Anesthetic Management in A Patient with Myasthenia Gravis Posted for Thymectomy

Myasthenia gravis is an autoimmune disease which causes disorder in transmission at the neuromuscular junction. In patients with myasthenia gravis undergoing surgical procedures administration of general anaesthesia becomes challenging. Overall safe general anaesthesia can be achieved through adequate preoperative assessment and optimization; vigilant intraoperative monitoring of neuromuscular transmission along with adequate dose titrations and by Train of four responses (TOF) guided administration of non depolarising muscle relaxants.

Feasibility of Perioperative Diaphragmatic Ultrasound in Assessment of Residual Neuromuscular Blockade / 中国医学科学院学报

Objective To evaluate the relationship between diaphragmatic ultrasound and postoperative residual neuromuscular blockade(PRNB). Methods The patients undergoing non-thoracic and abdominal surgery under general anesthesia from August to October in 2019 were randomly enrolled from Peking Union Medical College Hospital.Diaphragmatic ultrasound was acquired pre-operation and post extubation.A 4-15 MHz probe was used to measure diaphragmatic thickness at the intersection point of 8-9 intercostal space with right anterior axillary line at the end of inspiration and expiration during quiet breathing and deep breathing(DB),and the diaphragmatic thickness fraction(DTF)was calculated.A 1-5 MHz probe was used to measure diaphragmatic excursion(DE)at the intersection point of right costal margin with midaxillary line during quiet breathing and DB.Train of four ratio(TOFr)was recorded for neuromuscular monitoring.TOFr,observer assessment of alertness and sedation score at extubation,Aldrete score at postanesthesia care unit,and postoperative pulmonary complication were recorded. Results The PRNB rate was 54.7%.The DTF-DB [31.3(21.1,45.0)vs.38.5(26.6,53.9),P=0.045] and DE-DB(2.9±1.4 vs.4.1±1.0,P<0.001)in PRNB group was lower than those in the group without PRNB.DTF-DB(r=0.351,P=0.002)and DE-DB(r=0.580,P<0.001)were correlated with TOFr. Conclusion Perioperative diaphragmatic ultrasound may be helpful for the diagnosis of PRNB.

10 semanas de treinamento de força melhoram quais capacidades físicas em adolescentes fisicamente ativos? / 10 weeks of strength training improve what physical capabilities in physically active adolescents?

o estudo teve como objetivo verificar as adaptações geradas pelo treinamento de força (TF) nos parâmetros neuromusculares e na composição corporal de adolescentes. A amostra foi composta por 10 adolescentes do sexo masculino (16,4 ± 1,0 anos), o protocolo de treinamento de força teve duração de 10 semanas com 3 sessões semanais, divididos em treinos A e B. Para comparação do desempenho, foram avaliadas variáveis antropométricas e composição corporal (estatura, peso, índice de massa corporal e percentual de gordura), bem como, neuromusculares, por meio da resistência muscular de membros superiores (teste de flexão de braços), força explosiva de membros inferiores (teste de salto horizontal), flexibilidade (teste de sentar e alcançar), e força muscular (supino, puxada e leg press 45º). Para comparar os resultados pré e pós intervenção foram utilizadas as diferenças de médias estandardizadas e seus respectivos intervalos de confiança (IC= 90%) e as probabilidades (maior/similar/menor). Foram encontrados aumentos substanciais entre os períodos pré e pós intervenção, para a resistência muscular localizada de membros superiores (92/7/1, Likely), um impacto benéfico de força no supino (86/11/2, Likely), puxada (82/15/3, Likely) e leg press 45° (84/14/2, Likely), e redução em média de 3% na gordura corporal. Os resultados contribuem para uma reflexão crítica em relação ao incentivo a prática de TF em adolescentes, pois com supervisão adequada, planejamento, individualização das cargas de treino e educação técnica correta de cada exercício, os riscos foram suprimidos e os benefícios amplificados.(AU)

Our aim was to investigate the adaptations caused by strength training (ST) in neuromuscular parameters and body composition of adolescents. The sample consisted of 10 male adolescents (16.4 ± 1.0 years) and the strength training protocol lasted 10 weeks with 3 weekly sessions, divided into training sessions A and B. Anthropometric variables and body composition (height, weight, body mass index and percentage of fat) as well as neuromuscular performance (upper limb endurance strength, horizontal jump height, flexibility and muscle strength in bench-press, lat pull-down and 45º leg press exercises). Pre- and post-intervention results were compared using standardized mean differences and their respective confidence intervals (CI = 90%) and likelihood (greater / similar / lower). Substantial increases were found between the pre- and post-intervention periods for upper-limb muscle endurance (92/7/1, Likely) and bench press (86/11/2, Likely), lat pull-down (82 / 15/3, Likely) and leg press (84/14/2, Likely) strength, while a beneficial reduction of 3% in body fat was observed. The results contribute to a critical reflection regarding the incentive to practice ST in adolescents. With proper supervision, planning, individualization of training loads and correct technical education of each exercise, the potential risks were suppressed and the benefits amplified.(AU)

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.

Parálisis residual posoperatoria tras anestesia general sin monitorización neuromuscular objetiva: un estudio observacional en el Hospital Regional Docente de Cajamarca, Perú / Postoperative residual paralysis after general anesthesia without objective neuromuscular monitoring: An observational study at the Regional Cajamarca Hospital, Perú

Objetivo: Determinar la incidencia y severidad de la parálisis residual en pacientes sin monitorización neuromuscular intraoperatoria. Materiales y métodos: Se realizó un estudio prospectivo y observacional en 236 pacientes adultos ASA I-III intervenidos bajo anestesia general sin monitorización neuromuscular intraoperatoria. A su llegada a la Unidad de Cuidados Post-Anestesia (UCPA) se realizó la monitorización neuromuscular mediante aceleromiografía del músculo aductor del pulgar. La incidencia de parálisis residual con TOF ratio (TOFr) < 0,9 y TOFr < 0,7 fueron valorados. Resultados: La incidencia de parálisis residual en la UCPA con TOFr < 0,9 fue de 81,36% (IC 95%: 76,39-86,33) y con TOFr < 0,7 fue de 33,9% (IC 95%: 27,86-39,94). La neostigmina fue utilizada para revertir el bloqueo neuromuscular solamente en el 48,3% de los casos. La incidencia de parálisis residual con TOFr < 0,7 fue significativamente mayor entre los que no recibieron antagonistas del bloqueo neuromuscular y los que sí lo recibieron (42,62% vs. 24,56%, p=0.003). Conclusiones: La incidencia y severidad de la parálisis residual posoperatoria en pacientes sin monitorización neuromuscular fue elevada en nuestra institución, probablemente favorecida por una dosificación no guiada de los relajantes musculares, la escasa utilidad de los criterios subjetivos para valorar la recuperación de la función neuromuscular y la falta de reversión rutinaria del bloqueo neuromuscular.

Objective: To determine both the incidence and severity of residual paralysis in patients not undergoing intraoperative neuromuscular monitoring. Material and Methods: A prospective observational study was performed in 236 ASA I-III adult subjects who underwent surgery under general anesthesia without intraoperative neuromuscular monitoring. When patients were brought to the Post-Anesthesia Care Unit (PACU), neuromuscular monitoring was performed using acceleromiography of the adductor muscle of the thumb. The incidence of residual paralysis with TOF ratio (TOFr) values <0.9 and <0.7 was assessed. Results: The incidence of residual paralysis in the PACU with TOFr <0.9 was 81.36% (95% CI: 76.39%-86.33%) and with TOFr <0.7 was 33.9% (95% CI: 27.86%-39.94%). Neostigmine was used to revert neuromuscular blockade only in 48.3% of all cases. The incidence of residual paralysis with TOFr<0.7 was significantly higher in those subjects who did not receive neuromuscular blockade antagonists compared with those who did (42.62% vs. 24.56%, p= 0.03). Conclusions: Both the incidence and severity of residual postoperative paralysis in patients without neuromuscular monitoring was notoriously high in our institution, likely favored by a non-guided dosing of muscle relaxant agents, as well as due to low usefulness of subjective criteria for assessing recovery of neuromuscular function and the lack of routine reversion of neuromuscular blockade.

A Comparative Study Of Onset Time And Intubating Condition For Different Dose Of Rocuronium In Burn And Non-Burn Patients

An aberrant pharmacodynamics responses to neuromuscular blocking drugs(NMBD)in burn patients increases the potential for lethal hyperkalemia with the administration of depolarizing muscle relaxant eg:succinylcholine and 2.5–5 folds increase in the dose of plasma concentration requirement for non–depolarizing muscle relaxants like :D–tubocurarine,metacurine,pancuronium,atracurium,vecuronium.Therefore Rocuronium may be the drug of choice in burn patients.This study was planned to assess the onset time and intubating conditions with two different doses of rocuronium in patients with thermal injury.It was concluded that in non–burn patient onset time(loss of response to TOF) was 85.5�4.8 sec with a dose of 0.9 mg/kg as compared to 1.2 mg/kg it was 60.55�70.4,while in burn patients (more than 30% burn area) these values were 120.83�6.81 sec and 86.16�5.2 respectively.

Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey

BACKGROUND: Neuromuscular blocking agents (NMBAs) and neuromuscular monitoring in anesthetic management are integral for endotracheal intubation, better visualization of the surgical field, and prevention of residual neuromuscular blockade and pulmonary complications. Sugammadex is a drug that reduces risk of residual neuromuscular blockade, with more rapid recovery compared to anticholinesterase. The purpose of this study was to investigate current usage status of NMBAs and antagonist with neuromuscular monitoring, among anesthesiologists in Korea.METHODS: Anesthesiologists working in Korea were invited to participate in an online survey via email January 2–February 28, 2018. The questionnaire consisted of 45 items, including preferred NMBAs, antagonists, neuromuscular monitoring, and complications related to the use sugammadex. A total of 174 responses were analyzed.RESULTS: Rocuronium was a commonly used NMBA for endotracheal intubation (98%) of hospitals, and maintenance of anesthesia (83.3%) in of hospitals. Sugammadex, pyridostigmine, and neostigmine were used in 89.1%, 87.9%, and 45.4% of hospitals. Neuromuscular monitoring was employed in 79.3% of hospitals; however only 39.7% of hospitals used neuromuscular monitoring before antagonist administration. Usual dosage range of sugammadex was 2.1–4 mg/kg in 35.1% of hospitals, within 2 mg/kg in 34.5% of hospitals, and 1 vial regardless of body weight in 22.4% of hospitals. Sugammadex-related complications were encountered by 14.9% of respondents.CONCLUSIONS: This survey indicates several minor problems associated with the use of antagonists and neuromuscular monitoring. However, most anesthesiologists appear to have appropriate information regarding the usage of NMBAs and sugammadex.

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.

Effects of dexamethasone and hydrocortisone on rocuronium-induced neuromuscular blockade and reversal by sugammadex in phrenic nerve-hemidiaphragm rat model / 대한마취과학회지

BACKGROUND: The facilitator effects of steroids on neuromuscular transmission may cause resistance to neuromuscular blocking agents. Additionally, steroids may hinder sugammadex reversal of neuromuscular blockade, but these findings remain controversial. Therefore, we explored the effect of dexamethasone and hydrocortisone on rocuronium-induced neuromuscular blockade and their inhibitory effect on sugammadex. METHODS: We explored the effects of steroids, dexamethasone and hydrocortisone, in vitro using a phrenic nerve-hemidiaphragm rat model. In the first phase, an effective dose of rocuronium was calculated, and in the second phase, following sugammadex administration, the recovery of the train-of-four (TOF) ratio and T1 was evaluated for 30 minutes, and the recovery index was calculated in dexamethasone 0, 0.5, 5, and 50 μg/ml, or hydrocortisone 0, 1, 10, or 100 μg/ml. RESULTS: No significant effect of steroids on the effective dose of rocuronium was observed. The TOF ratios at 30 minutes after sugammadex administration were decreased significantly only at high experimental concentrations of steroids: dexamethasone 50 μg/ml and hydrocortisone 100 μg/ml (P < 0.001 and P = 0.042, respectively). There were no statistical significances in other concentrations. No differences were observed in T1. Recovery index was significantly different only in 100 μg/ml of hydrocortisone (P = 0.03). CONCLUSIONS: Acute exposure to steroids did not resist the neuromuscular blockade caused by rocuronium. And inhibition of sugammadex reversal on rocuronium-induced neuromuscular blockade is unlikely at typical clinical doses of dexamethasone and also hydrocortisone. Conclusively, we can expect proper effects of rocuronium and sugammadex when dexamethasone or hydrocortisone is used during general anesthesia.

Nefopam does not influence onset and recovery profiles of rocuronium-induced neuromuscular block: a prospective, double-blinded, randomized, controlled study

BACKGROUND: We investigated the hypothesis that pretreatment with nefopam 20 mg would influence the onset and recovery profiles of rocuronium-induced neuromuscular block. METHODS: After Institutional Review Board approval, 134 patients, aged between 20–65 years, belonging to the American Society of Anesthesiologists physical status classification I or II, were randomly allocated to receive either 0.9% normal saline (control group) or nefopam 20 mg (nefopam group), infused over one hour before induction of anesthesia. Anesthesia was induced with remifentanil and propofol, followed by endotracheal intubation with rocuronium 0.6 mg/kg. We recorded the lag time, onset time, clinical duration, recovery index, recovery time, and total recovery time. RESULTS: We included 111 patients in the final analysis. The lag time, onset time, clinical duration, recovery index, recovery time, and total recovery time of the nefopam group (n = 57) were not significantly different compared with that of the control group (n = 54). CONCLUSIONS: Pretreatment with nefopam 20 mg one hour before induction of anesthesia does not have a significant influence on the onset and recovery profiles of rocuronium-induced neuromuscular block.

Use of protocol and evaluation of postoperative residual curarization incidence in the absence of intraoperative acceleromyography - Randomized clinical trial / Aplicação de protocolo e avaliação da incidência de curarização residual pós-operatória na ausência de aceleromiografia intraoperatória - Ensaio clínico randomizado

Abstract Objective Evaluate the incidence of postoperative residual curarization (PORC) in the post-anesthesia care unit (PACU) after the use of protocol and absence of intraoperative acceleromyography (AMG). Methods Randomized clinical trial with 122 patients allocated into two groups (protocol and control). Protocol group received initial and additional doses of rocuronium (0.6 mg·kg-1 and 10 mg, respectively); the use of rocuronium was avoided in the final 45 min; blockade reversal with neostigmine (50 µg·kg-1); time ≥15 min between reversion and extubation. Control: initial and additional doses of rocuronium, blockade reversal, neostigmine dose, and extubation time, all at the discretion of the anesthesiologist. AMG was used in the PACU and PORC considered at T4/T1 ratio <1.0. Results The incidence of PORC was lower in protocol group than in control group (25% vs. 45.2%, p = 0.02). In control group, total dose of rocuronium was higher in patients with PORC than without PORC (0.43 vs. 0.35 mg·kg-1·h-1, p = 0.03) and the time interval between the last administration of rocuronium and neostigmine was lower (75.0 vs. 101.0 min, p < 0.01). In protocol group, there was no difference regarding the analyzed parameters (with PORC vs. without PORC). Considering the entire study population and the presence or absence of PORC, total dose of rocuronium was higher in patients with PORC (0.42 vs. 0.31 mg·kg-1·h-1, p = 0.01), while the time interval between the last administration of rocuronium and neostigmine was lower (72.5 vs. 99.0 min, p ≤ 0.01). Conclusion The proposed systematization reduced PORC incidence in PACU in the absence of intraoperative AMG.

Resumo Objetivo Avaliou-se a incidência de curarização residual pós-operatória (CRPO) na sala de recuperação pós-anestésica (SRPA) após emprego de protocolo e ausência de aceleromiografia (AMG) intraoperatória. Métodos Ensaio clínico, aleatório, com 122 pacientes, distribuídas em dois grupos: protocolo e controle. Protocolo: dose inicial e adicionais de rocurônio foram de 0,6 mg.kg-1 e 10 mg, respectivamente; evitou-se o uso de rocurônio nos 45 minutos finais; reversão do bloqueio com neostigmina (50 µg.kg-1); tempo ≥ 15 minutos entre reversão e extubação. Controle: doses inicial e adicional de rocurônio, reversão do bloqueio, dose de neostigmina e momento da extubação decididos pelo anestesiologista. Foi usada AMG na SRPA e considerado CRPO razão T4/T1 < 1,0. Resultados A incidência de CRPO foi menor no grupo protocolo em relação ao controle (25% vs. 45,2%; p = 0,02). No grupo controle, a dose total de rocurônio foi maior em pacientes com CRPO em relação àqueles sem CRPO (0,43 vs. 0,35 mg.kg-1.h-1; p = 0,03) e o intervalo entre a última administração de rocurônio e a neostigmina foi menor (75,0 vs. 101,0 min; p < 0,01). No grupo protocolo não houve diferença dos parâmetros analisados (com CRPO vs. sem CRPO). Considerando toda a população de estudo e a presença ou não de CRPO, a dose total de rocurônio foi maior em pacientes com CRPO (0,42 vs. 0,31 mg.kg-1.h-1; p = 0,01), enquanto o intervalo entre a última administração de rocurônio e a neostigmina foi menor (72,5 vs. 99,0 min; p ≤ 0,01). Conclusão A sistematização proposta reduziu a incidência de CRPO na SRPA na ausência de AMG intraoperatória.

Effect of dexamethasone on the onset time and recovery profiles of cisatracurium / 대한마취과학회지

BACKGROUND: The effect of dexamethasone injection on cisatracurium-induced neuromuscular block was compared according to different injection time points. METHODS: One hundred seventeen patients were randomly assigned to three groups: 8 mg of dexamethasone injected intravenously 2–3 h before anesthesia (group A), just before anesthesia induction (group B), and at the end of surgery (control group). Three minutes after anesthesia induction, intubation was performed without neuromuscular blockers, and acceleromyography was initiated. All patients received 0.05 mg/kg cisatracurium; the onset time and recovery profiles were recorded. RESULTS: Eighty patients were finally enrolled. The onset time (median [interquartile range], seconds) was significantly hastened in group A (520.0 [500.0–560.0], n = 30) compared to that in group B (562.5 [514.0–589.0], n = 22) (P = 0.008) and control group (586.5 [575.0–642.5], n = 28) (P < 0.001). The onset time in group B was faster than the control group (P = 0.015). The recovery time [mean (95% CI) minutes] was significantly hastened in group A [28.5 (27.3–29.6)] compared to that in group B [32.3 (31.0–33.6)] (P < 0.001) and control group [30.9 (29.9–31.8)] (P = 0.015). The total recovery time was significantly hastened more in group A [47.1 (45.5–48.6)] than group B [52.8 (51.6–54.0) minutes] (P < 0.001) and control group [50.5 (48.7–52.3) minutes] (P = 0.008). CONCLUSIONS: A single dose of 8 mg of dexamethasone hastened the onset and total recovery times of cisatracurium-induced block by approximately 15 and 9%, respectively if administered 2–3 h prior to surgery.

Factors that affect the onset of action of non-depolarizing neuromuscular blocking agents / 대한마취과학회지

Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.

What anesthesiologists ask to know and should know about the neuromuscular monitoring: an updated review

The increase in mortality and morbidity associated with the use of muscle relaxants, is associated with a lack of clinical pharmacological knowledge of the drugs, and a lack of understanding the risk of postoperative residual curarization. This is due to the absence of standards for neuromuscular monitoring. Clinicians experienced in neuromuscular monitoring and using muscle relaxants in the clinic may have some queries regarding the monitoring: Why should neuromuscular monitoring be done? Are clinical tests really not effective? Why is it not good when I actually perform neuromuscular monitoring? Would using sugammadex not require neuromuscular monitoring? This review answers most of the questions that many clinicians have, and also forwards the knowledge required of clinicians.

Comparison of clinical validation of acceleromyography and electromyography in children who were administered rocuronium during general anesthesia: a prospective double-blinded randomized study / 대한마취과학회지

BACKGROUND: Electromyography and acceleromyography are common neuromuscular monitoring devices. However, questions still remain regarding the use of acceleromyography in children. This study compared the calibration success rates and intubation conditions in children after obtaining the maximal blockade depending on each of the devices METHODS: Children, 3 to 6 years old, were randomly allocated to the TOF-Watch SX acceleromyography group or the NMT electromyography group. The induction was performed with propofol, fentanyl, and rocuronium. The bispectral index and 1 Hz single twitch were monitored during observation. The calibration of the each device was begun when the BIS dropped to 60. After successful calibration, rocuronium 0.6 mg/kg was injected. A tracheal intubation was performed when the twitch height suppressed to 0. The rocuronium onset time (time from administration to the maximal depression of twitch height) and intubating conditions were rated in a blinded manner. RESULTS: There was no difference in the calibration success rates between the two groups; and the calibration time in the electromyography group (16.7 +/- 11.0 seconds) was shorter than the acceleromyography group (28.1 +/- 13.4 seconds, P = 0.012). The rocuronium onset time of the electromyography group (73.6 +/- 18.9 seconds) was longer than the acceleromyography group (63.9 +/- 18.8 seconds, P = 0.042) and the intubation condition of the electromyography group (2.27 +/- 0.65) was better than the acceleromyography group (1.86 +/- 0.50, P = 0.007). CONCLUSIONS: Electromyography offers a better compromise than acceleromyography with respect to the duration of calibration process and surrogate for the optimal time of tracheal intubation in children.

Relationship between first-twitch depression and train-of-four ratio during sugammadex reversal of rocuronium-induced neuromuscular blockade / 대한마취과학회지

BACKGROUND: The primary outcome of sugammadex reversal for rocuronium-induced neuromuscular block (NMB) is a train-of-four ratio (TOFR) of 0.9, not first twitch (T1) height. We investigated whether the recovery of TOFR or T1 differs based on the reversal of NMB with neostigmine or sugammadex. METHODS: The acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in 80 patients after induction of anesthesia. The TOFR and T1 height were recorded, and saved in a personal computer using TOF-Watch SX Monitor software in all patients. Patients were randomly assigned to 2 groups to receive either neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg (neostigmine group, n = 40) or sugammadex 2.0 mg/kg (sugammadex group, n = 40). The primary objective was to determine the difference of recovery time between TOFR to 0.9 and T1 to 0.9 after sugammadex or neostigmine administration during moderate rocuronium-induced NMB. RESULTS: The recovery pattern of the TOFR 2 min after sugammadex administration was 1.0 or more, but that of T1 was less than 90% (T1 / control value) up to 6 min after drug was injected. The recovery pattern of TOFR and T1 was similar during the 20 min after reversal with neostigmine. CONCLUSIONS: If you have not performed the T1 monitoring, both TOFR and T1 should be considered to confirm suitable recovery during the 6 min after reversal with sugammadex during rocuronium-induced moderate NMB.

Late recurarization in the post-anesthetic care unit after total thyroidectomy: A case report

Residual paralysis, recurarization is defined as a remnant effect of neuromuscular blocking after surgery that can cause postoperative complications. Clinical complications of recurarization include dyspnea, gastric content aspiration, and atelectasis. Therefore, complete recovery of muscle strength at the end of surgery is a significant factor for patient safety. We report a case of a 53-year-old woman who presented with residual paralysis after total thyroidectomy. To improve her condition, we injected sugammadex intravenously in the post-anesthetic care unit. After that, we observed her for 1 hour and her muscle strength gradually recovered. She did not have any symptoms on the next day and was discharged on the 5th post-operative day.

Use of neuromuscular blockers in Brazil / Uso de bloqueadores neuromusculares no Brasil

ABSTRACTThe objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers, focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of neuromuscular blockers. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main neuromuscular blockers used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to neuromuscular blockers were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to neuromuscular blockers. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

RESUMOO objetivo desta pesquisa foi avaliar como os anestesiologistas brasileiros estão usando os bloqueadores neuromusculares (BNM), com foco na forma de estabelecer o diagnóstico da curarização residual pós-operatória e a incidência de complicações atribuídas ao uso de BNM. Um questionário foi enviado a anestesiologistas convidando-os a participar da pesquisa (tabela 1). A coleta online de dados permaneceu aberta de março de 2012 a junho de 2013. Durante o período de estudo foram coletadas 1.296 respostas. Rocurônio, atracúrio e cisatracúrio foram os principais bloqueadores neuromusculares usados em casos de cirurgia eletiva. Succinilcolina e rocurônio foram os principais BNM usados em casos de cirurgia de emergência. Menos de 15% dos anestesiologistas referiram que usam frequentemente monitores da função neuromuscular. Apenas 18% dos envolvidos no estudo referiram que todos os locais de trabalho têm tal monitor. A maioria dos entrevistados afirmou que usa somente o critério clínico para avaliar se o paciente está recuperado do relaxante. A maioria dos entrevistados também relatou que sempre usa algum tipo de reversão de bloqueio neuromuscular. As principais complicações atribuídas aos BNM foram curarização residual e bloqueio prolongado. Houve relato por 18 anestesiologistas de óbito atribuído a BNM. O bloqueio residual ou prolongado se registra, possivelmente, como consequência do alto índice do uso de critérios clínicos para diagnosticar se o paciente está recuperado ou não do bloqueio motor e, como um corolário, o baixo uso de monitores da transmissão neuromuscular na prática diária.

Neuromuscular profile of Handball players during a short-term condensed competition in Brazil / Perfil neuromuscular de atletas de handebol durante curta competição no Brasil

Abstract The aim of this study was to assess the neuromuscular profile of handball (TH) players during a short-term condensed competition. Nine TH athletes (age: 23 ± 3 years; height: 176.2 ± 10.5 cm; mass: 75.3 ± 8.6 kg) played 5 handball matches in 5 consecutive days and had exercise-induced muscle damage (EIMD) markers such as soreness (SOR), thigh circumference (CIR), knee range of motion (ROM) and countermovement jump height (CMJ) collected before the first match and at the end of each day of competition. Changes over time in these markers were analyzed. Significant changes were found for all EIMD markers assessed. CMJ significantly decreased at the fourth day of competition when compared to baseline (0.41 ± 0.03 m vs. 0.45 ± 0.02 m). ROM decreased on the first day of competition and remained stable until the last day of competition (baseline: 126.5 ± 7.2º; 1st day: 115.8 ± 5.9º; 2nd day: 115 ± 7º; 3rd day: 113.9 ± 8.8º; 4th day: 114.4 ± 8.6º). SOR and CIR were increased at the second day of competition and remained altered thereafter. It was concluded that the characteristics of short-term condensed competition have led TH athletes to significant EIMD. If not avoided, EIMD might lead to reductions in performance in the most important (final) matches.

Resumo O objetivo do presente estudo foi medir o perfil neuromuscular de jogadores de handebol durante uma competição em formato de jogos. Nove jogadores de handebol (idade: 23 ± 3 anos; estatura: 176,2 ± 10,5 cm; massa: 75,3 ± 8,6 kg) jogaram cinco partidas da modalidade em cinco dias consecutivos e tiveram marcadores de DM [como percepção subjetiva de dor (PSD), circunferência da coxa (CIR), amplitude de movimento do joelho (ADM) e altura de salto com contra-movimento (AS)] coletados antes da primeira partida e ao final de cada dia de competição. Mudanças ao longo do tempo nesses marcadores foram analisadas. Alterações significantes foram encontradas para todos os marcadores de DM coletados. A AS diminuiu significantemente durante o quarto dia de competição, quando comparado ao valor basal (0,41 ± 0,03 m vs. 0,45 ± 0,02 m). A ADM diminuiu após o primeiro dia de competição e permaneceu comprometida até o último dia (basal: 126,5 ± 7,2º; 1o dia: 115,8 ± 5,9º; 2o dia: 115 ± 7º; 3odia: 113,9 ± 8,8º; 4o dia: 114,4 ± 8,6º). A PSD e a CIR apresentaram aumento durante o segundo dia de competição e permaneceram alteradas até o final da mesma. Concluímos que a característica condensada das competições de handebol no Brasil leva a um quadro de DM significante. Se não evitado, o DM pode levar a comprometimentos no desempenho nas partidas mais importantes da competição (finais).

Effect of Priming Technique Combined with Time Limit on Shortening the Onset time of Cisatracurium Be-silate / 中国药师

Objective:To study the effect of priming technique combined with time limit on shortening the onset time of cisatra-curium besilate. Methods:Totally 112 adult patients undergoing selective operation with general anesthesia were randomly divided into group A, B and C. Fentanyl with the dose of 4 μg·kg-1 and propofol with the dose of 2 mg·kg-1 were used in the three groups as the inducing agents. Group A was first with intravenous injection of cisatracurium besilate 20 μg·kg-1 , and 3 minutes later, the in-ducing agents and cisatracurium besilate with the dose of 80 μg·kg-1 were respectively injected. Group B was first with intravenous injection of cisatracurium besilate with the dose of l00 μg·kg-1 , and 1. 5 minutes later, the inducing agents were injected. Group C was respectively injected with the inducing drugs and cisatracurium besilate with the dose of l00 μg·kg-1 . The T1 percentage before the induction, the time of 90% and 100% inhibition of muscle twitching, the rating of trachea cannula and adverse drug reactions in the three groups were observed and compared. Results:There was no significant difference in the excellent rate of trachea cannula a-mong the three groups (P>0. 05). Compared with group A and B, group C showed no T1 suppression before the induction, while group B with T1 of (9. 8 ± 2. 6) was higher than group A with T1 of (3. 2 ± 1. 5) (P<0. 01). The time of 90% and 100% inhibition of muscle twitching in group C was the longest (P<0. 01), and the incidence of adverse drug reactions in group C was also the highest (P<0. 05). Conclusion:The application of priming principle and time limit can effectively shorten the onset time of cisatracurium be-silate with significant effect and high safety.