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.

Comparison of two pharmacokinetic-pharmacodynamic models of rocuronium bromide during profound neuromuscular block: analysis of estimated and measured post-tetanic count effect.

BACKGROUND: Profound neuromuscular block (NMB) is important in surgeries where complete immobility is considered essential to improve tracheal intubation and surgical conditions. Rocuronium bromide is a commonly used NMB agent. This work describes a noninvasive approach for estimation of post-tetanic count (PTC) based on two pharmacokinetic (PK) models, the Saldien and the De Haes models. The aim was to investigate the rocuronium bromide PK-pharmacodynamic (PD) relationship in estimating the PTC effect during profound NMB. METHODS: In this prospective, non-randomised, observational study, an induction bolus of rocuronium bromide was administered followed by continuous infusion for maintenance of a PTC of 1-2. measured every 3 min. Measurements were analysed as discrete categorical data and by applying the nonlinear mixed-effect modelling approach. Performance of the selected models was evaluated through simulation model-based diagnostics, further assessing the precision of the parameter estimates and the performance of the models at the individual level. RESULTS: Data from 30 adult patients undergoing elective abdominal or neurosurgical procedures were included. Post-tetanic count response profiles during rocuronium bromide infusion were successfully characterised using the population PD analysis. The models showed a good performance for all PTC categories, albeit with a moderate over-prediction of PTC >6. CONCLUSIONS: Our findings indicate that using plasma concentrations of rocuronium bromide estimated with either of the two models, combined with a PD model, provides equal model performance when predicting PTC. These promising results may provide an important advance in guiding rocuronium bromide administration when profound NMB in routine clinical practice is desired.

Time interval between alfentanil and rocuronium administration necessary to prevent rocuronium-induced withdrawal movement.

BACKGROUND: We aimed to determine the time interval between alfentanil and rocuronium administration, at a 50% probability of preventing pain-induced withdrawal movement from rocuronium injection (TimeAR50). METHODS: A total of 64 patients scheduled for general anesthesia were enrolled in this study (33 men and 31 women). Anesthesia was induced with target-controlled infusion of propofol, at an effect-site target concentration of 3 µg/mL. Then, alfentanil 15 µg/kg was injected for 30 s. After 60 s, rocuronium 0.6 mg/kg was administered to the first patient. The Dixon's up-and-down method was used to determine the time interval for each subsequent patient (interval of 5 s). Mean arterial pressure (MAP) and heart rate (HR) were recorded at three time points: T0, pre-induction; T1, before rocuronium injection; and T2, 1 min after rocuronium injection. RESULTS: The TimeAR50 ± standard deviation (SD) was 5.6 ± 3.7 s and 21.9 ± 5.6 s in the male and female patients, respectively. Based on the probit regression, the TimeAR50 was 4.7 s (95% confidence interval [CI], 1.2-7.6 s) and 20.3 s (95% CI, 7.7-26.1 s) in the male and female patients, respectively. The TimeAR95 was 10.6 s (95% CI, 7.7-25.3 s) and 35.0 s (95% CI, 28.1-95.5 s) in the male and female patients, respectively, with significantly higher values in females than in males (P < 0.001). Compared with the T0, MAP and HR decreased significantly at T1 and T2 in both groups. CONCLUSION: The TimeAR50 required for preventing rocuronium-induced withdrawal movement were 4.7 s and 20.3 s in male and female patients, respectively. TRIAL REGISTRATION: This study was registered with the Chinese Clinical Trials Registry on April 7, 2021 (URL: http://www.chictr.org.cn . Registry number: ChiCTR2100045137 ) .

Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis.

BACKGROUND: A recent survey revealed that extensive off-label use of sugammadex in pediatric anesthesia deserved particular attention. The present study with trial sequential analysis (TSA) aimed to evaluate the effects of sugammadex for antagonizing neuromuscular blockade (NMB) in pediatric patients, and to investigate whether the findings achieved the required information size to draw conclusions. METHODS: PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to April 2021. All randomized controlled trials used sugammadex as reversal agent in pediatric patients were enrolled. Time from NMB reversal to recovery of the train-of-four ratio (TOFr) to 0.9 and extubation time were considered as co-primary outcomes, and incidences of adverse events were considered as secondary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of evidences. RESULTS: Data from 18 studies involving 1,065 pediatric patients were acquired. The results revealed that use of sugammadex was associated with shorter duration from administration of reversal agents to TOFr > 0.9 (MD = -14.42, with 95% CI [-17.08, -11.75]) and shorter interval from reversal from NMB to extubation (MD = -13.98, with 95% CI [-16.70, -11.26]) compared to control groups. TSA also indicated that the current sample sizes were sufficient with unnecessary further trials. Analysis of secondary outcomes indicated that administration of sugammadex was associated with less incidence of postoperative nausea and vomiting (PONV), bradycardia, and dry mouth compared to control groups. CONCLUSION: Considering of satisfactory and rapid neuromuscular blockade reversal with low incidences of adverse events, sugammadex might be considered as the preferred option for children in clinical anesthesia practice compared to acetylcholinesterase inhibitors. However, overall low-quality evidences in present study rated by GRADE system indicated that superiority of sugammadex employed in pediatric patients needs to be confirmed by more studies with high quality and large sample size in future.

Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization.

OBJECTIVE: Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. METHODS: Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. RESULTS: We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. CONCLUSIONS: Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.

Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study.

BACKGROUND: We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes. METHODS: We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used. RESULTS: Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively). CONCLUSIONS: In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.

Comparison of Rocuronium with Succinylcholine for Rapid Sequence Induction Intubation in the Emergency Department: A Retrospective Study at a Single Center in China.

BACKGROUND This retrospective study was conducted at a single center in China and aimed to compare rocuronium with succinylcholine for rapid sequence induction intubation in the Emergency Department of a hospital. MATERIAL AND METHODS An orotracheal intubation procedure was performed in a total of 267 patients by direct laryngoscopy using an intravenous bolus injection of 1 mg/kg of succinylcholine (n=141; SY group) or 1.2 mg/kg of rocuronium (n=126; RM group) for a rapid sequence induction in the emergency department. The success of orotracheal intubation was evaluated by a capnography curve. The modified Cormack-Lehane score was used to grade the direct laryngoscopy. RESULTS There was no statistically significant difference in numbers of patients with successful first-attempt orotracheal intubation between the groups (112 vs. 87, P=0.067). Fewer intubation failures under direct laryngoscopy were reported in the SY group than in the RM group (23 [16%] vs. 34 [27%], P=0.037). The number of intubation attempts was higher in the RM group than in the SY group (1.52±0.87 per patient vs. 1.27±0.60 per patient, P=0.032). CONCLUSIONS The findings from this study support results from previous studies, showing that even in the Emergency Department setting, rocuronium was equivalent to succinylcholine in achieving rapid sequence induction intubation, when the dose was appropriate. However, as current clinical guidelines highlight, succinylcholine has more contraindications and adverse effects, including hyperkalemia, which should be monitored, and rocuronium has a longer duration of action.

What is the Role of Sugammadex in the Emergency Department?

BACKGROUND: Sugammadex is a medication newly available to many emergency physicians. It effectively, and within minutes, reverses neuromuscular blockade in patients who have received rocuronium or vecuronium. The role of sugammadex for the reversal of neuromuscular blockade after rapid sequence intubation in the emergency department (ED) is evolving, and limited emergency medicine-specific literature exists. OBJECTIVE: This narrative review evaluates the role of sugammadex for the reversal of neuromuscular blockade in the ED. DISCUSSION: The basic pharmacology, duration of action, adverse effects, and important medication and disease interactions specific to sugammadex are well described. Case reports suggest sugammadex can reverse neuromuscular blockade to facilitate an urgent, neurologic examination by an emergency physician or consultant. Multiple case reports of failure to improve airway patency with the use of sugammadex, even when neuromuscular blockade is completely reversed, and concern for added difficulty of definitive airway management in a patient with spontaneous movement suggest that sugammadex should largely be omitted from failed or difficult airway management strategies. Instead, it is important to focus on the ability to oxygenate and ventilate, including progression to surgical airway or jet ventilation if needed. CONCLUSION: Sugammadex is an effective, rapid reversal agent for rocuronium and has the potential use to facilitate an urgent neurologic examination shortly after administration of rocuronium. Its routine inclusion in a failed or difficult emergency airway is not supported by available literature.

A Prospective, Randomized Trial Comparing Respiratory Status During Anesthesia for Airway Stenting: Spontaneous Respiration Versus Controlled Ventilation With Muscle Relaxants.

BACKGROUND: Airway stenting is a procedure in which a stent is inserted into a stenotic site of the airway. The safest method of ventilation for airway stenting is controversial. A prospective randomized interventional study was conducted on airway stenting. We conducted this study to investigate whether controlled ventilation with muscle relaxants (MR) during airway stenting reduces the incidence of desaturation events (percutaneous oxygen saturation [SpO2] <95%) in comparison with spontaneous respiration (SP). METHODS: Sixty-four patients were enrolled at our hospital between April 2016 and August 2018, and were randomly assigned to the controlled ventilation with MR group or SP group. For anesthesia, total intravenous anesthesia with propofol target-controlled infusion and remifentanil was performed. In the SP group, SP was maintained. In the MR group, a rigid bronchoscope was inserted after the administration of MR to perform controlled ventilation. The incidence of desaturation events was analyzed by logistic regression adjusted by the preoperative respiratory state and stenotic site of the airway. RESULTS: The incidence of desaturation events in the SP and MR groups was 75.0% (24/32) and 9.7% (3/31), respectively, with an odds ratio of 0.04 (95% confidence interval, 0.01-0.16, reference = SP group; P < .001). In the SP group, the mean intraoperative pH was lower than that in the MR group (7.2 ± 0.1 vs 7.4 ± 0.1, respectively; P < .001). In this group, the mean partial pressure of arterial carbon dioxide (PaCO2) was higher (70.2 ± 17.0 mm Hg vs 40.5 ± 8.0 mm Hg, respectively; P < .001) and the mean partial pressure of oxygen in the arterial blood/fraction of the inspiratory oxygen ratio was lower (263.1 ± 64.2 mm Hg vs 396.4 ± 69.4 mm Hg, respectively; P < .001). CONCLUSIONS: Controlled ventilation with MR during airway stenting reduced the incidence of desaturation events, maintaining a favorable respiratory status.

Barriers and aids to routine neuromuscular monitoring and consistent reversal practice-A qualitative study.

BACKGROUND: Neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is administered, but surveys have demonstrated inconsistent monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine neuromuscular monitoring and consistent reversal practice. METHODS: Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture. Interviews were conducted at five Danish and one US hospital. Data were analysed using template analysis. RESULTS: Danish anaesthetists used objective neuromuscular monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective neuromuscular monitoring, objective neuromuscular monitoring was generally not available and most had not used it. Danish anaesthetists used neuromuscular monitoring to assess readiness for extubation, whereas US residents used subjective neuromuscular monitoring, clinical tests like 5-second head lift and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and monitoring use. Barriers to consistent and correct neuromuscular monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of neuromuscular blocking agents and residual block, lack of standards and guidelines and departmental culture. CONCLUSION: Using qualitative methods, we found that though Danish anaesthetists generally apply objective neuromuscular monitoring routinely and residents at the US institution often apply subjective neuromuscular monitoring, barriers to consistent and correct use still exist.

The future of neuromuscular blocking agents.

PURPOSE OF REVIEW: The present review provides a summary of the literature on recent development of new neuromuscular blocking agents and presents clinically well established and new reversal agents. RECENT FINDINGS: Anesthesiologists are still waiting for the ideal neuromuscular blocking agent with a succinylcholine-like rapid onset and offset without side effects. Recent drug development led to a new series of neuromuscular compounds, called the chlorofumarates such as gantacurium, CW002, and CW011. These drugs have a promising pharmacodynamic profile; importantly, they can rapidly be reversed by L-cysteine adduction without relevant side effects. In addition, a new spectrum of reversal agents are currently examined in preclinical studies: adamgammadex sodium, a modified γ-cyclodextrin derivate that forms an inactive tight inclusion complex with rocuronium or vecuronium and calabadions, capable of reversing both benzylisoquinolines and steroidal neuromuscular blocking agents. SUMMARY: Although the recent advancements in neuromuscular research are very promising, to date, the presented drugs are currently not available for clinical use. Clinical studies will determine the role of these developments in anesthesia practice. Therefore, well established combinations such as rocuronium-sugammadex are popular in clinical practice to offer quick paralysis for intubation and to optimize surgical conditions, while providing a fast neuromuscular recovery at the end of surgery.

Anaesthetic management for hiatal hernia repair in a child with Bartter's syndrome: A case report.

Bartter syndrome is a rare disorder characterized by reduced sodium chloride transport in the distal nephrons of the kidney. Its clinical features are renal salt wasting, hypokalemic metabolic alkalosis, elevated renin and aldosterone levels with normal or low blood pressure, polyuria, hypercalciuria and malnutrition. The pathophysiologic and biochemical changes in these patients should be kept in mind when considering anaesthetic management. This case report describes our management in a nineteen months old, 3.6 kg weight male child with Bartter's syndrome who underwent elective repair of hiatal hernia and gastrostomy.

Early Skin Test after Anaphylaxis during Induction of Anesthesia: A Case Report.

BACKGROUND: It is recommended that a skin test be performed 4-6 weeks after anaphylaxis. However, there is little evidence about the timing of the skin test when there is a need to identify the cause within 4-6 weeks. CASE REPORT: A 57-year-old woman was scheduled to undergo surgery via a sphenoidal approach to remove a pituitary macroadenoma. Immediately after the administration of rocuronium, pulse rate increased to 120 beats/min and blood pressure dropped to 77/36 mmHg. At the same time, generalized urticaria and tongue edema were observed. Epinephrine was administered and the surgery was postponed. Reoperation was planned two weeks after the event. Four days after the anaphylactic episode, rocuronium was confirmed to be the cause by the skin prick test. Cisatracurium, which showed a negative reaction, was selected as an alternative agent for future procedures. Two weeks later, the patient underwent reoperation without any adverse events. CONCLUSIONS: The early skin test can be performed if there is a need even earlier than 4-6 weeks after anaphylaxis.

Effect of sugammadex on chest radiographic abnormality in the early postoperative period after video-assisted thoracoscopic lobectomy

Background/aim: Sugammadex, which offsets the effects of neuromuscular blocking agents (NMBs), has advantages over traditional reversal agents like pyridostigmine, as it enables fast and reliable recovery from neuromuscular blockade. This study compared the incidence of early postoperative chest radiographic abnormalities (CRA) between sugammadex (group S) and pyridostigmine (group P) following video-assisted thoracoscopic (VAT) lobectomy for lung cancer. Materials and methods: We performed a retrospective cohort analysis by reviewing the medical records of patients who underwent VAT lobectomy at a single university medical center. We defined the early postoperative CRA as a characteristic appearance on chest radiograph up to 2 days after surgery. Arterial blood gas analysis (ABGA), surgical time, anaesthesia time, extubation time, and the total dose of rocuronium were analysed. Postoperative nausea and vomiting (PONV) and pain scores were observed until 2 days after surgery. Results: A total of 257 patients underwent VAT lobectomy during the study period; 159 were included in the final analysis. Ninety patients received sugammadex while 69 received pyridostigmine. The incidence of early postoperative atelectasis was significantly lower in group S than in group P (26.7%, 95% CI: 17.5%‒35.8% and 43.5%, 95% CI: 31.8%‒55.2%, respectively, P = 0.013). The median dose of rocuronium was higher in group S than in group P (120 mg vs. 90 mg, P < 0.001). ABGA, extubation time, and PONV were similar in both groups. Conclusion: Sugammadex decreased the incidence of CRA in the early postoperative period despite higher NMB consumption.

Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis.

BACKGROUND: Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy. METHODS: Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg- 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement. RESULTS: Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg- 1 and 0.28(0.17) mg.kg- 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics. CONCLUSIONS: Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy. TRIAL REGISTRATION: Clinical Trial Registry of China ( http://www.chictr.org.cn ) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Case series of 331 cases of sugammadex compared to neostigmine in patients under 2 years of age.

BACKGROUND: Sugammadex is a novel neuromuscular blockade reversal agent approved by the Food and Drug Administration in 2015, but little literature exists for patients less than 2 years of age. AIMS: The aims of this study were to: describe a cohort of patients 2 years old and younger who received sugammadex; describe any adverse effects of sugammadex in this age group; compare time from end of surgery to out of operating room for sugammadex versus neostigmine; compare time between last dose of neuromuscular blocking drug and reversal; and use train-of-four data to assess reversal. METHODS: Chart review of the medical record and the anesthesia information system captured all patients in this age cohort who received sugammadex or neostigmine over a two-year period. Adverse medication events were pulled from a mandatory quality improvement field in the electronic anesthesia record. T-tests were used for analyses. RESULTS: No adverse effects were reported with 331 doses of sugammadex. The average time in minutes between end of surgery and out of operating room was similar for neostigmine (19.6) versus sugammadex (19.4) (mean difference 0.2, 95% CI -1.5-1.8, P = 0.85). The average time in minutes between last dose of neuromuscular blocking drug and reversal agent was longer for neostigmine (103) than for sugammadex (84) (mean difference 19, 95% CI 13-26, P < 0.001). CONCLUSIONS: Sugammadex administration in this young population did not result in any adverse effects. It appears to be equally effective as neostigmine in patients under 2 years of age.

[Algorithm-based preventive strategies for avoidance of residual neuromuscular blocks]. / Algorithmusbasierte Präventionsstrategien zur Vermeidung neuromuskulärer Restblockaden.

BACKGROUND: Postoperative residual neuromuscular block (train of four ratio <0.9) is an outcome-relevant problem in balanced anesthesia, which increases postoperative morbidity and mortality. Implementation of medium and short-acting muscle relaxants, quantitative neuromuscular monitoring and pharmacological reversal of muscle relaxation reduce the incidence of residual neuromuscular block. The question arises whether this is suitable to create a pragmatic algorithm integrating these three individual methods to reduce paralysis-associated complications? METHODS: A selective literature search was carried out in PubMed and guidelines of national specialist societies were searched using special terms. RESULTS: The incidence of residual neuromuscular block varied among the studies but was as high as 93%. Using calibrated acceleromyography it is possible to identify a residual relaxation with a negative predictive value of 97% (95% confidence interval, CI 83-100%). Reversal by administration of the acetylcholinesterase inhibitor neostigmine reduces the incidence of residual neuromuscular block to 15.4%, in combination with calibrated acceleromyography to 3.3%. Reversal with sugammadex can nearly completely eliminate residual neuromuscular block. Quantitative neuromuscular monitoring and pharmacological reversal can be suitably integrated into a stage-based, pragmatic treatment algorithm. CONCLUSION: The algorithm-based concept of quantitative neuromuscular monitoring and pharmacological reversal using neostigmine and sugammadex enables residual neuromuscular block to be treated within 10 min before extubation of the patient. Ongoing educational programs are essential for implementation of modern muscle relaxant management concepts. Quantitative neuromuscular monitoring should be mandatory for all patients receiving neuromuscular blocking drugs. It would be desirable that German-speaking societies for anesthesiology make appropriate recommendations in guidelines.

Acetylcholine receptor antagonists in acute respiratory distress syndrome: much more than muscle relaxants.

Acetylcholine receptor antagonists have been shown to improve outcome in patients with severe acute respiratory distress syndrome. However, it is incompletely understood how these agents improve outcome. In the current editorial, we discuss the mechanisms of action of acetylcholine receptor antagonists beyond neuromuscular blockade.

Lower intra-abdominal pressure has no cardiopulmonary benefits during laparoscopic colorectal surgery: a double-blind, randomized controlled trial.

BACKGROUND: Higher intra-abdominal pressure may impair cardiopulmonary functions during laparoscopic surgery. While 12-15 mmHg is generally recommended as a standard pressure, the benefits of lower intra-abdominal pressure are unclear. We thus studied whether the low intra-abdominal pressure compared with the standard pressure improves cardiopulmonary dynamics during laparoscopic surgery. METHODS: Patients were randomized according to the intra-abdominal pressure and neuromuscular blocking levels during laparoscopic colorectal surgery: low pressure (8 mmHg) with deep-block (post-tetanic count 1-2), standard pressure (12 mmHg) with deep-block, and standard pressure with moderate-block (train-of-four count 1-2) groups. During the laparoscopic procedure, we recorded cardiopulmonary variables including cardiac index, pulmonary compliance, and surgical conditions. We also assessed postoperative pain intensity and recovery time of bowel movement. The primary outcome was the cardiac index 30 min after onset of laparoscopy. RESULTS: Patients were included in the low pressure with deep-block (n = 44), standard pressure with deep-block (n = 44), and standard pressure with moderate-block (n = 43) groups. The mean (SD) of cardiac index 30 min after laparoscopy was 2.7 (0.7), 2.7 (0.9), and 2.6 (1.0) L min-1 m-2 in each group (P = 0.715). The pulmonary compliance was higher but the surgical condition was poorer in the low intra-abdominal pressure than the standard pressure (both P < 0.001). Other variables were comparable between groups. CONCLUSION: We observed few cardiopulmonary benefits but poor surgical conditions in the low intra-abdominal pressure during laparoscopy. Considering cardiopulmonary dynamics and surgical conditions, the standard intra-abdominal pressure may be preferable to the low pressure for laparoscopic surgery.

Small doses of epinephrine prolong the recovery from a rocuronium-induced neuromuscular block: a case report.

BACKGROUND: During anaesthesia it is not uncommon to administer epinephrine in patients blocked by non-depolarizing muscle relaxants. However, there are few reports on possible interaction of epinephrine with neuromuscular transmission in humans. CASE PRESENTATION: An otherwise healthy 74-yr-old man underwent transurethral resection of a benign prostatic hyperplasia under total intravenous anaesthesia. Because of repeated drop in heart rate and blood pressure the patient received in total three bolus of epinephrine 5 µg, respectively. Each time this small dose of epinephrine intensified a rocuronium-induced neuromuscular block verified by acceleromygraphy. Further anaesthetic course was uneventful. CONCLUSIONS: In this case reported here small doses of intravenously administered epinephrine markedly prolonged a rocuronium-induced neuromuscular block. Given the widely used co-administration of epinephrine and muscle relaxants possible adrenergic interference with neuromuscular transmission would have implications for daily anaesthetic practice.