The effect of sugammadex on patient morbidity and quality of recovery after general anaesthesia: a systematic review and meta-analysis.

BACKGROUND: Residual neuromuscular block is associated with increased patient morbidity. Therefore prevention of residual neuromuscular block is an important component of general anaesthesia where neuromuscular blocking agents are used. Whereas sugammadex improves reversal based on neuromuscular twitch monitoring parameters, there have been no prospective, adequately powered definitive studies demonstrating that sugammadex is also associated with less patient morbidity. METHODS: We performed a systematic review of randomised trials comparing sugammadex with anticholinesterase-based reversal or placebo reversal that reported important patient outcomes beyond the postanaesthesia care unit. RESULTS: We identified 43 articles, including 5839 trial participants. Only one trial reported days alive and out of hospital to 30 days (DAOH-30), which showed that the number of DAOH-30 was similar in those allocated to sugammadex compared with neostigmine-based reversal (25 days [19-27] vs 24 days [21-27], median difference 0.00 [-2.15 to 2.15]). Pooled analyses of data from 16 trials showed an estimated odds ratio (OR) for postoperative pulmonary complications of 0.67 (95% confidence interval 0.47-0.95) with sugammadex use. Pooled analysis showed that pneumonia (eight trials OR 0.51 [0.24-1.01] with sugammadex use), hospital length of stay (23 trials, mean difference -0.31 [-0.84 to 0.22] with sugammadex use), and patient-reported quality of recovery (11 trials, varied depending on metric used) are similar in those allocated to sugammadex vs control. The difference seen in mortality (11 trials, OR 0.39 [0.15-1.01] with sugammadex use) would be considered to be clinically significant and warrants further investigation, however, the rarity of these events precludes drawing definitive conclusions. CONCLUSION: Although few trials reported on DAOH-30 or important patient outcomes, sugammadex is associated with a reduction in postoperative pulmonary complications, however, this might not translate to a difference in hospital length of stay, patient-reported quality of recovery, or mortality. CLINICAL TRIAL REGISTRATION: PROSPERO database (CRD42022325858).

Comparison of Effects of Sugammadex and Neostigmine on Postoperative Neuromuscular Blockade Recovery in Patients with Interstitial Lung Diseases Undergoing Transbronchial Cryobiopsy: A Randomized Trial.

BACKGROUND While many studies have been conducted on sugammadex sodium and neostigmine in patients undergoing general anesthesia, few have explored their effects in patients with interstitial lung diseases (ILDs). MATERIAL AND METHODS Sixty-three patients who underwent transbronchial cryobiopsy under general anesthesia were enrolled in a prospective randomized study. The patients were randomly divided into 2 groups: neostigmine combined with atropine group (group C, n=32) and sugammadex group (group S, n=31). Induction and maintenance of anesthesia were the same in both groups. Patients received rocuronium during anesthesia. At the end of the procedure, when the T2 of the train-of-four stimulation technique (TOF) monitoring appeared, neostigmine 0.04 mg/kg combined with atropine 0.02 mg/kg was injected intravenously in group C, and sodium sugammadex 2 mg/kg was injected intravenously in group S. Time from administration of muscle relaxant antagonist to recovery of TOF ratio (TOFr) to 0.9 and extubation time were recorded. The residual rate of neuromuscular blockade at 1, 3, 5, 7, and 10 min after extubation was calculated. RESULTS Compared to group C, group S had a significantly shorter recovery time of TOFr to 0.9 (4.0[2.0] min vs 14.0[11.0] min, P<0.001) and extubation time (4.0[3.0] min vs 11.0[7.0] min, P<0.001). The residual rate of neuromuscular blockade was remarkably lower in group S than in group C at 3, 5, and 7 min after extubation (3.2% vs 31%, 0% vs 25%, 0% vs 6%, P<0.05). CONCLUSIONS Sugammadex is more effective than neostigmine in reversing the muscle-relaxant effect of rocuronium bromide in patients with ILDs.

Acute Colonic Pseudo-obstruction: Colonoscopy Versus Neostigmine First?

INTRODUCTION: Neostigmine (NEO) and decompressive colonoscopy (COL) are two efficacious treatment modalities for acute colonic pseudo-obstruction (ACPO). We hypothesize that a COL first strategy is associated with better outcomes compared to a NEO first strategy. METHODS: A single-center retrospective analysis was performed from 2013 to 2020. Patients ≥18 y with a diagnosis of ACPO were included. The outcome was a composite measure of acute operative intervention, 30-day readmission with ACPO, and 30-day ACPO-related mortality. A P-value of ≤ 0.05 indicated statistical significance. RESULTS: Of 910 encounters in 849 patients, 50 (5.5%) episodes of ACPO in 39 patients were identified after exclusion of one patient with colon perforation on presentation. The median (interquartile range) age was 68 (62-84) y. NEO and COL were administered in 21 and 25 episodes, respectively. In 16 (32%) episodes, no NEO or COL was administered. When patients were given NEO first, COL or additional NEO was required in 12/18 (67%) compared with a COL first strategy where a second COL and/or NEO was given in 5/16 (32%) (P = 0.05). Both strategies had similar outcomes (NEO, 4/18 versus COL, 4/16, P = 0.85). Twenty-two (44%) episodes had an early intervention (≤48 h) with NEO and/or COL. There was no difference in outcome between those that received an early intervention and those who did not (5/22 versus 5/28, P = 0.71). CONCLUSIONS: For patients failing conservative measures, a COL first approach was associated with fewer subsequent interventions, but with similar composite outcomes compared to a NEO first approach. Early (≤48 h) intervention with NEO and/or COL was not associated with improved outcomes.

Sugammadex Is Associated With Reduced Pulmonary Complications in Patients With Respiratory Dysfunction.

INTRODUCTION: Use of sugammadex is associated with fewer postoperative pulmonary complications (PPCs). This study investigated the relationship between sugammadex and PPCs in specific patients with respiratory dysfunction. MATERIALS AND METHODS: We reviewed the electronic medical and anesthesia records of patients with respiratory dysfunction who underwent laparoscopic gastric or intestinal surgery at a single center between May 1, 2018 and December 31, 2019. The patients were divided into the sugammadex group and the nonsugammadex group, based on whether they received sugammadex or neostigmine. Binary logistic regression analyses were used to characterize the differences in incidence of PPC. RESULTS: A total of 112 patients were included, of which 46 patients (41.1%) received sugammadex. In the logistic regression analysis, the incidences of PPC were fewer in the sugammadex group. Postoperative fever (odds ratio [OR] 0.330; 95% confidence interval [CI] 0.137-0.793, P = 0.0213), postoperative intensive care unit admission (OR 0.204; 95% CI 0.065-0.644, P = 0.007), cough (OR 0.143; 95% CI 0.061- 0.333, P < 0.001), pleural effusion (all) (OR: 0.280; 95% CI 0.104- 0.759, P = 0.012), pleural effusion (massive) (OR: 0.142; 95% CI 0.031- 0.653, P = 0.012), and difficulty in breathing (OR: 0.111; 95% CI 0.014-0.849, P = 0.039) showed significant differences between the two groups. CONCLUSIONS: Sugammadex is associated with a reduction in PPC in patients with respiratory dysfunction.

Update on the Diagnosis and Management of Acute Colonic Pseudo-obstruction (ACPO).

PURPOSE OF REVIEW: Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO. RECENT FINDINGS: Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72 h in those with cecal diameters < 12 cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.

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

BACKGROUND: We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). METHODS: This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. RESULTS: Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005). CONCLUSIONS: During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.

Sugammadex Versus Neostigmine for Recovery of Respiratory Muscle Strength Measured by Ultrasonography in the Postextubation Period: A Randomized Controlled Trial.

BACKGROUND: Although sugammadex is well known for its use in reducing the incidence of residual neuromuscular blockade, this has not always been translated to improved clinical measures of postoperative respiratory muscle strength. Expiratory muscles play an important role in airway clearance and inspiratory muscle capacity augmentation, yet they have not been well studied. Therefore, we tested the hypothesis on whether sugammadex could enhance expiratory muscle strength recovery more completely than neostigmine in the immediate postextubation period. METHODS: Adult patients having microlaryngeal surgery under total intravenous anesthesia were randomized to receive sugammadex or neostigmine. The thickening fraction of internal oblique abdominal muscle (TF IO ) and diaphragm excursion, respectively, reflecting expiratory and inspiratory muscle strength, were measured via ultrasonography at 3 time points: before induction (baseline), train-of-four ratio (TOFR) recovery to 0.9, and 30 minutes after postanesthesia care unit (PACU) arrival. The primary outcome was the change in TF IO from baseline to TOFR ≥0.9. The postoperative changes of diaphragm excursion from baseline, incidences of TF IO and diaphragm excursion returning to baseline levels, and the time from TOFR 0.9 to 0.95 and 1 were also measured. RESULTS: Among 58 patients, a significant difference in the change in TF IO from baseline to TOFR ≥0.9 between the sugammadex and neostigmine groups was observed: mean ± standard deviation, 9% ± 6% vs 16% ± 9%; difference in means: -6% (95% confidence interval [CI], -10 to -2); and adjusted P =.005 (adjusting for imbalanced variables between 2 groups). Sugammadex resulted in smaller changes in diaphragm excursion from baseline to TOFR ≥0.9 compared with neostigmine: difference in means: -0.83 cm (99.4% CI, -1.39 to -0.28 cm; Bonferroni-corrected P < .001). After 30 minutes in the postanesthesia care unit (PACU),33% of patients reversed with sugammadex versus 14% of those receiving neostigmine reached baseline TF IO levels (99.4% CI, -14 to 52; Bonferroni-corrected P > .999). The incidences of TF IO and diaphragm excursion returning to baseline were relatively low (<40%) in both groups despite TOFR reaching 1. The median time from TOFR of 0.9 to 0.95 and to 1 among patients receiving sugammadex was 7 and 10× faster than those receiving neostigmine (0.3 vs 2 minutes, Bonferroni-corrected P = .003; 0.5 vs 5.3 minutes, Bonferroni-corrected P < .001, respectively). CONCLUSIONS: Sugammadex provides a more complete recovery of expiratory muscle strength than neostigmine at TOFR ≥0.9. Our data suggest that the respiratory muscle strength might still be impaired despite TOFR reaching 1.

Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study.

BACKGROUND: Sugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery. METHODS: This single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes. RESULTS: Of the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (ß = 0.29 95% confidence interval {CI}: [- 1.13, - 0.54], P = 0.4912). However, it was associated with shorter PACU stay (ß = - 20.30 95% CI: [- 24.48, - 17.11], P < 0.0001), shorter time to postoperative ambulation movement (ß = - 0.43 95% CI: [- 0.62, - 0.23], P < 0.0001), and reduced time-to-first-defecation (ß = - 2.25 95% CI: [- 0.45, - 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05). CONCLUSIONS: Neuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.

Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery.

BACKGROUND: Postoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery. METHODS: Three hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed. RESULTS: Two hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19-90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18-94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0-10) vs. 3 (0-12) days, p = 0.036), and reduced time to first stool (median 2 (0-10) vs. 3 (0-12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2. CONCLUSIONS: Patients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

The efficacy and results of medical treatment in postoperative ileus.

Background: Postoperative paralytic ileus refers to the disruption of the normal coordinated propulsive motor activity of the gastrointestinal system following surgery. Surgery causes inflammation in the muscle walls of organs with an intestinal lumen that, in turn, leads to a decrease in intestinal motility. Aim: The aim of this study was to investigate the efficacy of gastrografin, neostigmine, and their combined administration in patients diagnosed with paralytic ileus in the postoperative period. Patients and Methods: One-hundred twelve patients were included from January 2017 and November 2019. The retrospective study is involving prolonged postoperative ileus cases following colorectal surgery. The effect of gastrografin, neostigmine, and gastrografin neostigmine combination was compared retrospectively in the treatment of prolonged ileus after surgery. Results: The study covered 112 patients. Gastrografin was administered to 63 patients; neostigmine was administered to 29, while 20 patients received the combination of the two. Data pertaining to the comparison of the two groups revealed that patients in the gastrografin group were discharged earlier than those in the neostigmine group. Further, patients in the combined group had earlier gas and/or stool discharge and were also discharged from the hospital earlier than those in the neostigmine group. Conclusion: Gastrografin and combined use of gastrografin and neostigmine are effective and viable methods for postoperative ileus cases. Gastrografin can safely be used in patients with anastomoses.

Randomized controlled trial: neostigmine for intra-abdominal hypertension in acute pancreatitis.

BACKGROUND: Intra-abdominal hypertension (IAH) in acute pancreatitis (AP) is associated with deterioration in organ function. This trial aimed to assess the efficacy of neostigmine for IAH in patients with AP. METHODS: In this single-center, randomized trial, consenting patients with IAH within 2 weeks of AP onset received conventional treatment for 24 h. Patients with sustained intra-abdominal pressure (IAP) ≥ 12 mmHg were randomized to receive intramuscular neostigmine (1 mg every 12 h increased to every 8 h or every 6 h, depending on response) or continue conventional treatment for 7 days. The primary outcome was the percent change of IAP at 24 h after randomization. RESULTS: A total of 80 patients were recruited to neostigmine (n = 40) or conventional treatment (n = 40). There was no significant difference in baseline parameters. The rate of decrease in IAP was significantly faster in the neostigmine group compared to the conventional group by 24 h (median with 25th-75th percentile: -18.7% [- 28.4 to - 4.7%] vs. - 5.4% [- 18.0% to 0], P = 0.017). This effect was more pronounced in patients with baseline IAP ≥ 15 mmHg (P = 0.018). Per-protocol analysis confirmed these results (P = 0.03). Stool volume was consistently higher in the neostigmine group during the 7-day observational period (all P < 0.05). Other secondary outcomes were not significantly different between neostigmine and conventional treatment groups. CONCLUSION: Neostigmine reduced IAP and promoted defecation in patients with AP and IAH. These results warrant a larger, placebo-controlled, double-blind phase III trial. Trial registration Clinical Trial No: NCT02543658 (registered August /27, 2015).

The effect of neostigmine on postoperative delirium after colon carcinoma surgery: a randomized, double-blind, controlled trial.

BACKGROUND: Postoperative delirium (POD) is a critical complication in patients accepting colon carcinoma surgery. Neostigmine, as a cholinesterase inhibitor, can enhance the transmission of cholinergic transmitters in synaptic space, and play an important role in maintaining the normal level of cognition, attention and consciousness. The objective of this study was to investigate the effect of neostigmine on POD and clinical prognosis. METHODS: A randomized, double-blind controlled trial was implemented in Qingdao Municipal Hospital Affiliated to Qingdao University. A total of 454 patients aged 40 to 90 years old accepted colon carcinoma surgery were enrolled between June 7, 2020, and June 7, 2021, with final follow-up on December 8, 2021. Patients were randomly assigned to two groups: the neostigmine group (group N) and the placebo group (group P), the patients in group N were injected with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine intravenously. The primary endpoint was the incidence of POD, researchers evaluated the occurrence of POD by the Confusion Assessment Method (CAM) twice daily (at 10 a.m. and 2 p.m.) during the first 7 postoperative days, POD severity was assessed by the Memorial Delirium Assessment Scale (MDAS). The secondary endpoints were the extubating time, postanesthesia care unit (PACU) time, the incidence of various postoperative complications, length of hospital stays, and 6 months postoperative mortality. RESULTS: The incidence of POD was 20.20% (81/401), including 19.39% (38/196) in group N and 20.98% (43/205) in group P. There was no significant statistical significance in the incidence of POD between group N and group P (P > 0.05); Compared to group P, the extubating time and PACU time in group N were significantly reduced (P < 0.001), the incidence of postoperative pulmonary complications (POPCs) decreased significantly in group N (P < 0.05), while no significant differences were observed in postoperative hospital stay and mortality in 6 months between the two groups (P > 0.05). CONCLUSION: For patients accepted colon carcinoma surgery, neostigmine did not significantly reduce the incidence of POD, postoperative mortality and postoperative hospital stay, while it indeed reduced the extubating time, PACU time and the incidence of POPCs. TRIAL REGISTRATION: The randomized, double-blind, controlled trial was registered retrospectively at www.chictr.org.cn on 07/06/2020 (ChiCTR2000033639).

Sugammadex reversal of muscle relaxant blockade provided less Post-Anesthesia Care Unit adverse effects than neostigmine/glycopyrrolate.

Sugammadex is a direct reversal agent of aminosteroid muscle relaxants, particularly rocuronium, with promptly and completely reverse of deep neuromuscular block (NMB), which allows better surgical conditions. Sugammadex exhibits advantages over indirect reversal agent acetylcholinesterase inhibitor neostigmine with less adverse effects. In this retrospective review, we compared the incidence of postoperative vomiting (POV), postoperative urinary retention (POUR), and hemodynamic changes between sugammadex and neostigmine/glycopyrrolate in reversal of muscular blockade. Sugammadex showed superior in all three aspects. The heart rate was 7.253 lower (P < 0.0001) and mean arterial pressure was 5.213 lower (P < 0.0001) in sugammadex group. The POV of neostigmine/glycopyrrolate group was 3.16 times more than sugammadex group (OR = 3.16, p < 0.0001), and POUR of neostigmine/glycopyrrolate group was 4.291 times more than sugammadex group (OR = 4.291, p < 0.0001). Sugammadex showed better hemodynamic stability, and lower incidence of POV and POUR than neostigmine/glycopyrrolate.

Half-Dose Sugammadex After Neostigmine Versus Neostigmine as a Routine Reversal Agent: A Pilot Randomized Trial.

PURPOSE: The use of sugammadex at a lower dose after a routine reversal dose of neostigmine may prevent residual neuromuscular blockade (rNMB). Our goal was to investigate the effects of the use of half-dose sugammadex for reversing rNMB after administration of neostigmine, and compare these effects to a routine full-dose of neostigmine. DESIGN: Prospective, single-blinded, randomized trial. METHODS: Ninety-eight patients having lower abdominal tumor resection surgery under general anesthesia were randomized into two groups. Group N (Neostigmine) (n = 48) patients received standard reversal dose of intravenous neostigmine 0.05 mg/kg and atropine 0.02 mg/kg before extubationl Group N + S (Neostigmine + Sugammadex) (n = 50) patients received 1 mg/kg of intravenous sugammadex three minutes after a standard neostigmine reversal dose. The primary end-point was the incidence of a train-of-four (TOF) ratio less than 0.9 at tracheal extubation. Secondary end-points were periods between the start of administration of reversal agents and extubation or operating room discharge in minutes to achieve recovery of TOF ratio < 0.9 to 0.7 and TOF ratio ≥ 0.9. FINDINGS: The demographic data were not different between the two groups (P > .005). The incidence of rNMB presented as TOF ratio < 0.9 to 0.7 was present in 52% of Group N patients compared to 8% in Group N + S patients (P < .0001). The time to recovery between administering reversal and extubation as well as operating room discharge in Group N were; 18.52 ± 6.34 minutes and 23.27 ± 6.95 minutes, respectively, whereas; in Group N + S, they were; 12.86 ± 5.05 and 17.82 ± 4.99 minutes, respectively. (P < .0001, P < .0001, respectively). Adverse events were similar between groups (P > .05). CONCLUSIONS: A half-dose sugammadex (1 mg/kg) after full-dose reversal of neostigmine provides a lower incidence of rNMB and shorter recovery times as compared to full-dose neostigmine reversal agent. This practice is safe and effective in case of rNMB.

[Evaluation of Postoperative Residual Curarisation after Administration of Neostigmine or Sugammadex by Diaphragmatic Ultrasonography:A Randomized Double-blind Controlled Trial].

Objective To evaluate and compare the incidence of postoperative residual curarisation (PORC) after administration of neostigmine or sugammadex by diaphragmatic ultrasonography.Methods A total of 100 patients with American Society of Anesthesiologists grade Ⅰ or Ⅱ who underwent elective joint replacement surgery from March to August in 2021 were randomly enrolled into the neostigmine+atropine group(N+A group,n=51) and sugammadex group(SUG group,n=49) according to a random number table.Muscle relaxation was monitored by train of four(TOF) stimulation of adductor pollicis muscle during anesthesia.The patients in N+A group were administrated with neostigmine 50 µg/kg + atropine 15 µg/kg and those in SUG group with sugammadex 2 mg/kg for reversing muscle relaxation.Endotracheal tube was removed only when TOF ratio≥0.9. Diaphragmatic ultrasonography was performed before surgery,10 min and 30 min after extubation.The right diaphragm excursion during deep breathing(DE-DB) and the diaphragm movement velocity during sniffing(V-S) were measured,with the low-frequency probe placed at the intersection of the right midclavicular line and the right costal margin.The diaphragmatic thickening fraction during deep breathing(TF-DB) was measured with the high-frequency probe placed at zone of apposition.The incidence of PORC was taken as the primary outcome,and DE-DB,TF-DB,and V-S as the secondary outcomes.Results When PORC was defined as TF-DB≤36%,the incidence of PORC in the SUG group was lower than that in the N+A group 10 min(4.3% vs.31.1%;χ2=11.541,P=0.001) and 30 min(0 vs.17.6%;P=0.001) after extubation.When PORC was defined as TF-DB≤36% or DE-DB≤4 cm,the incidence of PORC in the SUG group was also lower than that in the N+A group 10 min(8.2% vs.33.3%;χ2=9.543,P=0.002) and 30 min(0 vs.19.6%;χ2=8.608,P=0.003) after extubation.The DE-DB in the SUG group was higher than that in the N+A group 10 min[(6.5±1.6) cm vs.(5.6±1.4) cm;t=-3.185,P=0.002] and 30 min[(6.9±1.5) cm vs.(6.1±1.4) cm;t=-2.712,P=0.008] after extubation.The TF-DB in the SUG group was also higher than that in the N+A group 10 min[(60.1±18.8)% vs.(49.1±20.0)%;t=2.739,P=0.007] and 30 min[(65.0±20.1)% vs.(49.9±19.1)%,t=-3.686,P<0.001] after extubation.Conclusion Compared with neostigmine,sugammadex can significantly improve the postoperative diaphragm movement and decrease the incidence of PORC.

Residual neuromuscular block in the postanesthesia care unit: incidence, risk factors, and effect of neuromuscular monitoring and reversal agents.

BACKGROUND: The aim of this study was to determine the incidence of residual neuromuscular block (RNMB) in a tertiary care hospital. Secondary goals were to examine the characteristics of the use of intraoperative neuromuscular monitoring (NMM) and different reversal agents by the attending anesthesiologists, and to determine the factors related to the patient and perioperative processes on the development of RNMB. METHODS: The patients' arrival time at the postanesthesia care unit was accepted as point zero (T0). The acceleromyography of the patients' adductor pollicis muscle was monitored for NMM. Train of four ratios (TOFRs) were recorded at 0, 10, 20, and 30 min. A TOFR < 0.9 was defined as RNMB. Patients' demographic and perioperative data were also recorded. RESULTS: A total of 216 patients completed the study. RNMB was observed in 47 patients (21.8%). Seventy-eight patients (36%) were followed up with NMM. Neostigmine and sugammadex were used in 174 (80.5%) and 42 (19.5%) patients, respectively, and they were both underdosed (21.2 ± 3.0 mcg/kg and 1.5 ± 0.7 mg/kg, respectively). Use of neostigmine and absence of NMM were risk factors for RNMB (p: 0.01 and 0.001, respectively) along with the number of additional doses (>1 doses, p ≤ 0.02) and the timing of the last dose of rocuronium (<88 min, p ≤ 0.01). None of the patients who received both NMM and sugammadex experienced RNMB. DISCUSSION: The RNMB incidence was found to be 21.8%. The main reasons of it were the lack of intraoperative NMM and inappropriate use of reversal agents. Despite strong recommendations, the use of NMM is still insufficient and reversal agents are still underdosed.

Neuromuscular and Clinical Recovery in Thoracic Surgical Patients Reversed With Neostigmine or Sugammadex.

BACKGROUND: Patients undergoing thoracoscopic procedures may be at high-risk for incomplete neuromuscular recovery and associated complications. The aim of this clinical investigation was to assess the incidence of postoperative residual neuromuscular blockade in adult thoracic surgical patients administered neostigmine or sugammadex when optimal dosing and reversal strategies for these agents were used. The effect of choice of reversal agent on hypoxemic events and signs and symptoms of muscle weakness were also determined. Additionally, operative conditions in each group were graded by surgeons performing the procedures. METHODS: Two hundred patients undergoing thoracoscopic surgical procedures were enrolled in this nonrandomized controlled trial. One hundred consecutive patients maintained at moderate levels of neuromuscular blockade were reversed with neostigmine (neostigmine group) followed by 100 consecutive patients given sugammadex to antagonize deeper levels of neuromuscular blockade (sugammadex group). Anesthetic and neuromuscular management were standardized. Surgeons rated operative conditions at the conclusion of the procedure on a 4-point scale (grade 1 = excellent to grade 4 = poor). Train-of-four ratios were measured immediately before extubation and at PACU admission (primary outcomes). Postoperatively, patients were assessed for adverse respiratory events and 11 signs and 16 symptoms of muscle weakness. RESULTS: The 2 groups were similar in intraoperative management characteristics. The percentage of patients with residual neuromuscular blockade, defined as a normalized train-of-four ratio <0.9, was significantly greater in the neostigmine group than the sugammadex group at both tracheal extubation (80% vs 6%, respectively, P < .0001) and PACU admission (61% vs 1%, respectively, P < .0001). Patients in the neostigmine group had less optimal operative conditions (median score 2 [good] versus 1 [excellent] in the sugammadex group; P < .0001), and more symptoms of muscle weakness were present in these subjects (median number [interquartile range] 4 [1-8] vs 1 [0-2] in the sugammadex group, P < .0001). No differences between groups in adverse airway events were observed. CONCLUSIONS: Despite the application of strategies documented to reduce the risk of residual neuromuscular blockade, a high percentage of thoracoscopic patients whose neuromuscular blockade was reversed with neostigmine were admitted to the PACU with clinical evidence of residual paralysis. In contrast, muscle weakness was rarely observed in patients whose neuromuscular blockade was antagonized with sugammadex.

Juvenile Generalized Myasthenia Gravis: Presented as Unilateral Blepharoptosis and Successfully Managed with Pulse Intravenous Methylprednisolone.

Myasthenia Gravis is a rare autoimmune disorder of childhood and this is rarer in South Asia. We present a pre-pubertal 7 year old female child of seropositive Generalized Juvenile Myasthenia Gravis. She presented with unilateral blepharoptosis and later generalized symptoms appeared. Ice-pack test, Neostigmine challenge test and acetylcholine receptor antibody test were positive. Serum muscle specific tyrosine kinase antibody test was normal. She did not have thymic abnormalities. She did not respond to high dose (26 mg/kg/day) of Pyridostigmine and oral Prednisolone (2 mg/kg/day), but was successfully treated with a combination of pulse intravenous Methylprednisolone (30 mg/kg once a month for 6 months) and daily doses of oral Prednisolone (2 mg/kg/day) along with Pyridostigmine without significant side effects. This combination can be considered a potential inexpensive treatment for Juvenile Myasthenia Gravis in a resource limited area where other immunosuppressive treatments such as intravenous immunoglobulin is expensive and unaffordable.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus.

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Effects on Postoperative Gastrointestinal Motility After Neuromuscular Blockade Reversal With Sugammadex Versus Neostigmine/Glycopyrrolate in Colorectal Surgery Patients.

BACKGROUND: Neuromuscular blockers (NMBs) used during surgery have historically been reversed with acetylcholinesterase inhibitors and anticholinergic agents, which can slow gastrointestinal motility. Sugammadex (SUG) provides NMB reversal with minimal effects on gastrointestinal motility. OBJECTIVE: The purpose of this study was to determine if SUG for reversal of NMB is associated with decreased time to first bowel movement (BM) following laparoscopic colorectal surgery. METHODS: A retrospective cohort analysis divided 224 patients undergoing laparoscopic colorectal surgeries based on whether they received SUG or a combination of neostigmine and glycopyrrolate (NG) for NMB reversal. The primary outcome was time (in hours) from NMB reversal until first recorded BM. Secondary end points were postoperative ileus, postoperative nausea and vomiting, prevalence of residual NMB, and hospital length of stay. The relationship between NMB reversal agent and outcomes were analyzed using multivariable linear regression and Cox proportional hazards model. RESULTS: There were 128 patients who received NG and 96 who received SUG. Time to first BM was faster in the SUG group by 11.7 hours (P = 0.004). SUG maintained the effect in a multiple regression model (P = 0.012). A Cox Proportional Hazards regression model found 50% increased odds of a BM across time for the SUG group (P = 0.003). No adverse effects were noted. CONCLUSION AND RELEVANCE: This represents the first report demonstrating faster return of BM following colorectal surgery with SUG when compared with NG. Application of these data may add another tool to enhance recovery after colorectal surgery.