Sugammadex versus neostigmine for reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation: a large-scale, retrospective study / 中华麻醉学杂志

Objective:To compare the efficacy of sugammadex versus neostigmine on reversal of rocuronium-induced residual neuromuscular blockade in patients undergoing renal transplantation. Methods:The clinical data of patients undergoing kidney transplantation from donation after cardiac death in our hospital from January 2018 to December 2020 were retrospectively analyzed.Patients were divided into sugammadex group (group S) and neostigmine group (group N) according to the use of muscle relaxant antagonists.The onset time of antagonism, time of tracheal extubation, and time of postanesthesia care unit stay were recorded.The creatinine clearance rate was recorded before operation and at 1, 3, 5 and 7 days after operation.The occurrence of postoperative complications was recorded.Results:A total of 603 patients were enrolled in this study, with 278 patients in group S and 325 patients in group N. Compared with group N, the onset time of antagonism, time of extubation , and time of postanesthesia care unit stay were significantly shortened, the incidence of hypoxemia within 24 h after surgery and pulmonary infection occurred within 7 days after surgery was decreased ( P<0.05), and no significant change was found in the creatinine clearance rate at each time point and incidence of postoperative cardiovascular complications and graft complications in group S ( P>0.05). Conclusion:Compared with neostigmine, sugammadex can reverse rocuronium-induced residual neuromuscular blockade more quickly, which is helpful for early recovery with a higher safety when applied in the patients undergoing renal transplantation.

Effect of different withdrawal sequences on quality of recovery in patients undergoing endoscopic sinus surgery under combined intravenous and inhalation anesthesia / 中国基层医药

Objective:To investigate the effect of two different withdrawal sequences on the quality of recovery in patients undergoing nasal endoscopic surgery under combined intravenous and inhalation anesthesia.Methods:Seventy patients scheduled for endoscopic sinus surgery in The First Affiliated Hospital of Xiamen University, China from January to June 2019 were included in this study and randomly assigned to undergo intravenous anesthesia alone (Group A, n = 35) or combined intravenous and inhalation anesthesia (Group B, n = 35). Propofol 2-4 mg/kg, fentanyl 3-4 μg/kg, cisatracurium besylate 0.2 mg/kg were used to induce anesthesia. Propofol 4-6 mg/kg/h, remifentanil 6.5-13.0 mg/kg/h, sevoflurane ≥ 0.30 minimum alveolar concentration were used to maintain anesthesia. At 30 minutes before the end of surgery, inhalational sevoflurane administration and pump propofol administration were stopped in the groups A and B respectively. At 10 minutes before the end of surgery, pump propofol administration and inhalational sevoflurane administration were stopped in the groups A and B respectively. At the end of surgery, pump remifentanil administration was stopped in both groups A and B. The time to spontaneous breathing recovery, the time to consciousness recovery, and the time to tracheal extubation were recorded. Mean arterial pressure and heart rate were recorded at the time of entering the operation room (T0), at the end of anesthesia (T1), at the time of spontaneous breathing recovery (T2), consciousness recovery (T3) and tracheal extubation (T4), 5 minutes (T5) and 10 minutes after tracheal extubation (T6). Agitation score was recorded at T2-T6 and at 20 minutes after tracheal extubation (T7). Cough score was recorded at T4. Results:The time to spontaneous breathing recovery, the time to consciousness recovery, and the time to tracheal extubation in group A were (16.0 ± 4.6) minutes, (18.0 ± 5.3) minutes, (19.0 ± 5.5) minutes, respectively, which were significantly longer than (8.8 ± 3.5) minutes, (9.5 ± 4.1) minutes, (10.7 ± 4.5) minutes, respectively in the group B ( t = 9.554, 8.881, 9.011, all P < 0.05). There were no significant differences in mean arterial pressure and heart rate recorded at T0-T6 between groups A and B (all P > 0.05). There was no significant difference in agitation score measured at T3-T6 between groups A and B (all P > 0.05). There was no significant difference in cough score recorded at T4 between groups A and B ( P > 0.05). Conclusion:Two different withdrawal sequences can maintain stable hemodynamics and reduce agitation during recovery period and cough during extubation. The recovery time of remifentanil combined with propofol is longer than that of remifentanil combined with sevoflurane.

Opioid-free general anesthesia and induced recovery from anesthesia in a patient with myotonic dystrophy type-1: a case report / Anestesia geral sem opioide e recuperação induzida da anestesia em paciente com distrofia miotônica tipo-1: relato de caso

Abstract Myotonic dystrophy type-1 (Steinert disease) is an autosomal dominant, progressive multisystem disease in which myotonic crisis can be triggered by several factors including pain, emotional stress, hypothermia, shivering, and mechanical or electrical stimulation. In this report, dexmedetomidine-based general anesthesia, in combination with a thoracic epidural for laparoscopic cholecystectomy in a patient with Steinert disease, is presented. An Aintree intubation catheter with the guidance of a fiberoptic bronchoscope was used for intubation to avoid laryngoscopy. Prolonged anesthetic effects of propofol were reversed, and recovery from anesthesia was accelerated using an intravenous infusion of theophylline.

Resumo A Distrofia Miotônica (DM) tipo-1 (Doença de Steinert) é uma doença multissistêmica progressiva autossômica dominante em que a crise miotônica pode ser desencadeada por vários fatores, incluindo dor, estresse emocional, hipotermia, tremores e estímulo mecânico ou elétrico. O presente relato descreve anestesia geral realizada com dexmedetomidina em combinação com peridural torácica para colecistectomia laparoscópica em paciente com Doença de Steinert. Para evitar laringoscopia, a intubação traqueal foi realizada utilizando cateter de intubação Aintree guiado por broncofibroscopia óptica. Os efeitos anestésicos prolongados do propofol foram revertidos e a recuperação anestésica foi acelerada pelo uso de infusão intravenosa de teofilina.

Comparison of sugammadex and pyridostigmine bromide for reversal of rocuronium-induced neuromuscular blockade in short-term pediatric surgery: a prospective randomized study

BACKGROUND: Sugammadex reverses rocuronium-induced neuromuscular blockade quickly and effectively. Herein, we compared the efficacy of sugammadex and pyridostigmine in the reversal of rocuronium-induced light block or minimal block in pediatric patients scheduled for elective entropion surgery. METHODS: A prospective randomized study was conducted in 60 pediatric patients aged 2–11 years who were scheduled for entropion surgery under sevoflurane anesthesia. Neuromuscular blockade was achieved by administration of 0.6 mg/kg rocuronium and assessed using the train-of-four (TOF) technique. Patients were randomly assigned to 2 groups receiving either sugammadex 2 mg/kg or pyridostigmine 0.2 mg/kg and glycopyrrolate 0.01 mg/kg at the end of surgery. Primary outcomes were time from administration of reversal agents to TOF ratio 0.9 and TOF ratio 1.0. Time from the administration of reversal agents to extubation and postoperative adverse events were also recorded. RESULTS: There were no significant differences in the demographic variables. Time from the administration of reversal agents to TOF ratio 0.9 and TOF ratio 1.0 were significantly shorter in the sugammadex group than in the pyridostigmine plus glycopyrrolate group: 1.30 ± 0.84 vs. 3.53 ± 2.73 min (P < 0.001) and 2.75 ± 1.00 vs. 5.73 ± 2.83 min (P < 0.001), respectively. Extubation time was shorter in the sugammadex group. Adverse events, such as skin rash, nausea, vomiting, and postoperative residual neuromuscular blockade (airway obstruction), were not statistically different between the two groups. CONCLUSIONS: Sugammadex provided more rapid reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing surgery than did pyridostigmine plus glycopyrrolate.

Relajación residual posoperatoria en la unidad de cuidados postanestésicos de un hospital universitario: Estudio de corte transversal / Postoperative residual curarization at the post-anesthetic care unit of a university hospital: A cross-sectional study

Abstract Introduction: Postoperative residual curarization has been related to postoperative complications. Objective: To determine the prevalence of postoperative residual curarization in a university hospital and its association with perioperative conditions. Method: A prospective registry of 102 patients in a period of 4 months was designed to include ASA I-II patients who intraoperatively received nondepolarizing neuromuscular blockers. Abductor pollicis response to a train-of-four stimuli based on accelleromyography and thenar eminence temperature (TOF-Watch SX®. Organon, Ireland) was measured immediately upon arrival at the postanesthetic care unit and 30 s later. Uni-bivariate analysis was planned to determine possible associations with residual curarization, defined as two repeated values of T4/T1 ratio <0.90 in response to train-of-four stimuli. Results: Postoperative residual curarization was detected in 42.2% of the subjects. Pancuronium was associated with a high risk for train-of-four response <0.9 at the arrive at postoperative care unit [RR:2.56 (IC95% 1.99-3.30); p = 0.034]. A significant difference in thenar temperature (°C) was found in subjects with train-of-four <0.9 when compared to those who reach adequate neuromuscular function (29.9 ± 1.6 vs. 31.1 ± 2.2; respectively. p = 0.003). However, we were unable to demonstrate a direct attribution of findings in train-of-four response to temperature (R² determination coefficient = 0.08%). Conclusions: A high prevalence of postoperative residual curarization persists in university hospitals, despite a reduced use of "long-lasting" neuromuscular blockers. Strategies to assure neuromuscular monitoring practice and access to therapeutic alternatives in this setting must be considered. Intraoperative neuromuscular blockers using algorithms and continued education in this field must be priorities within anesthesia services.

Introducción: La relajación residual postoperatoria ha sido asociada con mayores complicaciones postoperatorias. Objetivo: determinar la prevalencia de relajación residual postoperatoria en un hospital universitario y su relación con condiciones perioperatorias. Métodos: Se diseñó un registro prospectivo de 4 meses de duración, que incluyó pacientes ASA I-II que intraoperatoriamente recibieran bloqueadores neuromusculares. Se registró la respuesta del abductor pollicis a un estímulo de tren de cuatro mediante aceleromiografía y se midió la temperatura de la eminencia tenar (TOF-Watch SX®.Organon, Ireland) inmediatamente al ingreso a recuperación y a los 30 segundos. Se realizó análisis uni y bivariado para determinar posibles asociaciones con relajación residual postoperatoria, definida como dos respuestas sucesivas al estímulo tren-de-cuatro con una relación T4/T1 <0.90. Resultados: Se reclutaron 102 pacientes, encontrando una prevalencia de relajación residual del 42.2%. Pancuronio fue asociado con un riesgo elevado de TOF < 0.9 al ingreso a recuperación [RR:2,56 (IC95% 1.99-3.30); p = 0.034]. Se evidenció una diferencia significativa en la temperatura tenar de los pacientes que presentaban relajación residual, al compararla con pacientes que recuperaron su función neuromuscular [Grupo evento = 29.9 ± 1.6 (n = 43); Grupo control = 31.1 ±2.2 (n = 59)]. Sin embargo no se logró determinar una atribución directa de relajación residual a esta medición (coeficiente de determinación = 0.08%). Conclusión: Persiste una alta prevalencia de relajación residual postoperatoria en los hospitales universitarios, a pesar del uso reducido de bloqueadores neuromusculares de larga duración. Se hace indispensable encaminar estrategias para incentivar la monitoria neuromuscular y establecer algoritmos que permitan un manejo eficiente de los bloqueadores neuromusculares.

Dyspnea due to Residual Neuromuscular Blockade in Elderly Patient with Unrecognized Pre-existing Unilateral Vocal Cord Paralysis / 이화의대지

Muscle relaxation using neuromuscular blocking agent is an essential process for endotracheal intubation and surgery, and requires adequate recovery of muscle function after surgery. Residual neuromuscular blockade is defined as an insufficient neuromuscular recovery that can be prevented by confirming train-of-four ratio >0.9 using objective neuromuscular monitoring. Sugammadex, a novel selective relaxant-binding agent, produces rapid and effective reversal of rocuronium-induced neuromuscular blockade. We report a case of the residual neuromuscular blockade accompanying dyspnea and stridor after general anesthesia in an unrecognized pre-existing symptomless unilateral vocal cord paralysis patient, who had experienced the disappearance of dyspnea and stridor after administration of sugammadex.

Analysis of the level of consciousness related to the oxygen therapy in patients in anesthesia recovery period / Análise do estado de consciência relacionado à oxigenoterapia em pacientes em recuperação anestésica

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Severe neurologic manifestations in acute intermittent porphyria developed after spine surgery under general anesthesia: a case report / 대한마취과학회지

Porphyrias are inherited metabolic disorders resulting from a specific enzyme defect in the heme biosynthetic pathway. Porphyrias are induced by various precipitants. Clinical features include abdominal pain, neurologic manifestations, autonomic neuropathy, and mental disturbance. Diagnosis may be delayed because of variable symptoms that mimic other diseases and because of the rarity of of porphyrias. Although most patients with known porphyria can complete anesthesia and surgery safely, undiagnosed porphyric patients are in danger of porphyric crisis due to inadvertent exposure to precipitating drugs and environment. We report a case of a patient who experienced delayed emergence with neurological disturbance after general anesthesia, ultimately diagnosed as acute intermittent porphyria.

Fast track em cirurgia cardíaca: quando e como fazer / Fast track in heart surgery: when and how to perform

Durante muito tempo, a anestesia em cirurgia cardíaca baseou-se em altas doses de opioides e outras drogas de meia-vida prolongada. Associada à circulação extracorpórea (CEC), heparinização e hipotermia, a recuperação anestésica mostrava-se extremamente prolongada, com uso de próteses ventilatórias e ventilação controlada por longo período após o término da cirurgia. Nos últimos anos, com a tendência à redução de custos e morbidade relacionada a essa recuperação prolongada e uso de agentes anestésicos de meia-vida mais curta, passou-se a considerar a possibilidade de despertar precoce, com extubação e retorno à ventilação espontânea em curto período de tempo após o término da cirurgia.

For a long time, cardiac anesthesia was based upon the use of high doses of opioids and long half-time drugs. Associated to the heart-lung by-pass, full heparinization and hypothermia, post-anesthetic recovery was extremely long, with the use of respiratory protesis and mechanical ventilation. During the last few years, the need to reduce intrahospitalarcosts and the morbidity related to those long recovery times, associated with the new coming of short half-time drugs, fast wake up times, with extubation and return to normal breathing are now being considered.