El bloqueo del plano del músculo erector espinal antes de la litotricia extracorpórea por ondas de choque reduce el tiempo de fluoroscopia y facilita el tratamiento de la litiasis renal: estudio prospectivo aleatorizado / Erector spinae plane block prior to extracorporeal shock wave lithotripsy decreases fluoroscopy time and promise a comfortable procedure for renal stones: a prospective randomized study

Introducción y objetivos Comparar la eficacia del bloqueo del plano del erector espinal (BPEE) y el diclofenaco sódico intramuscular (IM) en términos del manejo del dolor y su impacto sobre el estado libre de cálculos en pacientes sometidos a litotricia extracorpórea de ondas de choque (LEOCh). Pacientes y materiales El estudio incluyó a pacientes sometidos a LEOCh por litiasis renal en nuestro centro. Los pacientes fueron asignados aleatoriamente a los grupos de BPEE (Grupo 1: n = 31) y de 75 mg de diclofenaco sódico IM (Grupo 2: n = 30). Se registraron los datos demográficos de los pacientes, el tiempo de fluoroscopia durante la LEOCh, el número de focalizaciones, el total de disparos administrados, el voltaje, las tasas libre de cálculos (TLC), el método de analgesia, el número de sesiones de LEOCh, la puntuación de la Escala Visual Analógica (EVA) la localización de los cálculos, el tamaño máximo de los cálculos, el volumen de los cálculos y las unidades Hounsfield (UH). Resultados Un total de 61 pacientes fueron incluidos en el estudio. No hubo diferencias estadísticamente significativas entre los dos grupos en cuanto al tamaño, el volumen y la densidad de los cálculos, la duración de la LEOCh, el total de disparos administradas, el voltaje, el índice de masa corporal (IMC), el estado libre de cálculos y la localización de los cálculos. El tiempo de fluoroscopia y el número de veces que fue necesario focalizar el cálculo fueron significativamente inferiores en el grupo 1 con respecto al grupo 2 (p:0,002, p:0,021, respectivamente). La puntuación EVA fue significativamente inferior en el grupo 1 en comparación con el grupo 2 (p<0,001). Conclusiones Observamos que la puntuación EVA del grupo BPEE era menor que la del grupo de diclofenaco sódico IM y, aunque no de manera estadísticamente significativa, conseguimos una tasa libre de cálculos más alta en la primera sesión en el grupo BPEE. ... (AU)

Introduction and Objectives To compare the efficacy of erector spinae plane block (ESPB) and intramuscular (i.m.) diclofenac sodium in regard to pain management and impact on stone-free status in patients undergoing SWL. Patients or Materials The study included patients who underwent SWL for kidney stones in our institution. The patients were randomly assigned to the ESPB (Group 1: n = 31) and i.m. 75 mg diclofenac sodium (Group 2: n = 30) groups. The demographic data of the patients, fluoroscopy time during SWL, number of need of targeting, total shocks given, voltage, stone free rates (SFR), analgesy method, number of SWL sessions, VAS score, stone location, maximum stone size, stone volume and Hounsfield unit (HU) were also recorded. Results A total of 61 patients were included the study. There was no statistically significant difference between the two groups according to stone size, volume and density, SWL duration, total shocks given, voltage, BMI, stone-free status and stone location. Fluoroscopy time and number of need for stone targeting were significantly lower in group 1 than group 2 (p:0.002, p:0.021, respectively). The VAS score was significantly lower for group 1 compared to group 2 (p<0.001). Conclusions We observed that the VAS score was lower in the ESPB group compared to i.m. diclofenac sodium group and although it was not statistically significant, we achieved a higher rate of stone-free status in the first session in ESPB group. Most importantly, the patients in the ESPB group were exposed to less fluoroscopy and radiation. (AU)

Comparison of a Modern Digital Mechanomyograph to a Mechanomyograph Utilizing an Archival Grass Force Transducer.

BACKGROUND: Mechanomyography is the traditional gold standard research technique for quantitative assessment of neuromuscular blockade. Mechanomyography directly measures the isometric force generated by the thumb in response to ulnar nerve stimulation. Researchers must construct their own mechanomyographs since commercial instruments are no longer available. A mechanomyograph was constructed, and its performance was compared against an archival mechanomyography system from the 1970s that utilized an FT-10 Grass force transducer, hypothesizing that train-of-four ratios recorded on each device would be equivalent. METHODS: A mechanomyograph was constructed using 3D-printed components and modern electronics. An archival mechanomyography system was assembled from original components, including an FT-10 Grass force transducer. Signal digitization for computerized data collection was utilized instead of the original paper strip chart recorder. Both devices were calibrated with standard weights to demonstrate linear voltage response curves. The mechanomyographs were affixed to opposite arms of patients undergoing surgery, and the train-of-four ratio was measured during the onset and recovery from rocuronium neuromuscular blockade. RESULTS: Calibration measurements exhibited a positive linear association between voltage output and calibration weights with a linear correlation coefficient of 1.00 for both mechanomyography devices. The new mechanomyograph had better precision and measurement sensitivity than the archival system: 5.3 mV versus 15.5 mV and 1.6 mV versus 5.7 mV, respectively (P < 0.001 for both). A total of 767 pairs of train-of-four ratio measurements obtained from eight patients had positive linear association (R 2 = 0.94; P < 0.001). Bland-Altman analysis resulted in bias of 3.8% and limits of agreement of -13% and 21%. CONCLUSIONS: The new mechanomyograph resulted in similar train-of-four ratio measurements compared to an archival mechanomyography system utilizing an FT-10 Grass force transducer. These results demonstrated continuity of gold standard measurement of neuromuscular blockade spanning nearly 50 yr, despite significant changes in the instrumentation technology.

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial.

Importance: It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent. Objective: To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation. Design, Setting, and Participants: Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021. Interventions: Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 µg/kg; n = 575) immediately after injection of a hypnotic. Main Outcomes and Measures: The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%. Results: Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%). Conclusions and Relevance: Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference. Trial Registration: ClinicalTrials.gov Identifier: NCT03960801.

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.

Uso de infusión continua de bloqueadores neuromusculares en pacientes con COVID-19 en ventilación mecánica invasiva / Use of continuous infusion of neuromuscular blockers in patients with COVID-19 undergoing invasive mechanical ventilation

ANTECEDENTES: El objetivo del presente informe es: Describir el proceso para la elaboración de recomendaciones por el grupo de trabajo designado por el Ministerio de Salud, en adelante denominado grupo de trabajo. Trasladar las Recomendaciones efectuadas por dicho grupo de trabajo en atención al uso de infusión continua de bloqueadores neuromusculares en pacientes con COVID-19 en ventilación mecánica no invasiva, según la pregunta PICO (P: Población, I:Intervención, C:Comparador, O: Outcome o desenlaces) priorizada por el grupo de trabajo. La metodología considerada para arribar a la recomendación fue el Marco de Evidencia a la Decisión/Recomendación (EtD) desarrollado por el Grupo de Trabajo GRADE(1,2). METODOS: Formulación de la pregunta: ¿Debería utilizarse infusión continua de bloqueadores neuromusculares (BNM) versus no hacerlo, en pacientes con COVID-19 en ventilación mecánica invasiva (VMI? ¿Qué medicamento y qué pauta de dosificación debe administrarse? Identificación de la evidencia para la pregunta PICO: Se siguieron las orientaciones establecidas en el documento interno de UNAGESP: Orientaciones para el soporte metodológico otorgado al grupo de trabajo designado por el MINSA. Se describe a continuación los resultados del proceso: Se efectuó la búsqueda de guías de práctica clínica (GPC) que incluyeran recomendaciones respecto al uso de BNM en la población de interés, con fecha de búsqueda 15 de octubre de 2021 en las siguientes plataformas: eCOVID-19 living map of recommendations (eCovid-19 RecMap), Base internacional de Guías GRADE (BIGG) , Guidelines International Network (GIN), COVID-19 Guidelines Dashboard, National Institute for Health and Care Excellence - UK (NICE) y Trip database, identificándose 5 guías de práctica clínica (Ver Anexo 1). En base a criterios como fecha de búsqueda de la evidencia, uso de metodología GRADE para evaluar la certeza de la evidencia, disponibilidad de la tabla Perfil de evidencia o Resumen de hallazgos, disponibilidad de los criterios o Tabla EtD, tipo de recomendación emitida y valoración AGREE II realizada por el equipo de eCovid-19 RecMap, se seleccionó la GPC de Australia titulada "Australian guidelines for the clinical care of people with COVID-19"(5) elaborada por The National COVID-19 Clinical Evidence Taskforce, con fecha de publicación del 15 de octubre de 2021 que utilizó la metodología GRADE para la evaluación de la certeza de la evidencia y el Marco de Evidencia para la decisión (EtD) para esta pregunta PICO, estando disponibles a través de las plataformas magicapp(6) y eCovid RecMap(3). En ésta última plataforma, la evaluación de la calidad metodológica de la GPC mediante la herramienta AGREE II mostró puntajes adecuados en los dominios claves: Alcance y objetivos: 83.3%, Rigor en el desarrollo: 74% e Independencia editorial: 70.8%. La guía no identificó ningún estudio en COVID-19 y la evidencia que informó la recomendación provino de una revisión sistemática y meta-análisis de 5 ensayos clínicos en pacientes con Síndrome de distrés respiratorio agudo (SDRA) por otras causas. Sin embargo, no se identificó la fecha de búsqueda de los estudios ni los métodos realizados para esta revisión sistemática. La recomendación realizada en la GPC de Australia estuvo basada en evidencia con certeza muy baja. Debido a estos resultados, se decidió efectuar una búsqueda de estudios primarios en COVID-19, incorporando parcialmente los términos de búsqueda de la GPC de Australia. La búsqueda se realizó en MEDLINE/ vía Pubmed, plataforma L·OVE de Epistemonikos(7) y en MedRxiv, con fecha 15 de octubre de 2021 (Ver Anexo 1). Los criterios de selección de los estudios fueron: ensayos clínicos aleatorizados, cohortes o casos y control que evaluen la PICO planteada y reportaran al menos uno de los desenlaces de interés. En adición, se efectuó una búsqueda de revisiones sistemáticas de ensayos clínicos, que evaluaran el uso de la infusión continua de BNM en pacientes con SDRA, a fines de obtener evidencia indirecta que complementara los resultados de la búsqueda de estudios primarios en COVID-19. La evaluación de la calidad metodológica de las revisiones sistemáticas se realizó con la herramienta AMSTAR 2(8) y para ensayos clínicos se consideró la evaluación de riesgo de sesgo reportada por la revisión sistemática si esta utilizó la herramienta de Cochrane para ensayos clínicos aleatorios. En caso de estudios observacionales, se empleó la herramienta Risk Of Bias in Non-randomized Studies of Interventions (ROBINS-I)(9). La certeza de la evidencia fue realizada según el enfoque GRADE que toma en cuenta los siguientes criterios: diseño del estudio, riesgo de sesgo, inconsistencia en los resultados, ausencia de evidencia directa, imprecisión, sesgo de publicación, tamaño de efecto, gradiente dosis-respuesta, y efecto de los potenciales factores de confusión residual (los tres últimos aplicables en estudios observacionales)(10,11). Los resultados fueron presentados utilizando la Tablas de Resumen de Hallazgos (SOF, por sus siglas en inglés) construidas a partir del software en línea GRADEpro (https://gradepro.org/)(12). RECOMENDACIÓN: Se sugiere el uso de la infusión continua de bloqueador neuromuscular en pacientes con COVID-19 en ventilación mecánica invasiva con algunas de las siguientes condiciones: Síndrome de distrés respiratorio agudo (SDRA) moderado o grave (PaO2/FiO2 < 150 mmHg) en fase aguda Independientemente del valor de PaO2/FiO2: Asincronía ventilatoria mayor persistente, a pesar de una programación adecuada del ventilador mecánico. Ventilación en posición prona. Necesidad de sedación profunda. Persistencia de presiones plateau altas o PEEP alto. Presencia de barotrauma o riesgo elevado de desarrollarlo. JUSTIFICACIÓN DE LA RECOMENDACIÓN: Se identificó un estudio de cohorte retrospectivo multicéntrico(14) que utilizó la información disponible a través de registros electrónicos de pacientes de 174 centros de investigación en 31 países. El 12% de los centros participantes estaba ubicado en Latinoamérica. El estudio está disponible desde Febrero de 2021 como manuscrito aún no revisado por pares. El estudio incluyó a 2165 pacientes con COVID-19 en VMI, que ingresaron a UCI entre Febrero a Noviembre de 2021, en su mayoría durante la primera ola de la pandemia. El estudio comparó el uso de BNM por 2 o más días, sea uso continuo o intermitente (grupo intervención) versus el uso < 2 días luego del inicio de la VMI (grupo control). En conjunto, la mediana de la duración del BNM fue de 3 días (rango intercuartílico (RIC) 2-6) y en aquellos que usaron el BNM de forma continua, la duración fue de 2 días (RIC 1-5). Sin embargo, el estudio no reportó el BNM utilizado ni la dosis administrada. Asimismo, un 17% de participantes del grupo control llegó a recibir 2 días o más de BNM. La administración de co-intervenciones como pronación, maniobras de reclutamiento y uso de corticoides varió entre los grupos. El estudio realizó emparejamiento por puntaje de propensión en base a características clínicas y sociodemográficas y el análisis multivariado incluyó potenciales factores de confusión como uso de antibióticos, terapia de reemplazo renal continua, ECMO y decúbito prono. Una descripción más detallada del estudio está disponible en el Anexo 2. El estudio reportó un mayor riesgo de mortalidad a los 28 días entre los que habían recibido BNM (HRa: 2.20, IC 95%: 1.67-2.89; 1350 pacientes incluidos en el análisis multivariado). El riesgo de sesgo global fue calificado como Serio, dada la calificación de Serio en los dominios Sesgo debido a confusión, Sesgo en la clasificación de las intervenciones, Sesgo debido a datos perdidos y no información en el dominio Sesgos debido a desviaciones de las intervenciones propuestas, de la herramienta ROBINS-I. La certeza de la evidencia fue calificada como Baja debido a riesgo de sesgo muy serio.

BET 2: Is the use of long-acting neuromuscular blocking agents for intubation associated with reduced provision of postintubation sedation?

A short cut review was conducted to assess if the use of rocuronium in the ED was associated with a decrease in the provision of postintubation sedation. Four papers were identified that presented the best evidence to answer the question. Again the studies, relevant outcomes, results and weaknesses are tabulated. All the identified studies were retrospective and there was a plethora of outcome measures used. When compared with suxamethonium, rocuronium was associated with a delayed initiation and reduced dose of postintubation sedation.

Neuromuscular blockade management in patients with COVID-19.

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome, and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.

Effects of neuromuscular blocking agents on the clinical performance of i-gel® and surgical condition in elderly patients undergoing hand surgery: a prospective randomized controlled trial.

Background: The effects of neuromuscular blocking agents on the clinical performance of supraglottic airway devices and surgical condition in elderly patients undergoing hand surgery have not been established. We evaluated the effects of rocuronium on the clinical performance of an i-gel® supraglottic device and surgical condition in elderly patients undergoing orthopedic hand surgery. Methods: Patients aged 65-85 years were randomized to receive either rocuronium (rocuronium group) or saline (control group). We compared the rates of successful insertion of the i-gel on the first attempt as a primary outcome and also assessed the adequacy of i-gel maintenance during controlled ventilation, anesthetic requirement, surgical condition, and recovery time. Results: The rates of successful insertion of the i-gel on a first attempt were 93.1% in the rocuronium group versus 82.1% in the control group (P = 0.423). Peak inspiratory pressure (PIP) was lower in the rocuronium group than in the control group (15.2 vs. 17.9 cmH2O, respectively, P = 0.028). Spontaneous breathing was less common in the rocuronium group (24.1% vs. 57.1%, respectively, P = 0.011). The requirement of additional fentanyl to suppress spontaneous breathing or patient movement was less in the rocuronium group than in the control group (24.1% vs. 50.0%, respectively, P = 0.043). Surgical condition did not differ between the two groups. Recovery time was shorter in the rocuronium group than in the control group (8.4 vs. 9.9 min, respectively, P = 0.030). Conclusions: Rocuronium did not enhance the success rate of inserting the i-gel® or the surgical condition in elderly patients. However, using rocuronium reduced PIP, the frequency of spontaneous breathing, the requirement for additional fentanyl and patients' recovery time.

Lidocaine combined with magnesium sulfate preserved hemodynamic stability during general anesthesia without prolonging neuromuscular blockade: a randomized, double-blind, controlled trial.

BACKGROUND: Lidocaine and magnesium sulfate have become increasingly utilized in general anesthesia. The present study evaluated the effects of these drugs, isolated or combined, on hemodynamic parameters as well as on the cisatracurium-induced neuromuscular blockade (NMB). METHODS: At a university hospital, 64 patients, ASA physical status I and II, undergoing elective surgery with similar pain stimuli were randomly assigned to four groups. Patients received a bolus of lidocaine and magnesium sulfate before the tracheal intubation and a continuous infusion during the operation as follows: 3 mg.kg- 1 and 3 mg.kg- 1.h- 1 (lidocaine - L group), 40 mg.kg- 1 and 20 mg.kg- 1.h- 1 (magnesium - M group), equal doses of both drugs (magnesium plus lidocaine - ML group), and an equivalent volume of isotonic solution (control - C group). Hemodynamic parameters and neuromuscular blockade features were continuously monitored until spontaneous recovery of the train of four (TOF) ratio (TOFR > 0.9). RESULTS: The magnesium sulfate significantly prolonged all NMB recovery features, without changing the speed of onset of cisatracurium. The addition of lidocaine to Magnesium Sulfate did not influence the cisatracurium neuromuscular blockade. A similar finding was observed when this drug was used alone, with a significantly smaller fluctuation of mean arterial pressure (MAP) and heart rate (HR) measures during anesthesia induction and maintenance. Interestingly, the percentage of patients who achieved a TOFR of 90% without reaching T1-95% was higher in the M and ML groups. Than in the C and L groups. There were no adverse events reported in this study. CONCLUSION: Intravenous lidocaine plays a significant role in the hemodynamic stability of patients under general anesthesia without exerting any additional impact on the NMB, even combined with magnesium sulfate. Aside from prolonging all NMB recovery characteristics without altering the onset speed, magnesium sulfate enhances the TOF recovery rate without T1 recovery. Our findings may aid clinical decisions involving the use of these drugs by encouraging their association in multimodal anesthesia or other therapeutic purposes. TRIAL REGISTRATION: NCT02483611 (registration date: 06-29-2015).

Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network.

OBJECTIVES: Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality. DESIGN: Retrospective cohort study. SETTING: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS: Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63-0.99, adjusted absolute risk difference, -0.05; p = 0.048). CONCLUSIONS: In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.

Difficult airway predictors were associated with decreased use of neuromuscular blocking agents in emergency airway management: a retrospective cohort study in Thailand.

BACKGROUND: It is recommended that difficult airway predictors be evaluated before emergency airway management. However, little is known about how patients with difficult airway predictors are managed in emergency departments. We aimed to explore the incidence, management and outcomes of patients with difficult airway predictors in an emergency department. METHODS: We conducted a retrospective study using intubation data collected by a prospective registry in an academic emergency department from November 2017 to October 2018. Records with complete assessment of difficult airway predictors were included. Two categories of predictors were analyzed: predicted difficult intubation by direct laryngoscopy and predicted difficult bag-mask ventilation. The former was evaluated based on difficult external appearance, mouth opening and thyromental distance, Mallampati score, obstruction, and limited neck mobility as in the mnemonic "LEMON". The latter was evaluated based on difficult mask sealing, obstruction or obesity, absence of teeth, advanced age and reduced pulmonary compliance as in the mnemonic "MOANS". The incidence, management and outcomes of patients with these difficult airway predictors were explored. RESULTS: During the study period, 220 records met the inclusion criteria. At least 1 difficult airway predictor was present in 183 (83.2%) patients; 57 (25.9%) patients had at least one LEMON feature, and 178 (80.9%) had at least one MOANS feature. Among patients with at least one difficult airway predictor, both sedation and neuromuscular blocking agents were used in 105 (57.4%) encounters, only sedation was used in 65 (35.5%) encounters, and no medication was administered in 13 (7.1%) encounters. First-pass success was accomplished in 136 (74.3%) of the patients. Compared with patients without predictors, patients with positive LEMON criteria were less likely to receive neuromuscular blocking agents (OR 0.46 (95% CI 0.24-0.87), p = 0.02) after adjusting for operator experience and device used. There were no significant differences between the two groups regarding glottic view, first-pass success, or complications. The LEMON criteria poorly predicted unsuccessful first pass and glottic view. CONCLUSIONS: In emergency airway management, difficult airway predictors were associated with decreased use of neuromuscular blocking agents but were not associated with glottic view, first-pass success, or complications.

Perioperative approach of allergic patients.

Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.

Comparison of Bispectral Index and Patient State Index values according to recovery from moderate neuromuscular block under steady-state total intravenous anesthesia.

There were insufficient researches of the comparison between Bispectral Index (BIS) and Patient State Index (PSI) values during the recovery of moderate NMB. We investigated the response of these indices during neuromuscular blockade (NMB) reversal by sugammadex under steady-state total intravenous anesthesia (TIVA) using propofol/remifentanil. In this prospective, observational study, patients undergoing laparoscopic cholecystectomy were enrolled. At the end of surgery, after confirming that train-of-four (TOF) count as 1 or 2, we maintained a steady state (BIS value of 40-50). After administration of 2 mg kg-1 sugammadex, BIS, PSI, and electromyography (EMG) signal values were recorded at one-minute intervals for 10 min. The primary outcome was the difference between the changes in BIS and PSI from baseline to a TOF ratio (TOFR) of 90 after sugammadex administration in steady-state TIVA. A total of 48 patients completed this trial. There was no significant difference between the changes in BIS and PSI values from baseline to TOFR 90 (- 0.333 ± 4.955 vs. - 0.188 ± 4.616; 95% confidence interval [CI] - 2.095 to 1.803; p = 0.882). Both BIS-EMG and PSI-EMG values at baseline and TOFR 90 were not statistically different (95% CI - 0.550 to 1.092; p = 0.510, 95% CI - 1.569 to 0.527; p = 0.322, respectively). No patient experienced any complications. Changes in BIS and PSI values after NMB reversal during steady-state TIVA were not significantly different. Both BIS and PSI provide trustworthy values for monitoring anesthetic depth during NMB reversal under TIVA.Trial Registration: This study was registered in the Clinical Trial Registry of Korea ( https://cris.nih.go.kr : KCT 0003805).