Reversal Of Neuromuscular Blockade Research Articles

The Postoperative Effect of Sugammadex versus Acetylcholinesterase Inhibitors in Colorectal Surgery: An Updated Meta-Analysis.

the aim of this meta-analysis was to evaluate the postoperative effects of neuromuscular blockade reversal with sugammadex compared with acetylcholinesterase inhibitors in colorectal surgery. A systematic literature search was performed for studies comparing the postoperative course of patients receiving neuromuscular blockade reversal with either sugammadex or acetylcholinesterase inhibitors (control) after colorectal surgery. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios and standardized mean differences with 95% confidence intervals (CIs) were calculated. Five studies with a total of 1969 patients were included (sugammadex n = 1137, control n = 832). Sugammadex reversal resulted in a significantly faster return of defecation or flatus after surgery compared to acetylcholinesterase inhibitors (SMD 13.01, 95% CI 6.55-19.46, p = < 0.0001). There were no significant differences between the two groups in other clinical outcomes such as surgical morbidity and length of hospital stay. The present data support the beneficial impact of sugammadex on gastrointestinal motility after colorectal surgery. However, the effect of sugammadex on the prevention of surgical complications and a prolonged hospital stay is diminishing. Larger randomized controlled trials with standardized study protocols are needed to validate the results presented here.

Postoperative pulmonary complications after sugammadex reversal of neuromuscular blockade: a systematic review and meta-analysis with trial sequential analysis

BackgroundSugammadex has been reported to lower the incidence of postoperative residual neuromuscular blockade. Despite the advantages, until recently the effects of sugammadex on postoperative pulmonary complications (PPCs) were controversial. We conducted a systematic review and meta-analysis to determine whether reversal with sugammadex was associated with a lower risk of PPCs compared with neostigmine.MethodsPubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to May 2022. Randomized controlled trials (RCTs) and observational studies comparing PPCs in patients receiving sugammadex or neostigmine as reversal agent at the end of surgery were included. The primary outcomes focused on PPCs including desaturation, pneumonia, atelectasis, noninvasive ventilation (NIV) and reintubation. Trial sequential analysis was performed on the primary outcomes to confirm whether firm evidence was reached.ResultsMeta-analysis of included studies showed that the rate of desaturation (43.2% vs 45.0%, RR = 0.82; 95% CI 0.63 to 1.05; p = 0.11) were comparable between the two groups. When looking at other primary outcomes, significantly lower risk of pneumonia (1.37% vs 2.45%, RR = 0.65; 95% CI 0.49 to 0.85; p = 0.002), atelectasis (24.6% vs 30.4%, RR = 0.64; 95% CI 0.42 to 0.98; p = 0.04), NIV (1.37% vs 2.33%, RR = 0.65; 95% CI 0.43 to 0.98; p = 0.04) and reintubation (0.99% vs 1.65%, RR = 0.62; 95% CI 0.43 to 0.91; p = 0.01) in the sugammadex group were detected compared with the neostigmine group.ConclusionsWe concluded that sugammadex is more effective at reducing the incidence of PPCs including pneumonia, atelectasis, NIV and reintubation compared with neostigmine. Further evidence, preferably from RCTs, is required to confirm these findings.

Conventional reversal of rocuronium-induced neuromuscular blockade by sugammadex in Korean children: pharmacokinetics, efficacy, and safety analyses.

Background: Sugammadex is known to reverse neuromuscular blockade induced by non-depolarizing agents. In children, the recommended dose for reversal of moderate neuromuscular blockade is 2mg/kg. We investigated the pharmacokinetics and pharmacodynamics of sugammadex in Korean children. Methods: Children (2-17years of age) undergoing brain or spine surgery were enrolled and randomly assigned to control (neostigmine) and 2, 4, or 8mg/kg sugammadex groups. Following induction of anesthesia and monitoring of the response to train-of-four stimulation, 1mg/kg rocuronium was intravenously administered. Upon reappearance of the second twitch to train-of-four stimulation, the study drug was administered according to group allocation. The plasma concentrations of rocuronium and sugammadex were serially measured at nine predefined time points following study drug administration. To determine efficacy, we measured the time elapsed from drug administration to recovery of T4/T1 ≥ 0.9. For pharmacokinetics, non-compartmental analysis was performed and we monitored adverse event occurrence from the time of study drug administration until 24h post-surgery. Results: Among the 29 enrolled participants, the sugammadex (2mg/kg) and control groups showed recovery times [median (interquartile range)] of 1.3 (1.0-1.9) and 7.7 (5.3-21.0) min, respectively (p = 0.002). There were no significant differences in recovery time among the participants in sugammadex groups. The pharmacokinetics of sugammadex were comparable to those of literature findings. Although two hypotensive events related to sugammadex were observed, no intervention was necessary. Conclusion: The findings of this pharmacokinetic analysis and efficacy study of sugammadex in Korean children indicated that sugammadex (2mg/kg) may be safely administered for reversing moderate neuromuscular blockade. Some differences in pharmacokinetics of sugammadex were observed according to age. Clinical Trial Registration: http://clinicaltrials.gov (NCT04347486).

Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter.

Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children: Research Letter.

Coadministration of intravenous calcium along with neostigmine for rapid neuromuscular blockade recovery: A systematic review and meta-analysis.

Postoperative residual curarization (PORC) and the impact of the coadministration of intravenous calcium along with an acetylcholinesterase inhibitor on it are not well addressed. Extensive electronic database screening was done until October 7, 2022 after enlisting the protocol of this systematic review in PROSPERO (CRD42021274879). Randomized controlled trials (RCTs) evaluating the impact of intravenous calcium and neostigmine coadministration on neuromuscular recovery were included in this meta-analysis. Our search retrieved four RCTs with a total of 266 patients. The application of calcium shortened the neuromuscular recovery time (SMD = -2.13, 95% confidence interval [CI]: -2.66 to -1.59, I2 = 66%) and reduced the risk of PORC at 5 min (odds ratio [OR] = 0.21, 95% CI: 0.10-0.46, I2 = 0%), with an improved train-of-four (TOF) ratio at 5 min (mean difference [MD] = 9.28, 95% CI: 4-14.57, I2 = 66%). However, neither significant reduction in PORC at 10 min (OR = 0.41, 95% CI: 0.15-1.09, I2 = 0%) nor a better TOF ratio was associated with coadministration of calcium (MD = 0.40, 95% CI: -1.3-2.11). Coadministration of calcium along with neostigmine during the early period of neuromuscular blockade reversal can be used to enhance neuromuscular recovery.

Efficacy of Single-shot Epidural with Bupivacaine and Dexamethasone as an Adjuvant for Postoperative Analgesia in Patients Undergoing Major Abdominal Surgeries

Background: Apart from being distressful, postoperative pain produces a range of harmful effects, including morbidity and mortality. Epidural analgesia is a safe and effective method for the control of postoperative pain. Aim: This study compared the analgesic efficacy of single-shot epidural bupivacaine plus dexamethasone versus single-shot epidural bupivacaine and intravenous (IV) dexamethasone after major elective abdominal surgery. Methodology: A cross-sectional cohort study was conducted on 30 adult patients undergoing major elective abdominal surgery. Fifteen minutes before the reversal of neuromuscular blockade, study Group “A” received an epidural of 0.125% bupivacaine at the dose of 1.0 mL/segment and dexamethasone 8 mg and Group “B” included data of 30 adult patients which was drawn from the well-matched historic cohort, from past anesthesia records, where patients received an epidural of 0.125% bupivacaine at the dose of 1.0 mL/segment, but an injection of dexamethasone 8 mg was administered intravenously. Results: The primary outcome was a significantly longer duration of analgesia (905.97 ± 110.89 min) in Group “A” patients in comparison to Group “B” patients (731.0 ± 112.59 min) (P &lt; 0.0001). The secondary outcome included the requirement of total rescue analgesic dose of injection tramadol, which was significantly lower in Group “A” compared to Group “B” patients (163.90 ± 15.93 mg vs. 182.27 ± 30.61 mg, respectively), (P &lt; 0.005). Postoperative nausea and vomiting incidence was lower in patients of Group “B” due to the antiemetic effect of IV dexamethasone. Conclusion: Single-shot bupivacaine with dexamethasone gives longer postoperative analgesia and lesser rescue analgesic requirement compared to epidural bupivacaine with IV dexamethasone.

Systematic Evaluation of Neuromuscular Reversal Agents in Obese Patients After General Anesthesia for Bariatric Surgery

Background: There is no consensus regarding reversing neuromuscular blockade (NMB) under general anesthesia. For obese patients, complete and rapid recovery from NMB is essential. Objective: This study compared the effectiveness of methods to restore spontaneous breathing for obese patients who underwent laparoscopic sleeve gastrectomy after general anesthesia. Materials and Methods: Medical records were reviewed for those who underwent laparoscopic sleeve gastrectomy between January 2019 and December 2020. Patients were divided into two groups: (1) reversal of NMB (REV), who received a muscle relaxant antagonist; (2) received nothing (NONE). The REV group had two subgroups: sugammadex (SUG) and neostigmine (NEO). Groups were compared for extubation, recovery, hospitalization after surgery, and total hospitalization times. Major metabolic parameters were evaluated postoperatively at 1 and 6 months. Results: Time to extubation, recovery, hospitalization after surgery, and total hospitalization in the REV group were significantly shorter than in the NONE group. Moreover, the extubation time and hospitalization after surgery in the SUG group were significantly lower than in the NEO group. At each postoperative follow-up, both groups were comparable for all metabolism-related indicators. Conclusion: SUG was more effective for obese patients who underwent bariatric surgery with general anesthesia. The metabolism of obese patients might not be affected by the means to restore spontaneous breathing.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes. A retrospective cohort study. At a university hospital. Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016. An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016. The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p=0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p=0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p=0.57) or readmission (OR 1.22, p=0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant. The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Quality Metrics in Patients Undergoing Decompressive Craniectomy and Endoscopic Clot Evacuation after Spontaneous Supratentorial Intracerebral Hemorrhage: A Retrospective Observational Study.

We report adherence to 6 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) quality metrics (QMs) relevant to patients undergoing decompressive craniectomy or endoscopic clot evacuation after spontaneous supratentorial intracerebral hemorrhage (sICH). In this retrospective observational study, we describe adherence to the following ASPIRE QMs: acute kidney injury (AKI-01); mean arterial pressure < 65 mm Hg for less than 15 minutes (BP-03); myocardial injury (CARD-02); treatment of high glucose (> 200 mg/dL, GLU-03); reversal of neuromuscular blockade (NMB-02); and perioperative hypothermia (TEMP-03). The study included 95 patients (70% male) with median (interquartile range) age 55 (47 to 66) years and ICH score 2 (1 to 3) undergoing craniectomy (n=55) or endoscopic clot evacuation (n=40) after sICH. In-hospital mortality attributable to sICH was 23% (n=22). Patients with American Society of Anesthesiologists physical status class 5 (n=16), preoperative reduced glomerular filtration rate (n=5), elevated cardiac troponin (n=21) and no intraoperative labs with high glucose (n=71), those who were not extubated at the end of the case (n=62) or did not receive a neuromuscular blocker given (n=3), and patients having emergent surgery (n=64) were excluded from the analysis for their respective ASPIRE QM based on predetermined ASPIRE exclusion criteria. For the remaining patients, the adherence to ASPIRE QMs were: AKI-01, craniectomy 34%, endoscopic clot evacuation 1%; BP-03, craniectomy 72%, clot evacuation 73%; CARD-02, 100% for both groups; GLU-03, craniectomy 67%, clot evacuation 100%; NMB-02, clot evacuation 79%, and; TEMP-03, clot evacuation 0% with hypothermia. This study found variable adherence to ASPIRE QMs in sICH patients undergoing decompressive craniectomy or endoscopic clot evacuation. The relatively high number of patients excluded from individual ASPIRE metrics is a major limitation.

Changes in bispectral index and patient state index during sugammadex reversal of neuromuscular blockade under steady-state sevoflurane anesthesia

Few studies have investigated the changes in patient state index (PSI) and bispectral index (BIS) in response to abrupt increase in electromyographic (EMG) activity. These were performed using intravenous anesthetics or reversal agents for neuromuscular blockade (NMB) other than sugammadex. We compared the changes in BIS and PSI values caused by the sugammadex reversal of NMB during steady-state sevoflurane anesthesia. We enrolled 50 patients with American Society of Anesthesiologists physical status 1 and 2. At the end of the surgery, we administered 2 mg kg−1 sugammadex while maintaining sevoflurane for a 10-min study period. The changes in BIS and PSI from baseline (T0) to train of four ratio of 90% were not significantly different (median difference 0; 95% CI − 3 to 2; P = 0.83), neither were the changes in BIS and PSI values from T0 to their maximum values (median difference 1; 95% CI − 1 to 4; P = 0.53). Maximum BIS and PSI were significantly higher than their baseline values (median difference 6; 95% CI 4–9; P < 0.001 and median difference 5; 95% CI 3–6; P < 0.001, respectively). We found weak positive correlations between BIS and BIS-EMG (r = 0.12, P = 0.01), as well as PSI and PSI-EMG (r = 0.25, P < 0.001). Both PSI and BIS were affected to some extent by EMG artifacts after sugammadex administration.

Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study.

The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.

THE IMPORTANCE OF SUGAMMADEX AT POSTOPERATIVE RESIDUAL NEUROMUSCULAR BLOCK

Introduction: postoperative residual neuromuscular blockade is the postoperative muscle paralysis caused by incomplete or null antagonism of neuromuscular blocking agents. Post-surgical residual paralysis (PORP) has a high incidence and may cause adverse effects, increasing postoperative morbidity and mortality. The gold standard for complete reversal of neuromuscular blockade is a T4/T1 ratio of 0.9. Small degrees of paralysis are associated with an increased risk of postoperative pulmonary complications. Recent research indicates that residual neuromuscular blockade is a significant risk factor for patient safety. Objective: to detail the current information related to postoperative residual paralysis, in addition to explaining the use and characteristics of sugammadex in its reversal. Methodology: a total of 45 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 35 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: postoperative residual neuromuscular block, postoperative muscle weakness, sugammadex, anticholinesterase inhibitors. Results: Neuromuscular block occurs due to muscle fragility in the postoperative period due to antagonism, which produces a decrease in the musculature of the upper and lower airways. When this phase is properly managed, extubation delays are reduced, and postoperative pulmonary complications are reduced. Sugammadex is a relaxant that decreases the possibility of persistent neuromuscular paralysis; as neuromuscular blockade increases, contraction decreases. Therefore, when this drug is used, the risk of adverse effects, mostly respiratory, is avoided. This drug inactivates rocuronium, and the adverse effects it presents (although very infrequent) are dysgeusia, cough, grimacing or increased secretion through the endotracheal tube. Conclusions: sugammadex is suggested to be used before neostigmine, although it should be used in patients with high risk of postoperative complications, such as patients over 80 years of age or with post cardiothoracic surgery. However, sugammadex reverses neuromuscular blockade more rapidly, with a decrease in the frequency of residual neuromuscular blockade and postoperative pulmonary complications such as pneumonias. A point to consider is that sugammadex is more expensive and is usually accompanied by higher presentations of adverse effects. KEY WORDS: sugammadex, paralysis, residual, postoperative, antagonism, neuromuscular.

Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study

BackgroundSugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery.MethodsThis single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes.ResultsOf the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (β = 0.29 95% confidence interval {CI}: [− 1.13, − 0.54], P = 0.4912). However, it was associated with shorter PACU stay (β = − 20.30 95% CI: [− 24.48, − 17.11], P < 0.0001), shorter time to postoperative ambulation movement (β = − 0.43 95% CI: [− 0.62, − 0.23], P < 0.0001), and reduced time-to-first-defecation (β = − 2.25 95% CI: [− 0.45, − 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05).ConclusionsNeuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.

Sugammadex in Emergency Situations.

Sugammadex may be required or used in multiple emergency situations. Moderate and high doses of this compound can be used inside and outside the operating room setting. In this communication, recent developments in the use of sugammadex for the immediate reversal of rocuronium-induced neuromuscular blockade were assessed. In emergency surgery and other clinical situations necessitating rapid sequence intubation, the tendency to use rocuronium followed by sugammadex instead of succinylcholine has been increasing. In other emergency situations such as anaphylactic shock caused by rocuronium or if intubation or ventilation is not possible, priority should be given to resuming ventilation maintaining hemodynamic stability, in accordance with the traditional guidelines. If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion.

Cost-Effectiveness of Sugammadex Versus Neostigmine to Reverse Neuromuscular Blockade in a University Hospital in Taiwan: A Propensity Score-Matched Analysis.

Sugammadex has several pharmacological advantages over neostigmine, including faster reversal of neuromuscular blockade and fewer adverse effects. However, the economic impact of sugammadex remains controversial due to the considerable heterogeneity of study designs and clinical settings in previous studies. In a post-hoc analysis of a randomized controlled trial, we evaluated patients who underwent elective surgeries and general anesthesia with endotracheal intubation in a medical center in Taiwan between March 2020 and August 2020. Patients were divided into either the sugammadex or neostigmine group based on the neuromuscular blocking drug used. Propensity score matching was used to balance the baseline patient characteristics between the two groups. The patient’s recovery from anesthesia and the putative cost-effectiveness of sugammadex versus neostigmine was assessed. Derived cost-effectiveness using personnel costs in the operating room and the post-anesthesia care unit was estimated using multiple linear regression models. A total of 2587 and 1784 patients were included before and after matching, respectively. Time to endotracheal extubation was significantly shorter in the sugammadex group (mean 6.0 ± standard deviation 5.3 min) compared with the neostigmine group (6.6 ± 6.3 min; p = 0.0032). In addition, the incidence of bradycardia was significantly lower in the sugammadex group (10.2%) compared with the neostigmine group (16.9%; p < 0.001). However, the total costs were significantly lower in the neostigmine group (50.6 ± 21.4 United States dollars) compared with the sugammadex group (212.0 ± 49.5 United States dollars). Despite improving postoperative recovery, the benefits of sugammadex did not outweigh its higher costs compared with neostigmine, possibly due to the low costs of labor in Taiwan’s healthcare system.

Adequacy of Reversal of Neuromuscular Blockade with or without Train-of-Four Monitoring: A Randomised Controlled Study

Introduction: Adequate reversal of Neuromuscular Blockade (NMB) is essential when using muscle relaxants to avoid residual paralysis postoperatively. Reversal can be achieved using clinical parameters or, alternatively, by Train-of-Four (TOF) monitoring. Aim: To evaluate the adequacy of successful NMB reversal using clinical parameters-based endpoints compared to using TOF monitoring. Materials and Methods: The hospital-based randomised controlled study conducted in the Department of Anaesthesiology, SDM Medical College, Dharwad, Karnataka, India for a peroid of two years from November 2019 to December 2021. Consisted of 120 subjects divided into two groups: Group-C (Clinical parameters) and group T (TOF monitoring), aged 18-60 years of either sex with American Soceity of Anaesthesiologists (ASA) physical status I and II, undergoing elective surgery under general anaesthesia requiring intubation. Extubation was achieved in group C using clinical parameters like return of spontaneous respiratory efforts, adequate Tidal Volume (TV) (≥5 mL/kg), obeying simple commands, absence of excessive secretions, and in group T using TOF monitoring. The t-test was used to compare the difference between the groups. The Chi-square test was done for contingency data. A p-value of less than or equal to 0.05 (p-value≤0.05) indicates statistical significance. Results: In the study, both group C and group T were comparable in terms of age {(41.15±10.23 years, 41.03±11.9 years) p-value=0.95}, sex (m/f) {(46.6%/53.3% and 63.3%/36.6%) p-value=0.06}, and Basal Metabolic Index (BMI) {≤25=59.1%, 25- 30=33.3%, ≥30=7.5%, p-value=0.57}, respectively. Five patients in group C had residual paralysis, whereas none in group T. Reversal-extubation time in minutes (min) in group C {5.9± 2.2, 5.4 (2-15.2)} and group T {6.6± 1.9, 6.24 (3.3-12.2)} (p-value=0.07), TOF value at the time of extubation in group C {72.1±11.6, 72 (41-91)}, group T {72.75±2.74, 72 (70-79)} (p-value=0.69). TOF value after 10 minutes of extubation in group C {92.5±7.1, 94 (66- 100)} and group T {95.6±2.7, 96 (90-100)} (p-value=0.006). Conclusion: The TOF monitoring is better compared to a clinical parameters-based reversal strategy in reducing the incidence of residual paralysis and resulting complications whenever Neuromuscular Blocking Agents (NMBAs) are used. Hence, it is desirable to use Neuromuscular Monitoring with the use of NMBAs.

Adjust Intraoperative Oxygen Therapy for Oxygenation Reasons Only!

Adjust Intraoperative Oxygen Therapy for Oxygenation Reasons Only!

An appraisal ofneostigmine versus sugammadex for neuromuscular blockade reversal in patients with aprior heart transplant.

Heart transplant recipients present unique perioperative challenges for surgery. Specifically, autonomic system denervation has significant implications for commonly used perioperative drugs. This study investigates neuromuscular blocking antagonists in this population when undergoing subsequent non-cardiac surgery. A retrospective review was performed for the period 2015-2019 across our health care enterprise. Patients with previous orthotopic heart transplant and subsequent non-cardiac surgery were identified. A total of 185 patients were found, 67 receiving neostigmine (NEO) and 118 receiving sugammadex (SGX). Information of patient characteristics, prior heart transplant, and subsequent non-cardiac surgery was collected. Our primary outcome was the incidence of bradycardia (heart rate < 60 bpm) and/or hypotension (mean blood pressure (MAP) < 65 mmHg) following neuromuscular blockade reversal. Secondary outcomes included need of intra-operative inotropic agents, arrhythmia, cardiac arrest, hospital length of stay (hLOS), ICU admission, and death within 30 postoperative days. In unadjusted analysis, no significant differences were found between the two groups in change in heart rate [0 (-26, 14) vs. 1 (-19, 10), P = 0.59], change in MAP [0 (-22, 28) vs. 0 (-40, 47), P = 0.96], hLOS [2 days (1, 72) vs. 2 (0, 161), P = 0.92], or intraoperative hypotension [4 (6.0%) vs. 5 (4.2%), OR = 0.70, P = 0.60] for NEO and SGX respectively. After multivariable analysis, the results were similar for change in heart rate ( P = 0.59) and MAP ( P = 0.90). No significant differences in the incidence of bradycardia and hypotension were found in the NEO versus SGX groups. NEO and SGX may have similar safety profiles in patients with prior heart transplant undergoing non-cardiac surgery.

Investigation of proarrhythmic effect of high sugammadex doses: an experimental animal study

BackgroundStudies on higher doses of sugammadex effect on QT interval and leading arrhythmia have been limited. In this study, we aimed to investigate possible proarrhythmic effect of higher doses of sugammadex in conditions that required urgent reversal of neuromuscular blockade during general anesthesia in an experimental animal model.MethodsIt was experimental animal study. Total of 15 male New Zealand rabbits were randomly divided into three groups for low (4 mg/kg, n = 5), moderate (16 mg/kg, n = 5), and high dose of sugammadex (32 mg/kg, n = 5). All rabbits were premedicated by intramuscular ketamine 10 mg/kg, and general anesthesia was inducted by intravenous injection of 2 mg/kg of a propofol, 1 mcg/kg fentanyl, and 0.6 mg/kg rocuronium injection. Airway was provided by V-gel rabbit and connected to anesthetic device and ventilated at about 40 cycle/min and 10 ml/kg; oxygen 50% plus air 50% mixture was used with 1 MAC isoflurane to maintain anesthesia. Electrocardiographic monitorization and arterial cannulation were provided to follow-up mean arterial pressure and for arterial blood gas analyses. Intravenous sugammadex in three different doses were injected at 25th min of induction. After observing adequate respiration of all rabbits, V-gel rabbit was removed. Parameters and ECG recordings were taken basal value before induction and at the 5th, 10th, 20th, 25th, 30th, and 40th min to measure corrected QT intervals and were stored on digital media. QT interval was calculated as the time from the beginning of the Q wave to the end of the T wave. Corrected QT interval was calculated according to the Bazett’s formula. Possible adverse effects were observed and recorded.ResultsIn all three groups, there was no significant statistical difference in mean arterial blood gases parameters, arterial pressures, heart rates, and Bazett QTc values, and no serious arrhythmia was recorded.ConclusionWe found in animal study that low, moderate, and high doses of sugammadex did not significantly altered corrected QT intervals and did not cause any significant arrhythmia.

Efficacy and Safety of Sugammadex to Shorten Time-to-Extubation Following Cardiac Surgery: A Single-Center Randomized Placebo-Controlled Trial.

Single-center, randomized, double-blind, placebo-controlled trial. University-based cardiothoracic ICU. Patients (n = 90) undergoing elective aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) surgery. Participants were randomized to receive either sugammadex (2 mg/kg) or placebo after arrival to the ICU. The primary study endpoint was time from study drug administration to extubation. Of the 90 patients included in the study (45 in each group), a total of 68 patients underwent CABG, 13 AVR, and nine combined AVR and CABG. Baseline characteristics and intraoperative anesthetic medications were comparable between groups. Patients in sugammadex group had reduced time to extubation compared with the placebo group (median [interquartile range (IQR)]-sugammadex group: 126.0 min [84.0-274.0 min] vs placebo: 219.0 min [121.0-323.0 min]; difference in means [95% CI], 72.8 [1.5-144.1 min]; p = 0.01. There were no differences in negative inspiratory force (mean [sd]-sugammadex group: 33.79 cm H2O [8.39 cm H2O] vs placebo: -31.11 cm H2O [7.17 cm H2O]) and vital capacity (median [IQR]-sugammadex group: 1.1 L [0.9-1.3 L] vs placebo: 1.0 L [0.9-1.2 L]). There were no differences between groups in postoperative blood product requirement, dysrhythmias, length of ICU, or hospital stay. There were no serious adverse events in either group. This randomized trial showed that the administration of sugammadex after cardiac surgery decreased time to extubation by approximately 1 hour. Larger trials may be required to confirm these findings and determine the clinical implications.