Combined recurrent laryngeal nerve monitoring and one-lung ventilation using the EZ-Blocker and an electromyographic endotracheal tube

Continuous intraoperative neuromonitoring of the recurrent laryngeal nerve during lung operations

Background

The recurrent laryngeal nerve (RLN), especially on the left side, is particularly vulnerable during lung operations. Therefore, continuous intraoperative neuromonitoring (cIONM) would be desirable. With the use of a double-lumen tube (DLT) for single-lung ventilation, there is some uncertainty where the recording electrode should be positioned. The aim of this study was to assess the feasibility of this technique and to predict the ideal position of a single recording electrode.

Methods

Patients scheduled to undergo left thoracotomy due to pulmonary pathologies, two adhesive electrodes were affixed consecutively above the proximal cuff of the DLT prior to intubation for a precise location of the recording from the vocal cords. Following thoracotomy, the vagus nerve alongside the aortic arch was exposed. A continuous stimulation probe (Saxophone® electrode, Dr. Langer Medical, Waldkirch, Germany) was placed around the nerve. The signals of the respective electrode were recorded and analyzed with regard to previously defined limits of positive signaling.

Results

Strong signals with an amplitude of at least 165 µV were recorded in 18 of 20 patients. In these patients 100% of the signals were recorded via the distally located electrode. An additional signal was recorded via the proximal electrode in four patients. cIONM was found to be a safe and reproducible technique.

Conclusions

The described technique enables the use of cIONM of the RLN throughout the entire course of the surgical procedure.

Effects of Sugammadex versus Neostigmine on Intraoperative Coagulation Profiles in Patients with Thyroidectomy

Background

Sugammadex has been a revolutionary reversal of neuromuscular blockade. It is known to be highly efficient. However, a change in the coagulation profile is one of the most dangerous potential complications which is a concern for both surgeon and anesthetist. Bleeding may cause hypovolemic shock, hematoma, and so on. To investigate the effects of sugammadex on coagulation profiles in patients with thyroidectomy, we compared patients that were treated with either sugammadex or neostigmine.

Patients and Methods

Eighty patients with thyroid neoplasms undergoing thyroidectomy were randomly allocated to sugammadex group (group S) or neostigmine group (group N). Induction of anesthesia was preformed using propofol, sufentanil, and rocuronium. Group S received sugammadex 2.0mg/kg after trachea intubation, similarly Group N received neostigmine 40 µg/kg, for reversal of rocuronium-induced neuromuscular blockade. The intraoperative coagulation profiles were monitored after the rocuronium injection (T0), 10 minutes after reversal (T1) and 30 minutes after reversal (T2) by testing activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (FIB), thrombin time (TT), and TEG-Haemonetics. Amount of bleeding was recorded during perioperative period.

Results

There was no significant difference in the thromboelastogram, APTT, PT, FIB, or TT measurements at each time point in Group N. The reaction time (R time) and kinetics time (K time) of Group S in T1 were significantly longer than the corresponding times at T0 and T2, and the R times were significantly longer than those in Group N at the same time points (P<0.05). Additionally, in Group S, the APTT was prolonged in T1 and returned to normal in T2.

Conclusion

The result showed that sugammadex provided transient efficacy in prolonging the coagulation parameters, while neostigmine did not change the coagulation profile.