Bloqueio neuromuscular residual em pacientes cirúrgicos: conhecimento da equipe de enfermagem da recuperação anestésica / Residual neuromuscular blockade in surgical patients: knowledge of the nursing team at the anesthetic recovery / Bloqueo neuromuscular residual en pacientes quirúrgicos: conocimiento del equipo de enfermería sobre la recuperación anestésica

Objetivo: Identificar o conhecimento da equipe de enfermagem que atua na recuperação anestésica acerca da avaliação do bloqueio neuromuscular residual (BNMR) em pacientes cirúrgicos. Método: Estudo quantitativo, transversal, realizado em um hospital privado de São Paulo. Amostra composta por 50 profissionais, sendo 18 enfermeiros e 32 técnicos de enfermagem, que responderam um questionário validado por um corpo de cinco juízes. Coleta realizada de janeiro a março de 2022, utilizando-se a plataforma REDCap. Realizadas análises descritiva e inferencial, medidas de tendência central e de dispersão, testes de correlação de Pearson e t-Student, considerando-se nível de significância de 5%. Pesquisa conduzida segundo a Resolução 466/2012. Resultados: A média de acertos geral foi de 43%, sendo 44,4% entre enfermeiros e 42,2% entre técnicos. Seis (12%) profissionais já tinham feito algum treinamento sobre bloqueio neuromuscular e 10 (20%) relataram já ter atendido pacientes com BNMR. Não foram observadas diferenças estatisticamente significativas entre a média de acerto das questões e o tempo de formação e atuação profissional, especialização, experiência prévia ou execução de treinamentos. Conclusão: O estudo evidenciou déficits de conhecimento da equipe de enfermagem acerca do BNMR e a assistência durante esta intercorrência. Ressalta-se a importância de ações de educação permanente, com vista à capacitação dos profissionais para o atendimento desta complicação e melhoria dos cuidados de enfermagem prestados na recuperação anestésica para garantia da segurança do paciente

Objective: To identify the knowledge of the nursing team involved in anesthetic recovery regarding the assessment of residual neuromuscular blockage (RNB) in surgical patients. Method: This is a quantitative, cross-sectional study conducted in a private hospital in the state of São Paulo, Brazil. The sample com-prised 50 professionals, 18 nurses and 32 nursing technicians, who answered a questionnaire validated by five judges. The collection was carried out from January to March 2022, using the REDCap platform. Descriptive and inferential analyses, central tendency and dispersion measures, Pearson's correlation and Student's t-test were performed, considering a significance level of 5%. The research was conducted in accordance with Resolution 466/2012. Results: The average num-ber of correct answers was 43%, 44.4% among nurses and 42.2% among technicians. Six (12%) professionals had already took some training on neuromuscular blockade and 10 (20%) reported having treated patients with RNB. We observed no statistically significant differences between the average of correct answers of the questions and the length of training and professional performance, specialization, previous experience, or carrying out training. Conclusions: We identified deficits in the nursing team's knowledge of the RNB and care during this procedure. The importance of continuing education actions is emphasized, with a view to training professionals to treat this complication and improve the nursing care provided during anesthetic recovery to guarantee patient safety

Objetivo: Identificar el conocimiento del equipo de enfermería que trabaja en la recuperación anestésica respecto a la evaluación del bloqueo neuromuscular residual (BNMR) en pacientes quirúrgicos. Método: Estudio cuantitativo, transversal, realizado en un hospital privado de São Paulo. Muestra compuesta por 50 profesionales, 18 enfermeros y 32 técnicos de enfermería, quienes respondieron un cuestionario validado por un panel de cinco jueces. Recolección realizada de enero a marzo de 2022, utilizando la plataforma REDCap. Se realizaron análisis descriptivos e inferenciales, medidas de tendencia central y dispersión, pruebas de correlación de Pearson y t-Student, considerando un nivel de significancia del 5%. Investigación realizada según Resolución 466/2012. Resultados: El promedio global de aciertos fue del 43%, 44,4% entre enfermeros y 42,2% entre técnicos. Seis (12%) profesiona-les ya habían recibido algún entrenamiento en bloqueo neuromuscular y 10 (20%) informaron haber tratado ya pacientes con BNMR. No se observaron diferencias estadísticamente significativas entre el número medio de respuestas a las preguntas y el tiempo de formación y desempeño profesional, espe-cialización, experiencia previa o ejecución de la formación. Conclusión: El estudio destacó déficits de conocimiento entre el equipo de enfermería sobre el BNMR y la asistencia durante este incidente. Se destaca la importancia de acciones de educación continua, con miras a capacitar profesionales para enfrentar esta complicación y mejorar los cuidados de enfermería brindados durante la recuperación anestésica para garantizar la seguridad del paciente

A computed tomography image segmentation algorithm for improving the diagnostic accuracy of rectal cancer based on U-net and residual block / 生物医学工程学杂志

As an important basis for lesion determination and diagnosis, medical image segmentation has become one of the most important and hot research fields in the biomedical field, among which medical image segmentation algorithms based on full convolutional neural network and U-Net neural network have attracted more and more attention by researchers. At present, there are few reports on the application of medical image segmentation algorithms in the diagnosis of rectal cancer, and the accuracy of the segmentation results of rectal cancer is not high. In this paper, a convolutional network model of encoding and decoding combined with image clipping and pre-processing is proposed. On the basis of U-Net, this model replaced the traditional convolution block with the residual block, which effectively avoided the problem of gradient disappearance. In addition, the image enlargement method is also used to improve the generalization ability of the model. The test results on the data set provided by the "Teddy Cup" Data Mining Challenge showed that the residual block-based improved U-Net model proposed in this paper, combined with image clipping and preprocessing, could greatly improve the segmentation accuracy of rectal cancer, and the Dice coefficient obtained reached 0.97 on the verification set.

Prevalencia de bloqueo residual en la Unidad de Cuidados Postanestésicos del Hospital Metropolitano / Prevalence of residual blockade in the Postanesthetic Care Unit of the Hospital Metropolitano

RESUMEN El bloqueo residual se define como la debilidad muscular postoperatoria producida por un antagonismo incompleto de los relajantes neu-romusculares, siendo sus principales complicaciones las respiratorias. Actualmente, el mejor método de evaluación objetiva del bloqueo neuromuscular es el Tren de Cuatro (TOF). El objetivo de este estudio fue describir la prevalencia de bloqueo residual en la Unidad de Cuidados Postanestésicos (UCPA) en pacientes ASA I y ASA II sometidos a cirugía electiva y de emergencia bajo anestesia general en el Hospital Metropolitano. Se realizó un estudio observacional, descriptivo y prospectivo en 211 sujetos, donde mediante el TOF se deter-minó que la prevalencia de bloqueo residual en la UCPA fue del 8,5%, valor que se relacionó con la falta de monitorización de la función neuromuscular, determinando además que el empleo de fármacos que revierten el bloqueo neuromuscular no excluye la presencia de bloqueo residual. Se recomienda el uso rutinario de monitorización de la relajación neuromuscular para prevenir y diagnosticar el bloqueo residual, además de la administración de reversión farmacológica independientemente del tiempo quirúrgico.

ABSTRACT Residual blockade is defined as postoperative muscle weakness caused by incomplete antagonism of neuromuscular relaxants, its main complications being respiratory, currently the best method of objective evaluation of neuromuscular blockade is the Train of Four (TOF). The objective of this study was to describe the prevalence of residual block in the Post Anesthesia Care Unit (UCPA) in patients with ASA I and ASA II undergoing elective and emergency surgery under general anesthesia at the Metropolitan Hospital. An observational, descrip-tive and prospective study was conducted in 211 subjects, where it was determined that the prevalence of residual block in UCPA was 8.5% with TOF, a value that was related to the lack of monitoring of neuromuscular function, also determining that the use of drugs that reverse neuromuscular blockade does not exclude the presence of residual blockade. Routine use of neuromuscular relaxation monitoring is recommended to prevent and diagnose residual block, in addition to drug reversal administration regardless of surgical time.

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.

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.

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.

Atypical reaction to anesthesia in Duchenne/Becker muscular dystrophy / Reação atípica à anestesia em distrofia muscular de Duchenne/Becker

Abstract Background and objectives Duchenne/Becker muscular dystrophy affects skeletal muscles and leads to progressive muscle weakness and risk of atypical anesthetic reactions following exposure to succinylcholine or halogenated agents. The aim of this report is to describe the investigation and diagnosis of a patient with Becker muscular dystrophy and review the care required in anesthesia. Case report Male patient, 14 years old, referred for hyperCKemia (chronic increase of serum creatine kinase levels - CK), with CK values of 7,779-29,040 IU.L-1 (normal 174 IU.L-1). He presented with a discrete delay in motor milestones acquisition (sitting at 9 months, walking at 18 months). He had a history of liver transplantation. In the neurological examination, the patient showed difficulty in walking on one's heels, myopathic sign (hands supported on the thighs to stand), high arched palate, calf hypertrophy, winged scapulae, global muscle hypotonia and arreflexia. Spirometry showed mild restrictive respiratory insufficiency (forced vital capacity: 77% of predicted). The in vitro muscle contracture test in response to halothane and caffeine was normal. Muscular dystrophy analysis by Western blot showed reduced dystrophin (20% of normal) for both antibodies (C and N-terminal), allowing the diagnosis of Becker muscular dystrophy. Conclusion On preanesthetic assessment, the history of delayed motor development, as well as clinical and/or laboratory signs of myopathy, should encourage neurological evaluation, aiming at diagnosing subclinical myopathies and planning the necessary care to prevent anesthetic complications. Duchenne/Becker muscular dystrophy, although it does not increase susceptibility to MH, may lead to atypical fatal reactions in anesthesia.

Resumo Justificativa/objetivos Distrofia muscular de Duchenne/Becker afeta a musculatura esquelética e leva a fraqueza muscular progressiva e risco de reações atípicas anestésicas após exposição à succinilcolina ou halogenados. O objetivo do presente relato é descrever investigação e diagnóstico de paciente com distrofia muscular de Becker e revisar os cuidados necessários na anestesia. Relato de caso Paciente masculino, 14 anos, encaminhado por hiperCKemia (aumento crônico dos níveis séricos de creatinoquinase - CK), com valores de CK de 7.779-29.040 UI.L-1 (normal 174 UI.L-1). Apresentou discreto atraso da aquisição de marcos motores (sentou aos nove meses, andou aos 18). Antecedente de transplante hepático. No exame neurológico apresentava dificuldade para andar nos calcanhares, levantar miopático (apoiava mãos nas coxas para ficar de pé), palato arqueado alto, hipertrofia de panturrilhas, escápulas aladas, hipotonia muscular global e arreflexia. Havia insuficiência respiratória restritiva leve na espirometria (capacidade vital forçada: 77% do previsto). O teste de contratura muscular in vitro em resposta ao halotano e à cafeína foi normal. Estudo da distrofina muscular por técnica de Western blot mostrou redução da distrofina (20% do normal) para ambos os anticorpos (C e N-terminal), e permitiu o diagnóstico de distrofia muscular de Becker. Conclusão Na avaliação pré-anestésica, história de atraso do desenvolvimento motor, bem como sinais clínicos e/ou laboratoriais de miopatia, deve motivar avaliação neurológica, com o objetivo de diagnosticar miopatias subclínicas e planejar cuidados necessários para prevenir complicações anestésicas. Distrofia muscular de Duchenne/Becker, apesar de não conferir suscetibilidade aumentada à HM, pode levar a reações atípicas fatais na anestesia.

Initial experience with the unrestricted introduction of sugammadex at a large academic medical center: a retrospective observational study examining postoperative mechanical ventilation and efficiency outcomes / 대한마취과학회지

BACKGROUND: Sugammadex rapidly reverses deep neuromuscular blockade, but owing to cost, questions remain about its optimal utilization. After the unrestricted introduction of sugammadex at Emory University Hospital, we hypothesized that reductions would be demonstrated in the primary outcome of post-anesthesia care unit (PACU) mechanical ventilation (MV) and secondary outcomes of PACU length of stay (LOS) and emergence time (surgery end to anesthesia end time in the PACU). METHODS: This retrospective observational study included patients undergoing general anesthesia over a 12-month period. Using multiple variable penalized logistic regression in a one-group before-and-after design, we compared the categorized rates of PACU MV to examine the effect of sugammadex introduction following a post-hoc chart review to ascertain the reason for postoperative MV. Additionally, multiple variable linear regression was used to assess for differences in PACU LOS and emergence time within a propensity-matched set of patients receiving neostigmine or sugammadex. RESULTS: In total, 7,217 surgical cases met the inclusion criteria: 3,798 before and 3,419 after sugammadex introduction. The incidence of PACU MV was 2.3% before and 1.8% after (P = 0.118) sugammadex introduction. PACU MV due to residual neuromuscular blockade (rNMB) decreased from 0.63% to 0.20% (P = 0.005). Ventilation because of other causes was unchanged. PACU LOS and emergence time were unchanged in the propensity-matched set of 1,444 patients. CONCLUSIONS: rNMB was an important contributor to PACU MV utilization and its incidence significantly decreased after sugammadex introduction. The selected efficiency measures may not have been sufficiently granular to identify improvements following introduction.

Validação da lista de verificação (checklist) para o gerenciamento do despertar diário de pacientes críticos / Checklist validation for managing the critical patients daily wake-up

OBJETIVO: Validar o conteúdo do instrumento lista de verificação (checklist) "Despertar diário de sedação" para auxiliar no despertar diário de pacientes críticos internados em unidade de terapia intensiva. MÉTODOS: Estudo metodológico e de abordagem quantitativa para a validação de conteúdo do instrumento do tipo lista de verificação (checklist) "Despertar Diário de Sedação". A população-alvo foram os profissionais de saúde considerados especialistas, convidados a participar do estudo. A busca por estes especialistas deu-se por meio do currículo disponibilizado pela Plataforma Lattes do portal Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Para a obtenção do consenso entre os especialistas, foi utilizado o método Delphi cuja abordagem aos especialistas deu-se via correio eletrônico e a pontuação, por meio de uma escala do tipo Likert, com sete pontos. Como preconizado, foi considerado o cálculo Índice de Validade de Conteúdo (CVI) de, no mínimo, 0.78, para concordância aceitável entre os especialistas. RESULTADOS: Foram convidados 42 enfermeiros e 12 médicos para serem especialistas, sendo que 29 especialistas retornaram com o instrumento respondido. Após três rodadas de avaliação por especialistas, o CVI alcançado variou de .100 nos itens "Identificação do paciente" e "Em caso de falha nos 4 passos anteriores: Retornar com a sedação na dose descrita no item 2" a .79 em "Checar se há benzodiazepínico prescrito". O instrumento constituído por 15 itens manteve os atributos, sendo reformulados seis itens e nenhum excluído. Entre os 15 itens, 13 foram validados e dois não o foram. Com base nos resultados, pode-se dizer que o instrumento apresentou indicadores psicométricos de validade de conteúdo aceitáveis. CONCLUSÃO: O instrumento foi considerado como válido para o gerenciamento do "despertar diário", sendo adequado para utilização por profissionais que atuam em UTI. A aplicação do instrumento na prática cotidiana pode vir a contribuir para a sua validação clínica

OBJECTIVE: To validate the content of the instrument checklist "Daily sedation awakening" to assist in the daily awakening of critically ill patients admitted to the intensive care unit. METHODS: Methodological and quantitative approach for the validation of the content of the checklist "Daily Sedation Awakening". The target population were health professionals considered experts, invited to participate in the study. The search for these specialists took place through the curriculum provided by the Lattes Platform of the National Council for Scientific and Technological Development (CNPq) portal. In order to obtain the consensus among the experts, the Delphi method was used, whose approach to the specialists was given by electronic mail and the score, using a scale of the Likert type, with seven points. As recommended, the calculation of Content Validity Index (CVI) of at least 0.78 was considered for acceptable agreement among the specialists. RESULTS: 42 nurses and 12 physicians were invited to be specialists, and 29 specialists returned with the instrument answered. After three rounds of evaluation by specialists, the achieved CVI ranged from .100 in the items "Patient identification" and "In case of failure in the previous 4 steps: Return with sedation in the dose described in item 2" to .79 in "Check if there is a prescribed benzodiazepine." The instrument made up of 15 items retained the attributes, with six items being reformulated and none being excluded. Among the 15 items, 13 were validated and two were not. Based on the results, it can be said that the instrument presented acceptable psychometric indicators of content validity. CONCLUSION: The instrument was considered as valid for the management of "daily awakening", being suitable for use by professionals who work in the ICU. The application of the instrument in daily practice may contribute to its clinical validation

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.

Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report / 대한마취과학회지

Laryngospasm, an occlusion of the glottis, can occur at any time during anesthesia, and is associated with serious perioperative complications such as hypoxia, hypercabia, aspiration, bronchospasm, arrhythmia, prolonged recovery, cardiac collapse, and eventually catastrophic death. Importantly, postoperative negative pressure pulmonary edema (NPPE) is a rare, but well described life-threatening complication related to acute and chronic upper airway obstruction. Sugammadex well known for affirmatively reducing the postoperative pulmonary complications associated with residual neuromuscular blockade may have an indirect role in triggering the negative intrathoracic pressure by raising a rapid and efficacious respiratory muscle strength in acute upper airway obstruction. Herein, we report a case of postoperative NPPE following repetitive laryngospasm even after reversal of rocuronium-induced neuromuscular blockade using 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.

The effect of various kinematics on postoperative pain after instrumentation: a prospective, randomized clinical study

ABSTRACT Objective: To evaluate various kinematic movements on postoperative pain using a Reciproc system. Material and Methods: Fifty-six molar teeth were divided into four groups according to kinematics as follows: continuous rotation, 360° CCW – 30° CW, 270° CCW – 30° CW, and 150° CCW – 30° CW. Preoperative and postoperative pain levels using visual analogue scale (VAS), percussion pain, and analgesic intake were recorded for each subject. Postoperative pain levels at 1, 3, 5, and 7 d were evaluated. Data were analyzed statistically using the Kruskal-Walis, Mann-Whitney-U, one-way analysis of variance, and chi-square tests (p=0.05). Results: Continuous rotation resulted in more pain at Day 1 when compared with the reciprocating groups (360° CCW – 30° CW and 270° CCW – 30° C) (p<0.05). Conclusions: Continuous rotation resulted in more postoperative pain at Day 1 than in reciprocating groups, and thereafter no significant pain was found among the groups.

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

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

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

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.

Acupuncture accelerates recovery after general anesthesia: a prospective randomized controlled trial / 中西医结合学报

<p><b>BACKGROUND</b>Acupuncture anesthesia was created in the 1950's in China and continues to be used there today during most major surgeries. It is widely used in China for such complex operations as brain, heart, and abdominal surgery. It is popular in China because it is economical, practical, and beneficial to the patients. With acupuncture anesthesia there is less bleeding during surgery and there is also quicker post-operative recovery.</p><p><b>OBJECTIVE</b>This randomized prospective study aims at comparing the effect of two acupoints (Yongquan, KI1 and Renzhong, DU26) with sham acupuncture and no acupuncture on the time to recovery of consciousness after general anesthesia by means of the Bispectral Index monitor (BIS).</p><p><b>DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS</b>This is a prospective randomized controlled study. We randomly assigned 50 patients to 5 groups during recovery from surgical anesthesia. Four groups had acupuncture on KI1 (group A), DU26 (groups B), both KI1 and DU26 (group C), and sham points (group D), and one had no acupuncture (group E).</p><p><b>MAIN OUTCOME MEASURES</b>Bispectral Index (BIS), time to spontaneous eye opening, time to tracheal extubation, and time to following commands were measured as the main outcome measures.</p><p><b>RESULTS</b>Time to spontaneous eye opening differed among groups (P=0.002), as well as time to tracheal extubation (P<0.000 1) and time to following commands (P=0.000 6). BIS values differed significantly among groups both 5 and 10 min after the end of anesthesia (P<0.000 1 and P=0.000 4, respectively). BIS values of groups D and E were lower than those of the other groups and those of group C were higher. The same pattern was observed also 15 and 30 min after the end of anesthesia, although the difference among groups was not significant at these time points (P=0.164 and P=0.104, respectively).</p><p><b>CONCLUSION</b>Acupuncture on DU26 and KI1 accelerates recovery of consciousness after general anesthesia. Moreover, a possible synergistic effect of DU26 and KI1 is suggested. This issue may play a role in the optimization of operating room management and raise interest about the usefulness of acupuncture on unconsciousness states of different nature.</p>

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

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

Delayed emergence from anesthesia resulting from posterior cerebral artery infarction after Guglielmi detachable coil embolization / 대한마취과학회지

No abstract available.

Delayed emergence from anesthesia resulting from posterior cerebral artery infarction after Guglielmi detachable coil embolization / 대한마취과학회지

No abstract available.