Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial

Abstract Background Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. Methods One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg−1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. Results Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. Conclusions The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. Clinical trial number and registry URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.

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.

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.

Response to neuromuscular blockade with rocuronium during general anesthesia in a patient with dermatomyositis: A case report

Dermatomyositis is an idiopathic inflammatory myopathy characterized by skin changes and muscle weakness. Depending on the involvement of various muscles, dermatomyositis can cause aspiration pneumonia, ventilatory impairment, and heart failure. Several reports have documented normal or prolonged neuromuscular blockade following administration of different non-depolarizing neuromuscular blockers in patients with dermatomyositis. We observed delayed onset of blockade and prolonged recovery following administration of 0.6 mg/kg rocuronium in a patient with dermatomyositis. However, when the train-of-four ratio reached 0.3, the patient was administered pyridostigmine and glycopyrrolate, which led to normal response to reversal of rocuronium. The patient was extubated without respiratory complications. The outcomes of this case indicate that response to the usual dosage of muscle relaxants in patients with dermatomyositis might be different from that in patients without this condition. Anesthesiologists should pay attention to preoperative cardiorespiratory evaluation and intraoperative neuromuscular monitoring.

Effect of levetiracetam on rocuronium duration in patients undergoing cerebrovascular surgery

BACKGROUND: It has long been held that antiepileptics reduce the duration of action, and increase the requirement for, neuromuscular blocking agents. However, levetiracetam, a relatively novel antiepileptic agent, possesses different pharmacokinetic properties to other, conventional antiepileptics, such that its effect on neuromuscular blocking agents might also differ. The purpose of this retrospective study is to investigate the effect of levetiracetam on the clinical duration of rocuronium. METHODS: In this study, the duration of neuromuscular blockade induced by rocuronium was compared between control and levetiracetam-receiving groups. The data were retrieved from one of our previous studies. RESULTS: The control and levetiracetam groups comprised 16 and 13 patients, respectively, all of whom underwent cerebrovascular surgery. Subjects received supplementary rocuronium (0.15 mg/kg) whenever the train-of-four count reached 2 during surgery. The interval between supplementary rocuronium (0.15 mg/kg) injections was significantly longer in the levetiracetam vs. control group (50 and 39 minutes, respectively; P = 0.036). CONCLUSIONS: The present results challenge the convention that antiepileptics decrease the duration of action of neuromuscular blockers, thereby alerting clinicians to the possibility of prolonged neuromuscular blockade in patients taking levetiracetam. Anesthetic management should encompass careful neuromuscular monitoring in such patients.

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.

Effects of thiopental sodium, ketamine, and propofol on the onset time of rocuronium in children

BACKGROUND: In emergency condition, failure in securing airway is a common and serious reason of pediatric death. Rapid intubation is required to minimize physiologic complication in children due to airway failure. Rapid loss of consciousness and rapid onset of neuromuscular blocking agent are necessary for the rapid sequence intubation. In this study, we compared the effects of thiopental sodium, ketamine, and propofol (drugs commonly used to induce anesthesia in children) on the onset time of rocuronium. We also compared the effects of these anesthesia induction drugs on intubation condition and their duration of action. METHODS: A total of 89 patients undergoing various elective surgeries were enrolled and allocated to the following three groups according to the anesthesia induction drug: 1) Group T, thiopental sodium; 2) Group P, propofol; and 3) Group K, ketamine. After loss of consciousness, neuromuscular monitoring was performed and rocurunium 0.6 mg/kg was administered. Onset time and duration of action of rocuronium were measured. Intubation condition was recorded with a tracheal intubation scoring system. Hemodynamic changes were observed before induction until 5 min after endotracheal intubation. RESULTS: The onset time of rocuronium in group K (39.9 s) was significantly faster than that in group T (61.7 s) or group P (50.7 s). There was no significant difference in duration of action of rocuronium or intubation condition among the three groups. CONCLUSIONS: Ketamine can decrease the onset time of rocuronium significantly compared to thiopental sodium or propofol.

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.

Experience with reversal of a neuromuscular block with sugammadex in a child with Prader-Willi syndrome: A case report

We treated a 4-year-old patient with a genetic disorder, Prader-Willi syndrome, that was accompanied by pulmonary hypertension due to upper airway obstruction. Prader-Willi syndrome is a complex genetic condition characterized by hypotonia, feeding difficulties, poor growth, and delayed development. Hypotonia was the main concern in the anesthetic management of this patient, including the choice of a neuromuscular blocking agent. We report successful induction of anesthesia in this patient with sevoflurane inhalation, remifentanil infusion, and a non-depolarizing muscle relaxant, rocuronium, while following up the status of the neuromuscular block by train-of-four monitoring and reversing the neuromuscular block with sugammadex.

Experience with reversal of a neuromuscular block with sugammadex in a child with Prader-Willi syndrome: A case report

We treated a 4-year-old patient with a genetic disorder, Prader-Willi syndrome, that was accompanied by pulmonary hypertension due to upper airway obstruction. Prader-Willi syndrome is a complex genetic condition characterized by hypotonia, feeding difficulties, poor growth, and delayed development. Hypotonia was the main concern in the anesthetic management of this patient, including the choice of a neuromuscular blocking agent. We report successful induction of anesthesia in this patient with sevoflurane inhalation, remifentanil infusion, and a non-depolarizing muscle relaxant, rocuronium, while following up the status of the neuromuscular block by train-of-four monitoring and reversing the neuromuscular block with sugammadex.

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.

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.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists / Pesquisa de curarização residual no pós-operatório, eventos respiratórios agudos e abordagem de anestesiologistas

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate >20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR <0.9, and 15% (n = 61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

JUSTIFICATIVA E OBJETIVOS: A paralisia residual após o uso de bloqueadores neuromusculares (BNMs) sem monitoração neuromuscular continua sendo um problema clínico, mesmo quando BNMs são usados. Este estudo pesquisou a curarização residual pós-operatória e os eventos respiratórios críticos em sala de recuperação, bem como a abordagem clínica da CRPO feita pelos anestesiologistas em nossa instituição. MÉTODOS: Este estudo observacional incluiu 415 pacientes que receberam anestesia geral com BNMs de ação intermediária. A manutenção da anestesia foi feita por anestesiologistas não participantes, "cegos" para o estudo. A monitoração neuromuscular foi realizada no momento da chegada à sala de recuperação. Um ERC foi definido como necessidade de suporte ventilatório; saturação periférica de oxigênio <90% e 90-93%, a despeito de receber 3 L/min de O2 via cânula nasal; frequência respiratória >20 bpm; uso de musculatura acessória; dificuldade de engolir ou falar e necessidade de reintubação. A abordagem clínica de nossos anestesiologistas, em relação aos agentes de reversão, foi avaliada usando um miniquestionário de oito perguntas logo após o estudo. RESULTADOS: A incidência de CRPO foi de 43% (n = 179) para a SQE <0 e 15% (n = 61) para a SQE <0,7. A incidência de SQE <0,9 foi significativamente maior em mulheres, pacientes com estado físico ASA III e com anestesia de curta duração (p < 0,05). Além disso, 66% (n = 272) dos 415 pacientes que chegam à sala de recuperação haviam recebido neostigmina. Uma SQE <0,9 foi encontrada em 46% (n = 126) dos pacientes que receberam neostigmina. CONCLUSÃO: Quando a monitoração neuromuscular objetiva de rotina não está disponível, a CRPO continua sendo um problema clínico, a despeito do uso de BNMs. O momento e o antagonismo ideais do bloqueio neuromuscular e a monitoração neuromuscular objetiva de rotina são recomendados para aumentar a segurança do paciente.

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.