Safety and Efficacy of Rocuronium With Sugammadex Reversal Versus Succinylcholine in Outpatient Surgery-A Multicenter, Randomized, Safety Assessor-Blinded Trial.

Complex surgical procedures are increasingly performed in an outpatient setting, with emphasis on rapid recovery and case turnover. In this study, the combination of rocuronium for neuromuscular blockade (NMB) reversed by single-dose sugammadex was compared with succinylcholine followed by spontaneous recovery in outpatient surgery. This multicenter, randomized, safety assessor-blinded study enrolled adults undergoing a short elective outpatient surgical procedure requiring NMB and tracheal intubation. Patients were randomized to NMB with either rocuronium 0.6 mg/kg for tracheal intubation with incremental doses of rocuronium 0.15 mg/kg and subsequent reversal with sugammadex 4.0 mg/kg at 1-2 posttetanic counts or succinylcholine 1.0 mg/kg for intubation with spontaneous recovery. The primary efficacy end point was the time from sugammadex administration to recovery of the train-of-four ratio to 0.9; for succinylcholine, time from administration to recovery of the first twitch (T1) to 90% was assessed. From 167 patients enrolled, 150 received treatment. The all-subjects-treated population comprised 70 patients in the rocuronium-sugammadex group and 80 in the succinylcholine group. Geometric mean (95% confidence interval) time from the start of sugammadex administration to recovery of the train-of-four ratio to 0.9 was 1.8 (1.6-2.0) minutes. Geometric mean (95% confidence interval) time from succinylcholine administration to recovery of T1 to 90% was 10.8 (10.1-11.5) minutes. Health outcome variables were similar between the groups. Adverse events were reported in 87.1% and 93.8% of patients for rocuronium-sugammadex and succinylcholine, respectively. In conclusion, rocuronium for intubation followed by sugammadex for reversal of NMB offers a viable treatment option in outpatient surgery without prolonging recovery duration or jeopardizing safety.

The increases in potassium concentrations are greater with succinylcholine than with rocuronium-sugammadex in outpatient surgery: a randomized, multicentre trial.

BACKGROUND: Succinylcholine provides rapid onset of neuromuscular blockade and short duration of action, but its administration may be associated with hyperkalemia. Rocuronium is not known to increase potassium concentration, has fast onset of activity, and can be rapidly reversed by sugammadex. This study evaluated changes in plasma potassium concentrations in patients randomized either to rocuronium followed by sugammadex reversal or to succinylcholine in ambulatory surgery. METHODS: In this multicentre randomized active-controlled study, adult patients undergoing short surgical procedures in an outpatient setting received either rocuronium 0.6 mg·kg(-1) for intubation with sugammadex 4.0 mg·kg(-1) for reversal (n = 70) or succinylcholine 1.0 mg·kg(-1) with spontaneous recovery (n = 80). Blood potassium concentrations were assessed at baseline (before study drug administration) and at intervals up to 15 min after rocuronium, sugammadex, and succinylcholine. RESULTS: At the primary endpoint, five minutes post-administration, the changes in potassium concentrations from baseline were significantly smaller in patients treated with rocuronium than in those given succinylcholine [mean (SD): -0.06 (0.32) vs 0.30 (0.34) mmol·L(-1), respectively; P < 0.0001]. At baseline, potassium concentrations were similar in both groups, but they were greater at two, five, ten, and 15 min after succinylcholine than after rocuronium (P < 0.0001) for all time points. After sugammadex administration, there were no significant changes in mean potassium concentration from the pre-rocuronium baseline. No adverse effects related to hyperkalemia were observed. CONCLUSION: Succinylcholine was associated with a modest increase in potassium concentration; these changes were not seen after rocuronium or sugammadex ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00751179).

Recovery after ambulatory anesthesia.

PURPOSE OF REVIEW: The purview of ambulatory anesthesia continues to broaden in response to national interest in controlling healthcare costs and eliminating unnecessarily expensive hospital stays. Recent advances in anesthesia allow us to minimize side effects and complications of anesthesia and surgery that might otherwise delay recovery and discharge. The purpose of this review is to highlight some of these latest advances in clinical care that may soon change how we practice. RECENT FINDINGS: In many instances, hospitalization has been necessary to permit adequate control of pain and opioid-related side effects after surgery. A variety of multimodal analgesic techniques are described in this review (including alpha-2 agonists, beta-blockers,corticosteroids, cyclo-oxygenase 2 inhibitors, and regional anesthetic blocks) that reduce requirements for opioids, thereby eliminating some of the undesirable opioid related side effects. New antiemetic recommendations are included for management and prevention of postoperative nausea and vomiting. In addition, novel ways of reversing the effects of some anesthetic drugs (inhalational anesthetics and muscle relaxants) are described. SUMMARY: The research and advances in clinical care described will likely influence how we manage our patients in the future, eliminating the need for prolonged hospital stay after surgery.

Effects of bispectral index monitoring on recovery from surgical anesthesia in 1,580 inpatients from an academic medical center.

BACKGROUND: The purpose of this study was to determine whether monitoring Bispectral Index (BIS) would affect recovery parameters in patients undergoing inpatient surgery. METHODS: Anesthesia providers (n = 69) were randomly assigned to one of two groups, a BIS or non-BIS control group. A randomized crossover design was used, with reassignment at monthly intervals for 7 months. Duration of time in the postanesthesia care unit, time from the end of surgery to leaving the operating room, and incidence of delayed recovery (> 50 min in recovery) were compared in patients treated intraoperatively with or without BIS monitoring. Data were analyzed by analysis of variance, unpaired t test, or chi-square test as appropriate. RESULTS: One thousand five hundred eighty patients in an academic medical center were studied. The mean BIS in the monitored group was 47. No differences were found in recovery parameters between the BIS-monitored group and the control group when comparisons were made using all subjects or when data were analyzed within anesthetic subgroups stratified by anesthetic agent or duration of anesthesia. There were some small reductions in the intraoperative concentration of sevoflurane (but not isoflurane). CONCLUSIONS: The use of BIS monitoring for inpatients undergoing a wide variety of surgical procedures in an academic medical center had some minor effects on intraoperative anesthetic use but had no impact on recovery parameters.