Anterior knee pain post-multiple surgeries for tibia fracture effectively managed with infrapatellar fat pad injection: a case report.

BACKGROUND: The anterior knee compartment is filled by the infrapatellar fat pad (IFP) and has been emphasized as a source of anterior knee pain (AKP). CASE PRESENTATION: A 51-year-old woman sustained a right tibial plateau and open diaphyseal fracture 2 years earlier. She remained with chronic AKP after undergoing bone fixations. Increased anterior portion of the IFP brightness and decreased adipose tissue gliding with flexion and extension compared to the unaffected side was shown on ultrasonography. An injection of 0.2% lidocaine between the patellar tendon and IFP, and into the IFP under ultrasound guidance, immediately relieved the pain. The pain kept recurring although injections were effective for a while; thus, surgery was scheduled. Scar tissue on the IFP surface was endoscopically excised and her pain dramatically reduced. CONCLUSION: This is the first report in which the detection of increased brightness on ultrasound of IFP and the injections into the IFP triggered an additional surgical intervention. Ultrasound evaluation and injection may be beneficial in pain clinic patients presenting with AKP and may provide an opportunity for diagnosis.

Update on the SedLine® algorithm for calculating the Patient State Index of older individuals during general anesthesia: a randomized controlled trial.

BACKGROUND: The SedLine® sensor processes (Masimo Corporation; Irvine, CA, USA) raw electroencephalogram (EEG) signals and displays the depth of sedation as a Patient State Index (PSi). Reliance on standard processed EEG data and failure to recognize age-related effects can lead to an erroneous interpretation that low-amplitude EEG findings in an older patient signify an insufficient depth of anesthesia presented as abnormally high PSi values (AHPSi). We hypothesized that the incidence of AHPSi would decrease with the use of the recently-updated version of the SedLine® sensor, in which the Bispectral Index (BIS) values were used to titrate anesthesia. METHODS: Thirty-three patients undergoing sevoflurane-remifentanil anesthesia were randomized into two groups. SedLine® sensors designed based on an old (v.1203) or updated (v.2000) algorithms were used. The BIS (v.4.1) and absolute index of total EEG power (TP) were simultaneously recorded. The attending anesthesiologists titrated the anesthetics, and BIS was maintained at 40-60. The incidence of AHPSi (PSi>50 with BIS 40-60) was calculated during the first 30 min after the start of surgery. RESULTS: Compared to the old algorithm group, the incidence of AHPSi was significantly lower in the updated algorithm group (26.7% vs. 4.2%, P<0.001). Lower TP values and the use of the old algorithm have significant effect on increased PSi values (P<0.001). CONCLUSIONS: The incidence of AHPSi decreased with the use of the updated version of the SedLine® algorithm.

Effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) measurement.

To retrospectively investigate the effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) in 20 patients who underwent elective gynecologic surgery under general anesthesia. The study subjects were patients who underwent elective gynecologic surgery under general anesthesia between April 2016 and January 2017, and were administered a 5-ml intravenous injection of 0.4% indigo carmine for clinical purposes during surgery with ORi monitoring. Changes in ORi within 20 min after indigo carmine injection were observed. A relevant decrease in ORi was defined as ≥ 10% reduction in ORi from pre-injection level. ORi rapidly decreased after indigo carmine intravenous injection in all patients. In 10 of 19 patients, ORi decreased to 0 after indigo carmine injection. The median lowest value of ORi was 0 (range 0-0.16) and the median time to reach the lowest value of ORi was 2 min (range 1-4 min) after injection. ORi values returned to pre-injection levels within 20 min in 13 of 19 patients, and the median time to return to pre-injection levels was 10 min (range 6-16 min) after injection. During ORi monitoring it is necessary to consider the rapid reduction in ORi after intravenous injection of indigo carmine.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement with using the Revision L sensor.

The effects of intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated with the Revision L sensor. The subjects were 18 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was injected intravenously, and changes in SpHb concentrations between before and after the injection were evaluated. The mean age was 52.4 ± 12.8 years. Before injection, the median SpHb level was 10.1 (range, 6.8-13.4) g/dL. The results demonstrated no change in SpHb concentration between before and after indigo carmine injection as detected by the Revision L sensor. SpHb measurements as determined with the Revision L sensor were not affected, even after the intravenous injection of indigo carmine.

Coronary artery bypass grafting in a patient with hemophilia B: continuous recombinant factor IX infusion as per the Japanese guidelines for replacement therapy.

We herein report our experience of successfully managing the hemostatic system by controlling serum factor IX levels throughout the perioperative period in a patient with hemophilia B. Coronary artery bypass grafting with cardiopulmonary bypass was planned for a 52-year-old man with moderate severity of hemophilia B. During surgery, recombinant factor IX (rFIX; BeneFIX(®) Pfizer Japan inc., Tokyo, Japan) was administered by bolus infusion followed by continuous infusion as per the guidelines of the Japanese Society on Thrombosis and Hemostasis. The operative course was uneventful without any considerable bleeding or complications.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement.

The effects of an intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated. The subjects were 21 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was intravenously injected, and subsequent changes in SpHb concentrations were evaluated. The results demonstrate that the pre-injection SpHb level was 10 g/dL, and the minimum post-injection SpHb level was 8.3 g/dL. The amount of decrease was 1.8 g/dL. The time to reach the minimum value was 4 min, and the time to return to the pre-injection value was 15 min. The decrease in SpHb was greater in the group with a perfusion index (PI) < 1.4 than in the group with a PI > 1.4. The assessment of SpHb after an intravenous injection of indigo carmine necessitates caution.

Life-threatening urethral hemorrhage after placement of a Foley catheter in a patient with uroseptic disseminated intravascular coagulation due to chronic urinary retention induced by untreated benign prostatic hyperplasia.

Case: A 77-year-old man with severe septic disseminated intravascular coagulation following urinary infection was transported to our hospital. He had developed urinary retention induced by untreated prostatic hyperplasia. Immediate drainage with a Foley catheter was successfully carried out, but the hematuria progressed to life-threatening hemorrhage. Outcome: Complete hemostasis was impossible by surgical treatment because the tissue around the prostatic urethra was very fragile and hemorrhagic. Organized treatments (continuous hemodiafiltration combined with polymyxin-B immobilized fiber column hemoperfusion and systemic treatment with antibiotics and coagulation factors) were commenced soon after the operation. The patient eventually recovered from the septic disseminated intravascular coagulation. Conclusion: This case report illustrates the risk of placement of Foley catheters in patients with severe septic disseminated intravascular coagulation.

[Effects of Anesthetics on Perioperative Short-term Outcomes in Patients Undergoing Thoracic Surgery with One-lung Ventilation].

BACKGROUND: The present study was designed to evaluate the postoperative values such as body temperature (BT), white blood cells (WBC), P/F ratio and C-reactive protein (CRP) associated with propofol or sevoflurane in patients undergoing thoracic surgery with one-lung ventilation. METHODS: We retrospectively reviewed outcomes of patients undergoing video-associated thoracic surgery of the esophagus (VATS-E) with propofol (group P, n = 71) or sevoflurane (group S, n = 34). Data were taken at 1 POD and 2 POD in ICU. In addition, data of WBC and CRP were taken just before the operation and on 5 POD. Statistical analyses used t-value and two-way ANOVA with statistic significance as P < 0.05. RESULTS: There was no significant difference between the two groups and we could not find the correlation between anesthetics and each factor. CONCLUSIONS: Propofol and sevoflurane had similar effect on BT, WBC, P/F ratio and CRP in patients undergoing thoracic surgery with one-lung ventilation.

Two cases of bilateral lung transplantation combined with intracardiac repair and pulmonary artery replacement: perioperative managements based on the left ventricular function.

We report on two patients who underwent bilateral lung transplantation (BLTx) combined with cardiac surgery. Patient 1 was a female whose pulmonary hypertension resulted from a congenital atrial septal defect (ASD) and idiopathic pulmonary arterial hypertension. She had a very small left ventricle (LV). We initiated venoarterial extracorporeal membrane oxygenation (ECMO) before induction of general anesthesia. She underwent ASD patch closure, pulmonary artery replacement, and BLTx under cardiopulmonary bypass (CPB). At the weaning from CPB, primary graft dysfunction and pulmonary edema induced by LV diastolic dysfunction was apparent. We gradually decreased the ECMO support and eventually weaned off the ECMO on the 4th postoperative day (POD) and the ventilator on the 29th POD. Patient 2 was a male with Eisenmenger syndrome, which resulted from ASD and ventricular septal defect (VSD). He had a normal LV. General anesthesia was induced smoothly without ECMO. He underwent ASD and VSD patch closure, pulmonary artery replacement, and BLTx under CPB. Weaning from CPB proceeded smoothly. These patients needed different management because of their different LV function. Especially, perioperative management of the BLTx patient with LV diastolic dysfunction was difficult. Assessment of perioperative cardiac function is very important in BLTx combined with cardiac surgery.

Dislocated dental bridge covering the larynx: usefulness of tracheal tube guides under video-assisted laryngoscopy for induction of general anesthesia, thus avoiding tracheostomy.

BACKGROUND: To describe a case with dislodgement of dental bridge with clasps covering the vocal cords, in a patient who was successfully intubated using tube exchanger under video-assisted laryngoscopy. STUDY DESIGN, METHODS: Clinical case record with a video clip. SETTING: University hospital. CASE PRESENTATION: A 83-year-old woman presented with dislodgement of her dental bridge whilst eating. Laryngoscopy revealed a foreign body almost entirely covering the vocal cords, with the clasps of the dislodged partial denture piercing the pharyngeal wall. Before induction of general anesthesia, a tracheal tube introducer combined with video-assisted laryngoscopy was introduced into the trachea in the awake condition, followed by successful endotracheal intubation. Thereafter, the dislodged denture was extracted via the oral cavity. CONCLUSIONS: Tracheal tube introducers combined with video-assisted laryngoscopy appear to be useful for airway management, decreasing the number of avoidable tracheostomies performed.

[Anesthetic management of six patients with surgically repaired tetralogy of Fallot undergoing the second intra-cardiac surgery].

In Japan, more than 9,000 patients with congenital heart disease reach adulthood every year with improved medical treatment, and perioperative encounter with patients requiring the second intra-cardiac operation in adulthood is more often. Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease, and long-term prognosis is good. Therefore, we have more chances to care the postoperarive adult patients with TOF. This is a retrospective study in 6 patients with TOF who underwent the second intra-cardiac operation in adulthood from 2008 to 2012. Among the six patients, six had pulmonary valve replacement; four had tricuspid valve replacements or valvuloplastys; four had ventricular septal defect closures; two had right ventricular outflow tract obstruction releases; one had aortic valve replacement; and three had cryoablations. Right ventricular end-diastolic volume was 194.1 +/- 83.5 ml x m(-2) (mean +/- SD), and right ventricular ejection fraction was 38.2 +/- 4.8%. The factors which influence the anesthetic management were as follows: right cardiac failure by abnormality of the pulmonary valve; residual disease and deuteropathy of two or more combination; the risks associated with the second open chest surgery such as long operative time and severe bleeding. Perioperative management of an adult with congenital heart disease requires full understanding of its pathophysiology such as congenital heart disease, adult-specific complications, and the second open chest surgery.

Glucocorticoid mediates the transcription of OAT-PG, a kidney-specific prostaglandin transporter.

OAT-PG is a kidney-specific prostaglandin transporter and exclusively expressed at the basolateral membrane of proximal tubules in rodent kidneys. We previously reported that OAT-PG was dominantly expressed in the male kidney similar to the other SLC22 family proteins as organic anion transporter (OAT) 1 and OAT3. Recently, Wegner et al. revealed that a transcription factor, B-cell CLL/lymphoma 6 (BCL6), is associated with the male-dominant expressions of OAT1 and OAT3 in the rat kidney. Here, we performed the luciferase assay to investigate whether OAT-PG is also transcriptionally regulated by BCL6. However, the promoter activity of OAT-PG was not directly affected by BCL6 overexpression nor the testosterone treatment, suggesting that different regulatory mechanisms underlie the male-dominant transcriptional regulation of OAT-PG compared to those of OAT1 and OAT3. We newly found that adrenalectomy (Adx) of male rat caused a significant reduction of OAT-PG expression without any significant changes in the OAT1 and OAT3 expressions, and it was recovered by the dexamethasone administration. Furthermore, the renocortical PGE2 concentration was markedly increased in Adx male rat, concomitant with the downregulation of OAT-PG, and it was reduced to the basal level by dexamethasone treatment. In the luciferase assay, dexamethasone stimulated OAT-PG promoter activity but not OAT1. The luciferase activity responsiveness to dexamethasone was significantly reduced by the deletion of glucocorticoid response elements in the OAT-PG promoter region. These results suggest that glucocorticoid plays an important role in the regulation of the renocortical PGE2 concentration by the transcriptional regulation of OAT-PG in the rat kidney.

Decreased expression of a novel prostaglandin transporter, OAT-PG, facilitates renocortical PGE2 accumulation during rat pregnancy.

BACKGROUND: Prostaglandin (PG)-specific organic anion transporter (OAT-PG) is a recently identified renal transporter involved in the local clearance of prostaglandin E2 (PGE2). Since the renal biosynthesis of PGE2 is not increased during pregnancy, this transporter expression would affect the gestational changes in the renal PGE2 content. METHODS: Kidneys from rats at different gestational stages were used to examine gestational changes in the renocortical PGE2 concentration. The renal expression of OAT-PG and the enzymes for PGE2 synthesis was also examined sequentially, together with the gestational changes in renal renin production. RESULTS: The renocortical PGE2 concentration was significantly increased during midterm to late pregnancy, with a maximum increase of 47.6 ± 11.5% from the virgin value. Although the expression of the enzymes, such as cyclooxygenases and PG synthases, was not increased, that of OAT-PG was significantly decreased throughout pregnancy, inversely correlating with changes in the renocortical PGE2 concentration. Renal renin production was significantly increased during pregnancy. CONCLUSION: This study demonstrated for the first time that the tissue PGE2 concentration was increased in pregnant rat kidneys, which may be associated with the gestational rise in glomerular filtration rate. The decreased expression of OAT-PG was thought to be responsible for the increased tissue PGE2 content.

Logistic regression analysis of risk factors for prolonged pulmonary recovery in children from aspirated foreign body.

OBJECTIVE: Foreign body aspiration is a life-threatening emergency for children. Fried chicken is commonly available all over the world, but no cases have previously been reported addressing this food as a tracheobronchial foreign body. We report an extremely rare case of tracheobronchial aspiration of fried chicken complicated by severe bronchitis and postoperative atelectasis. To clarify predisposing factors related to bronchopulmonary complications, we also reviewed paediatric cases of tracheobronchial foreign bodies treated in our department over the past 14 years. METHODS: We retrospectively reviewed a total of 77 cases of tracheobronchial foreign bodies from 1988 to 2011. The main outcome measure was duration of hospitalisation, reflecting postoperative therapy. Logistic regression analyses were conducted to determine risk factors for longer hospitalisation. RESULTS: Age, sex, and interval between the aspiration episode and bronchoscopy were not significantly associated with longer hospitalisation. Regarding kinds of foreign bodies, higher rates of longer hospitalisation were noted for patients who had aspirated peanut or animal material, as compared to patients who had aspirated non-organic material (odds ratio, 5.80; 95% confidence interval, 1.12-30.43). CONCLUSIONS: In terms of predicting the risk of pulmonary complications, the type of foreign body aspirated offers a more meaningful factor than the interval between aspiration and operation. Specifically, peanuts or animal material containing oils appear to be associated with a more prolonged pulmonary recovery even after retrieval of the foreign body.

[Perioperative management of lung transplantations in patients with pulmonary arterial hypertension compared with that in patients with lymphangiomyomatosis].

BACKGROUND: The number of lung transplantation has tended to increase as a treatment for patients with pulmonary arterial hypertension (PAH) and lymphangiomyomatosis (LAM) in Japan. However, we have little evidence about the comparison of perioperative management in patients with PAH and that in patients with LAM. METHODS: In this retrospective study, ten patients with PAH and seventeen patients with LAM who underwent the lung transplantations between 2006 and 2011 were enrolled. RESULTS: PAH patients received double lung transplantation with intraoperative cardiopulmonary bypass (CPB) support. Before anesthesia induction, percutaneous cardiopulmonary support (PCPS) was begun. Most of LAM patients received single lung transplantation without using CPB support and PCPS support before anesthesia induction. But sometimes during an operation PCPS support was necessary. Postoperative PCPS support showed no significant differences between PAH and LAM. The four year survival rate was 80% (PAH) and 87.8% (LAM). Pao2/FIo2 in patients with PAH and in those with LAM, %FEV10 in those with LAM after surgery improved when compared to those before surgery. CONCLUSIONS: The large difference in perioperative management between patients with PAH and those with LAM is an important knowledge for anesthesist.

[Assessment of the perioperative factors contributing to the hemodynamic changes during surgery in ten patients with pheochromocytoma].

BACKGROUND: Intensive perioperative management is required for adrenalectomy in patients with pheocromocytoma because of the unstable hemodynamics and life threatening cardiovascular disturbances due to catecholamine surge from the neuroendocrine tumors. The aim of this study was to assess the perioperative factors contributing to the hemodynamic changes during surgery in pheochromocytoma. METHODS: Ten patients with pheochromocytoma undergoing elective adrenalectomy were enrolled in this retrospective study. The circulating blood volume before surgery and the perioperative factors associated with hemodynamic changes during surgery were assessd by the pulse dye densitometry and VigileoTM/ FroTracTM system, respectively. RESULTS: The decreases of blood pressure after resections of the central veins from tumors were significantly greater in laparotomy than those in laparoscopic surgery (P<0.05). In addition, the decreases of blood pressure after resection of the central were correlated with tumor sizes (R= -0.611), perioperative noradrenaline (NA) blood levels (R= -0.860), perioperative amounts of NA in urine (R= -0.743), and mean stroke volume variations for 5 min after resection of the veins(R= - 0.679). CONCLUSIONS: The decreases of blood pressure after resections of the central veins are dependent on the perioperative blood NA levels, the level of NA in the perioperative urine testig, and tumor sizes.

Differences in the released endothelial microparticle subtypes between human pulmonary microvascular endothelial cells and aortic endothelial cells in vitro.

Circulating endothelial microparticles (EMPs) are membrane vesicles that are shed into the blood stream from activated or apoptotic endothelial cells. We previously reported that circulating EMP numbers significantly increased in stable chronic obstructive pulmonary disease (COPD) patients and during exacerbation compared with healthy control subjects. However, different types of circulating EMPs with distinct time profiles were detectable during exacerbations. We hypothesized that the released EMP subtypes correlated with differences in the inflammatory stimuli and the endothelial cell type. We compared the EMP subtypes from human aortic endothelial cells (Aortic ECs) and human lung microvascular endothelial cells (Pulmonary microvascular ECs) released in response to various stimuli, including proinflammatory cytokines (TNFα), oxidative stress (H2O2), and cigarette smoke extracts (CSE) in vitro. We defined circulating EMPs by the expression of endothelial antigens: CD144(+) MPs (VE-cadherin EMPs), CD31(+)/CD41(-) MPs (PECAM EMPs), CD62E(+) MPs (E-selectin EMPs), and CD146(+) MPs (MCAM EMPs). E-selectin EMPs were released from both pulmonary microvascular and aortic ECs in response to TNFα but not to H2O2 or CSE stimulation. The amount of MCAM EMPs released from pulmonary microvascular ECs differed significantly between the cells stimulated with H2O2 and those stimulated with CSE. VE-cadherin EMPs were only released from aortic ECs, whereas PECAM EMPs were released exclusively from pulmonary microvascular ECs. The EMP subtypes released differ in vitro among TNFα, H2O2, and CSE stimulation as well as between pulmonary microvascular and aortic ECs. The differences in circulating EMP subtypes may reflect a condition or site of endothelial injury and may serve as markers for endothelial damage in COPD patients.

Higher fraction of inspired oxygen in anesthesia induction does not affect functional residual capacity reduction after intubation: a comparative study of higher and lower oxygen concentration.

BACKGROUND: Low fraction of inspired oxygen (FIO2) reduces the atelectasis area during anesthesia induction. However, atelectasis may occur during laryngoscopy and endotracheal intubation because lungs can collapse within a fraction of a second. We assessed the effects of ventilation with 100 and 40 % oxygen on functional residual capacity (FRC) in patients undergoing general anesthesia. METHODS: Twenty patients scheduled for elective open abdominal surgery were randomized into 40 % oxygen (GI, n = 10) and 100 % oxygen (GII, n = 10) groups and FRC was measured. Preoxygenation and mask ventilation with 40 and 100 % oxygen were used in GI and GII, respectively. In both groups, 40 % oxygen was used for anesthesia maintenance after intubation. Bilateral lung ventilation was performed with volume guarantee and low tidal volume (7 ml/kg predicted body weight) using bilevel airway pressure. We measured FRC and blood gas in all patients during preoxygenation, after intubation, and during surgery. RESULTS: FRC decreased from during preoxygenation (GI 2380 ml, GII 2313 ml) to after intubation (GI 1569 ml, GII 1586 ml) and significantly decreased during surgery (GI 1338 ml, GII 1417 ml) (P < 0.05). PaO2/FIO2 decreased from during preoxygenation (GI 419 mmHg, GII 427 mmHg) to after intubation (GI 381 mmHg, GII 351 mmHg) and significantly decreased during surgery (GI 333 mmHg, GII 291 mmHg) (P < 0.05). No significant differences were found between the groups in both parameters. CONCLUSIONS: FRC significantly decreased from the awake state to surgery in both groups. FRC was not influenced by FIO2 elevation at anesthesia induction.

[Seventeen cases of lung transplantations for lymphangioleiomyomatosis].

BACKGROUND: The number of lung transplantation has tended to increase as a treatment for patients with pulmonary lymphangioleiomyomatosis (LAM) in Japan. However, we have little evidence about the correlation between preoperative medical parameters and intraoperative complications. METHODS: A retrospective study was performed in 17 patients with LAM undergoing the lung transplantations between 2006 and 2011. RESULTS: Major intraoperative complications were as follows: hypotension, pulmonary hypertension, hypoxemia and blood loss of more than 1,000 ml. According to the medical records, no patients was diagnosed pulmonary hypertension before surgery and no preoperative parameters predicted intraoperative pulmonary hypertension. Therefore, according to the medical records it seemed difficult to predict the risk of the intraoperative pulmonary hypertension and hypotension. Intraoperative hypoxemia and the requirements of percutaneous cardiopulmonary support (PCPS) are not associated with preoperative PaO2 and %FEV1.0. Pleurodesis and the use of PCPS were significantly correlated with an increased risk of intraoperative massive bleeding. The four year survival rate was 87.8%. %FEV1.0, PaO2/FI(O) and %DL(CO) after surgery improved when compared to those before surgery. CONCLUSIONS: Although the intraoperative complications such as hypotension, pulmonary hypertension, hypoxemia and/or massive bleeding frequently occurred in patients with LAM during the lung transplantations, it was difficult to predict them except the massive bleeding of more than 1,000 ml before surgery. However, lung transplantation is a valuable therapy for patients with end-stage LAM.

[Use of sugammadex in patients undergoing caesarean section using general anesthesia with rocuronium].

Recently, rocuronium is being used in patients for caesarean section undergoing general anesthesia instead of suxamethonium. An increased dose of rocuronium improves intubating conditions but prolongs neuromuscular blockade. Sugammadex reverses rapidly and predictably even profound rocuronium-induced neuromuscular blockade. We experienced 13 cases of caesarean section patients undergoing general anesthesia with thiopental (3.5 mg x kg(-1)) and rocuronium (0.9 mg x kg(-1)). At the end of surgery, sugammadex (2 mg x kg(-1)) was administered every 3 minutes repeatedly until TOF>0.9. In two patients, neuromuscular blockade spontaneously recovered to TOF>0.9 at the end of surgery. In most patients administered sugammadex, TOF recovered to more than 0.9 within a few minutes. However, in one patient who had chronic renal failure (creatinine clearance rate: 12 ml x min(-1)), 10 minutes were required for TOF to recover to more than 0.7, and TOF never reached 0.9. All patients were successfully intubated at the first attempt. No signs of recurarization or adverse effects related to sugammadex were noted in the perioperative period.