Management of Muscle Relaxation With Rocuronium and Reversal With Neostigmine or Sugammadex Guided by Quantitative Neuromuscular Monitoring.

BACKGROUND: The optimal pharmacological reversal strategy for neuromuscular blockade remains undefined even in the setting of strong recommendations for quantitative neuromuscular monitoring by several national and international anesthesiology societies. We evaluated a protocol for managing rocuronium blockade and reversal, using quantitative monitoring to guide choice of reversal agent and to confirm full reversal before extubation. METHODS: We conducted a prospective cohort study and enrolled 200 patients scheduled for elective surgery involving the intraoperative use of rocuronium. Providers were asked to adhere to a protocol that was similar to local practice recommendations for neuromusculalr block reversal that had been used for >2 years; the protocol added quantitative monitoring that had not previously been routinely used at our institution. In this study, providers used electromyography-based quantitative monitoring. Pharmacological reversal was accomplished with neostigmine if the train-of-four (TOF) ratio was 0.40 to 0.89 and with sugammadex for deeper levels of blockade. The primary end point was the incidence of postoperative residual neuromuscular blockade (PRNB), defined as TOF ratio <0.9 at time of extubation. We further evaluated the difference in pharmacy costs had all patients been treated with sugammadex. RESULTS: A total of 189 patients completed the study: 66 patients (35%) were reversed with neostigmine, 90 patients (48%) with sugammadex, and 33 (17%) patients recovered spontaneously without pharmacological reversal. The overall incidence of residual paralysis was 0% (95% CI, 0-1.9). The total acquisition cost for all reversal drugs was United States dollar (USD) 11,358 (USD 60 per patient) while the cost would have been USD 19,312 (USD 103 per patient, 70% higher) if sugammadex had been used in all patients. CONCLUSIONS: A protocol that includes quantitative monitoring to guide reversal with neostigmine or sugammadex and to confirm TOF ratio ≥0.9 before extubation resulted in the complete prevention of PRNB. With current pricing of drugs, the selective use of sugammadex reduced the total cost of reversal drugs compared to the projected cost associated with routine use of sugammadex for all patients.

Evaluation of a Protocol for the Management of Maintenance and Reversal of Rocuronium Block Using Neostigmine or Sugammadex.

BACKGROUND: Postoperative residual neuromuscular blockade (PRNB) is defined as an adductor pollicis train-of-four ratio (TOFR) <0.9. It is a common postoperative complication when nondepolarizing muscle relaxants are either not reversed or reversed with neostigmine. PRNB has been reported in 25% to 58% of patients who receive intermediate-acting nondepolarizing muscle relaxants, and it is associated with increased morbidity and decreased patient satisfaction. We conducted a prospective descriptive cohort study during the implementation of a practice guideline that included the selective use of sugammadex or neostigmine. The primary study aim of this pragmatic study was to estimate the incidence of PRNB at arrival to the postanesthesia care unit (PACU) when the practice guideline is followed. METHODS: We enrolled patients undergoing orthopedic or abdominal surgery requiring neuromuscular blockade. Rocuronium administration was guided by surgical requirements and based on ideal body weight, with dose reductions for women and/or age >55 years. Only qualitative monitoring was available to the anesthesia providers, and selection of sugammadex or neostigmine was guided by tactile assessments of the response to train-of-four (TOF) stimulation by a peripheral nerve stimulator. Neostigmine was administered if no fade was detected in the TOF response at the thumb. Deeper blocks were reversed with sugammadex. The prespecified primary and secondary end points were the incidence of PRNB at arrival to the PACU, defined as a normalized TOFR (nTOFR) < 0.9, and severe PRNB, defined as nTOFR <0.7 on arrival to the PACU. Anesthesia providers were blinded to all quantitative measurements made by research staff. RESULTS: Analysis included 163 patients, and 145 underwent orthopedic and 18 abdominal surgeries. Of the 163 patients, 92 (56%) were reversed with neostigmine and 71 (44%) with sugammadex. The overall incidence of PRNB at PACU arrival was 5 of 163 or 3% (95% confidence interval [CI], 1-7). The incidence of severe PRNB in PACU was 1% (95% CI, 0-4). Three of the 5 subjects with PRNB had TOFR <0.4 at time of reversal but were given neostigmine since anesthesia providers detected no fade by qualitative assessment. CONCLUSIONS: The use of a protocol that specifies rocuronium dosing and selective use of sugammadex versus neostigmine based on qualitative assessment of TOF count and fade allowed us to achieve an incidence of PRNB of 3% (95% CI, 1-7) at PACU arrival. Quantitative monitoring may be needed to further reduce this incidence.

Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade.

This review provides recommendations for anesthesia providers who may not yet have quantitative monitoring and sugammadex available and thus are providing care within the limitations of a conventional peripheral nerve stimulator (PNS) and neostigmine. In order to achieve best results, the provider needs to understand the limitations of the PNS. The PNS should be applied properly and early. All overdosing of neuromuscular blocking drugs should be avoided and the intraoperative neuromuscular blockade should be maintained only as deep as necessary. The adductor pollicis is the gold standard site and must be used for the pre-reversal assessment, also when the ulnar nerve and thumb were not accessible intraoperatively. Spontaneous recovery should be maximized and neostigmine should be administered after a TOF count of 4 has been confirmed at the adductor pollicis. Extubation should not occur within 10 min after administration of an appropriate dose of neostigmine.

A case of rapid progression of postoperative hyperthermia: Dantrolene or not dilemma?

Malignant hyperthermia (MH) is an extremely rare and life-threatening differential diagnosis of postoperative fever. We present an 8-month-old child scheduled for elective outpatient procedure who rapidly developed high fever, tachycardia, and respiratory acidosis shortly after transfer to the postanesthesia care unit. MH hotline expert recommended administering dantrolene, but there was no evidence of hypermetabolism or lactic acidosis. The patient remained clinically stable after admission to the pediatric intensive care unit and was discharged home the next day. The fever was likely due to viral infections as confirmed by a positive result of viral polymerase chain reaction for human metapneumovirus and rhinovirus/enterovirus.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial.

BACKGROUND: Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration. METHODS: This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts. RESULTS: Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) Vte in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB. DISCUSSION: In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs. CONCLUSION: We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02237443 . Registered August 28, 2014.

Comparison of train-of-four count by anesthesia providers versus TOF-Watch® SX: a prospective cohort study.

PURPOSE: Qualitative monitoring of neuromuscular blockade using the train-of-four (TOF) count is widely used to determine the timing and dose of reversal agents for neuromuscular blockade. We compared TOF count measured manually by anesthesia providers with that determined by TOF-Watch® SX. METHODS: This prospective observational cohort study included patients who were American Society of Anesthesiologists physical status III or less and undergoing elective surgery. During recovery from an intubating dose of rocuronium or vecuronium, the TOF count was measured every 15 sec using TOF-Watch SX. Anesthesia providers assessed the TOF count twice at each level of TOF-count, 15 sec after the TOF-Watch SX count increased to the next level and then two to five minutes later. RESULTS: In 75 patients, 687 observations were collected. There was agreement between the TOF-Watch SX and the subjective assessment by the provider in 386 (56%) of these observations. The agreement was 87% at TOF counts of 0 and 4. In the 409 observations at TOF counts 1, 2, and 3, the agreement was 36%. Among the 264 observations with disagreement at these TOF counts, providers assessed a higher TOF count in 254 (96%) observations and a lower count in 10 (4%) observations compared with the TOF-Watch SX. CONCLUSION: Anesthesia providers report higher values of TOF count compared with the TOF-Watch SX, especially at intermediate levels of neuromuscular blockade. Since the dosing guidelines for the timing and dose of reversal agents are based on the TOF count derived from the TOF-Watch SX, a manually assessed TOF count may lead to inadequate dosing and/or premature administration of reversal agents.

Perioperative and intensive care management of pediatric tracheal tear.

Management of tracheal tears can prove to be challenging in the perioperative setting. This is a rare condition that can be life threatening. Here, we present a case of seven-year-old boy involved in a high-speed motor vehicle collision. The child sustained multiple injuries including a near fatal head injury, multiple facial fractures, and a tracheal injury associated with pneumomediastinum. Due to the imminent threat of brainstem herniation while being imaged in the CT scanner, the patient underwent an emergent craniotomy to evacuate his evolving intracranial bleed. Imaging prior to the craniectomy suggested a possible tracheal injury, given the extensive pneumomediastinum. However, initial perioperative ventilation was without any difficulty. After stabilization of intracranial pressure (ICP) and hemodynamics, on hospital day 4, the patient returned to the operating room to diagnose and repair his tracheobronchial injury. This is a unique polytrauma case in which a tracheal tear was managed in the midst of other life-threatening injuries.

Pediatric airway management.

Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.

Extraglottic airway devices: A review.

Extraglottic airway devices (EAD) have become an integral part of anesthetic care since their introduction into clinical practice 25 years ago and have been used safely hundreds of millions of times, worldwide. They are an important first option for difficult ventilation during both in-hospital and out-of-hospital difficult airway management and can be utilized as a conduit for tracheal intubation either blindly or assisted by another technology (fiberoptic endoscopy, lightwand). Thus, the EAD may be the most versatile single airway technique in the airway management toolbox. However, despite their utility, knowledge regarding specific devices and the supporting data for their use is of paramount importance to patient's safety. In this review, number of commercially available EADs are discussed and the reported benefits and potential pitfalls are highlighted.

Operating room fires: a closed claims analysis.

BACKGROUND: To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed. METHODS: All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors. RESULTS: There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P < 0.01). Payments to patients were more often made in fire claims (P < 0.01), but payment amounts were lower (median $120,166) compared to nonfire surgical claims (median $250,000, P < 0.01). Electrocautery-induced fires (n = 93) increased over time (P < 0.01) to 4.4% claims between 2000 and 2009. Most (85%) electrocautery fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care. CONCLUSIONS: Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires.

Initial assessment and management of pediatric trauma patients.

Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS(®) sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the "bigger picture." Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

Pediatric burn injuries.

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

Perioperative management of pediatric trauma patients.

Pediatric trauma presents significant challenges to the anesthesia provider.This review describes the current trends in perioperative anesthetic management, including airway management, choice of anesthesia agents, and fluid administration.The review is based on the PubMed search of literature on perioperative care of severely injured children.

Sedation and analgesia for the pediatric trauma patients.

The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.

Intraoperative neuromuscular monitoring site and residual paralysis.

BACKGROUND: Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis. METHODS: This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates. RESULTS: 150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8-8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1-14.5). CONCLUSIONS: Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.

Trends in trauma transfusion.

Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.

Propofol infusion syndrome in a super morbidly obese patient (BMI = 75).

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4-5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.

Analgesia and sedation for children undergoing burn wound care.

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.