Optimizing Reversal of Muscle Relaxation with Sugammadex to Accelerate Discharge Readiness in Operative Laryngoscopy: A Randomized Clinical Trial.

IMPORTANCE: Operative laryngoscopy is a commonly performed ambulatory procedure in patients with significant co-morbidity. Optimal anesthetics for surgical exposure with rapid return to baseline after the procedure enhances postoperative patient safety. OBJECTIVE: To determine whether sugammadex hastens recovery in patients undergoing operative laryngoscopy under general anesthesia with rocuronium-induced paralysis. DESIGN: Prospective clinical intervention randomized single-blinded, single-center study in an academic tertiary care center. Approved by the institutional review board and registered with ClinicalTrials.gov. SETTINGS: Single center tertiary care academic institution. PARTICIPANTS: 18 years or older, American Society of Anesthesiology physical status I-III with ability to give written informed consent undergoing operative laryngoscopy. INTERVENTION: Participants were randomized into two groups. Both groups received inhaled anesthetic: sevoflurane, remifentanil, and rocuronium at 0.6-1.2 mg/kg for intubation and anti-nausea prophylaxis. Group 1 received reversal with neostigmine (0.04 mg/kg) and glycopyrrolate (0.01 mg/kg). Group 2 received reversal with sugammadex (4 mg/kg). Vital signs were maintained at 20% of baseline in both groups. Post anesthesia care unit nurses were blinded to the reversal agent and were the evaluators of the discharge criteria and times. Primary end point was time to extubation after the procedures and secondary end points were: Subjective interpretation of surgical conditions by the surgeon, hemodynamic, respiratory parameters, anesthetics, and opioids used, operative time, and duration to achieve discharge readiness. RESULTS: A total of eighty-four participants, who were similar in age, sex, and weight in both groups. The primary end point and secondary end points were similar except time to meet discharge criteria in the two groups. 65% in the sugammadex versus 35% in the neostigmine group met Aldrete criteria of 18 or higher on arrival at the post anesthesia care unit. CONCLUSIONS: Optimizing the anesthetic regimen, along with stable intraoperative hemodynamics and reversal with sugammadex improves discharge readiness in patients undergoing operative laryngoscopy.

Acute intraoperative neurogenic myocardial stunning during intracranial endoscopic fenestration and shunt revision in a pediatric patient.

Neurogenic stunned myocardium (NSM) is syndrome of myocardial dysfunction following an acute neurological insult. We report a case of NSM that occurred intraoperatively in a pediatric patient undergoing endoscopic fenestration and shunt revision. Accidental outflow occlusion of irrigation fluid and ventricular distension resulted in an acute increase in heart rate and arterial blood pressure. Subsequently, the patient developed stunned myocardium with global myocardial hypokinesia and pulmonary edema. She was promptly treated intraoperatively then admitted to the pediatric intensive care unit with resolution of her symptoms within 12 h. She was later discharged to home on the fourth postoperative day. In the current endoscopic era, this report highlights the possibility of intraoperative NSM and neurogenic pulmonary edema in the pediatric population. Early detection and treatment with a team approach help to achieve optimal control of this life-threatening condition and improve the outcome.

Spatial cytokine distribution following traumatic injury.

Temporal changes in cytokine concentrations following traumatic injuries have been extensively studied. Less is known regarding spatial differences in cytokine concentrations following traumatic injury. The primary aim of this study was to determine the spatial relationship between cytokines and the zone of injury (ZOI). Muscle and vessel tissues obtained from rats subjected to an open femoral fracture were analyzed to determine if spatial cytokine gradients exist that could potentially be used as biomarkers of the ZOI. Samples were collected at 4 time points following fracture from 3 distinct locations: at the fracture site, 1-cm away from the fracture, and from the opposite leg. The concentrations of IL-6, IL-1α, IL-1ß, IL-2, GM-CSF, TNF-α, and MIP-1α were quantified in each sample. Temporally and spatially regulated variations in cytokine concentrations were found. IL-6 showed the most promise as a ZOI biomarker with statistically different spatial concentrations that were inversely proportional to the distance from the fracture in both tissues. IL-1ß and IL-2 also showed spatial differences in concentration in both tissues, while GM-CSF, MIP-1α, and TNF-α showed spatial differences in vessel samples. These results demonstrate that spatial cytokine gradients exist following traumatic injury, representing potential biomarkers that may be used to define the ZOI.