Reversal with sugammadex for rocuronium-induced deep neuromuscular block after pretreatment of magnesium sulfate in rabbits / 대한마취과학회지

BACKGROUND: Magnesium sulfate (MgSO4) has been used in the treatment of pre-eclampsia, hypertension and arrhythmia. Magnesium enhances the neuromuscular block of rocuronium. This study has been conducted to evaluate the reversal efficacy of sugammadex from deep rocuronium-induced neuromuscular block (NMB) during consistent pretreatment of MgSO₄ in rabbits. METHODS: Twenty-eight rabbits were randomly assigned to four groups, a control group or study groups (50% MgSO₄ 150–200 mg/kg and 25 mg/kg/h IV), and received rocuronium 0.6 mg/kg. When post-tetanic count 1–2 appeared, sugammadex 2, 4, and 8 mg/kg was administered in the 2-mg group, control and 4-mg group, and 8-mg group, respectively. The recovery course after reversal of sugammadex administration was evaluated in each group. RESULTS: The mean serum concentration of magnesium was maintained at more than 2 mmol/L in the study groups, and the total dose of MgSO₄ was more than 590 mg. The reversal effect of sugammadex on rocuronium-induced NMB in pretreated MgSO₄ was not different from that in the group without MgSO₄. The recovery time to train-of-four ratio 0.9 after sugammadex administration in the 2-mg group was longer than in the other groups (P < 0.001); there were no other significant differences among the groups. CONCLUSIONS: The reversal of sugammadex from a deep rocuronium-induced NMB during large pretreatment of MgSO₄ was not affected. However, we should consider that the reversal effect of sugammadex varied depending on the dose.

Reversal with sugammadex for rocuronium-induced deep neuromuscular block after pretreatment of magnesium sulfate in rabbits / 대한마취과학회지

BACKGROUND: Magnesium sulfate (MgSO4) has been used in the treatment of pre-eclampsia, hypertension and arrhythmia. Magnesium enhances the neuromuscular block of rocuronium. This study has been conducted to evaluate the reversal efficacy of sugammadex from deep rocuronium-induced neuromuscular block (NMB) during consistent pretreatment of MgSO₄ in rabbits. METHODS: Twenty-eight rabbits were randomly assigned to four groups, a control group or study groups (50% MgSO₄ 150–200 mg/kg and 25 mg/kg/h IV), and received rocuronium 0.6 mg/kg. When post-tetanic count 1–2 appeared, sugammadex 2, 4, and 8 mg/kg was administered in the 2-mg group, control and 4-mg group, and 8-mg group, respectively. The recovery course after reversal of sugammadex administration was evaluated in each group. RESULTS: The mean serum concentration of magnesium was maintained at more than 2 mmol/L in the study groups, and the total dose of MgSO₄ was more than 590 mg. The reversal effect of sugammadex on rocuronium-induced NMB in pretreated MgSO₄ was not different from that in the group without MgSO₄. The recovery time to train-of-four ratio 0.9 after sugammadex administration in the 2-mg group was longer than in the other groups (P < 0.001); there were no other significant differences among the groups. CONCLUSIONS: The reversal of sugammadex from a deep rocuronium-induced NMB during large pretreatment of MgSO₄ was not affected. However, we should consider that the reversal effect of sugammadex varied depending on the dose.

Influence of acute normovolemic hemodilution on the potency and time course of action of rocuronium in rabbits

BACKGROUND: We performed this study to evaluate the potency and time course of rocuronium-induced neuromuscular block following moderate or severe acute normovolemic hemodilution (ANH) in rabbits. METHODS: Forty five rabbits were randomly assigned to the control (C) group, the moderate ANH (M) group, or the severe ANH (S) group. After stabilization of sevoflurane anesthesia, ANH was achieved by drainage of arterial blood and an intravenous infusion of 6% hydroxyethyl starch, during which hematocrit (Hct) decreased to 26.2 ± 2.5% in the M group and 17.6 ± 2.2% in the S group. We determined dose-response relationships of rocuronium in the three groups and created a time course of the action of 0.6 mg/kg rocuronium. RESULTS: The 50% effective dose (ED50) for rocuronium was 45% and 50% lower in the M and S groups, respectively, than in the C group (50.9 ± 6.3 µg/kg) (P < 0.001). The onset time after 0.6 mg/kg rocuronium was faster in the ANH groups compared with the C group (P < 0.001). The duration of neuromuscular block was prolonged by 38% and 43% in the M and S groups, respectively, compared with the C group (49.1 ± 6.9 min) (P < 0.001). CONCLUSIONS: ANH resulted in high potency, rapid onset, and prolonged duration of rocuronium. However, the severity of ANH did not alter the potency and duration of action of rocuronium.

Effect of capsicum plaster at the P6 acupoint on postoperative nausea and vomiting in patients undergoing endoscopic sinus surgery

BACKGROUND: We evaluated the efficacy of capsicum plaster, applied to the Chinese acupuncture point (acupoint) Pericardium 6 (P6), in reducing postoperative nausea and vomiting (PONV) in patients who underwent endoscopic sinus surgery (ESS). METHODS: One hundred and fifty patients scheduled for ESS were randomly placed in one of 3 groups. Each group had 50 patients. Inactive tape was affixed at both P6 acupoints and both shoulders in the control (placebo) group. Capsicum plaster was affixed at both P6 acupoints and inactive tape was affixed at both shoulders in the capsicum plaster (P6) group. Capsicum plaster was affixed at both shoulders and inactive tape at both P6 acupoints in the sham group. Plasters and tapes were affixed before the induction and removed 8 hours after surgery. RESULTS: The incidence of PONV and requirement for antiemetics were significantly lower in the P6 group than in the control and sham groups during the 24 hours after surgery. At postoperative 0-24 hour, nausea was 42% in the control group, 2% in the P6 group, and 38% in the sham group. Postoperative vomiting was 28%, 0% and 26%, respectively, and the use of antiemetics was 34%, 0% and 32%, respectively. CONCLUSIONS: Stimulation of the P6 acupoint with capsicum plaster is effective for preventing PONV at postoperative 0-24 hour in patients undergoing ESS.

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.

Effectiveness of sugammadex in reversing prolonged neuromuscular block in a patient with acquired immune deficiency syndrome (AIDS) taking streptomycin: A case report

The duration of the effect of muscle relaxants is extended in patients with acquired immunodeficiency syndrome (AIDS); however, a specific mechanism for this effect has not yet been discovered. In addition, streptomycin is known to prolong the action of muscle relaxants by blocking activity at neuromuscular junctions. Here, we report the case of patient with AIDS taking streptomycin for pulmonary tuberculosis for which sugammadex was effective in reversing prolonged paralysis induced by rocuronium and vecuronium for video-assisted thoracoscopic surgery (VATS) lung wedge resection.

Accidental ingestion of a fixed partial denture during general anesthesia: A case report

Swallowing a foreign body of dental origin is a rare occurrence; but, it can be dangerous if the foreign body is large, sharp, and pointed. We report a case in which a large fixed partial denture became dislodged and was ingested while the patient was undergoing general anesthesia, and was removed postoperatively with endoscopy. Anesthesiologists should understand the dangers and recognize this complication when it occurs, and prepare a suitable treatment plan.

Postoperative nausea and vomiting after capsicum plaster at the P6 acupoint after laparoscopic cholecystectomy according to gender

BACKGROUND: Postoperative nausea and vomiting (PONV) has a remarkably high reported incidence (70%) in female patients after anesthesia. This study aims to evaluate the clinical effect of capsicum plaster at the P6 acupoint with respect to gender in preventing PONV after laparoscopic cholecystectomy. METHODS: A prospective, placebo-controlled, double-blind study was conducted with 120 patients undergoing laparoscopic cholecystectomy and who were randomly assigned to four groups (n = 30 each): Group MC = male patients with capsicum plaster at the P6 acupoint; Group MP = male patients with placebo tape at the P6 acupoint; Group FC = female patients with capsicum plaster at the P6 acupoint; Group FP = female patients with placebo tape at the P6 acupoint. The treatment tape was applied before the induction of anesthesia and was removed eight hours after the operation. RESULTS: The incidence of nausea was reduced in both genders with application of capsicum plaster at P6 acupoint. No change in vomiting or use of anti-emetics was observed. Satisfaction scores with PONV control were improved with this intervention. No gender difference was observed which actually the initial objective of this study was. CONCLUSIONS: The application of capsicum plaster at the P6 acupoint is a proven antiemetic method in both gender after laparoscopic cholecystectomy, however there are no intergender differences.

Use of high-frequency oscillatory ventilation with inhaled nitric oxide in congenital diaphragmatic hernia, omphalocele, and patent ductus arteriosus / 대한마취과학회지

No abstract available.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration / 대한마취과학회지

BACKGROUND: The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration. METHODS: A total of 140 adult patients were randomized into 4 groups to receive either 30 microg/kg ephedrine (Group 30, n = 35), 70 microg/kg ephedrine (Group 70, n = 35), 110 microg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration. RESULTS: An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 +/- 44.7 s, Group 70: 152.6 +/- 40.3 s, Group 110: 151.2 +/- 51.6 s) compared to Group C (224.6 +/- 56.9 s) after 0.15 mg/kg of cisatracurium (P 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups. CONCLUSIONS: We conclude that pre-treatment with ephedrine 70 microg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects.

The use of 3 sugammadex out of 5 reversal of during recovery of rocuronium-induced neuromuscular blockade in a patient with post-tonsillectomy hemorrhage: a case report / 대한마취과학회지

Post-tonsillectomy hemorrhage (PTH) is the most frequent complication of tonsillectomy, and occasionally results in a lethal outcome. A 21-year-old man (height 180 cm, weight 95 kg) was scheduled for a bilateral tonsillectomy and uvulopalatopharyngoplasty for treatment of obstructive sleep apnea. He required 5 rounds of general anesthesia due to recurrent PTH. The anesthesiologist used sugammadex a total of 3 times to achieve the successful reversal of the deep neuromuscular blockade (NMB) induced by rocuronium. After sugammadex 2 mg/kg was administered, the NMB was reversed in 2 minutes each time. Re-administration of rocuronium within a short time interval after sugammadex may result in unpredictable effects of neuromuscular blocking agents. Sugammadex made it possible to perform a rapid, complete reverse when the residual block was maintained by an incomplete reversal of anticholinesterase.

Optimal precurarizing dose of rocuronium to decrease fasciculation and myalgia following succinylcholine administration / 대한마취과학회지

BACKGROUND: Succinylcholine commonly produces frequent adverse effects, including muscle fasciculation and myalgia. The current study identified the optimal dose of rocuronium to prevent succinylcholine-induced fasciculation and myalgia and evaluated the influence of rocuronium on the speed of onset produced by succinylcholine. METHODS: This randomized, double-blinded study was conducted in 100 patients randomly allocated into five groups of 20 patients each. Patients were randomized to receive 0.02, 0.03, 0.04, 0.05 and 0.06 mg/kg rocuronium as a precurarizing dose. Neuromuscular monitoring after each precurarizing dose was recorded from the adductor pollicis muscle using acceleromyography with train-of-four stimulation of the ulnar nerve. All patients received succinylcholine 1.5 mg/kg at 2 minutes after the precurarization, and were assessed the incidence and severity of fasciculations, while myalgia was assessed at 24 hours after surgery. RESULTS: The incidence and severity of visible muscle fasciculation was significantly less with increasing the amount of precurarizing dose of rocuronium (P < 0.001). Those of myalgia tend to decrease according to increasing the amount of precurarizing dose of rocuronium, but there was no significance (P = 0.072). The onset time of succinylcholine was significantly longer with increasing the amount of precurarizing dose of rocuronium (P < 0.001). CONCLUSIONS: Precurarization with 0.04 mg/kg rocuronium was the optimal dose considering the reduction in the incidence and severity of fasciculation and myalgia with acceptable onset time, and the safe and effective precurarization.

Anesthetic considerations in patients with large obstructing vocal process granuloma / 대한마취과학회지

No abstract available.

Epidural contrast flow patterns of retrograde interlaminar ventral epidural injections stratified by the final catheter tip placement

BACKGROUND: The aim of the study is to evaluate the relevant spreading for contrasts in the ventral and dorsal epidural space during retrograde interlaminar ventral epidural injections (RIVEIs) with the catheter tip placed ventral or dorsal to the spinal nerve. METHODS: For RIVEIs, a 17G Tuohy needle was inserted in retrograde fashion. Catheter containing a removable stylet was inserted and advanced via the needle and passed to the lower aspect of contralateral pedicles in 75 patients. Fluoroscopic images were recorded at 1.5 ml increments of contrast. Using the fluoroscopy, the contrast spreading pattern and whether the contrast spread to the specific anatomic landmarks (superior aspect of the supra-adjacent intervertebral disc [SIVD] and inferior aspect of the infra-adjacent intervertebral disc [IIVD]) were evaluated. Whether the catheter was placed ventral or dorsal to the spinal nerve was assessed with the computed tomography axial and sagittal views. RESULTS: There were no significant differences in the mean levels of epidural contrast spreading extents between ventral and dorsal catheter placements. Ventral or dorsal catheter tip placements demonstrated ventral concurrent flows over to the SIVD and IIVD over 80% of subjects with 3.0 ml of contrast. CONCLUSIONS: During RIVEIs, the catheter tip placed ventral to the spinal nerve did not show superiority with regards to epidural spreading extent as compared with dorsal catheter placement. One-level instead of a two-level injection may be considered for the two-level central pathology.

Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients / 대한마취과학회지

BACKGROUND: Rapid and complete reversal of neuromuscular blockade (NMB) is desirable at the end of surgery. Sugammadex reverses rocuronium-induced NMB by encapsulation. It is well tolerated in Caucasian patients, providing rapid reversal of moderate (reappearance of T2) rocuronium-induced NMB. We investigated the efficacy and safety of sugammadex versus neostigmine in Korean patients. METHODS: This randomized, safety assessor-blinded trial (NCT01050543) included Korean patients undergoing general anesthesia. Rocuronium 0.6 mg/kg was given prior to intubation with maintenance doses of 0.1-0.2 mg/kg as required. Patients received sugammadex 2.0 mg/kg or neostigmine 50 microg/kg with glycopyrrolate 10 microg/kg to reverse the NMB at the reappearance of T2, after the last rocuronium dose. The primary efficacy endpoint was the time from sugammadex or neostigmine administration to recovery of the train-of-four (TOF) ratio to 0.9. The safety of these medications was also assessed. RESULTS: Of 128 randomized patients, 118 had evaluable data (n = 59 in each group). The geometric mean (95% confidence interval) time to recovery of the TOF ratio to 0.9 was 1.8 (1.6, 2.0) minutes in the sugammadex group and 14.8 (12.4, 17.6) minutes in the neostigmine group (P < 0.0001). Sugammadex was generally well tolerated, with no evidence of residual or recurrence of NMB; four patients in the neostigmine group reported adverse events possibly indicative of inadequate NMB reversal. CONCLUSIONS: Sugammadex was well tolerated and provided rapid reversal of moderate rocuronium-induced NMB in Korean patients, with a recovery time 8.1 times faster than neostigmine. These results are consistent with those reported for Caucasian patients.

Antiemetic efficacy of capsicum plaster on acupuncture points in patients undergoing thyroid operation / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) occurs in up to 63-84% of patients after thyroid surgery. This study aims to assess the effects of using a capsicum plaster to reduce PONV after thyroid surgery at either the Chinese acupuncture point (acupoint) Pericardium 6 (P6) or Korean hand acupuncture point K-D2. METHODS: One-hundred eighty-four patients who underwent thyroid surgery were randomized in four groups (n = 46 each): control group = inactive tape at P6 acupoints and on both shoulders as a nonacupoint; P6 group = capsicum plaster at P6 points and inactive tape on both shoulders; K-D2 group = capsicum plaster at K-D2 acupoints and inactive tape on both shoulders; Sham group = capsicum plaster on both shoulders and inactive tape at P6 acupoints. The capsicum plaster was applied before the induction of anesthesia and removed at 8 hr after surgery. RESULTS: The incidence and severity of nausea and vomiting and the need for rescue antiemetics were decreased in the patients in the P6 and K-D2 groups compared to the patients in the control and sham groups (P < 0.001). The patients in the P6 and K-D2 groups also reported that they were more satisfied (P < 0.05). CONCLUSIONS: We conclude that the capsicum plaster at the P6 and K-D2 acupoint was a promising antiemetic method for the patients undergoing thyroid surgery.

Optimal positive end-expiratory pressure during robot-assisted laparoscopic radical prostatectomy / 대한마취과학회지

BACKGROUND: Increased intra-abdominal pressure during laparoscopic surgery causes cephalad displacement of the diaphragm, resulting in the formation of atelectasis, which can be overcome by positive end-expiratory pressure (PEEP). The aim of this prospective study was to investigate the level of optimal PEEP to maintain adequate arterial oxygenation and hemodynamics during robot-assisted laparoscopic radical prostatectomy (RLRP). METHODS: One hundred patients undergoing RLRP were randomly allocated to one of five groups (n = 20) (0, 3, 5, 7 and 10 cmH2O of PEEP). Hemodynamic variables and respiratory parameters were measured at baseline with the patient in the supine position; at 30 min, 1, 2, 3 and 4 h during CO2 insufflation with the patient in the post-Trendelenburg position; and after deflation in the supine position with increasing PEEP. RESULTS: The PaO2 levels and alveolar-arterial difference in oxygen tension (AaDO2) were improved in patients with PEEPs compared with patients in whom PEEP was not used. The application of PEEP (10 cmH2O) resulted in higher PaO2 levels compared to those with lower PEEP levels, but excessive peak airway pressure (PAP) was sometimes observed. The application of a PEEP of 7 cmH2O resulted in similar PaO2 levels without causing excessive PAP. There was a significant difference in central venous pressure between the groups, but there were no significant differences in heart rate, mean arterial pressure or minute ventilation between the groups. CONCLUSIONS: A PEEP of 7 cmH2O is associated with the greater improvement of PaO2 and AaDO2 without causing excessive PAP during RLRP.

The effect of hand dominance on neuromuscular monitoring at the adductor pollicis muscle / 대한마취과학회지

BACKGROUND: Neuromuscular blockade of the adductor pollicis muscle may be influenced by hand dominance resulting in conflicting results of several studies. The current study examined whether hand dominance could influence the measurements of neuromuscular blockade with acceleromyography at the adductor pollicis. METHODS: The acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in both hands in 31 patients after induction of anesthesia. Onset, maximum effect, and offset of rocuronium were measured and compared in both hands. The train-of-four (TOF) ratios to 0.9 were recorded in all patients. RESULTS: In total, 27 patients were right-handed and 4 patients were left-handed. The mean supramaximal threshold or initial TOF ratio was not different between dominant and nondominant hands. No statistically significant differences were found between 716 paired TOF ratios in both hands. A correlation was seen between the dominant and nondominant hand (Nondominant = 0.931.Dominant + 1.714, R = 0.929). The analysis by the Bland-Altman plot showed an excellent agreement with a bias of 1.6% and limits of agreement of -21.2 to 24.5%. CONCLUSIONS: Dominant and nondominant hands can be used interchangeably for neuromuscular monitoring at the adductor pollicis.

Hemodynamic parameters during robotic radical prostatectomy in elderly patients with increased cardiac risk

BACKGROUND: We studied the hemodynamic changes associated with steep Trendelenburg position and prolonged pneumoperitoneum during robot-assisted laparoscopic prostatectomy in elderly patients with cardiac diseases. METHODS: Hemodynamic variables were measured at baseline supine position, at 30 min, 1, 2, 3 and 4 h during CO2 insufflation in post-Trendelenburg position, and after deflation in the supine position. RESULTS: In comparison with normal subjects, the cardiac index and systemic vascular resistance index of patients with cardiac diseases were significantly affected by the Trendelenburg position and pneumoperitoneum (P < 0.001). However, other variables of heart rate, mean arterial pressure and central venous pressure were not differed between the groups. CONCLUSIONS: We conclude that attention should be paid to maintain adequate hemodynamic status during prolonged pneumoperitoneum in the Trendelenburg position, and which is unfeasible in patients with severe heart failure and unstable angina.

Clinical use of sugammadex

An ideal reversal agent could be given at any time after the administration of a neuromuscular blocking agent, and should have no muscarinic side-effects. Sugammadex is a modified gamma-cyclodextrin designed to encapsulate rocuronium bromide, providing a rapid reversal of neuromuscular blockade. Sugammadex is a revolutionary investigational reversal drug currently undergoing Phase III testing whose introduction into clinical practice in Korea may change the face of clinical neuromuscular pharmacology. The dose of sugammadex for reversal of moderate block (when T2 is detectable) is approximately 2 mg/kg, the dose is 4-8 mg/kg for profound block (post-tetanic count 1-2) and a larger dose of 16 mg/kg for immediate reversal. The use of sugammadex has not been reported to be associated with recurrence of block provided a dose that is adequate for reversal has been used. Sugammadex appears to have an acceptable safety profile. Volatile agent such as sevoflurane seems not to influence the sugammadex ability to reverse the rocuronium neuromuscular blockade.