Neuromuscular Blockade Group Research Articles

Effects of deep vs moderate neuromuscular block on the quality of recovery after robotic gastrectomy.

It remains unclear whether deep neuromuscular blockade results in better postoperative recovery than does moderate neuromuscular blockade. Therefore, in this study, we aimed to compare the effects of deep neuromuscular blockade and moderate neuromuscular blockade on the quality of postoperative recovery in patients undergoing robotic gastrectomy. In this prospective, double-blind, single-center randomized controlled superiority trial with two parallel groups, 56 adult patients (19-80years) scheduled for elective robotic gastrectomy were randomly assigned to a moderate neuromuscular blockade group or a deep neuromuscular blockade group in a 1:1 ratio. In the deep and moderate neuromuscular blockade groups, the infusion rate for rocuronium was adjusted to maintain a post-tetanic count of 1-2 or a train-of-four count of 1-2, respectively. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day 1. Secondary outcomes included the QoR-40 score on postoperative day 2, intraoperative hemodynamic data, intraoperative respiratory data, visual analog scale score for pain, postoperative incidences of nausea and vomiting, postoperative rescue analgesic use, and postoperative rescue antiemetic use. The postoperative QoR-40 score was similar between the two groups on postoperative days 1 and 2. Moreover, the two groups showed no differences in intraoperative hemodynamic and respiratory data or postoperative pain, nausea and vomiting, and rescue medication use. Our findings suggest that the quality of recovery after robotic gastrectomy is similar for deep and moderate neuromuscular blockade. Therefore, deep neuromuscular blockade during robotic gastrectomy may be unnecessary, at least in patients with normal body mass index.

Influence of depth of neuromuscular blockade on surgical conditions during low-pressure pneumoperitoneum laparoscopic cholecystectomy: A randomized blinded study

Study objectiveTo evaluate the influence of neuromuscular blockade (NMB) on surgical conditions during low-pressure pneumoperitoneum (8mmHg) laparoscopic cholecystectomy (LC), while comparing moderate and deep NMB. Secondary objective was to evaluate if surgical conditions during low-pressure pneumoperitoneum LC performed with deep NMB could be comparable to those provided during standard-pressure pneumoperitoneum (12mmHg) LC. DesignProspective, randomized, blinded clinical trial. SettingOperating room. PatientsNinety ASA 1–2 patients scheduled for elective LC. InterventionsPatients were allocated into 3 groups: Group 1: low-pressure pneumoperitoneum with moderate-NMB (1–3 TOF), Group 2: low-pressure pneumoperitoneum with deep-NMB (1–5 PTC) and Group 3: standard pneumoperitoneum (12mmHg). Rocuronium was used to induce NMB and acceleromiography was used for NMB monitoring (TOF-Watch-SX). MeasurementsThree experienced surgeons evaluated surgical conditions using a four-step scale at three time-points: surgical field exposure, dissection of the gallbladder and extraction/closure. Main resultsLow-pressure pneumoperitoneum (Group 1 vs. 2): good conditions: 96.7 vs. 96.7%, 90 vs. 80% and 89.6 vs. 92.3%, respectively for the time-points, p>0.05. No differences in optimal surgical conditions were observed between the groups. Surgery completion at 8mmHg pneumoperitoneum: 96.7 vs. 86.7%, p=0.353.Standard-pressure pneumoperitoneum vs. low-pressure pneumoperitoneum with deep NMB (Group 3 vs. 2): good conditions: 100% in Group 3 for the three time-points (p=0.024 vs. Group 2 at dissection of the gallbladder). Significantly greater percentage of optimal conditions during standard-pressure pneumoperitoneum LC at the three time points of evaluation. ConclusionsThe depth of NMB was found not to be decisive neither in the improvement of surgical conditions nor in the completion of low-pressure pneumoperitoneum LC performed by experienced surgeons. Surgical conditions were considered better with a standard-pressure pneumoperitoneum, regardless of the depth of NMB, than during low-pressure pneumoperitoneum with deep NMB.

Neuromuscular blockade requirement is associated with good neurologic outcome in cardiac arrest survivors treated with targeted temperature management

PurposeWe examined the association between neuromuscular blockade (NMB) requirements and outcomes and lactate clearance in cardiac arrest survivors treated with targeted temperature management (TTM). MethodsWe included consecutive adult cardiac arrest survivors treated with TTM between 2012 and 2015. NMB use was categorized into 3 groups: no NMB, bolus NMB (intermittent bolus use), and continuous NMB (continuous infusion). Serum lactate levels were measured on admission and at 12h, 24h, and 48h after admission. The primary outcome was neurologic outcome at discharge. The secondary outcomes were in-hospital mortality and lactate clearance. ResultsIn total, 309 patients were included. Of these, 206 (66.7%) and 73 (23.6%) were discharged with poor neurologic outcome and death, respectively. Multivariate analysis revealed that continuous NMB, as opposed to no NMB use, was associated with decreased poor neurologic outcomes (odds ratio [OR], 0.317; 95% confidence interval [CI], 0.124–0.815) and decreased in-hospital mortality (OR, 0.414; 95% CI, 0.183–0.941). There were no differences in lactate clearance between the NMB groups. ConclusionContinuous NMB requirement was associated with improved neurologic outcome and decreased in-hospital mortality in cardiac arrest survivors treated with TTM. The NMB requirement was not associated with lactate clearance.

Evaluation of Clinical Efficacy of Intravenous Glyco-P® (Glycopyrrolate)

Background: Glycopyrrolate has been widely used globally as an adjunct in anesthesia since early 1970’s. However, this agent has never been used in Thailand until recent introduction of the Glyco-P ® (0.2 mg IV glycopyrrolate). The clinical efficacy and safety of intravenous glycopyrrolate in Thai population was unknown. Objective: To evaluate the clinical efficacy of intravenous glycopyrrolate in 3 areas 1) antisialagogue 2) effect on heart rate and 3) anticholinergic effects when used with neostigmine for neuromuscular blockade reversal. Methods: Single-centered, prospective observational study, which enrolled 121 ASA 1-3 patients receiving intravenous sedation or general anesthesia. The patients were given an IV glycopyrrolate and had their data collected and categorized by clinical indications into 3 groups-secretion group (SCR), heart rate group (HR) and reversal of neuromuscular blockade group (NMR). We recorded heart rate and blood pressure at baseline and every 5 minutes and recorded secretion score every 10 minutes after treatment. Results : Intravenous glycopyrrolate demonstrated good antisialagogue properties as 76.1-85.6% of patients in SCR group recorded minimal secretion score, between 0-1 out of 5, at 10-20 minutes. A mild to modest chronotropism was observed as mean heart rate was increased from 72.85 to 79.85 within 5 minutes. When used with neostigmine for reversal of neuromuscular blockade, the well-balanced anticholinergic effect was seen as stable heart rate and minimal secretion. Conclusion : An intravenous Glyco-P ® demonstrates its clinical efficacy in Thais at the same recommended dose as previously described in western population for both antisialagogue and stable heart rate when used alone and used in conjunction with neostigmine for neuromuscular blockade reversal.

Abstract 11885: Neuromuscular Blockade Requirement is Associated With Good Neurologic Outcome in Cardiac Arrest Survivors Treated With Targeted Temperature Management

Introduction: The optimal method for neuromuscular blockade (NMB) in post-resuscitation care has not been fully elucidated. We aimed to examine the association of NMB use with neurologic outcome and lactate clearance in cardiac arrest survivors treated with targeted temperature management (TTM). Methods: This retrospective observational study included consecutive adult cardiac arrest survivors treated with TTM from 2012 to 2015. NMB use was categorized into 3 groups: no NMB, bolus NMB (intermittent bolus use), and continuous NMB (continuous infusion). The serum lactate was obtained on admission and at 12 h, 24 h, and 48 h after admission. The primary outcome was poor neurologic outcome at hospital discharge. The secondary outcome was lactate clearance. Results: A total of 309 patients were included, and 206 (66.7%) were discharged with poor neurologic outcomes. No NMB, bolus NMB, and continuous NMB groups included 93, 119, and 97 patients, respectively. No NMB, bolus NMB, and continuous NMB use was associated with poor neurologic outcomes in 81/93 (87.1%), 78/119 (65.5%), and 47/97 (48.5%), respectively ( p < 0.001). Multivariate analysis revealed that older age (odd ratio [OR] 1.038, 95% confidence interval [CI] 1.015-1.061, p = 0.001), shockable rhythm (OR 0.273, 95% CI 0.125-0.599, p =0.001), cardiac etiology (OR 0.262, 95% CI 0.115-0.599, p =0.001), longer downtime (OR 1.051, 95% CI 1.026-1.076, p <0.001), high Glasgow coma scale (OR 0.550, 95% CI 0.416-0.728, p <0.001), and continuous NMB (OR 0.317, 95% CI 0.124-0.815, p =0.017) compared to no NMB use were associated with poor neurologic outcomes. Serum lactate level ( p = 0.658) and lactate clearance ( p = 0.440) were not different among NMB groups. The serum lactate level decreased significantly over time ( p <0.001), and was different between good and poor neurologic outcomes ( p <0.001), while lactate clearance was not different ( p = 0.701). Conclusions: Continuous NMB use, rather than no NMB use, was associated with good neurologic outcome at discharge in cardiac arrest survivors treated with TTM. The method of NMB was not associated with serum lactate level and lactate clearance.

Comparison of heart rate variability response in children undergoing elective endotracheal intubation with and without neuromuscular blockade: a randomized controlled trial

The routine use of neuromuscular blocking drugs (NMBD) for endotracheal intubation in children is the subject of much controversy. The analysis of heart rate variability (HRV) can reveal information about the functional state of the autonomic nervous system (ANS). The purpose of this study was to determine if HRV elucidates differences in the sympathovagal balance of children undergoing elective endo-tracheal intubation with and without neuromuscular blockade (NMB). In this prospective study, 38 children (2-6 years) scheduled for adenotonsillectomy were randomized into two groups to receive fentanyl 2 μg·kg(-1) and propofol 4 mg·kg(-1) , with either mivacurium 0.25 mg·kg(-1) (NMB group) or saline solution (NoNMB group) for anesthesia induction. The same experienced, blinded anesthesiologist performed endotracheal intubation. Heart rate variability, RR intervals, ECG as well as an electroencephalogram were recorded with HRV and BIS XP monitors, respectively. Heart rate variability was analyzed in the frequency domain. There was no significant difference in HRV changes immediately after mivacurium administration compared with an administration of saline. The groups were comparable for the bispectral index value (NMB 35 [33-41] vs NoNMB 34 [32-42]) during endotracheal intubation. Changes in both the low-frequency power and the low-/high-frequency ratio immediately after endotracheal intubation compared with the unstimulated state before laryngoscopy were significantly higher without NMB (P = 0.015 and P = 0.006, respectively), whereas there was no significant difference with respect to the high-frequency power. The stress response during endotracheal intubation in pediatric patients represented by the frequency domain analysis of HRV was found to be higher without NMB. When mivacurium was added to a propofol-fentanyl induction regimen, the ANS alterations during endotracheal intubation decreased significantly.

Neuromuscular blockade for early severe acute respiratory distress syndrome: Does sedation make the difference?

Drs. Needham and Brindley provided a thorough analysis of the paper by Dr. Papazian et al. regarding the use of cisatracurium in the early management of severe acute respiratory distress syndrome. However, it is important to consider that the observed benefit might be an unintended consequence of the sedative prescription rather than a direct effect of neuromuscular blockade (NMB). When converted to morphine equivalents, the control group received an average of 1,200 mg more morphine over the first seven days than the NMB group (5,000 lg vs 3,800 lg sufentanil equivalents; P = 0.54). Conversely, patients in the NMB group received twice as much ketamine as those in the control group (28,968 mg vs 14,220 mg over seven days, or an average of 2.5 mg kg hr compared with 1.2 mg kg hr for a 70 kg patient; P = 0.06). Although neither difference reached statistical significance, the hemodynamic effects of these differences could be important, as opioids are potent venodilators while ketamine has venoconstricting properties. Unfortunately, the study only partially addressed this question. The control and NMB groups were similar with respect to the duration of vasoactive drug support, but the analysis of hemodynamic support did not consider accumulated fluid balance as a variable. Consequently, it is unknown whether differences in the amount of intravenous fluids were necessary to maintain hemodynamic stability. This may be relevant, as a restrictive fluid strategy has been shown to improve outcomes in patients with acute lung injury when compared with a more liberal approach. The reasons behind the differences in the sedation prescription of the two groups are unclear. Perhaps the use of NMB influences the treating physician’s perception of anesthetic requirements and the consequent prescription of ketamine is considered a dissociative anesthetic agent. Perhaps the elimination of the visible manifestations of respiratory distress results in less opioid administration. Regardless of the reason, attributing the benefit observed in this study to a direct effect of NMB may be premature in the absence of an assessment of differences in fluid administration.

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group). A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.

Nitrous Oxide Potentiates Succinylcholine Neuromuscular Blockade in Humans

Sixty ASA physical status I and II adults received 0.3 mg/kg succinylcholine to determine the effect of prolonged administration of thiopental and that of nitrous oxide on succinylcholine neuromuscular blockade. Succinylcholine was administered either 1 min (group 1) or 6 min (groups 2 and 3) after induction of anesthesia with thiopental. In group 2, anesthesia was maintained with thiopental and the patients' lungs were ventilated with oxygen. In group 3, anesthesia was maintained with only 70% nitrous oxide in oxygen. Train-of-four stimulation of the ulnar nerve was started 30 s before the administration of succinylcholine and repeated every 12 s. The force of contraction of the adductor pollicis muscle was measured. Maximum blockade (mean +/- SEM) did not vary significantly between group 1, where thiopental had been administered for 1 min, and group 2, where it had been administered for 6 min (group 1: 61% +/- 6%; group 2: 54% +/- 8%). However, the addition of nitrous oxide increased neuromuscular blockade (group 3: 80% +/- 6%; P less than 0.05 compared with group 2). The degree of twitch augmentation, i.e., greater than maximal response, and times to twitch augmentation and to maximum blockade did not vary significantly among the groups. It is concluded that nitrous oxide increases succinylcholine neuromuscular blockade and that this is manifest within 6 min. This effect is not due to the duration of the anesthetic because thiopental, administered over a similar time period, did not potentiate succinylcholine.