Respiratory muscle activity after spontaneous, neostigmine- or sugammadex-enhanced recovery of neuromuscular blockade: a double blind prospective randomized controlled trial

Tom Schepens,Koen Janssens,Sabine Maes,Vera Saldien,Davina Wildemeersch,Jurryt Vellinga,Philippe G Jorens

doi:10.1186/s12871-019-0863-y

Tom Schepens, Koen Janssens + Show 5 more

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https://doi.org/10.1186/s12871-019-0863-y

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Abstract

BackgroundThe use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. In previous studies, we found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex. It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. In this study, we wanted to assess the effect of commonly used degrees of NMB and their possible reversal strategies on respiratory muscle activity after the return of normal neuromuscular transmission.MethodsThis is a randomized, controlled, parallel-group, single-centre, double-blind study in patients scheduled for intracranial surgery at a tertiary academic hospital in Belgium. All participants received target controlled propofol/remifentanil anesthesia and were randomized into one of five groups, receiving either a shallow NMB with no reversal (shallow/saline), a shallow NMB with sugammadex reversal (shallow/sugammadex), a moderate NMB with neostigmine reversal (moderate/neostigmine), a moderate NMB with sugammadex reversal (moderate/sugammadex), or a deep NMB with sugammadex reversal (deep/sugammadex). Primary and secondary outcome parameters were diaphragm and intercostal electromyographic (EMG) activity at the moment of resumed spontaneous breathing activity, defined as a maximal interval of 10 min after the first spontaneous breath.ResultsFor the five groups, a total of 55 patients could be included in the final analysis. Median time of spontaneous breathing analyzed was 5 min (IQR 3–9.5 min). Both the moderate/sugammadex and the moderate/neostigmine groups had lower levels of diaphragm EMG compared to the shallow/sugammadex group. The moderate/neostigmine group had lower levels of intercostal EMG activity compared to the shallow/saline group.ConclusionsIn this study, the depth of neuromuscular blockade and type of reversal strategy impacts respiratory muscle activity at the moment of resumed spontaneous breathing and recovery of neuromuscular blockade. Both groups that received moderate NMB had lower levels of diaphragm EMG, compared to the shallow NMB group with sugammadex reversal. Compared to the shallow NMB group with no reversal, the moderate NMB with neostigmine reversal group had lower intercostal EMG activity.Trial registrationClinicaltrials.gov NCT01962298 on October 9, 2013 and EudraCT 2013–001926-25 on October 10, 2013.

Highlights

The use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications
The third group received a 0.6 mg/kg bolus of rocuronium at the beginning of anesthesia and had their level of NMB titrated to a TOF of 1–2 with additional boluses of rocuronium during the surgery, and received a 50 μg/kg neostigmine with 10 μg/kg glycopyrrolate at the end of the surgery with a TOF of T2
The patients with a moderate block and sugammadex reversal received a median of 40 mg of rocuronium after initial neuromuscular blockade, a similar amount compared to the moderate block and neostigmine reversal group, who had a median of 45 mg (P = 0.454)

Summary

Introduction

The use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. We found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. The use of neostigmine has been associated with postoperative respiratory complications in some studies [3,4,5], possibly due to paradoxical neostigmine-induced muscle weakness. We found lower diaphragmatic activity after neostigmine reversal of a NMB, compared to sugammadex [9, 10]. Neither the use of reversal agents, nor the choice of neostigmine or sugammadex decreased the risk for these complications [13]

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