESIGN Nonrandomised in vivo experiments. METHODS Fourteen adult horses undergoing different research procedures were anaesthetised with detomidine and isoflurane. All horses received NMB with rocuronium 0.3 mg/kg IV. Neuromuscular function was measured with acceleromyographic train-of-four (TOF) ratio. Recovery occurred spontaneously in five horses weighing (median [range]) 548 (413-594) kg and was enhanced with sugammadex 200 mg (total dose) in nine horses (433 [362-515]) kg. Recovery time from moderate NMB to a TOF ratio 1.0, and total duration of NMB were compared between groups. Cases of recurarisation (decrease in the TOF ratio <0.9 after recovery) were identified within 30 min after sugammadex. RESULTS The dose of sugammadex was 0.46 (0.39-0.55) mg/kg. The recovery period lasted 21 (17-39) minutes for spontaneous and 4 (3-7) minutes for sugammadex. Total duration of NMB was 58 (41-70) minutes for spontaneous and 36 (21-43) for sugammadex (both p ≤ 0.003). There were no instances of recurarisation. MAIN LIMITATIONS Small sample size. CONCLUSIONS A dose of sugammadex of approximately 0.5 mg/kg substantially shortened the recovery period from rocuronium-induced NMB from a median of 21 to 4 min, when given at a moderate depth of NMB. No recurarisation was observed within the next 30 min.
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Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Daniel M Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
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Baba H, Wakabayashi R, Ichiyanagi H, Suzuki A, Sato N. Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle. Cureus 2024; 16:e52456. [PMID: 38371001 PMCID: PMC10872652 DOI: 10.7759/cureus.52456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.
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Affiliation(s)
- Hiroko Baba
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Ryo Wakabayashi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Hiroki Ichiyanagi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Aki Suzuki
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Nobukazu Sato
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
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Rodney G, Raju P, Brull S. Neuromuscular block management: evidence-based principles and practice. BJA Educ 2024; 24:13-22. [PMID: 38495745 PMCID: PMC10941205 DOI: 10.1016/j.bjae.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
| | - P. Raju
- Ninewells Hospital, Dundee, UK
| | - S.J. Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
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29
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Katerenchuk V, Calçada A, Louzada R, Rosinha D, Batista AC, Capelão A, Cordeiro L. Cardiac Arrest in the Post-anesthesia Care Unit (PACU): Postoperative Recurrence of Neuromuscular Block After Sugammadex Reversal. Cureus 2024; 16:e52681. [PMID: 38380199 PMCID: PMC10878829 DOI: 10.7759/cureus.52681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Sugammadex has transformed clinical practice by enabling the rapid reversal of rocuronium-induced neuromuscular block (NMB) at any depth. We present a case of cardiac arrest following postoperative recurarization despite the sugammadex-induced transient reversal of NMB. Despite its proven clinical reliability, this case highlights the often overlooked aspects that must be considered when using this drug. An 84-year-old male patient was scheduled for a laparoscopic partial gastrectomy for gastric cancer. At the end of the procedure, reversal of NMB was evidenced by an acceleromyographic train-of-four (TOF) ratio of ≥0.9 following sugammadex administration. In the post-anesthesia care unit (PACU), pulseless electrical activity was perceived, with a regression of TOF count to 1. After providing successful advanced cardiac life support, additional sugammadex administration led to uneventful extubation. When the concentration of free rocuronium decreases in the central compartment following sugammadex administration, redistribution of rocuronium from the peripheral to the central and effect-site compartments may cause recurarization. Special care is required in cases involving obese and elderly patients as well as those with renal impairment or hypothermia. To provide effective and predictable reversal of NMB, proper use of sugammadex should be pursued, including adequate dosing and monitoring.
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Affiliation(s)
| | | | - Raquel Louzada
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Daniela Rosinha
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Ana C Batista
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Andreia Capelão
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
| | - Lisbete Cordeiro
- Anesthesiology, Centro Hospitalar de Setúbal E.P.E., Setúbal, PRT
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30
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Fuchs-Buder T, Lewald H, Kranke P. [ESAIC and ASA guidelines for the management of neuromuscular blockade]. DIE ANAESTHESIOLOGIE 2024; 73:51-55. [PMID: 38175190 DOI: 10.1007/s00101-023-01372-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Thomas Fuchs-Buder
- Klinik für Anästhesie und Intensivmedizin, CHRU Nancy, Nancy, Frankreich.
| | - Heidrun Lewald
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Peter Kranke
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinikum Würzburg, Würzburg, Deutschland
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31
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Culp WC, Garmon EH. Opioids and postoperative respiratory depression. Proc AMIA Symp 2023; 37:61-62. [PMID: 38174022 PMCID: PMC10761030 DOI: 10.1080/08998280.2023.2276614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- William C. Culp
- Baylor Scott & White Medical Center, Baylor College of Medicine, Temple, Texas, USA
| | - Emily H. Garmon
- Baylor Scott & White Medical Center, Baylor College of Medicine, Temple, Texas, USA
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32
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Jansson PS, Pimentel MPT, Seethala RR. Emergency department usage of sugammadex in a large regional health system. Acad Emerg Med 2023. [PMID: 38112045 DOI: 10.1111/acem.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Paul S Jansson
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc P T Pimentel
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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33
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Renew JR, Brull SJ. Moving perioperative care forward while reversing: Is there hidden benefit to neuromuscular blockade antagonism with Sugammadex? J Clin Anesth 2023:111357. [PMID: 38103989 DOI: 10.1016/j.jclinane.2023.111357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Affiliation(s)
- J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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Epstein RH, Perez OF, Hofer IS, Renew JR, Brull SJ, Nemes R. Validation of a convolutional neural network that reliably identifies electromyographic compound motor action potentials following train-of-four stimulation: an algorithm development experimental study. BJA OPEN 2023; 8:100236. [PMID: 38026082 PMCID: PMC10654528 DOI: 10.1016/j.bjao.2023.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/30/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023]
Abstract
Background International guidelines recommend quantitative neuromuscular monitoring when administering neuromuscular blocking agents. The train-of-four count is important for determining the depth of block and appropriate reversal agents and doses. However, identifying valid compound motor action potentials (cMAPs) during surgery can be challenging because of low-amplitude signals and an inability to observe motor responses. A convolutional neural network (CNN) to classify cMAPs as valid or not might improve the accuracy of such determinations. Methods We modified a high-accuracy CNN originally developed to identify handwritten numbers. For training, we used digitised electromyograph waveforms (TetraGraph) from a previous study of 29 patients and tuned the model parameters using leave-one-out cross-validation. External validation used a dataset of 19 patients from another study with the same neuromuscular block monitor but with different patient, surgical, and protocol characteristics. All patients underwent ulnar nerve stimulation at the wrist and the surface electromyogram was recorded from the adductor pollicis muscle. Results The tuned CNN performed highly on the validation dataset, with an accuracy of 0.9997 (99% confidence interval 0.9994-0.9999) and F1 score=0.9998. Performance was equally good for classifying the four individual responses in the train-of-four sequence. The calibration plot showed excellent agreement between the predicted probabilities and the actual prevalence of valid cMAPs. Ten-fold cross-validation using all data showed similar high performance. Conclusions The CNN distinguished valid cMAPs from artifacts after ulnar nerve stimulation at the wrist with >99.5% accuracy. Incorporation of such a process within quantitative electromyographic neuromuscular block monitors is feasible.
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Affiliation(s)
- Richard H. Epstein
- Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Olivia F. Perez
- Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ira S. Hofer
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Sorin J. Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Réka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
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35
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Makino M, Kaneko S, Sato S, Kawazoe Y, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effects of the attachment method of the stimulating electrodes Nihon-Kohden NM-345Y™ and changes in forearm position on stimulus current values during calibration in electromyography-based neuromuscular monitoring: a single-center experimental study. J Anesth 2023; 37:888-895. [PMID: 37653275 DOI: 10.1007/s00540-023-03250-z] [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: 04/08/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The traditionally recommended method for attaching electromyography (EMG) electrodes (NM-345Y™) during EMG-based neuromuscular monitoring developed by Nihon-Kohden may decrease the monitoring accuracy when forearm limb position changes. This study investigated methods for attaching stimulating electrodes that maintained stable EMG-based neuromuscular monitoring accuracy, regardless of forearm limb position changes. METHODS This single-center experimental study recruited 28 healthy adults from October 2022 to December 2022. The NM-345Y™ was attached to the forearm using three patterns: Pattern N, electrodes attached according to the attachment pattern recommended by Nihon-Kohden; Pattern U, electrodes attached along the ulnar nerve identified using an ultrasound device; Pattern C, electrodes attached where the ulnar nerve crosses the line connecting the centers of the anode and cathode of the stimulating electrodes. The stimulus current values during calibration were measured at three forearm positions for each attachment pattern: supination 90 degrees; pronation 0 degrees; pronation 90 degrees. The differences in stimulus current values caused by forearm position changes were calculated as the difference between values at supination 90 degrees and pronation 0 degrees and between values at supination 90 degrees and pronation 90 degrees. RESULTS Pattern C showed significantly smaller differences than Pattern N between the stimulus current values at supination 90 degrees and pronation 0 degrees (p = 0.018) and between the stimulus current values at supination 90 degrees and pronation 90 degrees (p = 0.008). CONCLUSION Crossing the ulnar nerve with the line connecting the anode and cathode of the stimulating electrodes may stabilize EMG-based neuromuscular monitoring accuracy.
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Affiliation(s)
- Madoka Makino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yurika Kawazoe
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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36
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Carvalho H, Verdonck M, Eleveld DJ, Ramirez D, D'Haese J, Flamée P, Geerts L, Wylleman J, Cools W, Barbe K, Struys MMRF, Poelaert J. Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial. J Clin Anesth 2023; 90:111225. [PMID: 37542918 DOI: 10.1016/j.jclinane.2023.111225] [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: 03/22/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Objective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s STUDY OBJECTIVE: The present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements. DESIGN Observational trial. SETTING Tertiary Belgian hospital, from August 2020 up to September 2021. PATIENTS AND INTERVENTIONS Seventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria). MAIN RESULTS Published rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance. CONCLUSIONS Simulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
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Affiliation(s)
- Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium; Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Belgium.
| | - Michaël Verdonck
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Douglas J Eleveld
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - David Ramirez
- Servicio Anestesiología y Reanimación, Fundación Valle de Lili, Cali, Colombia
| | - Jan D'Haese
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Panagiotis Flamée
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Lieselot Geerts
- Department of Anaesthesia, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jasper Wylleman
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Wilfried Cools
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kurt Barbe
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel M R F Struys
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
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37
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Fuchs-Buder T, De Robertis E, Thilen SR, Champeau MW. Joint Letter to the Editor from the American Society of Anesthesiologists and the European Society of Anaesthesiology and Intensive Care on Management of Neuromuscular Blockade. Eur J Anaesthesiol 2023; 40:874-875. [PMID: 37265344 DOI: 10.1097/eja.0000000000001867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Thomas Fuchs-Buder
- From the University Hospital Nancy, Hôpital de Brabois, Vandoeuvre-Les-Nancy Cedex, France (T.F.-B.).
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38
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Wong P, Ashby O. Monitoring and Antagonism of Neuromuscular Blockade: Problems with Succinylcholine. Anesthesiology 2023; 139:712-714. [PMID: 37702620 DOI: 10.1097/aln.0000000000004705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Affiliation(s)
- Patrick Wong
- Te Whatu Ora - Health New Zealand, Hamilton, Waikato, New Zealand (P.W.).
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39
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Tseng CT, Sakai DM, Lorenzutti AM, Martin-Flores M. Evaluation of a three-axial acceleromyography monitor in dogs compared with mechanomyography. Vet Anaesth Analg 2023; 50:408-414. [PMID: 37500406 DOI: 10.1016/j.vaa.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To compare the ratio of the train-of-four (TOF) and double burst stimulation (DBS) obtained with three-axial acceleromyography (AMG) and mechanomyography (MMG) in dogs during recovery from a rocuronium-induced neuromuscular block. STUDY DESIGN Prospective, randomized, experimental study. ANIMALS A total of six intact healthy adult male Beagle dogs, weighing 9.1 ± 1.9 kg and aged 3-5 years. METHODS Dogs were anesthetized with intravenous (IV) dexmedetomidine and propofol, and isoflurane in oxygen. Neuromuscular function was measured with AMG and MMG in the contralateral thoracic limbs. Rocuronium (0.5 mg kg-1) was administered IV, and the TOF and DBS ratios measured. During neuromuscular block offset, MMG values were recorded when AMG first reached ratios of 0.9 and 1.0. True recovery from neuromuscular block was determined as MMG ratio ≥ 0.9. The false-positive (AMG ≥ 0.9 or 1.0, and MMG ratio < 0.9) rate was determined. Paired values were compared, and bias and limits of agreement were calculated. Receiver operating characteristic (ROC) curves were created. RESULTS When AMG first reached 0.9 and 1.0 during recovery, MMG values were lower (p < 0.040). When AMG reached 0.9, the false-positive rate was 29% with TOF and 27% with DBS. It decreased to 12% (TOF) and 11% (DBS) when a ratio of 1.0 was used. AMG values were higher than paired MMG values (p < 0.001). The AMG overestimated MMG by 24% and 22% for TOF and DBS, respectively. Areas under the ROC curves (95% confidence interval) were 0.91 (0.89, 0.94) and 0.86 (0.81, 0.94) for TOF and DBS, respectively. CONCLUSIONS and clinical relevance The three-axial AMG monitor overestimated neuromuscular function and, in some cases, indicated adequate recovery despite the MMG ratio being < 0.9. A TOF or DBS ratio of at least 1.0 should be considered when monitoring recovery of neuromuscular block with this AMG device.
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Affiliation(s)
- Chia T Tseng
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA; Crown Veterinary Specialists, Lebanon, NJ, USA
| | - Daniel M Sakai
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA; Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
| | - Augusto M Lorenzutti
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET, Universidad Catolica de Cordoba, Cordoba, Argentina
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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40
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Poelaert J, Hunter JM. Educating anaesthetists on neuromuscular monitoring: the challenges continue. Br J Anaesth 2023; 131:429-431. [PMID: 37380566 DOI: 10.1016/j.bja.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023] Open
Abstract
The need to introduce guidelines on neuromuscular monitoring emphasising the use of quantitative techniques that record the train-of-four ratio is now recognised by an increasing number of national anaesthetic societies in the Western world. But the challenge of convincing individual anaesthetists to adopt and use this practice routinely remains. For >10 yr, it has been recognised that all staff in anaesthetic departments need to have regular training in modern neuromuscular monitoring techniques. We discuss a publication in this journal that describes the challenges of setting up multicentre training in Spain to expand the use of quantitative neuromuscular monitoring and their short-term results.
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Affiliation(s)
- Jan Poelaert
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium; Department of Anaesthesia, ICU and Chronic Pain Therapy, Hospital Maria Middelares, Ghent, Belgium.
| | - Jennifer M Hunter
- Department of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Sugimura S, Khanh HV, Kawashima S, Nakajima Y, Kinoshita H. Electrocardiogram Cream Reduces Skin-Electrode Impedance Upon Neuromuscular Monitoring Using TOF-Cuff®. Cureus 2023; 15:e44670. [PMID: 37799239 PMCID: PMC10550304 DOI: 10.7759/cureus.44670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
Background Mechanistic insight into the high failure rate of TOF-Cuff® (RGB Medical Devices, Madrid, Spain) measurements on the lower leg is unclear. Aims We aimed to determine whether materials applied to pseudo-skin can reduce the impedance between a model arm and TOF-Cuff® electrodes and whether a material between TOF-Cuff® electrodes and the patient's skin surface decreases the skin-TOF-Cuff® electrode impedance within the appropriate range. Methods This was a combination of an in vitro study using non-living materials and a prospective observational clinical study. Eight patients aged > 70 years who had undergone elective surgery were eligible. One of the primary outcomes was whether water, electrocardiogram (ECG) cream, or ECG gel applied on the pseudo-skin could reduce the impedance between the model arm and the TOF-Cuff® electrodes in the in vitro study. Another was whether a material between the TOF-Cuff® electrodes and the patient's skin surface decreased the skin-TOF-Cuff® electrode impedance to an appropriate level of less than 5,000 Ω in the clinical study. Results The application of water, ECG cream, and ECG gel similarly reduced the impedance values within the electrical circuit in the in vitro study. ECG cream application between the patient's skin surface and the TOF-Cuff® electrodes decreased the skin-TOF-Cuff® electrode impedance (median (interquartile range (IQR)) Ω) from 8,600 (6,450 to 9,775) to 2,000 (1,600 to 2,600) (P = 0.012) in surgical patients. Conclusion ECG cream application between the patient's skin surface and the TOF-Cuff® electrodes decreased the skin-TOF-Cuff® electrode impedance appropriately, and thus, the application can facilitate precise TOF-Cuff® measurements in patients.
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Affiliation(s)
- Sho Sugimura
- Departments of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Huynh V Khanh
- Departments of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Shingo Kawashima
- Departments of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Yoshiki Nakajima
- Departments of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Hiroyuki Kinoshita
- Departments of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
- Department of Dental Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, JPN
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Bai YX, Han JJ, Liu J, Li X, Xu ZZ, Lv Y, Liu KX, Wu QP. Sugammadex Reduced the Incidence of Postoperative Pulmonary Complications in Susceptible Patients Identified by ARISCAT Risk Index: Systematic Review and Meta-analysis. Adv Ther 2023; 40:3784-3803. [PMID: 37351811 DOI: 10.1007/s12325-023-02535-9] [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: 02/19/2023] [Accepted: 04/27/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION The efficacy of sugammadex on postoperative pulmonary complications (PPCs) in susceptible patients, compared with neostigmine, remains indeterminate. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) Group Investigators proposed a risk index for the early identification of susceptible patients, with excellent externally validated discrimination ability. Meta-analytical techniques were applied to evaluate the efficacy of sugammadex on PPCs in patients with ARISCAT-defined risk factors. METHODS The study is registered on PROSPERO, number CRD42021261156. We searched PubMed, Scopus, Embase, Cochrane library, GreyNet, and OpenGrey for eligible randomized controlled trials (RCTs) without restricting the language or year of publication. RESULTS Twelve RCTs consisting of 1182 patients susceptible to PPCs were included. A robust reduction was observed on the incidence of PPCs in susceptible patients who received sugammadex [RR 0.66; 95% CI (0.54, 0.80), p < 0.01], with a low level of between-study heterogeneity (I2 = 45.98%; H2 = 1.85). Similar protective effects were also proved in avoiding residual neuromuscular block (NMB) [RR 0.25; 95% CI (0.11, 0.56); p < 0.01], atelectasis [RR 0.74; 95% CI (0.59, 0.95); p = 0.02], pneumonia [RR 0.49; 95% CI (0.28, 0.88); p = 0.02], and respiratory failure [RR 0.61; 95% CI (0.39, 0.96); p = 0.03]. No difference was observed regarding adverse events [RR 0.85; 95% CI (0.72, 1.01); p = 0.06]. CONCLUSION Low to moderate quality of evidence demonstrated the edge of sugammadex over neostigmine for NMB reversal in reducing the likelihood of PPCs and residual NMB in patients with ARISCAT-defined risk factors. Clinicians may reassess the type of reversal agent when treating patients susceptible to PPCs.
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Affiliation(s)
- Yun-Xiao Bai
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jing-Jing Han
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jie Liu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xia Li
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhen-Zhen Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yong Lv
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qing-Ping Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Fuchs-Buder T, De Robertis E, Thilen SR, Champeau MW. Joint Letter to the Editor from the American Society of Anesthesiologists and the European Society of Anaesthesiology and Intensive Care on Management of Neuromuscular Blockade. Anesthesiology 2023; 139:366-367. [PMID: 37265347 DOI: 10.1097/aln.0000000000004630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Thomas Fuchs-Buder
- University Hospital Nancy, Hôpital de Brabois, Vandoeuvre-Les-Nancy Cedex, France (T.F.-B.).
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Cao M, Huang H, Tong J, Ou Y, Liao Y. Optimal dose of neostigmine antagonizing cisatracurium-induced shallow neuromuscular block in elderly patients: a randomized control study. BMC Anesthesiol 2023; 23:269. [PMID: 37563623 PMCID: PMC10413529 DOI: 10.1186/s12871-023-02233-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Residual neuromuscular block after using neuromuscular blocking agents is a common and potentially harmful complication of general anesthesia. Neostigmine is a widely used antagonist, but its optimal dose for elderly patients is unclear. OBJECTIVES To compare the optimal dosage and safety of neostigmine for reversing shallow residual block in elderly patients after cisatracurium-induced neuromuscular block. METHODS A randomized controlled trial was conducted in 196 elderly patients undergoing non-cardiac surgery under general anesthesia with cisatracurium. Patients were assigned to receive either no neostigmine (control group) or neostigmine at 20 µg/kg, 40 µg/kg or 50 µg/kg when train-of-four (TOF) ratio reached 0.2 at the end of surgery. The primary outcome was the time to reach TOF ratio of 0.9 after administration. Secondary outcomes included TOF ratio at 10 min after administration, postoperative nausea and vomiting, postoperative cognitive impairment and post-anesthesia care unit (PACU) stay time. RESULTS The time to reach TOF ratio of 0.9 in the 20 µg/kg, 40 µg/kg and 50 µg/kg groups was significantly shorter than the control group (H = 104.257, P < 0.01), and the time of 40 µg/kg group and 50 µg/kg group was significantly shorter than the 20 µg/kg group (P < 0.001). There was no significant difference between 40 µg/kg and 50 µg/kg groups (P = 0.249). The TOF ratio at 10 min after administration showed similar results. There were no significant differences among groups in postoperative nausea and vomiting, postoperative cognitive impairment or post-operation hospital stay. CONCLUSIONS Timely use of neostigmine after general anesthesia in elderly patients can significantly shorten time of TOF value reaching 0.9, among which 40 µg/kg dosage may be a more optimized choice. TRIAL REGISTRATION this study was registered on chictr.org.cn (ChiCTR2100054685, 24/12/2021).
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Affiliation(s)
- Mengya Cao
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Huifan Huang
- Department of Anesthesiology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, P.R. China
| | - Jianbin Tong
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
- Hunan Province Key Laboratory of Brain Homeostasis, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Yangwen Ou
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Yan Liao
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, P.R. China.
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Johnson KB, Chacin R. Clarifying the grey space of sugammadex induced bradycardia. Curr Opin Anaesthesiol 2023; 36:422-427. [PMID: 37314178 DOI: 10.1097/aco.0000000000001282] [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: 06/15/2023]
Abstract
PURPOSE OF REVIEW This review describes recent prospective and retrospective work exploring the incidence and clinical consequence of sugammadex-induced bradycardia and an update of recent evidence and adverse event reports to the United States Food and Drug Administration regarding the incidence of sugammadex induced bradycardia. RECENT FINDINGS This work suggests that the incidence of sugammadex-induced bradycardia can range from 1 to 7% depending on the definition to reverse moderate to deep neuromuscular blockade. For most instances, the bradycardia is inconsequential. For those instances that have hemodynamic instability, the adverse physiology is easily treated with appropriate vasoactive agents. One study demonstrated that the incidence of bradycardia from sugammadex is less than with neostigmine. There are several case reports that describe marked bradycardia with cardiac arrest from reversal with sugammadex. The incidence of this type of reaction to sugammadex appears to be very rare. Data from the United States Food and Drug Administration's Adverse Event Reporting System public dashboard corroborates this presence of this rare finding. SUMMARY Sugammadex-induced bradycardia is common and, in most instances, of minimal clinical consequence. Nevertheless, anesthesia providers should maintain proper monitoring and vigilance to treat hemodynamical instability with each administration of sugammadex.
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Affiliation(s)
- Ken B Johnson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Bartels K, Fernandez-Bustamante A, Vidal Melo MF. Reversal of neuromuscular block: what are the costs? Br J Anaesth 2023; 131:202-204. [PMID: 37246063 PMCID: PMC10217563 DOI: 10.1016/j.bja.2023.04.037] [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: 02/01/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023] Open
Abstract
Patients requiring neuromuscular block for anaesthesia have a higher risk of adverse postoperative outcomes. The choice of reversal drug and its corresponding dose is critical for improving clinical outcomes. Although drug costs are higher for sugammadex relative to neostigmine, additional factors need to be considered when choosing one drug over the other. New data from a recent study in the British Journal of Anaesthesia indicate cost advantages for sugammadex in low-risk and ambulatory patients, but for neostigmine in high-risk patients. These findings highlight the need to take local and temporal factors into consideration in addition to clinical effectiveness when performing cost analyses for administrative decision-making.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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47
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Smith JD, Mentz G, Leis AM, Yuan Y, Stucken CL, Chinn SB, Casper KA, Malloy KM, Shuman AG, McLean SA, Rosko AJ, Prince MEP, Tremper KK, Spector ME, Schechtman SA. Use of neuromuscular blockade for neck dissection and association with iatrogenic nerve injury. BMC Anesthesiol 2023; 23:254. [PMID: 37507689 PMCID: PMC10375630 DOI: 10.1186/s12871-023-02217-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Cranial nerve injury is an uncommon but significant complication of neck dissection. We examined the association between the use of intraoperative neuromuscular blockade and iatrogenic cranial nerve injury during neck dissection. METHODS This was a single-center, retrospective, electronic health record review. Study inclusion criteria stipulated patients > 18 years who had ≥ 2 neck lymphatic levels dissected for malignancy under general anesthesia with a surgery date between 2008 - 2018. Use of neuromuscular blockade during neck dissection was the primary independent variable. This was defined as any use of rocuronium, cisatracurium, or vecuronium upon anesthesia induction without reversal with sugammadex prior to surgical incision. Univariate tests were used to compare variables between those patients with, and those without, iatrogenic cranial nerve injury. Multivariable logistic regression determined predictors of cranial nerve injury and was performed incorporating Firth's estimation given low prevalence of the primary outcome. RESULTS Our cohort consisted of 925 distinct neck dissections performed in 897 patients. Neuromuscular blockade was used during 285 (30.8%) neck dissections. Fourteen instances (1.5% of surgical cases) of nerve injury were identified. On univariate logistic regression, use of neuromuscular blockade was not associated with iatrogenic cranial nerve injury (OR: 1.73, 95% CI: 0.62 - 4.86, p = 0.30). There remained no significant association on multivariable logistic regression controlling for patient age, sex, weight, ASA class, paralytic dose, history of diabetes, stroke, coronary artery disease, carotid atherosclerosis, myocardial infarction, and cardiac arrythmia (OR: 1.87, 95% CI: 0.63 - 5.51, p = 0.26). CONCLUSIONS In this study, use of neuromuscular blockade intraoperatively during neck dissection was not associated with increased rates of iatrogenic cranial nerve injury. While this investigation provides early support for safe use of neuromuscular blockade during neck dissection, future investigation with greater power remains necessary.
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Affiliation(s)
- Joshua D Smith
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine - University of Michigan, 1H247 UH, SPC 5048, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Aleda M Leis
- Department of Anesthesiology, Michigan Medicine - University of Michigan, 1H247 UH, SPC 5048, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Yuan Yuan
- Department of Anesthesiology, Michigan Medicine - University of Michigan, 1H247 UH, SPC 5048, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Chaz L Stucken
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
| | - Steven B Chinn
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Keith A Casper
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Kelly M Malloy
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Andrew G Shuman
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Scott A McLean
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
| | - Andrew J Rosko
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
| | - Mark E P Prince
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Kevin K Tremper
- Department of Anesthesiology, Michigan Medicine - University of Michigan, 1H247 UH, SPC 5048, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Matthew E Spector
- Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine - University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Comprehensive Cancer Center, Michigan Medicine University of Michigan, Ann Arbor, MI, 48109, USA
| | - Samuel A Schechtman
- Department of Anesthesiology, Michigan Medicine - University of Michigan, 1H247 UH, SPC 5048, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Waheed Z, Amatul-Hadi F, Kooner A, Afzal M, Ahmed R, Pande H, Alfaro M, Lee A, Bhatti J. General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances. Cureus 2023; 15:e41565. [PMID: 37554600 PMCID: PMC10405976 DOI: 10.7759/cureus.41565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2023] [Indexed: 08/10/2023] Open
Abstract
Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.
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Affiliation(s)
- Zahra Waheed
- Anesthesia, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | | | - Amritpal Kooner
- Medical School, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, USA
| | - Muhammad Afzal
- Medical School, St. George's University School of Medicine, True Blue, GRD
| | - Rahma Ahmed
- Medical School, Kennesaw State University, Kennesaw, USA
| | | | - Moses Alfaro
- Medical School, Long School of Medicine at University of Texas Health Science Center San Antonio, San Antonio, USA
| | - Amber Lee
- Medical School, Arkansas College of Osteopathic Medicine, Fort Smith, USA
| | - Joravar Bhatti
- Medical School, Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, USA
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Todd MM, Kopman AF. Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal. Anesthesiology 2023; 139:1-3. [PMID: 37279102 DOI: 10.1097/aln.0000000000004587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Michael M Todd
- Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Aaron F Kopman
- Retired from the Department of Anesthesiology, Weill Cornell Medical College, New York, New York
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50
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Germano-Filho PA, Cavalcanti IL, Micuci AJQR, Velarde LGC, de Boer HD, Verçosa N. Recurarization with magnesium sulfate administered after two minutes sugammadex reversal: A randomized, double-blind, controlled trial. J Clin Anesth 2023; 89:111186. [PMID: 37393856 DOI: 10.1016/j.jclinane.2023.111186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023]
Abstract
STUDY OBJECTIVE The current study tested the hypothesis that magnesium sulfate after reversal with sugammadex causes recurarization. DESIGN A single-center, prospective, randomized, double-blind, controlled trial. SETTING Terciary care hospital in Rio de Janeiro, Brazil. PATIENTS Included 60 patients undergoing for elective otolaryngological surgery. INTERVENTIONS All patients received total intravenous anesthesia and a single dose of rocuronium (0.6 mg/kg). In 30 patients, the neuromuscular blockade was reversed with sugammadex (4 mg/kg) at the reappearance of one or two posttetanic counts (deep-blockade series). In 30 other patients, sugammadex (2 mg/kg) was administered at the reappearance of the second twitch of the train-of-four (moderate-blockade series). After the normalized train-of-four ratio recovered to ≥0.9, the patients in each series were randomized to receive intravenous magnesium sulfate (60 mg/kg) or placebo for 10 min. Neuromuscular function was measured by acceleromyography. MEASUREMENTS The primary outcome was the number of patients who exhibited recurarization (normalized train-of-four ratio < 0.9). The secondary outcome was rescue with an additional dose of sugammadex after 60 min. MAIN RESULTS In the deep-blockade series, a normalized train-of-four ratio < 0.9 occurred in 9/14 (64%) patients receiving magnesium sulfate and 1/14 (7%) receiving placebo, RR 9.0 (95% CI: 62-1.30), and (p = 0.002), with four rescues with sugammadex. In the moderate-blockade series, neuromuscular blockade recurred in 11/15 (73%) patients receiving magnesium sulfate and in 0/14 (0%) receiving placebo (p < 0.001), with two rescues. The absolute differences in recurarization were 57% and 73% in the deep-blockade and moderate-blockade, respectively. CONCLUSIONS Single-dose magnesium sulfate led to a normalized train-of-four ratio < 0.9, 2 min after recovery from rocuronium-induced deep and moderate neuromuscular blockade using sugammadex. Additional sugammadex reversed prolonged recurarization.
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Affiliation(s)
- Paulo A Germano-Filho
- Department of Surgery, Anesthesiology, Surgical Sciences Postgraduate Program, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Department of General and Specialized Surgery, Anesthesiology, Universidade Federal Fluminense, Niterói, Brazil.
| | - Ismar L Cavalcanti
- Department of General and Specialized Surgery, Anesthesiology, Universidade Federal Fluminense, Niterói, Brazil; Department of General and Specialized Surgery, Anesthesiology, Medical Sciences Postgraduate Program, Universidade Federal Fluminense, Niterói, Brazil
| | - Angelo J Q R Micuci
- Department of Anesthesiology, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Luis G C Velarde
- Department of Statistics, Medical Sciences Postgraduate Program Universidade Federal Fluminense, Niterói, Brazil
| | - Hans D de Boer
- Department of Anesthesiology and Pain Medicine, Martini General Hospital, Groningen, the Netherlands
| | - Nubia Verçosa
- Department of Surgery, Anesthesiology, Surgical Sciences Postgraduate Program, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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