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

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.

Successful pre-emptive emergency management of a compromised airway with a Proseal™ Laryngeal Mask Airway followed by tracheostomy.

Following hemi-glossectomy and right neck dissection a 63-year-old female patient presented as an emergency with a large neck hematoma. There were significant concerns over difficulty in intubation and mask ventilation leading to deterioration into a cannot intubate cannot ventilate (CICV) situation. After careful discussion and planning with the surgical team, who planned a tracheostomy, the situation was salvaged using a ProSealTM Laryngeal Mask Airway (PLMA). The PLMA enabled rapid establishment of a clear airway early in anesthetic induction, controlled ventilation and safe airway maintenance during a difficult tracheostomy.

Managing perioperative neuromuscular block. Facial muscle monitoring may lead to faulty clinical decisions

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Efecto techo de la neostigmina: valor de la monitorización neuromuscular en su diagnóstico / Utility of neuromuscular monitoring to diagnose neostigmine ceiling effect

No disponible

Recomendaciones para el manejo de la vía aérea difícil mediante dispositivos extraglóticos en el paciente adulto sometido a cirugía ambulatoria / No disponible

No disponible

[Phase II blockade after a subclinical dose of succinylcholine: importance of neuromuscular monitoring]. / Bloqueo fase II después de una dosis subclínica de succinilcolina. Importancia de la monitorización neuromuscular.

Neuromuscular monitoring is not a routine practice in clinical settings worldwide. The little interest expressed is mainly because clinicians lack information and documentation, even though the literature on the subject is vast and experts agree that routine monitoring reduces morbidity related to the use of neuromuscular blockers. We report a case of an unusual phase II neuromuscular block from a subclinical dose of succinylcholine. The blockade lasted longer than expected in a patient with diminished plasma cholinesterase activity. We emphasize that monitoring neuromuscular function aided diagnosis and observation of the block during emergency surgery.

[Neuromuscular blockade monitoring. Part 1]. / Monitorización del bloqueo neuromuscular. 1a parte.

Many recent studies have underlined the importance of quantitative neuromuscular monitoring and the high incidence of residual block in clinical practice in spite of the use of nondepolarizing neuromuscular blockers of intermediate duration. Neuromuscular monitoring facilitates the tailoring of the muscular paralysis and appropriate patient recovery at the end of surgery. Monitoring also controls or prevents residual block and serves to guide the use of reversing agents. This review describes the physiology of neuromuscular junctions as well as the principles and patterns of nerve stimulation and clinical monitoring. In addition to drawing on their own experience, the authors have reviewed the literature available through evidence-based indexes and other databases up to December 2008. Most references found were case series and reviews. Quantitative monitoring is an evidence-based practice that should be applied in all situations in which a neuromuscular block is established.

Bloqueo fase II después de una dosis subclínica de succinilcolina. Importancia de la monitorización neuromuscular / Phase II blockade after a subclinical dose of succinylcholine: importance of neuromuscular monitoring

La monitorización neuromuscular es una práctica clínicapoco habitual en todo el mundo. Existe poco interésfundamentado en la falta de información y documentación.Aún así la enorme literatura publicada y los expertosestán de acuerdo en que la monitorización rutinariadisminuye la morbilidad relacionada con el uso de losbloqueantes neuromusculares. Describimos un caso debloqueo neuromuscular por succinilcolina a dosis subclínicas,más prolongado de lo esperable en un pacientecon actividad colinesterásica plasmática reducida, quedesarrolló un bloqueo en fase II, fenómeno poco habitual.Queremos hacer énfasis en la ayuda que aportó lamonitorización de la función neuromuscular como diagnósticoy observación del bloqueo neuromuscular en elcontexto de la cirugía de urgencias(AU)

Neuromuscular monitoring is not a routine practice inclinical settings worldwide. The little interest expressedis mainly because clinicians lack information anddocumentation, even though the literature on the subjectis vast and experts agree that routine monitoringreduces morbidity related to the use of neuromuscularblockers. We report a case of an unusual phase IIneuromuscular block from a subclinical dose ofsuccinylcholine. The blockade lasted longer thanexpected in a patient with diminished plasmacholinesterase activity. We emphasize that monitoringneuromuscular function aided diagnosis and observationof the block during emergency surgery(AU)

Monitorización del bloqueo neuromuscular. 1ª parte / Neuromuscular blockade monitoring. Part 1

En recientes publicaciones han aparecido múltiplesestudios sobre la importancia de la monitorizaciónneuromuscular cuantitativa y la alta incidencia delbloqueo residual en la práctica clínica, a pesar de lautilización de fármacos bloqueantes neuromusculares nodespolarizantes de duración intermedia. El uso de lamonitorización neuromuscular permite realizar unaparálisis muscular a medida y recuperar al pacienteadecuadamente al final de la cirugía, evitando ocontrolando el bloqueo residual, y sirviendo de guía parala utilización de los reversores de dicho bloqueo. Estarevisión describe específicamente la fisiología de la uniónneuromuscular, principios, patrones de estimulación ypráctica de la monitorización neuromuscular en laclínica. Además de la propia experiencia de los autoresen el uso de la monitorización neuromuscular, se harealizado una revisión de la literatura médica existentehasta diciembre de 2008 mediante una búsqueda en lasbases de datos de medicina basada en la evidencia, y enlas bases de datos bibliográficas. La mayor parte de lasreferencias encontradas son series de casos y revisiones.La monitorización cuantitativa es una práctica basadaen la evidencia que debe consecuentemente utilizarsesiempre que se utiliza un bloqueo neuromuscular(AU)

Many recent studies have underlined the importanceof quantitative neuromuscular monitoring and the highincidence of residual block in clinical practice in spite ofthe use of nondepolarizing neuromuscular blockers ofintermediate duration. Neuromuscular monitoringfacilitates the tailoring of the muscular paralysis andappropriate patient recovery at the end of surgery.Monitoring also controls or prevents residual block andserves to guide the use of reversing agents. This reviewdescribes the physiology of neuromuscular junctions aswell as the principles and patterns of nerve stimulationand clinical monitoring. In addition to drawing on theirown experience, the authors have reviewed the literatureavailable through evidence-based indexes and otherdatabases up to December 2008. Most references foundwere case series and reviews. Quantitative monitoring isan evidence-based practice that should be applied in allsituations in which a neuromuscular block is established(AU)

Monitorización del bloqueo neuromuscular. 2ª parte / No disponible

No disponible

Sobre la extubación, la curarización residual y sus circunstancias / No disponible

No disponible

A case series of the use of the ProSeal laryngeal mask airway in emergency lower abdominal surgery.

The ProSeal laryngeal mask airway (PLMA) has been used routinely for anaesthesia and for difficult airway management including airway rescue in non-fasted patients. Compared with the classic laryngeal mask airway the PLMA increases protection against gastric inflation and pulmonary aspiration, by separating the respiratory and gastro-intestinal tracts. The PLMA has potential advantages over use of the tracheal tube including smoother recovery, reduced pharyngolaryngeal morbidity and even reduced postoperative pain. We report a series of patients scheduled for emergency appendicectomy, without other risk factors for regurgitation, managed with the PLMA. Anaesthesia was induced and maintained with remifentanil, target controlled propofol and rocuronium. A series of 102 cases were managed without complications and high rates of first time placement of the PLMA (inserted over a suction tube placed in the oesophagus). With careful patient selection the PLMA may offer an alternative airway for use by experienced anaesthetists in patients undergoing minor lower abdominal surgery.