Is 1 mg/kg of sugammadex sufficient to reverse moderate neuromuscular block? A randomized clinical trial / ¿Es suficiente 1mg/kg de sugammadex para revertir el bloqueo neuromuscular moderado? Ensayo clínico aleatorizado

Abstract Background: Sugammadex has made it possible to reverse any type of rocuronium-induced block quickly and safely. The most frequent neuromuscular blockade is the moderate one where doses smaller than those recommended by the industry could get a full reversal. Objective: We aimed to evaluate the effectiveness of half the industry recommended dose of sugammadex to reverse a moderate neuromuscular block. Methods: Unicenter phase IV clinical trial that included 34 patients undergoing laparoscopic cholecystectomy. Intravenous general anesthesia was induced, with acceleromyographic monitoring of the neuromuscular block. After the intervention, the block was reversed with all or half the dose of sugammadex recommended for moderate blocks, using a blinded syringe. Results: Patient characteristics of the 2 groups were similar. Mean time to recovery was 3.6± 1.7minutes for the study group and 3.1 ± 1.7minutes for the control group (P=0.42). Reversal of the block was complete with a single dose of sugammadex in all patients. There was an important linear correlation between depth of block and time to recovery. Conclusion: Intraoperative monitoring is essential to allow us to individualize the dose of the neuromuscular blocking agent. To reverse a moderate block under neuromuscular monitoring, a dose of 1 mg/kg is sufficient in most cases and is equally safe and effective.

Resumen Introducción: El sugammadex permite revertir cualquier tipo de bloqueo inducido por rocuronio de forma rápida y segura. El bloqueo neuromuscular más frecuente es el moderado, en el cual dosis inferiores a las recomendadas por la industria podrían revertirlo completamente. Objetivo: Evaluar la efectividad de la mitad de la dosis de sugammadex recomendada por la industria para revertir un bloqueo neuromuscular moderado. Métodos: Ensayo clínico de fase IV en un unico centro que incluyó a 34 pacientes intervenidos de colecistectomía laparoscópica. Se realizó anestesia general intravenosa con monitoreo aceleromiográfico del bloqueo neuromuscular. Tras la intervención, el bloqueo se revirtió con la totalidad o con la mitad de la dosis de sugammadex recomendada para bloqueos moderados, utilizando una jeringa ciega. Resultados: Las características de los pacientes de los dos grupos fueron similares. La media de tiempo de recuperación fue de 3,6 ± 1,7 minutos para el grupo de estudio y de 3,1 ± 1,7 minutos para el grupo de control (p = 0,42). La reversión del bloqueo se completó con una dosis única de sugammadex en todos los pacientes. Hubo una correlación lineal importante entre la profundidad del bloqueo y el tiempo de recuperación. Conclusión: El monitoreo transquirúrgico es esencial para individualizar la dosis del agente de bloqueo neuromuscular. Para revertir un bloqueo moderado bajo monitoreo neuromuscular, una dosis de 1mg/kg es suficiente e igualmente segura y efectiva.

Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty.

PURPOSE: To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics. METHODS: Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols. RESULTS: A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 ± 1.5 vs. 1.7 ± 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups. CONCLUSION: Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used. LEVEL OF EVIDENCE: I.

Estudio multicéntrico sobre el manejo del bloqueo neuromuscular durante la anestesia general en una cohorte de 1.545 pacientes / Neuromuscular block management during general anesthesia in a cohort of 1545 patients: a multicenter study

Introducción: tradicionalmente se ha relacionado el uso de bloqueantes neuromusculares con la posibilidad de aparición de complicaciones respiratorias, aunque establecer este tipo de conclusiones requiere de la elaboración de estudios complejos, con una muestra importante. En este estudio se pretende analizar los datos obtenidos del estudio ARISCAT para ofrecer una visión global del uso de bloqueantes neuromusculares (BNM) y de su reversión en Cataluña. Material y Métodos: de los datos obtenidos en el estudio ARISCAT se han analizado los relacionados con el uso de BNM. Se agruparon a los pacientes en cuatro grupos: NO-BNM si no se había administrado ningún BNM, SC si los pacientes habían recibido únicamente succinilcolina como BNM, BNM-DU si habían recibido una única dosis de BNM no despolarizante y BNM-DR más de una dosis de BNM no despolarizante o administración en perfusión continua. Se analizaron las características demográficas, clínicas y quirúrgicas y las complicaciones intra y postoperatorias en cada uno de los grupos. También se analizaron estas variables en función de si hubo o no reversión. Resultados: de los 2991 pacientes incluidos en el estudio ARISCAT, 1545 fueron sometidos a anestesia general o combinada. De éstos, 1267 (89%) recibieron BNM y en el 54.4% de ellos se realizó reversión con anticolinesterásicos. La distribución de los pacientes fue: NO-BNM (n=103), SC (n=31), BNM-DU (n=527) y BNM DR (n=709). Este último grupo presentó más patología asociada, una duración más prolongada de la cirugía, un mayor número de complicaciones intra y postoperables, y una mayor estancia hospitalaria. La reversión fue significativamente más frecuente en cirugía cardiotorácica y abdominal superior. No se encontraron diferencias en las complicaiones entre ambos grupos. Conclusiones: el uso de bloqueantes neuromusculares no despolarizantes es muy frecuente en Cataluña durante la anestesia general y está asociado a la duración y el tipo de cirugía. El uso de reversión farmacológica de los BNM es relativamente alto en Cataluña respecto a otras zonas geográficas (AU)

BACKGROUND AND OBJECTIVE: Neuromuscular blockers (NMBs) have traditionally been thought to increase the risk of respiratory complications, although drawing conclusions in this respect would require complex studies in large patient samples. The aim of this study was to analyze data from the ARISCAT study to obtain an overall picture of how NMBs are being used and blocks are reversed in Catalonia, Spain. MATERIAL AND METHODS: NMB use as reflected in data from the ARISCAT study was analyzed. Case information from the database was organized into 4 groups: for patients not receiving a NMB (No-NMB), patients whose NMB block was performed with succinylcholine alone (SC), patients who received a single dose of a nondepolarizing NMB (SD-NMB), and patients who received additional doses of a nondepolarizing NMB or a continuous perfusion (AD-NMB). We analyzed patient characteristics, clinical and surgical characteristics, and complications during and after surgery in each of the groups. Variables were also analyzed according to whether the NMB effect had to be reversed. RESULTS: Of the 2991 patients included in the ARISCAT study, 1545 received general or combined anesthesia. Of the 1545 patients, 1267 (89%) received a NMB and the block was reversed with an anticholinesterase agent in 54%. The group distribution was as follows: No-NMB, 103 patients; SC, 31; SD-NMB, 527; and AD-NMB, 709. The highest rate of comorbidity, longest duration of surgery, highest rate of complications during and after surgery, and the longest hospital stays were observed in the last of the 4 groups (AD-NMB). Reversion was required significantly more often after cardiothoracic and upper abdominal surgical procedures; the complication rates after those 2 types of surgery were statistically similar. CONCLUSIONS: Nondepolarizing NMBs are used in combination with general anesthesia often in Catalonia; their use is associated with duration and type of surgery. A reversal drug is administered relatively more often in Catalonia than in other geographic areas (AU)

[Ambulatory anesthesia in Catalonia, Spain]. / Anestesia ambulatoria en Cataluña.

BACKGROUND AND OBJECTIVE: The aim of this arm of the ANESCAT study was to describe the characteristics of ambulatory anesthesia in Catalonia, Spain. PATIENTS AND METHOD: Relevant data was extracted from a survey of anesthetic procedures in 131 public, publicly contracted, and private hospitals on 14 representative days in 2003. RESULTS: Of the estimated 603,189 anesthesias performed, 206,992 (34.32%; 95% confidence interval, 33.3%-35.4%) were on outpatients. The median (10th to 90th percentile) age of patients was 59 (22-80) years and 56.6% were women. The physical status of patients according to the American Society of Anesthesiologists (ASA) classification was ASA I or II for 75.1% of the patient sample. The most common approach to anesthesia was sedation/monitoring (47.7%), followed by regional anesthesia (28.9%). The types of regional anesthesia reported most often were peri- or retrobulbar blocks (50.8% of the regional blocks), followed by spinal anesthesia (22.2%). Anesthesia was required for surgery in 76.5% of the cases and for diagnostic or other nonsurgical procedures in 22%. The individual surgical specialties creating the greatest demand for anesthetic procedures were ophthalmology (39%) and orthopedic and trauma surgery (10.9%). The specific interventions accounting for the largest percentages of anesthetic procedures were cataract extraction (32.3%) and digestive tract endoscopy (16.7%). In 8.2% of the cases, patients did not require a stay in the postanesthetic recovery unit. Private hospitals, facilities with fewer than 250 beds, and those not accredited to provide medical resident training had higher rates of ambulatory anesthesia. CONCLUSIONS: Ambulatory procedures account for approximately a third of the anesthesia workload in Catalonia. Sedation/monitoring and regional anesthesia are the approaches that predominate in this category. Ambulatory anesthesia is applied mainly in ophthalmology and the rate of endoscopic procedures requiring outpatient anesthesia is also high.

Anestesia ambulatoria en Cataluña / Ambulatory anesthesia in Catalonia, Spain

Fundamento y objetivo: Describir las características de la anestesia ambulatoria en Cataluña (España) en 2003. Pacientes y método: Datos referentes a anestesia de la encuesta epidemiológica ANESCAT 2003, basada en los actos anestésicos realizados en 131 hospitales públicos, concertados y privados de Cataluña durante 14 días representativos del año 2003. Resultados: De la estimación de 603.189 anestesias realizadas, 206.992 (34,32%; intervalo de confianza del 95%, 33,3-35,4%) fueron ambulatorias. La edad mediana (percentiles 10-90) de los pacientes fue de 59 (22-80) años y el 56,6% eran mujeres. El 75,1% correspondió a pacientes con clase 1 o 2 de la clasificación de la American Society of Anesthesiologists (ASA). La sedación/vigilancia fue la forma de anestesia más frecuente (47,7%), seguida de la anestesia regional (28,9%); de esta última, las técnicas más utilizadas fueron los bloqueos peri/retrobulbares (un 50,8% de las anestesias regionales), seguidos de la anestesia subaracnoidea (22,2%). El 76,5% de las anestesias se aplicaron para intervenciones quirúrgicas y el 22% para exploraciones o procedimientos no quirúrgicos. Las especialidades quirúrgicas más implicadas fueron la oftalmología (39%) y la cirugía ortopédica y traumatología (10,9%). Los procedimientos más frecuentes fueron la cirugía de cataratas (32,3%) y las endoscopias digestivas (16,7%). El 8,2% de los pacientes no requirió recuperación postanestésica. El índice de anestesias ambulatorias fue superior en hospitales privados, de tamaño inferior a 250 camas y sin docencia de programa de residencia. Conclusiones: La anestesia ambulatoria en Cataluña supone aproximadamente la tercera parte de todas las anestesias, con predominio de la sedación/vigilancia y anestesia regional. Se aplica principalmente a cirugía oftalmológica y tiene una importante tasa de procedimientos endoscópicos

Background and objective: The aim of this arm of the ANESCAT study was to describe the characteristics of ambulatory anesthesia in Catalonia, Spain. Patients and method: Relevant was extracted from a survey of anesthetic procedures in 131 public, publicly contracted, and private hospitals on 14 representative days in 2003. Results: Of the estimated 603,189 anesthesias performed, 206,992 (34.32%; 95% confidence interval, 33.3%-35.4%) were on outpatients. The median (10th to 90th percentile) age of patients was 59 (22-80) years and 56.6% were women. The physical status of patients according to the American Society of Anesthesiologists (ASA) classification was ASA I or II for 75.1% of the patient sample. The most common approach to anesthesia was sedation/monitoring (47.7%), followed by regional anesthesia (28.9%). The types of regional anesthesia reported most often were peri- or retrobulbar blocks (50.8% of the regional blocks), followed by spinal anesthesia (22.2%). Anesthesia was required for surgery in 76.5% of the cases and for diagnostic or other nonsurgical procedures in 22%. The individual surgical specialties creating the greatest demand for anesthetic procedures were ophthalmology (39%) and orthopedic and trauma surgery (10.9%). The specific interventions accounting for the largest percentages of anesthetic procedures were cataract extraction (32.3%) and digestive tract endoscopy (16.7%). In 8.2% of the cases, patients did not require a stay in the postanesthetic recovery unit. Private hospitals, facilities with fewer than 250 beds, and those not accredited to provide medical resident training had higher rates of ambulatory anesthesia. Conclusions: Ambulatory procedures account for approximately a third of the anesthesia workload in Catalonia. Sedation/monitoring and regional anesthesia are the approaches that predominate in this category. Ambulatory anesthesia is applied mainly in ophthalmology and the rate of endoscopic procedures requiring outpatient anesthesia is also high