Reversal Of Neuromuscular Block Research Articles

Improving quantitative neuromuscular monitoring: an education initiative on stimulating electrode placement.

Quantitative neuromuscular monitoring reduces the incidence of residual neuromuscular block, but broad acceptance of monitoring has been elusive despite recommendations for quantitative monitoring for decades. Acceptance of quantitative monitoring may, in part, be related to the quality of the data from monitoring systems. This evaluation explored proper stimulating electrode positioning for electromyographic (EMG) monitoring, the impact of an educational intervention on electrode positioning and anesthesia provider (anesthesiologist, resident, anesthetist) confidence in the monitoring data from the device. In a single-center, observations of EMG electrode placement by anesthesia technicians, in 55 adult elective surgery patients were made by an independent observer. Separately, the anesthesia provider satisfaction with EMG derived data was recorded after reversal of neuromuscular block. An educational intervention then occurred on proper electrode positioning, including prior observations of electrode positioning, and prior anesthesia provider satisfaction with the EMG derived data. After the intervention, stimulating electrode position was observed with an additional 60 patients and anesthesia provider satisfaction with the data was again ascertained. The educational intervention significantly increased the proportion of ideal ulnar nerve groove electrode positioning from 74.5% to 95% (P < 0.003) and ideal wrist crease positioning (distal electrode within 2cm of crease) from 61.8% to 96.7% (P < 0.001). Anesthesia provider confidence with EMG derived information during anesthesia delivery, increased from 67 to 90% after the education (P = 0.005). There was a significant relationship between correct stimulating electrode placement and anesthesia provider confidence in the EMG derived data on neuromuscular block status. An educational intervention to improve EMG electrode positioning proved meaningful. It increased anesthesia provider confidence in the EMG derived data during anesthesia case management.

Train-of-four ratio, counts and post tetanic counts with the Tetragraph electromyograph in comparison to mechanomyography.

Automated EMG devices to detect compound muscle action potentials from the adductor pollicis muscle in response to ulnar nerve stimulation, regardless of hand and thumb position, may serve as a better reference ("gold standard") for clinical assessment of neuromuscular function than traditional mechanomyography (MMG) systems that need custom design and validation in lab settings. This evaluation compared the TetraGraph EMG system against a validated MMG device to investigate the accuracy and repeatability of this quantitative EMG monitor for detecting onset, offset and deep neuromuscular block. Simultaneous muscle action potential recordings from the EMG neuromuscular monitor and muscle contractions from an in-house developed MMG monitor in response to ulnar nerve stimulation were obtained from patients having elective surgery requiring neuromuscular block. Train-of-four (TOF) ratios, TOF counts, and post-tetanic counts (PTCs) were recorded simultaneously from the same hand muscle and compared. In total, 685 pairs of simultaneous TOF ratios were evaluated. The mean difference (bias) of TOF ratios between devices was small (-2.1%). TOF counts from 285 data pairs were within a count of 2 or less 96% of the time. During deep block, PTC comparisons from 215 data pairs were within a count of 2 or less 95% of the time. These findings, along with prior EMG device evaluations, indicate that real-time EMG neuromuscular monitoring technology to detect muscle action potentials from the adductor pollicis in the clinical setting is closely aligned with the force of thumb contraction determined from MMG. The accuracy of quantitative EMG technology of the TetraGraph EMG system lends strong support for this monitor, along with other similarly validated EMG monitors, to become a clinical standard for all phases (onset, depth and reversal) of neuromuscular block in clinical practice.

Effects of neuromuscular block reversal with neostigmine/glycopyrrolate versus sugammadex on bowel motility recovery after laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveTo compare the effects of neostigmine/glycopyrrolate (a traditional agent) and sugammadex on bowel motility recovery and the occurrence of digestive system complications after colorectal surgery. DesignProspective, randomized controlled trial. SettingA single tertiary center. Patients111 patients undergoing laparoscopic colorectal surgery. InterventionsPatients were randomized into two groups based on the block reversal agent: 1) a mixture of 50 μg.kg−1 of neostigmine and 10 μg.kg-1 of glycopyrrolate (neostigmine group) and 2) 2 mg.kg−1 of sugammadex (sugammadex group). MeasurementsThe primary outcome was the time from the surgery's completion to the first flatus.The time to the first postoperative defecation, incidences of postoperative nausea or vomiting, ileus, and dry mouth, as well as postoperative length of stay, were also assessed. Main resultsThe time to the first flatus was significantly shorter in the sugammadex group than in the neostigmine group (59 [42–79] h vs 69 [53–90] h, P = 0.027). The time to the first defecation and the incidences of postoperative nausea or vomiting and ileus did not differ between the groups, nor did the postoperative length of stay. However, the incidence of postoperative dry mouth was significantly lower in the sugammadex group than in the neostigmine group (7 patients [13%] vs 39 patients [71%], P < 0.001). ConclusionsThe time to the first flatus was shorter using 2 mg.kg−1 sugammadex to reverse the neuromuscular block for laparoscopic colorectal surgery compared to reversal with conventional neostigmine/glycopyrrolate.

Perioperative efficiency of sugammadex following minimally invasive gastric sleeve surgery: A superiority trial.

Studies have proposed that the routine use of sugammadex could provide perioperative time savings and a reduction in the incidence of postoperative nausea and vomiting. The purpose of this study was to test the effectiveness of sugammadex on perioperative times and on the incidences of adverse events when compared with the active control, neostigmine, for minimally invasive gastric sleeve surgery. Following institutional review board approval, patient characteristics, type of primary neuromuscular blocking reversal agents, operating room discharge times, post-anaesthesia care unit recovery times, and incidences of and treatment for postoperative nausea and vomiting and orotracheal reintubation were the measures of interest. Superiority testing determined the between-group means differences of the reversal agents on the two perioperative time periods of interest. Superiority testing demonstrated no improvement of the two perioperative times with sugammadex. There was no clinical difference in the incidence of postoperative nausea and vomiting or in the number of antiemetic doses received in the post-anaesthesia care unit between the two groups. Finally, the two orotracheal reintubations in the post-anaesthesia care unit were in the sugammadex administered group. These results with sugammadex provide no perioperative time savings or reduce the incidence and treatment for postoperative nausea and vomiting in the post-anaesthesia care unit when compared with neostigmine.

Reversal of neuromuscular block with neostigmine and sugammadex: a retrospective cohort study in two centers using different types of neuromuscular monitoring.

This bicentric retrospective cohort study evaluates reversal of muscle relaxation in real life achieved either by neostigmine or sugammadex in two hospitals using different types of neuromuscular monitoring (acceleromyography and kinemyography). The research question concerns compliance with recommendations. Patients who underwent an abdominal surgery under general anesthesia in the period from January 2017 through December 2020 with a neuromuscular block with rocuronium were included in the study. Data were extracted from the Centricity anesthesia information management system. In total, 2242 patients were assessed: 459 in center 1 (61 having received neostigmine and 398 sugammadex) and 1783 in center 2 (531 and 1252, respectively). Patients' characteristics differed between centers, with more high-risk patients in center 1. The mean train-of-four (TOF) ratio after supramaximal current determination (supramaximal threshold) was higher in center 1 (p < 0.001). Most patients received neostigmine while the TOF ratio was < 40% (68.6% in center 1 and 62.4% in center 2), while extubation was performed while the TOF ratio was > 90% in 61.0% in center 1 and in 32.1% in center 2 (p < 0.001). Patients received sugammadex irrespective of the number of responses to TOF before reversal, and extubation was performed while the TOF ratio was > 90% in 85.0% in center 1 and in 53.6% in center 2 (p < 0.001). No side effect was encountered. Despite guidelines for the TOF ratio before extubation, recommendations were not adequately respected and more vigilance is mandatory. The TOF test before use gave values that were 100% far apart with an underestimation with acceleromyography and an overestimation using kinemyography.

Association of Intravenous Neostigmine and Anticholinergics or Sugammadex with Postoperative Delirium: A Retrospective Cohort Study.

Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine. We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery. Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium (P = .637) or postoperative early delirium (P = .904). Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.

Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review

Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.

Low-dose sugammadex reverses moderate rocuronium-induced neuromuscular block in horses.

Neuromuscular block (NMB) during general anaesthesia has an implicit risk of inadvertent residual NMB during recovery. Reversal of NMB is commonly encouraged to decrease this risk, and has historically been performed with neostigmine/atropine, two agents with important cardiac and gastrointestinal side effects. Sugammadex is a new selective relaxant binding agent that can reverse rocuronium-induced NMB efficiently and without these complications. Recommended doses are possibly cost-prohibitive. To measure the recovery time from rocuronium-NMB after administration of low-dose sugammadex, compared with spontaneous recovery. Nonrandomised in vivo experiments. Fourteen adult horses undergoing different research procedures were anaesthetised with detomidine and isoflurane. All horses received NMB with rocuronium 0.3 mg/kg IV. Neuromuscular function was measured with acceleromyographic train-of-four (TOF) ratio. Recovery occurred spontaneously in five horses weighing (median [range]) 548 (413-594) kg and was enhanced with sugammadex 200 mg (total dose) in nine horses (433 [362-515]) kg. Recovery time from moderate NMB to a TOF ratio 1.0, and total duration of NMB were compared between groups. Cases of recurarisation (decrease in the TOF ratio <0.9 after recovery) were identified within 30 min after sugammadex. The dose of sugammadex was 0.46 (0.39-0.55) mg/kg. The recovery period lasted 21 (17-39) minutes for spontaneous and 4 (3-7) minutes for sugammadex. Total duration of NMB was 58 (41-70) minutes for spontaneous and 36 (21-43) for sugammadex (both p ≤ 0.003). There were no instances of recurarisation. Small sample size. A dose of sugammadex of approximately 0.5 mg/kg substantially shortened the recovery period from rocuronium-induced NMB from a median of 21 to 4 min, when given at a moderate depth of NMB. No recurarisation was observed within the next 30 min.

EE110 Economic Analysis of Sugammadex for Neuromuscular Block Reversal for Laparoscopic Surgery from a Single Hospital System in China

EE110 Economic Analysis of Sugammadex for Neuromuscular Block Reversal for Laparoscopic Surgery from a Single Hospital System in China

Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting

Study objectivePerioperative neuromuscular blocking agents are pharmacologically reversed to minimize complications associated with residual neuromuscular block. Neuromuscular block reversal with anticholinesterases (e.g., neostigmine) require coadministration of an anticholinergic agent (e.g., glycopyrrolate) to mitigate muscarinic activity; however, sugammadex, devoid of cholinergic activity, does not require anticholinergic coadministration. Single-institution studies have found decreased incidence of post-operative urinary retention associated with sugammadex reversal. This study used a multicenter database to better understand the association between neuromuscular block reversal technique and post-operative urinary retention. DesignRetrospective cohort study utilizing large healthcare database. SettingNon-profit, non-governmental and community and teaching hospitals and health systems from rural and urban areas. Patients61,898 matched adult inpatients and 95,500 matched adult outpatients. InterventionsNeuromuscular block reversal with sugammadex or neostigmine plus glycopyrrolate. MeasurementsIncidence of post-operative urinary retention by neuromuscular block reversal agent and the independent association of neuromuscular block reversal technique and risk of post-operative urinary retention. Main resultsThe incidence of post-operative urinary retention was 2-fold greater among neostigmine with glycopyrrolate compared to sugammadex patients (5.0% vs 2.4% inpatients; 0.9% vs 0.4% outpatients; both p < 0.0001). Multivariable logistic regression identified reversal with neostigmine to be independently associated with greater risk of post-operative urinary retention (inpatients: odds ratio, 2.20; 95% confidence interval, 2.00 to 2.41; p < 0.001; outpatients: odds ratio, 2.57; 95% confidence interval, 2.13 to 3.10; p < 0.001). Post-operative urinary retention-related visits within 2 days following discharge were five-fold higher among those reversed with neostigmine than sugammadex among inpatients (0.05% vs. 0.01%, respectively; p = 0.018) and outpatients (0.5% vs. 0.1%; p < 0.0001). ConclusionThough this study suggests that neuromuscular block reversal with neostigmine can increase post-operative urinary retention risk, additional studies are needed to fully understand the association.

Phase III clinical trial comparing the efficacy and safety of adamgammadex with sugammadex for reversal of rocuronium-induced neuromuscular block

BackgroundPreliminary clinical trials of adamgammadex, a new cyclodextrin-based selective reversal agent, have demonstrated its efficacy in reversing neuromuscular block by rocuronium. MethodsThis multicentre, randomised, double-blind, positive-controlled, non-inferiority phase III clinical trial compared the efficacy and safety of adamgammadex and sugammadex. We randomised 310 subjects to receive adamgammadex (4 mg kg−1) or sugammadex (2 mg kg−1) at reappearance of the second twitch of the train-of-four (TOF), and standard safety data were collected. ResultsFor the primary outcome, the proportion of patients with TOF ratio ≥0.9 within 5 min was 98.7% in the adamgammadex group vs 100% in the sugammadex group, with a point estimate and 95% confidence interval (CI) of 1.3% (–4.6%, +1.3%); the lower limit was greater than the non-inferiority margin of –10%. For the key secondary outcome, the median (inter quartile range) time from the start of administration of adamgammadex or sugammadex to recovery of TOF ratio to 0.9 was 2.25 (1.75, 2.75) min and 1.75 (1.50, 2.00) min, respectively. The difference was 0.50 (95% CI: 0.25, 0.50); the upper limit was lower than the non-inferiority margin of 5 min. In addition, there were no inferior results observed in secondary outcomes. Adamgammadex had a lower incidence of adverse drug reactions compared with sugammadex (anaphylactic reaction, recurarisation, decreased heart rate, and laryngospasm; P=0.047). ConclusionsAdamgammadex was non-inferior to sugammadex with a possible lower incidence of adverse drug reactions compared with sugammadex. Adamgammadex may have a potential advantage in terms of its overall risk–benefit profile. Clinical trial registrationChinese Clinical Trial Registry, ChiCTR2000039525. Registered October 30, 2020. https://www.chictr.org.cn/showproj.html?proj=56825

Sugammadex: A Milestone that Brings Changes in Anesthesia Practice

Sugammadex is a modified form of gamma-cyclodextrin that reverses the effects of rocuronium and vecuronium, which are aminosteroid non-depolarizing muscle relaxants (NDMR). It is the first and only reversal agent in the class of selective relaxant binding agents (SRBA) that reverses any depth of neuromuscular blockade without the unwanted muscarinic side effects of neostigmine (bronchospasm, nausea, vomiting, bradycardia, diarrhea, etc.) and anti-muscarinic side effects of glycopyrrolate (dry mouth, palpitations, urinary retention, constipation, etc.). It is an Food and Drug Administration (FDA)-approved agent that is safe for the reversal of neuromuscular block (NMB) caused by rocuronium and is available worldwide. Sugammadex practical use is predicted to alleviate many of the faults in present anesthetic practice regarding the antagonistic effects of rocuronium and other aminosteroid muscle relaxants. Despite being a novel agent in the reversal of NMB, the cost of sugammadex may limit its use as a regular antagonist of neuromuscular-blocking drugs.

Propensity of use of neuromuscular blocking agents among Indian anaesthesiologists: A questionnaire-based survey

This survey aimed to understand the use of neuromuscular blockers (NMBs) with respect to neuromuscular monitoring, reversal of residual neuromuscular block, and incidence of adverse events among Indian anaesthesiologists.A 40-item questionnaire was sent to 250 anaesthesiologists across India via email and their responses were statistically analysed.The response rate was 50%. To facilitate tracheal intubation, 81.0% respondents preferred cisatracurium, 72.2% preferred atracurium, 43.7% preferred vecuronium, 58.7% preferred rocuronium, and 70.6% preferred succinylcholine. Safety and recovery time are the most important criteria for an ideal NMB. About 84% respondents expressed concerns about the adverse effects of NMBs, especially recovery of neuromuscular function (31.1%) and hemodynamic effects (26.4%). The train-of-four (TOF) ratio for residual paralysis was not checked by 57% respondents. Reversal agents were used by &amp;#62;2/3 respondents; however, 86.5% used them after cisatracurium was used. Concerns about adverse effects of anticholinesterase/antimuscarinic agents were expressed by 63.4% respondents, while 85% expressed the need for availability of sugammadex in India. Almost two-thirds opined that conventional nerve stimulators and quantitative TOF monitors should be available in the operating room.The survey showed that safety and recovery time are the most important parameters in selecting an NMB. Cisatracurium was the most widely used NMB for tracheal intubation because of its safety, duration of action, less anaphylactic reactions, and fewer hemodynamic fluctuations. The use of TOF for monitoring was low. While reversal agents were used by &amp;#62;2/3 respondents, many respondents used them after cisatracurium was used as an NMB.

Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy

BackgroundSugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. MethodsWe performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg−1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. ResultsTwenty-five patients were included in this study. Compared with baseline, BIS increased at 4–6 min (β coefficient: 3.63; 95% confidence interval [CI]: 2.22–5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2–4 min (β coefficient: 0.29; 95% CI: 0.05–0.52; P=0.016) and 4–6 min (β coefficient: 0.71; 95% CI: 0.47–0.94; P<0.001), and EMG increased at 4–6 min (β coefficient: 1.91; 95% CI: 1.00–2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2–4 min (β coefficient: 93; 95% CI: 1–185; P=0.046) and 4–6 min (β coefficient: 208; 95% CI: 116–300; P<0.001), and decreased delta power was observed at 4–6 min (β coefficient: −526.72; 95% CI: −778 to −276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. ConclusionsAfter neuromuscular block reversal with 2 mg kg−1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.

Sugammadex Reduced the Incidence of Postoperative Pulmonary Complications in Susceptible Patients Identified by ARISCAT Risk Index: Systematic Review and Meta-analysis.

The efficacy of sugammadex on postoperative pulmonary complications (PPCs) in susceptible patients, compared with neostigmine, remains indeterminate. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) Group Investigators proposed a risk index for the early identification of susceptible patients, with excellent externally validated discrimination ability. Meta-analytical techniques were applied to evaluate the efficacy of sugammadex on PPCs in patients with ARISCAT-defined risk factors. The study is registered on PROSPERO, number CRD42021261156. We searched PubMed, Scopus, Embase, Cochrane library, GreyNet, and OpenGrey for eligible randomized controlled trials (RCTs) without restricting the language or year of publication. Twelve RCTs consisting of 1182 patients susceptible to PPCs were included. A robust reduction was observed on the incidence of PPCs in susceptible patients who received sugammadex [RR 0.66; 95% CI (0.54, 0.80), p<0.01], with a low level of between-study heterogeneity (I2=45.98%; H2=1.85). Similar protective effects were also proved in avoiding residual neuromuscular block (NMB) [RR 0.25; 95% CI (0.11, 0.56); p<0.01], atelectasis [RR 0.74; 95% CI (0.59, 0.95); p=0.02], pneumonia [RR 0.49; 95% CI (0.28, 0.88); p=0.02], and respiratory failure [RR 0.61; 95% CI (0.39, 0.96); p=0.03]. No difference was observed regarding adverse events [RR 0.85; 95% CI (0.72, 1.01); p=0.06]. Low to moderate quality of evidence demonstrated the edge of sugammadex over neostigmine for NMB reversal in reducing the likelihood of PPCs and residual NMB in patients with ARISCAT-defined risk factors. Clinicians may reassess the type of reversal agent when treating patients susceptible to PPCs.

Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal.

Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal.

Neuromuscular block: Monitoring, reversal, and residual blockade in small animals.

Nondepolarizing neuromuscular blocking agents are used frequently during ophthalmic surgery of dogs and cats. Residual neuromuscular block (NMB)-impaired neuromuscular function at recovery from anesthesia-is a main concern when these agents are used in small animals. In humans, residual NMB reduces the ability to protect the airway (swallow and cough) and increases the incidence of hypoxia and upper airway collapse after recovery from anesthesia. In dogs, impaired neuromuscular function of the larynx can be detected even after common indicators of neuromuscular function suggest that recovery from NMB is complete. Objective monitoring of NMB is a simple, cost-effective strategy to minimize the risk of residual NMB. This review summarizes relevant aspects of monitoring and reversal of NMB, and strategies to minimize the risk of residual NMB in clinical practice of small animals.

Postoperative oxygenation assessed by SpO2/FiO2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study

Study objectiveResidual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization. DesignRetrospective cohort analysis. SettingPostoperative recovery area of a tertiary care hospital. PatientsAdults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex. InterventionsNone. MeasurementsThe primary outcome was the lowest SpO2/FiO2 ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications. Main resultsAmong 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO2/FiO2 ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of −3.5 (95% confidence interval: −5.3, −1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease. ConclusionsPostoperative minimum SpO2/FiO2 ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.

Postoperative Risk of Transfusion After Reversal of Residual Neuromuscular Block With Sugammadex Versus Neostigmine: A Retrospective Cohort Study.

Sugammadex and neostigmine are routinely used to reverse residual neuromuscular blocks at the end of surgery. Sugammadex has been linked with prolongation of laboratory coagulation markers, but clinical relevance on postoperative blood loss and transfusions remains unclear. In this retrospective, single-center, cohort study, we analyzed medical records of adult patients having noncardiac surgery who were given sugammadex or neostigmine from May 2016 to December 2020. Our primary outcome was the incidence of any postoperative transfusion of red blood cells, and/or fresh-frozen plasma, and/or platelets. Secondary outcomes were duration of hospitalization, need for resurgery, and postoperative intensive care unit (ICU) admission. After propensity score weighting, the odds ratio (OR) for postoperative transfusion was assessed in both groups (sugammadex versus neostigmine) using a generalized estimation equation to count within-subject correlation weighted by the inverse propensity score. Out of 39,325 eligible surgeries, 33,903 surgeries in 29,062 patients were included in the analysis; with 4581 patients receiving sugammadex and 29,322 patients receiving neostigmine. The raw incidence of postoperative transfusion was 7.40% in sugammadex and 7.45% in the neostigmine group. After weighting by propensity score, the incidence of postoperative transfusion was 8.01% in the sugammadex and 7.38% in the neostigmine group (OR, 1.11 [95% confidence interval [CI], 0.97-1.26; P = .118]). There was no difference in duration of hospitalization and need for resurgery, but odds of postoperative ICU admission were significantly higher for patients receiving sugammadex than those receiving neostigmine (OR, 1.33 [98.33% CI, 1.17-1.52; P < .0001]). Our a priori planned analysis of coagulation laboratory parameters could not be completed because of a high amount of missing laboratory data. There is no statistically significant nor clinically important difference in the risk of postoperative transfusion in patients receiving sugammadex or neostigmine.

Perfusion index during endotracheal intubation and extubation: A prospective observational study.

Perfusion index (PI) can be detected using a pulse oximeter. Its value decreases in response to noxious stimuli. Here, we investigated its efficacy in detecting hemodynamic responses during endotracheal intubation and extubation. An approval from the institutional ethics committee was obtained along with a written informed consent from the patients involved in this study. A sample size of 30 was calculated. Reading of PI, heart rate, and blood pressures (systolic, diastolic, and mean arterial) were recorded at pre-intubation, post-intubation, during neuromuscular block reversal, pre-extubation and at extubation. Clinically significant heart rate, blood pressure (systolic, diastolic, and mean) and PI was defined as increase by >10 bpm, rise by ≥15 bpm and a decrease by ≥10%, respectively, from pre-intubation value. Clinically significant change in PI was seen at all intervals with maximum decrease in PI occurring during neuromuscular block reversal (42.6% at the start and 56.7% at the end of neuromuscular block reversal). A negative correlation was noted between PI and the other non-invasive hemodynamic parameters. PI decreases on noxious stimuli and correlates negatively with the other non-invasive hemodynamic parameters. Hemodynamic response at neuromuscular block reversal is maximum.