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.

Ease of Application of Various Neuromuscular Devices for Routine Monitoring.

BACKGROUND: Subjective evaluations to confirm recovery from neuromuscular blockade with a peripheral nerve stimulator (PNS) is inadequate. Quantitative monitors are the only reliable method to confirm adequate recovery of neuromuscular function. Unfortunately, many clinicians are unfamiliar with such devices and there is concern that the introduction of objective monitoring would be exceedingly laborious and could cause workflow delays. This study investigates how long it takes experienced nurse anesthetists to apply various neuromuscular devices as well as their perception regarding the ease of application. METHODS: Twenty nurse anesthetists were consented and participated in an educational session that familiarized them with 3 devices: SunStim Plus PNS (SunMed, Grand Rapids, MI), the acceleromyography-based IntelliVue NMT device (Philips, Amsterdam, the Netherlands), and electromyography-based TetraGraph device (Senzime B.V., Uppsala, Sweden). Participants were timed while placing each monitor on patients in a real-world setting. For the quantitative devices (IntelliVue NMT and TetraGraph), participants were also timed when obtaining calibrated baseline train-of-four (TOF) ratios. Friedman test and pairwise Wilcoxon signed-rank tests were used to evaluate the difference in time to connect different devices. Participants were surveyed about how easy they found it to utilize these devices. RESULTS: After adjusting for multiple comparison, time to connect was significantly less for PNS (median, 29; range, 16-58 seconds) compared to either the TetraGraph device (median, 62.8; range, 32-101 seconds; P < .001) or the IntelliVue NMT device (median, 46; range: 28-90 seconds; P < .001). The difference in time to connect between the TetraGraph device and the IntelliVue NMT device was not statistically significant (P = .053), but it took significantly less time to calibrate the TetraGraph device than the IntelliVue NMT device (median difference, -16; range, -88 to 49 seconds; P = .002). The participants found applying either the IntelliVue NMT device (P = .042) or the TetraGraph device (P = .048) more difficult than applying a PNS while finding it easier to calibrate the TetraGraph device versus the IntelliVue NMT device (P < .001). CONCLUSIONS: It takes 19 seconds longer to apply a quantitative neuromuscular monitor (the IntelliVue NMT device) than a PNS. While this difference reached significance, this relatively minimal additional time represents an inappropriate barrier to the application of quantitative monitors. Regardless of which quantitative monitor was utilized, these nurse anesthetists found the application and utilization of such devices relatively straightforward.

REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study.

BACKGROUND: Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery. METHODS: A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications. RESULTS: A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs). CONCLUSIONS: The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.

A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography: A prospective observational study.

BACKGROUND: Neuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative. OBJECTIVE: The aim of our study was to compare NMB onset and recovery at both sites. DESIGN: Prospective observational study. SETTING: Operating rooms at the University Hospital of Poitiers, France. PATIENTS: Sixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia. INTERVENTION: After atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously. MAIN OUTCOME MEASURES: The time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF = 4, T4/T1 ratio = 0.75 and T4/T1 ratio more than 0.90. RESULTS: NMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4 ±â€Š1.5 versus 3.7 ±â€Š1.2 min at adductor pollicis (P = 0.0001). Recovery to TOF = 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF = 4. The full recovery of NMB (T4/T1 > 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ±â€Š9.9 versus 64.5 ±â€Š10.7 min at adductor pollicis (P < 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0 ±â€Š12.2 min at flexor hallucis brevis versus 54.0 ±â€Š12.4 min at adductor pollicis (P = 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients. CONCLUSION: Flexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02825121).

Comparison of neostigmine vs. sugammadex for recovery of muscle function after neuromuscular block by means of diaphragm ultrasonography in microlaryngeal surgery: A randomised controlled trial.

BACKGROUND: Postoperative residual curarisation (PORC) is a risk directly related to the use of neuromuscular blocking agents during surgical procedures. Acceleromyography is distressing for conscious patients when assessing PORC. Diaphragm ultrasonography could be a valid alternative. OBJECTIVES: The primary objective was to achieve a 28% lower incidence of PORC in patients who, after rocuronium administration, received neostigmine or sugammadex at 30 min after surgery. To assess PORC, diaphragm ultrasonography was used, and thickening fractioning [the difference of thickness at the end of inspiration (TEI) and at the end of expiration (TEE), normalised for TEE (TEI - TEE/TEE)] was measured. PORC was defined as thickening fractioning of 0.36 or less. The secondary object was the comparison, in the two treatment groups, of the return to baseline thickening fractioning at 30 min after surgery (ΔTF30). DESIGN: Randomised, double-blind, single-centre study. SETTING: University Hospital Careggi, Florence, Italy. PATIENTS: Patients of American Society Anesthesiologists' physical status 1 or 2, 18 to 80 years, receiving rocuronium during microlaryngeal surgery. INTERVENTIONS: At the end of surgery participants were randomised to receive neostigmine (NEO group) or sugammadex (SUG group) as the reversal drug. Thickening fractioning and ΔTF30 were evaluated at baseline and at 0, 10 and 30 min after surgery. MAIN OUTCOME MEASURES: TEE and TEI at each time point. RESULTS: A total of 59 patients with similar demographic characteristics were enrolled. An association between lack of recovery (thickening fractioning ≤0.36) and drug treatment was only observed at 0 min (SUG vs. NEO, P < 0.05). Concerning ΔTF, at 30 min more patients in the SUG group returned to baseline than those in the NEO group (P < 0.001), after adjusting for side (P = 0.52), baseline thickening fractioning (P < 0.0001) and time of measurement (P < 0.01). CONCLUSION: We found an early (0 min) but not long-lasting (30 min) association between diaphragm failure and treatment allocation; a full recovery in baseline diaphragm function was observed only in patients receiving sugammadex. We cannot exclude that further differences have not been found due to interpatients variability in assessing diaphragm contractility by ultrasonography. TRIAL REGISTRATION: EudraCT Identifier: 2013-004787-62, Clinicaltrials.gov Identifier: NCT02698969.

Comparison of rocuronium requirement in children with continuous infusion versus intermittent bolus: A randomised controlled trial.

BACKGROUND: Minimising rocuronium administration during paediatric surgery helps to reduce the incidence of residual muscular blockade. OBJECTIVE: To determine whether intermittent bolus injection (Bolus group) or continuous infusion (group) requires the lesser amount of rocuronium. DESIGN: A randomised, single-blind controlled trial. SETTING: A single university hospital from March to June 2017. PATIENTS: Sixty-six children undergoing general anaesthesia. INTERVENTIONS: Dose of rocuronium for maintenance of muscle relaxation in either Bolus or continuous infusion group. Train-of-four (TOF) count of two was maintained during surgery. When TOF count reached three, 0.1 mg kg of rocuronium was administered in Bolus group or infused at an increased rate of 0.1 mg kg h in continuous infusion group. MAIN OUTCOME MEASURES: Primary outcome was the dose of rocuronium given (µg kg min). The recovery time from the TOF count four to TOF 0.7 (RT0.7), and 0.9 (RT0.9) were recorded. All adverse events were recorded up to 30 min after extubation. RESULTS: Mean (SD) rocuronium dose in the Bolus group was 6.1 (0.9), [95% confidence interval (95% CI) 5.7 to 6.4] µg kg min and 4.9 (1.0), (95% CI 4.6 to 5.3) µg kg min in the continuous infusion group (P = 0.001). RT0.7 was 24.0 (13.7), 95% CI 19.3 to 28.7) min in the Bolus group, and 25.7 (16.0), (95% CI 20.2 to 31.2) min in the continuous infusion group (P = 0.73). RT0.9 was 30.7 (17.1), (95% CI 24.9 to 36.5) min in the Bolus group, and 30.0 (17.6), (95% CI 24.0 to 36.0) min in the continuous infusion group (P = 0.91). The incidence of adverse events was not significantly different between two groups. CONCLUSION: In children undergoing general anaesthesia, the dose of rocuronium given by continuous administration was less than that with intermittent bolus. TRIAL REGISTRATION: ClinicalTrials.gov (identifier: NCT03060707).

Delayed Emergence in Pediatric Patients with Neurologic Disease Presenting for Ambulatory Surgery.

OBJECTIVES: Management of pediatric patients with neurological diagnoses can be challenging for anesthesiologists. We sought to determine whether preexisting neurologic disease could serve as an intrinsic risk factor for prolonged emergence. METHODS: Following institutional review board approval, we conducted a database search from 2012 to 2015. Included were patients aged 0 to 18 years undergoing ambulatory procedures, and carrying neurological diagnoses that profoundly affected their development. Patients were excluded if they received a total intravenous anesthetic, were not managed with an endotracheal tube, or were extubated deep. A healthy case-control group also was obtained for comparison. The primary outcome was emergence from anesthesia: time from anesthetic cessation to extubation. Our secondary outcome was time from extubation to discharge. Descriptive statistics were calculated for demographic data, outcomes were analyzed for differences using the Student t test, and regression analysis was performed. RESULTS: Data from 69 patients and 169 controls met criteria. There were no differences between study and control groups for age, sex, procedural length, or intraoperative temperatures. The study group had higher American Society of Anesthesiologists scores (2.4 vs 1.4). The primary outcome of time to emergence was longer in the study group (15.2 vs 11.0 min), and time to discharge also was prolonged (101.0 vs 86.1 min). Regression analysis on most differing variables did not yield a correlation to primary/secondary outcomes, but neurologic disease did correlate to both. CONCLUSIONS: In this case-controlled retrospective study, there was a prolongation of anesthetic emergence and hospital discharge times for pediatric patients with severe neurologic disease, mostly independent of external factors.

Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file.

BACKGROUND: Residual neuromuscular block (rNMB) after surgery is not difficult to identify if proper neuromuscular monitoring is used, but many clinicians do not use quantitative neuromuscular monitoring. OBJECTIVE: The aim of this study was to develop a REsidual neuromuscular block Prediction Score (REPS) to predict postoperative rNMB and compare the predictive accuracy of the prediction score with train-of-four count (TOFC) measurement at the end of a surgical case. DESIGN: Retrospective cohort study of data on file. DATA SOURCE: Electronic patient data and peri-operative data on vital signs, administered medications, and train-of-four ratio (TOFR) obtained in the postoperative recovery rooms [postanaesthesia care unit (PACU)] at Massachusetts General Hospital in Boston, Massachusetts, USA. PATIENTS: Quantitative TOFR measurements obtained on admission to the PACU were available from 2144 adult noncardiac surgical patients. MAIN OUTCOME MEASURE: Presence of rNMB at PACU admission, defined as a TOFR of less than 0.9. RESULTS: In the score development cohort (n=2144), rNMB occurred in 432 cases (20.2%). Ten independent predictors for residual paralysis were identified and used for the score development. The final model included: hepatic failure, neurological disease, high-neostigmine dose, metastatic tumour, female sex, short time between neuromuscular blocking agent administration and extubation, aminosteroidal neuromuscular blocking agent, BMI more than 35, absence of nurse anaesthetist and having an experienced surgeon. The model discrimination by C statistics was 0.63, 95% confidence interval (0.60 to 0.66), and risk categories derived from the REPS had a higher accuracy than the last documented intra-operative TOFC for predicting rNMB (net reclassification improvement score 0.26, standard error 0.03, P < 0.001). CONCLUSION: The REPS can be used to identify patients at greater risk of rNMB. This tool may inform anaesthetists better than an intra-operative TOFC and thus enable peri-operative anaesthetic practices to be tailored to the patient and minimise the undesirable effects of rNMB. TRIAL REGISTRY NUMBER: Approved by Partners Human Research Committee (protocol number 2016P000940) at MGH in Boston, Massachusetts, USA on 25 April 2016.

Dexamethasone concentration affecting rocuronium-induced neuromuscular blockade and sugammadex reversal in a rat phrenic nerve-hemidiaphragm model: An ex vivo study.

BACKGROUND: The concentration range of dexamethasone that inhibits neuromuscular blockade (NMB) and sugammadex reversal remains unclear. OBJECTIVE: To evaluate the effects of dexamethasone on rocuronium-induced NMB and sugammadex reversal. DESIGN: Ex vivo study. SETTING: Asan Institute for Life Sciences, Asan Medical Center, Korea, from July 2015 to November 2015. ANIMALS: One hundred sixty male Sprague-Dawley rats. INTERVENTIONS: We assessed the effect of four concentrations of dexamethasone [0, 0.5, 5 (clinical concentrations) and 50 µg ml (experimental concentration)] on partial NMB on 40 phrenic nerve-hemidiaphragm preparations (n=10 per concentration). Once the first twitch of train-of-four (TOF) had been depressed by 50% with rocuronium, dexamethasone was administered. To assess the effect of dexamethasone on sugammadex reversal, 120 phrenic nerve-hemidiaphragm preparations were used in three subexperiments (n=40 per experiment), using three administration regimens of rocuronium-equimolar sugammadex: a single dose, a split-dose (split and ) and a reduced split-dose (split and ). After complete NMB was achieved, dexamethasone and sugammadex were administered. MAIN OUTCOME MEASURES: The change in the first twitch height, the recovery time to a TOF ratio at least 0.9, and the TOF ratio at 30 min were evaluated. RESULTS: There were no significant differences in the first twitch height among groups (P = 0.532). With a single dose of sugammadex, dexamethasone did not affect the recovery time to a TOF ratio at least 0.9 (P = 0.070). After using a split-dose of sugammadex, the recovery time to a TOF ratio at least 0.9 was delayed only at a concentration of 50 µg ml of dexamethasone. With a reduced split-dose of sugammadex, the TOF ratio at 30 min was lowered only by a concentration of 50 µg ml of dexamethasone (P < 0.010). CONCLUSION: Acute bolus administration of dexamethasone at clinical concentrations had no effect on NMB or on sugammadex reversal.

Complications of Moderate Sedation Versus Deep Sedation/General Anesthesia for Adolescent Patients Undergoing Third Molar Extraction.

PURPOSE: To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. MATERIALS AND METHODS: We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ(2) test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. RESULTS: Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). CONCLUSIONS: The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction.

Independent predictors of delay in emergence from general anesthesia.

Some patients with intellectual disabilities spend longer than others in emergence from ambulatory general anesthesia for dental treatment. Although antiepileptic drugs and anesthetics might be involved, an independent predictor for delay of the emergence remains unclear. Thus, a purpose of this study is to identify independent factors affecting the delay of emergence from general anesthesia. This was a retrospective cohort study in dental patients with intellectual disabilities. Patients in need of sedative premedication were removed from participants. The outcome was time until emergence from general anesthesia. Stepwise multivariate regression analysis was used to extract independent factors affecting the outcome. Antiepileptic drugs and anesthetic parameters were included as predictor variables. The study included 102 cases. Clobazam, clonazepam, and phenobarbital were shown to be independent determinants of emergence time. Parameters relating to anesthetics, patients' backgrounds, and dental treatment were not independent factors. Delay in emergence time in ambulatory general anesthesia is likely to be related to the antiepileptic drugs of benzodiazepine or barbiturates in patients with intellectual disability.

Residual neuromuscular blockade and postoperative critical respiratory events: literature review.

AIMS AND OBJECTIVES: To investigate and synthesise published literature on the associations between residual neuromuscular blockade and critical respiratory events of postoperative adult patients in the postanaesthesia care unit. BACKGROUND: Residual neuromuscular blockade continues to be common among patients transferred to the postanaesthesia care unit after general anaesthesia, while negative effects of residual neuromuscular blockade on respiratory function have been demonstrated in laboratory volunteers. DESIGN: Literature review. METHODS: Using key terms, a search was conducted in Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database and EMBASE (January 1990-May 2013) for clinical trials or observational studies on the associations between residual neuromuscular blockade and critical respiratory events, published in English-language journals. RESULTS: Nine articles met the inclusion criteria. Residual neuromuscular blockade definition threshold differed between studies. Among critical respiratory events, only hypoxaemia was investigated in all included studies. Residual neuromuscular blockade was significantly associated with increased incidence of hypoxaemia during postanaesthesia care unit stay in most studies, while associations with the rest of the critical respiratory events were inconclusive. CONCLUSIONS: Although limited, existing research has provided evidence that patients with residual neuromuscular blockade are at high risk of early postoperative hypoxaemia. Further studies are needed to investigate independent associations between residual neuromuscular blockade and critical respiratory events, along with causality of these associations. The clinical importance of residual neuromuscular blockade for groups at high risk of critical respiratory events should also be investigated. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals have to be aware of the increased risk of hypoxaemia in patients with residual neuromuscular blockade. Efforts to decrease residual neuromuscular blockade incidence, combined with identification and appropriate evaluation of patients with residual neuromuscular blockade during postanaesthesia care unit stay, are recommended.

[A case of delayed arousal after anesthesia due to aberrant epidural catheter placement in a blood vessel].

A 71-year-old man underwent a total gastrectomy. An epidural catheter was inserted before the induction of general anesthesia. Blood was withdrawn from an epidural catheter inserted at T8-9 interspace with a median approach. The epidural catheter was then reinserted in T8-9 interspace with a paramedian approach and neither blood nor cerebrospinal fluid was withdrawn with careful aspiration. The catheter placement was confirmed with 1% lidocaine 3 ml. Anesthesia was induced with fentanyl, propofol, and rocuronium, and was maintained with sevoflurane, oxygen, air, fentanyl, and epidural analgesia. Total of 0.375% ropivacaine 15 ml was administered through the epidural catheter in about 1 hr. All anesthetics but continuous epidural analgesia with 0.2% ropivacaine at a speed of 4 ml x hr(-1) were terminated when the operation was completed; however, the patient was not arousable for 2 hours thereafter. When we carefully aspirated the epidural catheter, fresh blood was withdrawn from the catheter. We confirmed that the delayed arousal was due to the administration of ropivacaine into the blood by aberrant epidural catheter placement in a blood vessel. Unaccountable tachycardia and mild hypertension observed persistently during the operation would have been the warning to the toxicity of local anesthetics during general anesthesia.

[A case of prolongation of rocuronium neuromuscular blockade in a pregnant patient receiving magnesium].

A 35-year-old pregnant female with systemic lupus erythematosus and lupus nephritis underwent emergency cesarean section at 24 weeks of gestation under general anesthesia. The patient had received magnesium sulfate with a diagnosis of pregnancy-induced hypertension since 20 weeks of gestation. Anesthesia was induced with thiopental 3.5 mg x kg(-1) and tracheal intubation was facilitated by administration of rocuronium 1.0 mg x kg(-1). No additional rocuronium was needed during operation. After operation, no twitch was noted on the ulnar nerve TOF monitor. The TOF returned to 4/4 at postoperative 11 hours and the patient was extubated uneventfully. When rocuronium is used to facilitate general endotracheal anesthesia in a patient for emergency cesarean delivery, it is important to recognize that magnesium may prolong neuromuscular block significantly.

The effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia.

Potatoes contain solanaceous glycoalkaloids (SGAs), which inhibit both butyrylcholinesterase (BuChE) and acetylcholinesterase (AChE). The present study investigated the effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia. ASA I-II, adult patients, scheduled for elective surgery, were included in a randomized, blind and controlled study. Patients were randomly divided into two groups. Patients in Group P (n = 21) ate a standard portion of potatoes in their last meal prior to pre-operative fasting, while patients in Group C (n = 23) ate food not containing SGAs. Patients were premedicated with midazolam. Anesthesia was induced with thiopental and fentanyl, and maintained with sevoflurane in 50 % O2/air and fentanyl, as needed. Succinylcholine 1 mg kg(-1) was administered to facilitate endotracheal intubation. Duration of succinylcholine blockade, awakening and recovery times from anesthesia were measured. Serum BuChE levels were also measured at baseline and 4 time-points within 24 h post-consumption. Duration of succinylcholine-induced neuromuscular block, awakening and recovery time from anesthesia was significantly longer in Group P than in Group C (p < 0.05). Serum BuChE levels decreased at 6 h after consumption start in Group P. In addition, in both groups, BuChE levels markedly decreased after succinylcholine blockade, increased thereafter, but did not return to baseline within 24 h of consumption start. None of these differences observed in BuChE levels was statistically significant. This study suggests that potatoes eaten before anesthesia can prolong the duration of succinylcholine-induced neuromuscular block and delay recovery from anesthesia.

A case of delayed emergence from anesthesia caused by postoperative brain edema associated with unexpected cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is rare but displays various and often dramatic clinical symptoms. Few cases of CVST have been reported in the field of anesthesiology. We encountered an unexpected case of CVST that presented with delayed emergence from anesthesia after resection of a brain tumor. A 55-year-old man was scheduled for resection of an oligoastrocytoma in his right frontal lobe. After smooth induction of general anesthesia, anesthesia was maintained uneventfully for about 7 h with target-controlled infusion (TCI) of propofol and remifentanil, except for a seizure generated when the right anterior central gyrus was stimulated to allow motor evoked potential monitoring. Immediately after the cessation of TCI, spontaneous respiration was restored. However, the patient was unexpectedly comatose, and no response to painful stimuli or coughing during tracheal suctioning was observed. A computed tomogram taken 2 h after surgery showed diffuse brain edema, even though the neurosurgeons did not notice any cerebral swelling during closing of the dura mater. A magnetic resonance venogram revealed thromboses in the superior sagittal and straight sinuses. On the 9th postoperative day, the patient died without recovering consciousness or his brainstem reflexes. Anesthesiologists should be aware of CVST as a cause of delayed emergence from anesthesia after craniotomy.

Retrospective observational study of the effects of residual neuromuscular blockade and sugammadex on motor-evoked potential monitoring during spine surgery in Japan.

Given neuromuscular blockade (NMB) can affect the amplitude and detection success rate of motor-evoked potentials (MEP), sugammadex may be administered intraoperatively. We evaluated the factors affecting the degree of residual NMB (i.e., the train-of-four [TOF] ratio) and the relationship between TOF ratio and MEP detection success rate in Japanese patients undergoing spine surgery. This single-center retrospective observational study included adults who underwent spine surgery under propofol/remifentanil anesthesia, received rocuronium for intubation, and underwent myogenic MEP monitoring after transcranial stimulation. TOF ratios were assessed using electromyography. Sugammadex was administered after finishing the MEP setting and the TOF ratio was ≤0.7. To identify factors affecting the TOF ratio, TOF ratio and MEP detection success rate were simultaneously measured after finishing the MEP setting; to compare the time from intubation to the start of MEP monitoring after NMB recovery between sugammadex and spontaneous recovery groups, multivariable analyses were performed. Of 373 cases analyzed, sugammadex was administered to 221 (59.2%) cases. Age, blood pressure, hepatic impairment, and rocuronium dose were the main factors affecting the TOF ratio. Patients with higher TOF ratios (≥0.75) had higher MEP detection success rates. The time from intubation to the start of MEP monitoring after NMB recovery was significantly shorter in patients administered sugammadex versus patients without sugammadex (P < .0001). The MEP detection success rate was higher in patients with a TOF ratio of ≥0.75. Sugammadex shortened the time from intubation to the start of MEP monitoring after NMB recovery.

Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial.

BACKGROUND: Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively. METHODS/DESIGN: In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I-III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively. DISCUSSION: Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT05040490 . Registered on 3 September 2021.

Fatty Liver Is an Independent Risk Factor for Delayed Recovery from Anesthesia.

Fatty liver (FL) is associated with altered activity of hepatic drug-metabolizing enzymes, but the clinical significance is unknown. Many anesthetic agents are metabolized in the liver. We aimed to determine whether FL impacts recovery from anesthesia as a surrogate for altered drug metabolism. This was a single-center, retrospective, case-control study of all adults who underwent anesthesia and concurrent abdominal imaging (n = 2,021) in a hospital setting. FL (n = 234) was identified through radiology reports. Anesthesia recovery, the primary endpoint, was defined by Aldrete's recovery score (RS, 0-10), assessed following postanesthesia care unit (PACU) arrival, with RS ≥8 considered discharge eligible. FL and controls were compared using univariate and multivariate analyses, adjusting for confounders. A secondary matched-pairs analysis matched FL and controls 1:1 for confounders. Time from airway removal to discharge eligibility was compared using multivariate Cox regression. On PACU arrival, 54.1% of FL were discharge eligible compared to 61.7% of controls (P = 0.03), with lower activity scores on univariate (P = 0.03) and multivariate analysis (P = 0.03). On matched-pairs analysis, discharge eligibility, activity, consciousness, and total RSs were lower in FL (P ≤ 0.04 for all). Median time from airway removal to discharge eligibility was 43% longer in FL (univariate, P = 0.01; multivariate hazard ratio, 1.32; P = 0.046). To further exclude confounding by obesity, we performed a sensitivity analysis limited to a body mass index <30, where FL was still associated with lower activity (P = 0.03) and total RS (P = 0.03). Conclusion: Patients with FL have delayed recovery from anesthesia, suggesting altered drug metabolism independent of metabolic risk factors.

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

ABSTRACT: Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02-8.33), BUN ≥9 mmol/L (OR 4.05, 1.37-8.41), infusion of red blood cell suspension (OR 3.93, 1.25-7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24-5.20), age ≥6 (OR 3.01, 1.38-6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.