Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review.

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

Effect of Deep Versus Moderate Neuromuscular Block on Pain After Laparoscopic Colorectal Surgery: A Randomized Clinical Trial.

BACKGROUND: Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, results in the existing literature are controversial. OBJECTIVE: The study aimed to evaluate the effect of deep neuromuscular block on postoperative pain at rest and during coughing after laparoscopic colorectal surgery. DESIGN: The design is a parallel-group, randomized clinical trial. SETTINGS: The study was conducted at a tertiary care center. PATIENTS: Patients undergoing laparoscopic resection of colorectal tumors were included. INTERVENTIONS: Patients were randomly assigned to either a deep (posttetanic count 1 to 2) or moderate (train-of-four 1 to 2) neuromuscular group. MAIN OUTCOME MEASURES: The coprimary efficacy outcomes were numeric rating scale scores of the postoperative pain at rest and during coughing after surgery. RESULTS: Pain was lower in the deep neuromuscular block group at rest and during coughing at 1, 6, 24, and 48 hours after surgery (median difference of 2 points and 1 point at 1 h; p < 0.001 at each time point). The deep neuromuscular block group displayed a significantly lower number of bolus attempts by the patient (4 in the deep group vs 9 in the moderate group; p < 0.001) and boluses delivered (4 in the deep group vs 9 in the moderate group; p < 0.001) on postoperative day 1. The number of rescue analgesics was lower in the deep group on postoperative day 2 (p < 0.001). The deep neuromuscular block group showed a lower frequency of postoperative nausea and vomiting (p = 0.02) and lower intraoperative intra-abdominal pressure (p < 0.001). LIMITATIONS: This was a single-center study. CONCLUSIONS: Deep neuromuscular block resulted in better pain relief and lower opioid consumption and use of rescue analgesics after laparoscopic colorectal surgery. Deep neuromuscular block was associated with less postoperative nausea and vomiting and facilitated the use of lower intra-abdominal pressure in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/B458. EFECTO DEL BLOQUEO NEUROMUSCULAR PROFUNDO VERSUS MODERADO EN EL DOLOR, DESPUS DE LA CIRUGA COLORRECTAL LAPAROSCPICA UN ENSAYO CLNICO ALEATORIZADO: ANTECEDENTES:La anestesia con bloqueo neuromuscular profunda para cirugía laparoscópica, puede resultar con menor dolor postoperatorio y con menos presión intraabdominal. Sin embargo, los resultados en la literatura existente son controvertidos.OBJETIVO:El objetivo del estudio, fue evaluar el efecto del bloqueo neuromuscular profundo en dolor postoperatorio de reposo y con la tos, después de cirugía colorrectal laparoscópica.DISEÑO:Ensayo clínico aleatorizado de grupos paralelos.AJUSTE:El estudio se realizó en un centro de atención terciaria.PACIENTES:Se incluyeron pacientes sometidos a resección laparoscópica de tumores colorrectales.INTERVENCIONES:Los pacientes fueron aleatorizados a un grupo neuromuscular profundo (recuento posttetánico 1 a 2) o moderado (tren de cuatro 1 a 2).PRINCIPALES MEDIDAS DE RESULTADO:Los resultados coprimarios de eficacia, fueron las puntuaciones numéricas en la escala de calificación del dolor postoperatorio en reposo y durante la tos, después de la cirugía.RESULTADOS:El dolor fue menor en el grupo de bloqueo neuromuscular profundo en reposo y durante la tos, en 1, 6, 24, 48 horas después de la cirugía, (diferencia de mediana de 2 puntos y 1 punto respectivamente en 1 hora; p <0,001 en cada punto de tiempo). El grupo de bloqueo neuromuscular profundo, mostró un número significativamente menor de intentos de bolo por parte del paciente, (4 en el grupo profundo versus 9 del grupo moderado, p <0,001) y de bolos administrados (4 en el grupo profundo versus 9 en el grupo moderado, p <0,001) en el primer día postoperatorio. El número de analgésicos de rescate, fue menor en el grupo profundo en el segundo día postoperatorio (p <0,001). El grupo de bloqueo neuromuscular profundo, mostró una menor frecuencia de náuseas y vómitos postoperatorios (p = 0,02) y una menor presión intraoperatoria e intraabdominal (p <0,001).LIMITACIONES:Este estudio fue un estudio de un solo centro.CONCLUSIONES:El bloqueo neuromuscular profundo, resultó en mayor alivio del dolor y menor consumo de opioides y uso de analgésicos de rescate, después de la cirugía colorrectal laparoscópica. El bloqueo neuromuscular profundo, se asoció con menos náuseas y vómitos posoperatorios y facilitó el uso de una presión intraabdominal más baja, en la cirugía laparoscópica. Consulte Video Resumen en http://links.lww.com/DCR/B458.

Continuous Neuromuscular Blockade Following Successful Resuscitation From Cardiac Arrest: A Randomized Trial.

Background Neuromuscular blockade (NMB) agents are often administered to control shivering during targeted temperature management following cardiac arrest. In this study, we hypothesized that early, continuous NMB would result in a greater reduction in serum lactate levels among comatose patients after cardiac arrest. Methods and Results Randomized trial of continuous NMB for 24 hours versus usual care following cardiac arrest conducted at 5 urban centers in the United States. Adult patients who achieved return of spontaneous circulation, remained unresponsive, and underwent targeted temperature management after cardiac arrest were included. The primary outcome was change in lactate over 24 hours. A total of 83 patients were randomized, and 80 were analyzed (37 and 43 in the NMB and usual care arms, respectively). There was no significant interaction between time and treatment group with respect to change in lactate over 24 hours (median lactate change from 4.2 to 2.0 mmol/L [-2.2 mmol/L] in the NMB arm versus 4.0 to 1.7 mmol/L [-2.3 mmol/L] in the usual care arm; geometric mean difference, 1.3 [95% CI, 1.0-1.8]; P=0.07 for the interaction term). There was no difference in hospital survival (38% [NMB] versus 33% [usual care]; P=0.63) or survival with good functional outcome (30% [NMB] versus 21% [usual care]; P=0.35). There were no adverse events in either arm attributed to study interventions. Conclusions Continuous NMB compared with usual care did not reduce lactate over the first 24 hours after enrollment compared with usual care. There was no difference in overall hospital survival, hospital survival with good neurologic outcome, or adverse events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02260258.

Neuromuscular blockade reversal with sugammadex versus pyridostigmine/glycopyrrolate in laparoscopic cholecystectomy: a randomized trial of effects on postoperative gastrointestinal motility.

BACKGROUND: Acetylcholinesterase inhibitors (e.g., pyridostigmine bromide) are used for neuromuscular blockade (NMB) reversal in patients undergoing surgery under general anesthesia (GA). Concurrent use of anticholinergic agents (e.g., glycopyrrolate) decreases cholinergic side effects but can impede bowel movements. Sugammadex has no cholinergic effects; its use modifies recovery of gastrointestinal (GI) motility following laparoscopic cholecystectomy compared to pyridostigmine/glycopyrrolate. This study evaluated the contribution of sugammadex to the recovery of GI motility compared with pyridostigmine and glycopyrrolate. METHODS: We conducted a prospective study of patients who underwent laparoscopic cholecystectomy. Patients were randomly allocated to the experimental group (sugammadex, Group S) or control group (pyridostigmine-glycopyrrolate, Group P). After anesthesia (propofol and rocuronium, and 2% sevoflurane), recovery was induced by injection of sugammadex or a pyridostigmine-glycopyrrolate mixture. As a primary outcome, patients recorded the time of their first passage of flatus ('gas-out time') and defecation. The secondary outcome was stool types. RESULTS: One-hundred and two patients participated (Group S, 49; Group P, 53). Mean time from injection of NMB reversal agents to gas-out time was 15.03 (6.36-20.25) h in Group S and 20.85 (16.34-25.86) h in Group P (P = 0.001). Inter-group differences were significant. Time until the first defecation as well as types of stools was not significantly different. CONCLUSIONS: Sugammadex after laparoscopic cholecystectomy under GA resulted in an earlier first postoperative passage of flatus compared with the use of a mixture of pyridostigmine and glycopyrrolate. These findings suggest that the use of sugammadex has positive effects on the recovery of GI motility.

Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs: A Time Series Analysis.

BACKGROUND: The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors' hypothesis was that sugammadex use and associated costs would decrease. METHODS: A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. RESULTS: Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). CONCLUSIONS: Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair: A randomised, blinded study.

BACKGROUND: Laparoscopic ventral hernia repair is a common surgical procedure. However, muscle contractions and general muscle tension may impair the surgical view and cause difficulties suturing the hernial defect. Deep neuromuscular blockade (NMB) paralyses the abdominal wall muscles and may help to create better surgical conditions. OBJECTIVES: The current study investigated if deep compared with no NMB improved the surgical view during laparoscopic ventral hernia repair. DESIGN: Crossover study. SETTING: The study was carried out at Herlev and Gentofte Hospital, University of Copenhagen, Denmark and conducted from May 2015 until February 2017. PARTICIPANTS: A total of 34 patients were randomised in an investigator-initiated, assessor-blinded crossover design of deep vs. no NMB during laparoscopic ventral hernia repair. INCLUSION CRITERIA: Adults scheduled for elective laparoscopic ventral hernia repair. EXCLUSION CRITERIA: Known allergy to any study medication, known homozygous variants in the butyrylcholinesterase gene, severe renal disease, neuromuscular disease, lactating or pregnant women, any indication for rapid sequence induction. INTERVENTIONS: Deep NMB was established with rocuronium and reversed with sugammadex. Anaesthesia was conducted with propofol and remifentanil. MAIN OUTCOME MEASURES: The primary outcome was evaluation of surgical view assessed on a five-point rating scale. Other outcomes included the surgical conditions during laparoscopic suturing of the hernia defect. RESULTS: We found no difference in ratings for the surgical view when comparing deep with no NMB: mean -0.1 (95% confidence interval -0.4 to 0.2) (P = 0.521, paired t test). However, deep compared with no NMB improved the rating score for surgical conditions while suturing the hernia defect (P = 0.012, Mann-Whitney U test). No differences were found in either total length of surgery (P = 0.76) or hernia suturing time (P = 0.81). CONCLUSION: Deep compared with no NMB did not change the rating score of the surgical view immediately after introduction of trocars during laparoscopic ventral hernia repair, but the surgical condition were improved during suturing of the hernia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02247466.

Frequency of inadequate neuromuscular blockade during general anesthesia.

STUDY OBJECTIVE: We used electronic health record data to define frequency of inadequate intraoperative neuromuscular blockade (NMB). DESIGN: Retrospective observational study using electronic health record data. SETTING: Operating room in a tertiary care academic hospital. PATIENTS: A total of 129,209 adult patients with American Society of Anesthesiologists physical status 1 to 5 undergoing general anesthesia in an outpatient or inpatient setting who received nondepolarizing NMB. We excluded patients intubated before arrival to the operating room, patients undergoing a liver transplant or cardiac surgery, and patients who remained intubated at the end of the operation. INTERVENTIONS: None. MEASUREMENTS: The primary outcomes were inadequate NMB defined by (1) documentation of patient movement and (2) documentation of surgical request for additional NMB, followed by NMB agent administration. MAIN RESULTS: A total of 1261 patients (1.0%) demonstrated either intraoperative movement (369 or 0.29%) or prompted surgical request for additional NMB agent (921 or 0.71%). Trend analysis showed a variation in the annual rate of inadequate NMB, with an increase from 2004 to 2013 for criteria 1 and 2. CONCLUSIONS: Nearly 1% of all general anesthetic procedures involving NMB exhibit inadequate relaxation resulting in procedural interruption. These data suggest that current use of neuromuscular blocking drugs and NMB monitoring expose patients to inadequate blockade. The risk of this phenomenon warrants further study.

Adjuvants to Mechanical Ventilation for Acute Respiratory Failure. Adoption, De-adoption, and Factors Associated with Selection.

RATIONALE: Adoption and de-adoption of adjuvant strategies to mechanical ventilation for acute respiratory failure (ARF), and factors associated with their selection, have not been extensively evaluated. OBJECTIVES: To evaluate change in use of adjuvants to mechanical ventilation for ARF (2008-2013), the impact of landmark publications on adoption and de-adoption, and factors associated with use. METHODS: Changes in use of four adjuvants for ARF from 2008 to 2013, the impact of landmark publications on use, and factors associated with use were evaluated with the Premier Database. Extracorporeal membrane oxygenation (ECMO), inhaled nitric oxide, inhaled epoprostenol, and continuous neuromuscular blockading agents (cNMBAs) in adult mechanically ventilated patients were identified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes and billing data. MEASUREMENTS AND MAIN RESULTS: Among 514,913 patients with ARF, 11,567 (2.3%) were treated with at least one adjuvant. cNMBAs were the most frequently used adjuvants (n = 10,073, 2.1% in capable hospitals), followed by inhaled pulmonary vasodilators (n = 1,878, 1.0% in capable hospitals; 58% nitric oxide), and ECMO (n = 195, 0.2% in capable hospitals). There was an increase in ECMO and inhaled epoprostenol over time but no change in nitric oxide or cNMBAs. Segmented regression analysis was used to evaluate whether clinical practice was in accordance with emerging evidence from landmark studies. Using the relevant landmark publication dates, these analyses did not reveal any change in use over time after publication with the exception of inhaled epoprostenol-for which rates of growth decreased over time, possibly in response to the evidence. There was a significant amount of variability in patient and hospital factors associated with use with between adjuvants. CONCLUSIONS: Between 2008 and 2013, there was an increase in use of ECMO and inhaled epoprostenol, and no change in use of inhaled nitric oxide or continuous intravenous infusion of a neuromuscular blocking agent. There was considerable variability in patient and hospital factors associated with use across different adjuvants.

The Impact of Residual Neuromuscular Blockade, Oversedation, and Hypothermia on Adverse Respiratory Events in a Postanesthetic Care Unit: A Prospective Study of Prevalence, Predictors, and Outcomes.

BACKGROUND: Residual neuromuscular blockade (RNMB) has been linked to adverse respiratory events (AREs) in the postanesthetic care unit (PACU). However, these events are often not attributed to RNMB by anesthesiologists because they may also be precipitated by other factors including obstructive sleep apnea, opioids, or hypnotic agents. Many anesthesiologists believe RNMB occurs infrequently and is rarely associated with adverse outcomes. This study evaluated the prevalence and predictors of RNMB and AREs. METHODS: This prospective cohort study included 599 adult patients undergoing general anesthesia who received neuromuscular blocking agents. Baseline demographic, surgical, and anesthetic variables were collected. RNMB was defined as a train-of-four ratio below 0.90 measured by electromyography on admission to the PACU. AREs were defined based on the modified Murphy's criteria. RESULTS: RNMB was present in 186 patients (31% [95% confidence interval (CI), 27%-35%]) on admission to the PACU. One or more AREs were experienced by 97 patients (16% [95% CI 13-19]). AREs were more frequent in patients with RNMB (21% vs 14%, P = .033). RNMB was significantly associated with age (adjusted relative risk [RR], 1.17 [95% CI, 1.06-1.29] per 10-year increase), type of operation (adjusted RR, 0.59 [95% CI, 0.34-0.99] for laparoscopic surgery compared with open abdominal surgery), and duration of operation (adjusted RR, 0.59 [95% CI, 0.39-0.86] for ≥90 minutes compared with <90 minutes). Using multivariate logistic regression, AREs were found to be independently associated with decreased level of consciousness (adjusted RR, 4.76 [95% CI, 1.49-6.76] for unrousable/unconscious compared with alert/awake) and lower core temperature (adjusted RR, 1.43 [95% CI, 1.04-1.92] per 1°C decrease). Although univariate analysis found a significant association between AREs and RNMB, the significance became borderline after adjusting for other covariates (adjusted RR, 1.46 [95% CI, 0.99-2.08]). CONCLUSIONS: The prevalence of RNMB in the PACU was >30%. Older age, open abdominal surgery, and duration of operation <90 minutes were associated with increased risk of RNMB in our patients. Our RR estimate for AREs was highest for depressed level of consciousness. When AREs occur in the PACU, potentially preventable causes including RNMB, hypothermia, and reduced level of consciousness should be readily identified and treated appropriately. Delaying extubation until the patient is awake and responsive may reduce AREs.

Kinesiotaping. Evidencia actual / Kinesiotaping. Current evidence

En este artículo se revisa la función y el uso de los vendajes tipo Kinesiotaping en la medicina deportiva actual y la Ortopedia. Se estudian las diferentes lesiones dentro de la medicina del deporte en la cual se pueden usar y la evidencia clínica existente. Esta revisión concluye que la utilidad del kinesiotaping es confusa. La literatura no aporta evidencia clínica probada sobre el uso de este vendaje e incluso podría intuirse un fin mercantilista en su uso

This paper reviews the function and use of Kinesiotaping in today’s Sports Medicine and Orthopedics. The different sports medicine injuries in which could be used and the current clinical evidence are reviewed. This review concludes the utility of Kinesiotaping is not clear. Literature shows lack of proved clinical evidence about the use of this bandage and even a mercantilist purpose could be suspected

Do we really need sugammadex as an antagonist of muscle relaxants in anesthesia?

PURPOSE OF REVIEW: Sugammadex is a selective relaxant-binding agent that is designed to encapsulate rocuronium and chemically similar steroidal muscle relaxants such as vecuronium. This review summarizes recent information on the use of sugammadex in clinical practice. RECENT FINDINGS: The main advantages of sugammadex when compared with conventional anticholinesterase agents are a much faster recovery time and its unique ability to reverse rapidly and efficiently, for the first time, deep levels of neuromuscular blockade. However, there is paucity of evidence-based studies on the benefit of deep neuromuscular block, and then routine administration of sugammadex to reverse any level of block, for example, during laparoscopic surgery. It appears that reduction of costs depends mainly on organizational factors. Finally it must be remembered that sugammadex only works with steroidal nondepolarizing muscle relaxants; therefore neostigmine should not be withdrawn because it is the only reversal agent effective against atracurium or cisatracurium. SUMMARY: Sugammadex offers a significantly faster and more predictable recovery profile than neostigmine. It is now possible to reverse rapidly and efficiently any level of neuromuscular blockade and to avoid the risk of adverse events because of residual paralysis such as critical respiratory events during recovery from anesthesia.

Should we maintain deep-moderate neuromuscular block until the end of laparoscopic surgery? The evidence and a clash of strong opinions / ¿Se debería mantener un bloqueo neuromuscular profundo-moderado hasta completar las intervenciones laparoscópicas? Los hallazgos y el choque de posturas definidas

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Reversal of moderate and intense neuromuscular block induced by rocuronium with low doses of sugammadex for intraoperative facial nerve monitoring

We report two cases in which moderate and intense rocuronium-induced neuromuscular block was reversed intraoperatively with low sugammadex doses in order to facilitate electromyographic evaluation of facial nerve function during surgery of the parotid gland and the middle ear. Acceleromyography was used to assess reversal of neuromuscular block before starting electromyography monitoring. Rocuronium-induced neuromuscular block was reversed with sugammadex 0.22mgkg−1 when the TOF ratio was 0.14 in the first patient, and with sugammadex 2mgkg−1 during intense block (PTC 0) in the second patient. In each case, appropriate neuromuscular function (TOF ratio ≥ 0.9) was established soon after sugammadex administration, and electromyographic evaluation of facial nerve was successfully conducted. The use of rocuronium and sugammadex, coupled with objective neuromuscular monitoring with acceleromyography, assured complete restoration of neuromuscular function and created the optimal conditions for the surgical team

Presentamos 2 casos con bloqueo neuromuscular superficial e intenso inducidos por rocuronio y revertidos intraoperatoriamente con dosis bajas de sugammadex para facilitar la evaluación de la función del nervio facial mediante electromiografía durante la cirugía de la glándula parótida y oído. La aceleromiografía se utilizó para poder valorar el grado de bloqueo neuromuscular antes del comienzo de la electromiografía y para titular la dosis baja apropiada del antagonista. El bloqueo neuromuscular se revirtió con sugammadex 0,22 mgkg−1 para un ratio del tren de 4 (TOFr) de 0,14 en el primer paciente y con sugammadex 2 mgkg−1 durante un bloqueo intenso (PTC 0) en el segundo paciente. La recuperación completa de la función neuromuscular (TOFr ≥ 0,9) se alcanzó después de la administración de sugammadex en ambos casos. La evaluación mediante electromiografía del nervio facial se realizó con éxito después de la reversión con sugammadex. El uso de rocuronio y de sugammadex a dosis bajas, asociado con monitorización objetiva por medio de aceleromiografía, aseguró el restablecimiento completo de la función neuromuscular y permitió condiciones óptimas de trabajo para el equipo quirúrgico

[Peripheric blockades in plastic and reconstructive surgery: up-to-date trends and prospects (a 30-year experience)].

The article presents the own 30-year experience in the use of more than 1000 prolonged peripheral nerves and plexus block anaesthesia in reconstructive surgery, based on experimental and clinical studies. The evolution peripheric blockades technique is given:from a separate anaesthesia method to balanced anesthesia based on peripheric blockades. The current state of the problem was analyzed according to the literature.