Administration Of Muscle Relaxants Research Articles

The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial

BackgroundGlycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly patients. Therefore, this study aimed to compare the cardiovascular effects of G/N and A/N for the reversal of NMB in elderly patients.MethodsElderly patients aged 65–80 years who were scheduled for elective non-cardiac surgery under general anesthesia were randomly assigned to the glycopyrrolate group (group G) or the atropine group (group A). Following the last administration of muscle relaxants for more than 30 min, group G received 4 ug/kg glycopyrrolate and 20 ug/kg neostigmine, while group A received 10 ug/kg atropine and 20 ug/kg neostigmine. HR, mean arterial pressure (MAP), and ST segment in lead II (ST-II) were measured 1 min before administration and 1–15 min after administration.ResultsHR was significantly lower in group G compared to group A at 2–8 min after administration (P < 0.05). MAP was significantly lower in group G compared to group A at 1–4 min after administration (P < 0.05). ST-II was significantly depressed in group A compared to group G at 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, and 15 min after administration (P < 0.05).ConclusionsIn comparison to A/N, G/N for reversing residual NMB in the elderly has a more stable HR, MAP, and ST-II within 15 min after administration.

Healthcare-associated infection management in 62 ICUs for patients with congenital heart disease in China: a survey study.

All patients with congenital heart disease (CHD) receive postoperative management in ICUs. Infection prevention and control (IPC) has a significant impact on prognosis. This study provides a preliminary understanding of the fundamental aspects of IPC in ICUs following CHD surgery in China. From September to October 2023, we initiated a survey on healthcare-associated infection (HAI) management in hospitals that perform CHD surgeries independently. The questionnaires were jointly completed by the ICU physicians and IPC personnel. Duplicate or unqualified questionnaires were excluded from the study. The contents of our questionnaires covered hospital and ICU capacity, performance of the infection control department, HAI surveillance, implementation of IPC measures, and antimicrobial stewardship (AMS). Qualified questionnaires were compared according to the volume of annual CHD surgeries performed in different ICUs. Group 1 was defined as volume more than 300 cases and group 2 was defined as volume less than or equal to 300 cases. Sixty-two of the 118 questionnaires were completed, with a response rate of 53%. The CHD surgical volume in 2022 of the 62 hospitals was 36342, accounting for 52% of the annual CHD surgical volume (69672) across the country. The postoperative infection rates obtained from the 15 ICUs varied from 1.3 to 15%, with a median rate of 4.5%. A total of 16 ICUs provided data on drug-resistant bacteria, Klebsiella pneumoniae exhibiting the highest frequency. More than 95% of ICUs have established complete HAI management systems. Information-based HAI surveillance was conducted in 89% of ICUs. Approximately 67% of ICUs stopped prophylactic antibiotics within 48 hours after surgery. In complex cases, carbapenems were administered empirically in 89% of ICUs. Group 1 had an advantage over group 2 in preventing multi-drug-resistant organisms (all instruments should be used alone 100% vs. 86%, P =0.047; cleaning and disinfection of environmental surfaces, 100% vs. 81%, P =0.035; antibiotic consumption control 85% vs. 61%, P =0.044) and in preventing surgical site infections (perioperative blood glucose monitoring, 88% vs. 67%, P =0.048). However, Group 1 did not perform well in preventing catheter-related bloodstream infection (delayed catheter removal due to convenience of laboratory tests, 31% vs. 6%, P =0.021) and catheter-associated urinary tract infection (delayed catheter removal due to muscle relaxant administration, 88% vs. 58%, P =0.022). A relatively complete HAI management system has been established throughout the country in ICUs for CHD patients. Information-based surveillance of HAI needs to be promoted, and actions should be taken to facilitate the implementation of IPC measures and AMS bundles. Training and feedback are critical for implementing IPC measures.

Quantification of muscle tone by using shear wave velocity during an anaesthetic induction: a prospective observational study

ObjectivesThe quantitative assessment of muscle stiffness or weakness is essential for medical care. Shear wave elastography is non-invasive ultrasound method and provides quantitative information on the elasticity of soft tissue. However, the universal velocity scale for quantification has not been developed. The aim of the study is to determine the shear wave velocities of abdominal muscle during anesthetic induction and to identify methods to cancel the effects of confounders for future development in the quantitative assessment of muscle tone using the universal scale.MethodsWe enrolled 75 adult patients undergoing elective surgery with ASA-PS I – III in the period between December 2018 and March 2021. We measured and calculated the shear wave velocity (SWV) before and after opioid administration (i.e., the baseline at rest and opioid-induced rigidity condition), and after muscle relaxant administration (i.e., zero reference condition). The SWV value was adjusted for the subcutaneous fat thickness by our proposed corrections. The SWVs after the adjustment were compared among the values in baseline, rigidity, and relaxation using one-way repeated-measures ANOVA and post hoc Tukey–Kramer test. A p-value of < 0.05 was considered to be statistically significant. UMIN Clinical Trials Registry identifier UMIN000034692, registered on October 30, 2018.ResultsThe SWVs in the baseline, opioid-induced rigidity, and muscle relaxation conditions after the adjustment were 2.08 ± 0.48, 2.41 ± 0.60, and 1.79 ± 0.30 m/s, respectively (p < 0.001 at all comparisons).ConclusionThe present study suggested that the SWV as reference was 1.79 m/s and that the SWVs at rest and opioid-induced rigidity were ~ 10% and ~ 30% increase from the reference, respectively. The SWV adjusted for the subcutaneous fat thickness may be scale points for the assessment of muscle tone.

Update on neuromonitoring procedures applied during surgery of the spine - observational study.

Motor evoked potentials (MEPs) are currently considered as a more useful method for neurophysiological intraoperative monitoring than somatosensory evoked potentials in cases of surgery applied to patients with adolescent idiopathic scoliosis. The non-invasive approach is preferred to modify MEP recordings, criticizing, in many cases, the fundamentalism for neurophysiological monitoring based only on needle recordings. The aim of the review is to provide our own experience and practical guidelines with reference to neuromonitoring innovations. Recordings of MEPs with surface electrodes instead of needle electrodes including nerve instead of muscle combinations during neurophysiological monitoring associated with surgical interventions to the spine have become more relevant for pediatric purposes, avoiding the anesthesiology-related influences. Observations on 280 patients with Lenke A-C types of spine curvature are presented before and after the surgical correction. The MEPs recorded from nerves do not undergo fluctuations at different stages of scoliosis corrections and the anesthesia effect more than MEPs recorded from muscles. The use of non-invasive surface electrodes during neuromonitoring for MEP recordings shortens the total time of the surgical procedure without diminishing the precision of the neural transmission evaluation. The quality of MEP recordings during intraoperative neuromonitoring from muscles can be significantly influenced by the depth of anesthesia or administration of muscle relaxants but not those recorded from nerves. The proposed definition of "real-time" neuromonitoring comprises the immediate warning from a neurophysiologist about the changes in a patient's neurological status during scoliosis surgery (especially during pedicle screws' implantation, corrective rods' implantation, correction, distraction and derotation of the spine curvature) exactly during the successive steps of corrective procedures. This is possible due to the simultaneous observation of MEP recordings and a camera image of the surgical field. This procedure clearly increases safety and limits financial claims resulting from possible complications.

Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion.

Retrospective, single-center, cohort study. Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration. Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting. Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics. The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ). Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.

Skeletal and Dental Fractures Associated With Electroconvulsive Therapy.

During the motor seizure associated with electroconvulsive therapy (ECT), the muscles of the trunk and limbs contract forcefully and repetitively, predisposing to injuries to muscles, joints, teeth, and bones. This motor seizure is irrelevant to the therapeutic action of the treatment. It is therefore modified by the administration of an intravenous muscle relaxant, such as succinylcholine, after the administration of the anesthesia in the ECT premedication. Well-modified ECT is associated with markedly diminished skeletal muscle contractions and hence with minimal skeletal and dental risks. In this context, anecdotal reports across a range of skeletal disorders testify to the safety of well-modified ECT in ultrahigh-risk patients. Population-based data suggest that the fracture risk with modified ECT is 2 events per 100,000 ECTs; if only recent data are examined, the risk may be as low as 0.36 events per 100,000 ECTs. Population-based data also suggest that the dental fracture risk with modified ECT is 0.02% per ECT and 0.17% per ECT course. The overall magnitude of skeletal and dental fracture risk depends on patient factors and on how well the ECT procedure is performed. Preexisting bone and dental disease increase the risk; good seizure modification, proper use of bite blocks, and effective jaw immobilization during ECT reduce the risk. Careful assessment of preexisting risk and good ECT practice can minimize the risk of skeletal and dental complications during ECT.

Patient Comfort During Postop Period in Breast Cancer Surgeries: A Randomized Controlled Trial Comparing Opioid and Opioid-Free Anesthesia.

Anesthetic management practices have advanced to opioid-free anesthesia (OFA) often replacing opioids in oncologic surgeries. The study was conducted to find the quality of recovery (QoR) of patients undergoing breast cancer surgeries receiving OFA. A double-blinded, randomized controlled study was conducted with 60 patients randomized to group OFA and group OA (opioid anesthesia). Group OFA received one-time dosing of ketamine 0.3 mg/kg, lignocaine 1.5 mg/kg, and dexmedetomidine 1 mcg/kg. Group OA received fentanyl 2mcg/kg. Intraoperatively, Group OFA received dexmedetomidine 0.4 mcg/kg/h and theOA group received fentanyl 0.5 mcg/kg/h infusion.Bispectral index (BIS), hemodynamics, muscle relaxant administration, and sevoflurane concentration were noted. A modified QoR-40 score was used to assess the quality of recovery in the postoperative period. A higher QoR-40 score was found in the OA group (median 182, IQR 178-186) compared to the OFA group (median 180, IQR 178-184). Out of the five components, the patient's emotional state was better in the group OA (39.9±2.77) than in the OFA group (37.9±2.77). The patient's physical comfort was found to be better in the group OFA (52.52±3.23) compared to group OA (50.93±3.23). Physical independence, psychological support, and pain were comparable between the two groups. Patients in group OFA received less sevoflurane, a muscle relaxant, and showed a mild reduction in heart rate and mean arterial pressure (MAP) when compared to group OA. The time taken to reach a Modified Aldrete score of 9 was high in OFA (11.47±2.16) and (9.17±1.09) when compared to group OA. No significant differences were noted with the visual analog score (VAS) score, Ramsay sedation score, and modified post-anesthesia discharge scoring system (PADSS) score. We conclude that the quality of recovery of patients receiving opioid-free methods of anesthesia was not inferior to OA in patients undergoing breast cancer surgeries.

Occurrence of butyrylcholinesterase polymorphisms in patients undergoing surgery in Slovakia.

Post-operative residual curarization is a persisting problem, characterized by muscle fatigue, exhaustion or paresis, caused by the use of neuromuscular blocking agents with prolonged postoperative effect. Genetically, determined changes in cholinesterase activity can be a major reason for persistent muscle blockade after administration of muscle relaxants. Regarding the subsistence of polymorphisms in the plasma cholinesterase gene causing change in enzyme activity and metabolism of applied drugs, we investigated the frequency of two polymorphisms known to reduce its activity significantly in patients undergoing surgery. Primary results show a relatively high occurrence of plasma cholinesterase K risk allele (18.75%). Characterization of the lacking information about genetic background of changes in plasma cholinesterase activity within Slovakia may allow for easier decision-making in clinical practice when selecting alternative neuromuscular blocking and also reversal agents.

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Measuring Success of Patient Safety Initiatives: The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade

Effect of etomidate and propofol on airway mechanics during induction - A prospective randomized trial.

Intravenous induction agents like propofol and etomidate change the airway mechanics and thus influence mask ventilation. These changes have an impact on the administration of muscle relaxant in a difficult mask ventilation scenario. The difference in dynamics of airway after administration of two different intravenous agents has been assessed in this study. After formal registry in clinical trials, patients undergoing general anesthesia were recruited and randomized into group P and E. Patients were induced with either of the intravenous agents, and mask ventilation was performed with a ventilator. After 60 s, rocuronium was administered and ventilation continued. Measurements of tidal volume, peak airway pressure, and compliance were taken from the anesthesia ventilator at different time points - induction, relaxant, and intubation. There was no statistically significant difference between the two groups with respect to demographics, airway parameters, and airway mechanics, as measured by tidal volume, peak airway pressure, and lung compliance. There was an improvement in the tidal volume and compliance following induction with propofol, with a P value of 0.007 and 0.032, respectively, obtained in within-group comparison. Propofol and etomidate were comparable in airway mechanics, but compliance and tidal volumes improved with propofol, which facilitated face mask ventilation.

Current Practices Supporting Rigid Bronchoscopy-An International Survey.

There are no guidelines for anesthesia or staff support needed during rigid bronchoscopy (RB). Identifying current practice patterns for RB pertinent to anesthesia, multidisciplinary teams, and algorithms of intra and post-procedural care may inform best practice recommendations. Thirty-three-question survey created obtaining practice patterns for RB, disseminated via email to the members of the American Association of Bronchology and Interventional Pulmonology and the American College of Chest Physicians Interventional Chest Diagnostic Procedures Network. One hundred seventy-five clinicians participated. Presence of a dedicated interventional pulmonology (IP) suite correlated with having a dedicated multidisciplinary RB team ( P =0.0001) and predicted higher likelihood of implementing team-based algorithms for managing complications (39.4% vs. 23.5%, P =0.024). A dedicated anesthesiology team was associated with the increased use of high-frequency jet ventilation ( P =0.0033), higher likelihood of laryngeal mask airway use post-RB extubation ( P =0.0249), and perceived lower rates of postprocedural anesthesia adverse effects ( P =0.0170). Although total intravenous anesthesia was the most used technique during RB (94.29%), significant variability in the modes of ventilation and administration of muscle relaxants was reported. Higher comfort levels in performing RB are reported for both anesthesiologists ( P =0.0074) and interventional pulmonologists ( P =0.05) with the presence of dedicated anesthesia and RB supportive teams, respectively. Interventional bronchoscopists value dedicated services supporting RB. Multidisciplinary dedicated RB teams are more likely to implement protocols guiding management of intraprocedural complications. There are no preferred modes of ventilation during RB. These findings may guide future research on RB practices.

Evaluation of QT interval of patients using muscle relaxants under general anesthesia, randomized clinical trial

Objective: The aim of the study was to investigate the effects of rocuronium, mivacurium, and atracurium on arrhythmia markers, QT interval, and QT dispersion (QTd). Method: Ninety patients scheduled for septorhinoplasty were randomly assigned to one of three groups of 30. During the induction of anesthesia, muscle relaxants of 0.6 mg/kg rocuronium in Group R, 0.2 mg/kg mivacurium in Group M, and 0.5 mg/kg atracurium in Group A were employed. Mean blood pressure (MAP), heart rate (HR), and electrocardiogram (ECG) values were measured before induction of anesthesia (T0), immediately after induction of anesthesia (T1), at 1 minute (T2), 5 minutes (T3), 10 minutes (T4) and 15 minutes (T5) after muscle relaxant administration, and QT, corrected QT (QTc), QTd and corrected QTd (QTcd) intervals were recorded. Results: When the groups were compared in terms of QTcd values, the difference between mivacurium and atracurium was significant in terms of T5 values, and atracurium (T5) QTcd was found to be shorter (p<0.05). Group M had 5 of the 6 measures with pathological QTc prolongation. Conclusions: Because the prevalence of pathological QTc is greater in mivacurium, further clinical trials should be conducted to challenge the use of mivacurium in individuals with a long QT interval.

Perioperativna anafilaksa izazvana mišićnim relaksantima - da li znamo dovoljno?

Perioperative anaphylaxis caused by muscle relaxants represents a relatively rare, albeit a serious complication during anesthesia. It can result in serious morbidity or even mortality. This reaction usually happens before or after intubation of a patient, that is, a few minutes after muscle relaxant administration. The beginning of the reaction can be missed, even by the most experienced anesthesiologist, since its recognition depends on the severity of the symptoms. There are no guidelines specific to the therapy of muscle relaxant anaphylaxis and therefore therapy is based simply on the general guidelines. Also, in many countries, there are no registries of the incidence of anaphylaxis caused by muscle relaxants. Therefore, this is an extremely important subject for anesthesiology practice, and it requires more attention.

Closed-PICU perioperative management of congenital tracheal stenosis.

Perioperative management of congenital tracheal stenosis (CTS) is challenging. In the present study, compared the effect of closed-pediatric intensive care unit (PICU) perioperative management by pediatric intensivists and open-PICU management by surgeons. Outcomes in terms of ventilator-free days (VFD) and length of postoperative PICU stay in children with CTS were evaluated. This retrospective cohort study was conducted in a PICU in Japan. Children with CTS who underwent slide tracheoplasty were grouped according to whether they were perioperatively managed in an open (January 2015 to April 2016) or a closed (May 2016 to August 2019) PICU. Data were extracted from patients' medical records. In total, 13 and 38 patients were included in the open- and closed-PICU groups, respectively. Compared to the open-PICU group, the closed-PICU group had shorter duration of muscle relaxant administration (median 4 vs 5 days; P < 0.001), earlier enteral nutrition (34/38 [90%] vs 1/13 [8%]; P < 0.001), more 28-day VFD (median 21 vs 20 days; P = 0.04), and shorter duration of postoperative PICU stay (median 16 vs 36 days; P = 0.002), but mortality did not differ significantly between the two groups (0/38 [0%] vs 1/13 [8%]; P = 0.25). Closed-PICU perioperative management with pediatric intensivists' participation significantly increased 28-day VFD and reduced the length of postoperative PICU stay in patients with congenital tracheal stenosis.

Physical Compatibility of Nafamostat with Analgesics, Sedatives, and Muscle Relaxants for Treatment of Coronavirus Disease 2019.

Severe coronavirus disease 2019 (COVID-19) may require continuous administration of analgesics, sedatives, and muscle relaxants. Nafamostat has recently been reported as a therapeutic agent for COVID-19. However, there is a lack of information on the compatibility of nafamostat with the aforementioned drug classes. This study evaluated the physical compatibility of nafamostat with these drug classes. Nafamostat was combined with 1-3 target drugs (fentanyl, morphine, midazolam, dexmedetomidine, and rocuronium). Fifteen physical compatibility tests were conducted. Nafamostat was dissolved in 5% glucose solution; the final concentration was 10 mg/mL. All other medications were diluted in 0.9% sodium chloride to obtain clinically relevant concentrations. The power of hydrogen (pH) of all medications was measured during each test. Compatibility tests were conducted with 4 test solutions in which nafamostat and the target drugs were compounded at equal volume ratios (1:1, 1:1:1, or 1:1:1:1). Visual appearance, turbidity, and pH were evaluated immediately after mixing and at 1 and 3 hours. Physical incompatibilities were defined as gross precipitation, cloudiness, appearance of the Tyndall effect, or a turbidity change of ≥0.5 nephelometric turbidity units (NTU) based on nafamostat. The mean pH of nafamostat was 3.13 ± 0.03. The combination of nafamostat, fentanyl, and dexmedetomidine had the highest pH (3.39 ± 0.01; 3 hours after mixing). All drugs were compatible with nafamostat until 3 hours after admixture, with a mean turbidity value of ≤0.03 NTU. Infusions combining nafamostat with the tested sedatives, analgesics, and muscle relaxants could be safely administered.

Central muscle relaxants in rheumatology practice

The article describes the general principles of the treatment of musculoskeletal pain, discusses modern approaches to the treatment of osteoarthritis (OA) and nonspecific back pain (NBS). The issues discussed are: the efficacy and tolerability of the combined use of non-steroidal anti-inflammatory drugs (NSAIDs) of predominantly selective action (aceclofenac) and a centrally acting muscle relaxant (tolperisone) in the treatment of OA and NBS. Two clinical observations are presented that confirm the benefits of combined administration of NSAIDs and muscle relaxants in the treatment of OA and NBS. The efficacy and favorable safety profile of aceclofenac has been demonstrated in patients with comorbid diseases. Tolperisone has shown its efficacy both as a mean of controlling pain associated with muscle tension, and as an element of combination therapy not only for NBS, but also for OA.

Utilisation des curares en réanimation

L’usage des curares en réanimation répond essentiellement a deux objectifs : améliorer les conditions d’intubation et faciliter la ventilation des patients en SDRA. Les conditions de l’intubation qui sont souvent celles de l’urgence imposent l’administration d’un curare d’action rapide : succinylcholine ou rocuronium. Le cisatracurium est le curare de référence pour la curarisation continue. La curarisation diminue les pressions intra-thoraciques et améliore les échanges gazeux mais pas la survie des patients ayant un ARDS. La relation entre neuromyopathie de réanimation et curarisation reste discutée. The use of muscle relaxants in intensive care patients aims facilitating tracheal intubation and improving mechanical ventilation in ARDS patients. Since tracheal intubation is performed most of the time in emergency, succinylcholine is the gold standard for rapid sequence induction avoiding gastric content inhalation. However succinylcholine has contra-indications that favour the use of rocuronium in some patients. Patients who require muscle paralysis to be maintained, receive most of the time a continuous infusion of cisatracurium. Continuous administration of muscle relaxants improves gas exchanges and aims decreasing barotrauma in ARDS patients. Muscle relaxant administration in ICU patients is thought to be associated with ICU-acquired neuromuscular pathology although this remains to be clearly demonstrated owing to the multiple mechanisms that could be implicated.

The impact of deep versus standard neuromuscular block on intraoperative safety during laparoscopic surgery: an international multicenter randomized controlled double-blind strategy trial \u2014 EURO-RELAX TRIAL

BackgroundMuscle relaxants are routinely used during anesthesia to facilitate endotracheal intubation and to optimize surgical conditions. However, controversy remains about the required depth of neuromuscular block (NMB) needed for optimal surgical working conditions and how this relates to other outcomes. For instance, a deep neuromuscular block yields superior surgical working conditions compared to a standard NMB in laparoscopic surgery, however, a robust association to other (safety) outcomes has not yet been established.MethodsTrial design: an international multicenter randomized controlled double-blind strategy trial.Trial population: 922 patients planned for elective, laparoscopic or robotic, abdominal surgery.Intervention: Patients will be randomized to a deep NMB (post-tetanic count 1–2 twitches) or standard care (single-dose muscle relaxant administration at induction and repeated only if warranted by surgical team).Main trial endpoints: Primary endpoint is the difference in incidence of intraoperative adverse events during laparoscopic surgery graded according to ClassIntra® classification (i.e., ClassIntra® grade ≥ 2) between both groups. Secondary endpoints include the surgical working conditions, 30-day postoperative complications, and patients’ quality of recovery.DiscussionThis trial was designed to analyze the effect of deep neuromuscular block compared to standard neuromuscular block on intra- and postoperative adverse events in patients undergoing laparoscopic surgery.Trial registrationClinicalTrials.gov NCT04124757(EURO-RELAX); registration URL: https://clinicaltrials.gov/ct2/show/NCT04124757, registered on October 11th, 2019.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BackgroundPostoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors. MethodsTwo-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis. ResultsFifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors. ConclusionA significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

A novel system that continuously visualizes and analyzes respiratory sounds to promptly evaluate upper airway abnormalities: a pilot study

Although respiratory sounds are useful indicators for evaluating abnormalities of the upper airway and lungs, the accuracy of their evaluation may be limited. The continuous evaluation and visualization of respiratory sounds has so far been impossible. To resolve these problems, we developed a novel continuous visualization system for assessing respiratory sounds. Our novel system was used to evaluate respiratory abnormalities in two patients. The results were not known until later. The first patient was a 23-year-old man with chronic granulomatous disease and persistent anorexia. During his hospital stay, he exhibited a consciousness disorder, bradypnea, and hypercapnia requiring tracheal intubation. After the administration of muscle relaxant, he suddenly developed acute airway stenosis. Because we could not intubate and ventilate, we performed cricothyroidotomy. Subsequent review of our novel system revealed mild stridor before the onset of acute airway stenosis, which had not been recognized clinically. The second patient was a 74-year-old woman who had been intubated several days earlier for tracheal burn injury, and was extubated after alleviation of her laryngeal edema. After extubation, she gradually developed inspiratory stridor. We re-intubated her after diagnosing post-extubation laryngeal edema. Subsequent review of our novel system revealed serially increased stridor after the extubation, at an earlier time than was recognized by healthcare providers. This unique continuous monitoring and visualization system for respiratory sounds could be an objective tool for improving patient safety regarding airway complications.