Neuromuscular Blockade Research Articles

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.

Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections

Background & Objective: This study examined the use of dexmedetomidine 5 μg as an adjuvant to 10 mg of intrathecal hyperbaric 0.5% bupivacaine in elective cesarean sections and aimed to assess dexmedetomidine’s impact on block characteristics and post-operative pain management. As spinal anesthesia is commonly employed for cesarean deliveries, the study seeks to determine whether the addition of dexmedetomidine as an adjuvant can prolong the duration and enhance the quality of the block, leading to improved post-operative pain relief. Methodology: This randomized controlled trial included 100 parturients undergoing elective cesarean section over a period of six months. Participants were allocated to either Group B or Group D using a non-random consecutive sampling technique. In Group D, 2 mL of 0.5% bupivacaine mixed with 0.05 mL of dexmedetomidine (5µg) was injected intrathecally, while Group B received 2 mL of 0.5% hyperbaric bupivacaine along with an equivalent volume of saline. Sensory and motor block assessments were conducted prior to the start of surgery. Post-operatively, the duration of motor block and post-operative pain relief were assessed. Results: The addition of dexmedetomidine as an adjuvant to intrathecal bupivacaine resulted in significant reductions in the onset time of sensory block (4.22 ± 0.79 min vs 5.66 ± 1.21 min) and motor block (4.20 ± 0.81min vs 6.32 ± 1.20 min) (P < 0.001). Furthermore, the duration of motor block was longer in the dexmedetomidine + bupivacaine group compared to the bupivacaine alone group (7.32 ± 0.95 h vs 4.38 ± 1.27 h). Additionally, patients who received intrathecal dexmedetomidine as an adjuvant to bupivacaine experienced significantly longer durations of post-operative analgesia (7.32 ± 0.95 h) as compared to the bupivacaine alone group (4.38 ± 1.27 h) (P < 0.001). Conclusion: Dexmedetomidine as an intrathecal adjuvant to hyperbaric bupivacaine extends the duration of analgesia and motor block, providing prolonged pain relief. Additionally, it exhibits an early onset of sensory and motor block, ensuring prompt pain relief and rapid anesthesia onset. Clinical Trial Registration: [www.clinicaltrials.gov], identifier: ID NCT05469529 Abbreviations: CS - cesarean section; OT - Operation Theater; SA - Spinal anesthesia; VAS - visual analogue scale; Keywords: cesarean section, dexmedetomidine, bupivacaine, spinal anesthesia Citation: Qureshi RA, Jadoon H, Shabbir M. Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections. Anaesth. pain intensive care 2024;28(5):866−870. DOI: 10.35975/apic.v28i5.2558 Received: December 03, 2023; Reviewed: December 15, 2023; Accepted: August 16, 2024

The impact of different doses of intrathecal dexmedetomidine used as adjuvant to hyperbaric prilocaine in short ambulatory procedures under spinal anesthesia: a randomized controlled study

Objective: This study aimed to determine the most effective dose of dexmedetomidine as an adjuvant to prilocaine in spinal anesthesia. Methods: Sixty-nine adult patients (21 to 65 y) scheduled for elective surgeries under spinal anesthesia were included in the study. Patients received spinal anesthesia with 3 mL of prilocaine and 0.5 mL dexmedetomidine of dose according to randomization of 5,10 and15 µg (D5, D10 and D15 respectively). Time of the first request of analgesia was set as a primary outcome. Results: Time of the first request of rescue opioid was significantly shorter in D5 group (8 ± 6 h) compared to D15group (21 ± 4 h) (P < 0.018). 24 h of postoperative Nalbuphine consumption was higher in D5 group (4.67 ± 0.59 mg) compared to D15 group (2.5 ± 0.71 mg) (P = 0.012). The onset of sensory and motor blocks was significantly earlier in group D15 and D10 compared to group D5. Group D15 showed a significantly prolonged duration of sensory and motor blockade than Groups D10 and D5. The duration of sensory and motor blockade was significantly prolonged in group D10 compared with group D5 (P < 0.001). Conclusion: 10 and 15 μg dexmedetomidine as an adjuvant to prilocaine in spinal anesthesia shortened the onset of both sensory and motor block, prolonged the duration of sensory block, motor block, and the time to first analgesic. Clinical trial registration: The study was registered on Pan African Clinical Trial Registry (www.pactr.org) (ID: PACTR202204558879194-April 2022). Keywords: Intrathecal Dexmedetomidine; Hyperbaric prilocaine; Ambulatory Surgery; Spinal Anesthesia Citation: Biekhet EG, Elazzazi H, Hussein W, Zedan M, Abdelhamid BM. The impact of different doses of intrathecal dexmedetomidine used as adjuvant to hyperbaric prilocaine in short ambulatory procedures under spinal anesthesia: a randomized controlled study. Anaesth. pain intensive care 2024;28(4):664−672; DOI: 10.35975/apic.v28i4.2509 Received: February 20, 2024; Reviewed: April 01, 2024; Accepted: April 20, 2024

A comparative study of low-dose intrathecal bupivacaine 0.5% (heavy), levobupivacaine 0.5% (plain), and levobupivacaine 0.5% (heavy) with fentanyl as an adjuvant in transurethral resection of prostate surgery: A prospective randomized study

Background: Spinal anesthesia is the technique of choice for transurethral resection of the prostate (TURP) surgeries. Levobupivacaine, an S-enantiomer of bupivacaine, is less cardiotoxic than bupivacaine; therefore, a low dose of local anesthetic with fentanyl as an adjuvant has been used to decrease toxicity and increase efficacy. Aims and Objectives: The aim of this study was to compare and evaluate the efficacy of hyperbaric bupivacaine 0.5%, isobaric levobupivacaine 0.5%, and hyperbaric levobupivacaine 0.5% with fentanyl as an adjuvant. Materials and Methods: One hundred and five patients scheduled for elective TURP surgeries were randomly divided into three groups. Group BH (n=35) received 1.5 mL of 0.5% hyperbaric bupivacaine with 25 μg of fentanyl, Group LH (n=35) received 1.5 mL of 0.5% hyperbaric levobupivacaine with 25 μg of fentanyl, and Group LP (n=35) received 1.5 mL of 0.5% isobaric levobupivacaine with 25 μg of fentanyl intrathecally. Results: The onset of sensory and motor block was earlier and the duration of analgesia and motor block were longer in the BH group (P<0.001) as compared to LH and LP groups. The demographic data, duration of surgery, heart rate, SpO2, pruritus, and shivering were comparable between the groups (P>0.05). The visual analog scale score was higher in the LP group. Hypotension, nausea, and vomiting were seen in the BH group. Conclusion: Hyperbaric is better than isobaric group due to quicker onset and longer duration. Levobupivacaine is better than bupivacaine in terms of the early mobilization and a lesser incidence of side effects, making hyperbaric levobupivacaine a better alternative to isobaric levobupivacaine and hyperbaric bupivacaine.

Comparison of the effect of intrathecal fentanyl citrate and magnesium sulfate as adjuvants to hyperbaric levobupivacaine 0.5% for spinal anesthesia in patients undergoing lower limb orthopedic surgeries

Background: Subarachnoid blockade is a safe, reliable, and inexpensive technique that provides surgical anesthesia along with prolonged post-operative analgesia. The quality of subarachnoid block is enhanced by the addition of intrathecal adjuvants, such as fentanyl citrate and magnesium sulfate to hyperbaric levobupivacaine. Aims and Objectives: The aim of this study was to compare the effects of fentanyl and magnesium sulfate as adjuvants to 0.5% hyperbaric levobupivacaine in orthopedic surgeries under subarachnoid block. Materials and Methods: This prospective randomized study included 90 American Society of Anesthesiologists Grade I and II patients aged 18–60 years undergoing orthopedic surgeries. Group LS received 3 mL 0.5% levobupivacaine heavy+0.5 mL normal saline. Group LF received 3 mL 0.5% levobupivacaine heavy+fentanyl 25 μg, and Group LM, 3 mL 0.5% levobupivacaine heavy+magnesium sulphate 50 mg+0.4 mL normal saline. The onset and duration of sensory and motor block and intraoperative hemodynamics were recorded. In the post-operative period, duration of analgesia, Visual Analog Scales scores, and side effects were observed. Results: The onset of sensory block was 4.04±0.74 min in Group LM (P<0.001) as compared to Groups LF (2.01±0.23 min) and LS (2±0.24 min). The onset of motor blockade took 5±1.14 min in the control group, 7.01±0.94 in group LF, and 8.11±1.33 min in group LM (P<0.001). The duration of analgesia in group LS was 183.73±12.08 min, 317±18.6 min in group LF, and 219.43±20.89 in group LM (P<0.001). Conclusion: The addition of fentanyl and magnesium as adjuvants enhanced the quality of subarachnoid block when added to hyperbaric levobupivacaine. The duration of analgesia was longest in fentanyl, followed by magnesium and then control. The incidence of side effects was greatest in fentanyl, followed by control and nil in magnesium.

A comparative study to evaluate the efficacy of cisatracurium and rocuronium for endotracheal intubation in pediatric patients: A prospective randomized study

Background: Cisatracurium and rocuronium are non-depolarizing neuromuscular blockers with an intermediate duration of action and are used safely in short and intermediate-duration surgical procedures in the pediatric population. Aims and Objectives: A prospective randomized study is to assess the efficacy of cisatracurium compared to rocuronium in terms of intubating conditions, clinical duration of action, hemodynamic parameters, and side effects in pediatric patients undergoing surgeries under general anesthesia. Materials and Methods: In this study, 50 patients aged 2–12 years with the American Society of Anesthesiologists grades I and II were randomly allocated into two groups: Group I received injection cisatracurium 0.15 mg/kg IV and Group II received injection rocuronium 0.6 mg/kg IV for intubation. Intubating conditions by Cooper et al., score, TOF count, hemodynamic parameters, signs of histamine release, and complications if any were noted. Results: According to the Cooper et al., score, intubating conditions were excellent in 100% of patients in Group II and 84% of patients in Group I, which was statistically significant. The time required for the first maintenance dose was shorter in Group II (14.04±2.95 min) compared to Group I (20.08±3.68 min). Hemodynamic parameters and demographic profiles were comparable between the two groups. No associated signs of histamine release or any other complications were noted in either group. Conclusion: We concluded that rocuronium 0.6 mg/kg provides better intubating conditions and a shorter duration of action compared to cisatracurium 0.15 mg/kg without any signs of histamine release in pediatric patients.

The median effective concentration of epidural ropivacaine with different doses of dexmedetomidine for motor blockade: an up-down sequential allocation study.

Recent studies have shown that dexmedetomidine can be safely used in peripheral nerve blocks and spinal anesthesia. Epidural administration of dexmedetomidine produces analgesia and sedation, prolongs motor and sensory block time, extends postoperative analgesia, and reduces the need for rescue analgesia. This investigation seeks to identify the median effective concentration (EC50) of ropivacaine for epidural motor blockade, and assess how incorporating varying doses of dexmedetomidine impacts this EC50 value. Prospective, double-blind, up-down sequential allocation study. Operating room, post-anesthesia care unit, and general ward. One hundred and fifty patients were allocated into five groups in a randomized, double-blinded manner as follows: NR (normal saline combined with ropivacaine) group, RD0.25 (0.25 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.5 (0.5 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.75 (0.75 μg/kg dexmedetomidine combined with ropivacaine) group, RD1.0 (1.0 μg/kg dexmedetomidine combined with ropivacaine) group. The concentration of epidural ropivacaine for the first patient in each group was 0.5%. Following administration, the patients were immediately placed in a supine position for observation, and the lower limb motor block was assessed every 5 min using the modified Bromage score within 30 min after drug administration. According to the sequential method, the concentration of ropivacaine in the next patient was adjusted according to the reaction of the previous patient: effective motor block was defined as the modified Bromage score > 0 within 30 min after epidural administration. If the modified Bromage score of the previous patient was >0 within 30 min after drug administration, the concentration of ropivacaine in the next patient was decreased by 1 gradient. Conversely, if the score did not exceed 0, the concentration of ropivacaine in the next patient was increased by 1 gradient. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine. Adverse events, hemodynamic changes, demographic data and clinical characteristics. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% (95% CI, 0.622-0.743%) in the NR group, 0.624% (95% CI, 0.550-0.728%) in the RD0.25 group, 0.549% (95% CI, 0.456-0.660%) in the RD0.5 group, 0.463% (95% CI, 0.408-0.527%) in the RD0.75 group, and 0.435% (95% CI, 0.390-0.447%) in the RD1.0 group. The EC50 of the NR group and the RD0.25 group were significantly higher than that of the RD0.75 and the RD1.0 groups, and the EC50 of the RD0.5 group was significantly higher than that of the RD1.0 group. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% in the NR group, 0.624% in the RD0.25 group, 0.549% in the RD0.5 group, 0.463% in the RD0.75 group, and 0.435% in the RD1.0 group. Dexmedetomidine as an adjuvant for ropivacaine dose-dependently reduce the EC50 of epidural ropivacaine for motor block and shorten the onset time of epidural ropivacaine block. The optimal dose of dexmedetomidine combined with ropivacaine for epidural anesthesia was 0.5 μg/kg.

A comparative study to assess the effects of intrathecal fentanyl and intrathecal tramadol combined with 0.5% bupivacaine heavy in patients undergoing elective urological surgeries: A prospective randomized study

Background: Urological operations frequently involve the use of spinal anesthesia. In the present scenario, adding different adjuvants to local anesthetic improve its quality and duration has become common. Aims and Objectives: In patients undergoing elective urological procedures, the purpose of this study was to assess the effects of intrathecal fentanyl or tramadol with 0.5% bupivacaine heavy. Materials and Methods: Patients were divided into two groups of 30 patients each, a total of 60 patients aged 20–60 years undergoing elective urological surgeries participated in this prospective, randomized study in which 25 μg fentanyl and 2.5 mL of 0.5% bupivacaine heavy were given to Group F, while 25 mg tramadol and 2.5 mL of 0.5% bupivacaine heavy were given to Group M. The onset and duration of sensory and motor blockage, the duration of analgesia, post-operative Visual Analog Scale score, hemodynamic changes, and adverse effects were evaluated. Results: Fentanyl had a lower mean time of onset for sensory (2:33±0:22 min vs. 4:50±0:33 min) and motor block (3:36±0:28 min vs. 5:52±0:38 min) (P<0.001), the duration of sensory (185.67±3.155 min vs. 152.60±4.264), motor block (172.00±4.177 min vs. 136.40±5.575 min), and post-operative analgesia was longer in the fentanyl group (P<0.001), whereas the incidence of adverse effects such as pruritus, shivering, and nausea was lower in the tramadol group. Conclusion: The quality and duration of spinal anesthesia were found to be significantly increased by the use of fentanyl as an adjuvant in our study. However, tramadol also produced stable hemodynamics and exhibited fewer adverse effects than fentanyl.

Eliminating residual neuromuscular blockade: a literature review.

Although millions of patients receive neuromuscular blocking agents (NMBAs) each year as part of an anesthetic, residual neuromuscular blockade (NMB) remains a too-frequent occurrence and its adverse consequences continue to negatively impact patient outcomes. The goal of this manuscript is to provide clinicians with the information they need to decrease the incidence of residual NMB. Published literature was reviewed and incorporated into the narrative as appropriate. Search terms for articles included nondepolarizing NMBAs, residual NMB, monitoring depth of NMB, qualitative monitoring, quantitative monitoring, reversal agents, sugammadex, and anticholinesterases. This review will define what is currently considered adequate recovery of neuromuscular function, discuss and compare the different modalities to determine the depth of NMB, discuss the currently available NMBAs-including their durations of action and dosing, describe the incidence and complications associated with residual NMB, and discuss reversal of nondepolarizing NMB with neostigmine or sugammadex. Nondepolarizing NMBAs are commonly used as part of a general anesthetic. Understanding the pharmacology of the neuromuscular blocking and reversal agent, in combination with quantitative monitoring of depth of NMB is essential to avoid residual paralysis. Quantitative monitoring and dosing of either neostigmine or sugammadex based on the results of monitoring is essential to eliminate residual NMB associated with the use of nondepolarizing NMBAs.

Characterization of Awareness and Depth of Blockade During Neuromuscular Blockade Infusions in Critically Ill Children.

The Society of Critical Care Medicine released the first guideline for the prevention and -management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit. This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS). Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4. Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions.

Is intrathecal bupivacaine plus dexmedetomidine superior to bupivacaine in spinal anesthesia for a cesarean section? A systematic review and meta-analysis.

This study aimed to investigate whether the administration of intrathecal dexmedetomidine as a bupivacaine adjuvant for caesarean section can prolong the duration of analgesia compared with bupivacaine alone. Secondary outcomes included postoperative pain, the time interval to the first analgesic request, the level of sedation, the incidence of adverse effects, and the fetal outcomes. A systematic review and meta-analysis were conducted. The study compared the intrathecal administration of bupivacaine plus dexmedetomidine (group BD) to the intrathecal administration of bupivacaine alone (group B) for cesarean sections. Fourteen publications were included. Among patients who underwent spinal anesthesia for a cesarean section, 514 patients received intrathecal bupivacaine alone, and 533 patients received intrathecal bupivacaine plus dexmedetomidine. The onset of sensory and motor block was essentially the same in both groups; the time for sensory and motor block regression was significantly longer in the BD group. Postoperative Visual Analogue Scale (VAS) values were similar in group BD when compared to group B. Postoperative VAS scores remained consistently low in Group BD compared to Group B, starting from 1 hour after surgery. The level of sedation measured at the end of the cesarean section in both groups was almost similar. No difference in terms of safety, adverse events, and neonatal outcomes was found between the two groups. Use of intrathecal dexmedetomidine for spinal anesthesia in cesarean section significantly prolongs sensory and motor block compared to using bupivacaine alone as an adjuvant. It also improves analgesia after 1 hour with no difference in the incidence of maternal and neonatal adverse effects compared to bupivacaine alone. The optimal dose of dexmedetomidine to use remains to be ingested.

Neuromuscular Blockade in the Critically Ill

The management of sedation in intensive care medicine has changed substantially in the last few years. Neuromuscular blocking agents (NMBA) are only rarely indicated in modern intensive care medicine. In this review, the mechanism of action, potential side effects, and special considerations for the application of NMBA to critically ill patients will be discussed. We further present the rationale for the use of NMBA for the remaining indications, such as endotracheal intubation, selected cases of severe acute respiratory distress syndrome, and shivering during temperature control after cardiac arrest. The review will close with a description of potential side effects of NMBA use in the intensive care setting, such as awareness, acquired skeletal muscle weakness as well as corneal injuries, and how monitoring of sedation and peripheral muscle blockade may be handled.

Update: Neuromuscular Blockade during General Anesthesia

The correct use of muscle relaxants and neuromuscular monitoring during anesthesia has been subject of controversial discussions for decades. Particularly important in clinical practice are identification and management of residual neuromuscular blockages and avoidance of associated complications. Despite the differences in the molecular mechanisms of action between depolarizing and non-depolarizing muscle relaxants the blockade of the postsynaptic nicotinic acetylcholine receptor remains a common ending pathway. Due to its unfavorable side effect profile, succinylcholine should only be used in justified exceptional cases. The use of muscle relaxants generally reduces the complication rate in airway management. However, even the single use of muscle relaxants increases the likelihood of postoperative pulmonary complications. These complications associated with the use of muscle relaxants, such as residual neuromuscular blockade, must be anticipated. The application of guideline-based approaches, including continuous neuromuscular monitoring and the application of muscle relaxant reversal agents, may significantly reduce the rate of adverse events associated with the use of muscle relaxants.

Continuous Positive-Pressure Oxygen Supply Improves Fiberoptic Intubation Efficacy and Safety in Patients With Simulated Cervical Spinal Injury: A Prospective Double-Blind Randomized Controlled Study.

Fiberoptic intubation is an important method for tracheal intubation in patients with cervical spine injury. How to effectively and safely complete fiberoptic intubation while maintaining the stability of the cervical spine is very important. This study compared the efficiency and safety of fiberoptic intubation after anesthesia induction under different types of air pressure in patients with simulated cervical spinal injury. In total, 59 adult patients who underwent fiberoptic intubation with a cervical collar for simulated cervical spinal injury were randomly allocated to continuous positive-pressure oxygen, normal-pressure, or intermittent negative-pressure suction groups. After the induction of anesthesia and adequate 100% oxygenation, which confirmed effective neuromuscular blockade, it was deemed appropriate to begin fiberoptic intubation. In the continuous positive-pressure oxygen group, the fiberoptic device was connected through the negative-pressure suction path with 5 L/min oxygen. In the intermittent negative-pressure suction group, the fiberoptic device was connected to the negative-pressure suction device. In the normal-pressure group, the flexible fiberoptic device was not connected to either the oxygen source or the negative-pressure suction device. The intubation time was recorded as the primary outcome measure. The intubation success rate, number of attempts, minimum SpO2, objective lens contamination rate, and incidence of complications were also compared among the groups. Compared with those in the other groups, the median (range) intubation time in the continuous positive-pressure group was 59 (36-181) seconds, which was significantly shorter than that in the normal-pressure group, 167 (46-181) seconds, and the intermittent negative-pressure suction group, 132.5 (38-181) seconds (P=0.04). The success rate of nasotracheal intubation was significantly greater in the continuous positive-pressure group (94.7%, 18/19) than in the normal-pressure group (50%, 10/20) and intermittent negative-pressure suction group (50%, 10/20) (P=0.004). There was a significant difference among the three groups (P=0.043). The median (range) minimum SpO2 during fiberoptic intubation was 100% (99-100%) in the continuous positive-pressure group, 100% (90-100%) in the normal-pressure group, and 99% (88-100%) in the intermittent negative-pressure suction group (P=0.029). However, no statistically significant difference was detected among the groups with complications. The continuous use of positive-pressure oxygen via the negative-pressure suction pathway can improve the efficiency and safety of fiberoptic intubation in patients with simulated cervical spinal injury after anesthesia induction.

Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study.

Sugammadex is a neuromuscular blockade (NMB) reversal agent introduced in the United States in 2016, which allows the reversal of deep NMB, not possible with neostigmine. Few data describe associated practice changes, if any, in NMB medication use that may have resulted from its availability. We hypothesized that after institutional introduction, use of NMB agents increased. Furthermore, as NMB medication is typically used when the airway has been secured with an endotracheal tube (ETT), we speculated that ETT use may have also increased over the same time period as a result of sugammadex availability. This was a single-center cross-sectional study of patients ages 2 to 17 years undergoing general anesthesia for surgical cases where anesthesia providers often have discretion over NMB medication use or whether to use an ETT versus a laryngeal mask airway (LMA), comparing the time periods 2014 to 2016 (presugammadex) to 2017 to 2019 (early sugammadex) and 2020 to 2022 (established sugammadex). Outcomes included use of (1) any nondepolarizing NMB medication during the case and (2) an ETT versus LMA. We used generalized linear mixed models to examine changes in practice patterns over time. We also examined whether patient age group and in-room provider (resident versus certified registered nurse anesthetist [CRNA]) were associated with increased NMB medication or ETT use. There were 25,638 eligible anesthetics. Patient and surgical characteristics were similar across time periods. In adjusted analyses, the odds of NMB medication use increased from 2017 to 2019 (odds ratio [OR], 1.55, 95% confidence interval [CI], 1.38-1.75) and 2020 to 2022 (OR, 5.62, 95% CI, 4.96-6.37) relative to 2014 to 2016, and were higher in older children (age 6-11 years vs 2-5 years OR, 1.81, 95% CI, 1.63-2.01; age 12-17 years vs 2-5 years OR, 7.01, 95% CI, 6.19-7.92) and when the primary in-room provider was a resident rather than a CRNA (OR, 1.24, 95% CI, 1.12-1.37). The odds of ETT use declined 2017 to 2019 (OR, 0.69, 95% CI, 0.63-0.75) and 2020 to 2022 (OR, 0.71, 95% CI, 0.65-0.78), more so in older children (age 6-11 years vs 2-5 years OR, 0.45, 95% CI, 0.42-0.49; age 12-17 years vs 2-5 years OR, 0.28, 95% CI, 0.25-0.31). Resident presence at induction was associated with increased odds of ETT use (OR, 1.50, 95% CI, 1.38-1.62). The decision to use NMB medication as part of an anesthetic plan increased substantially after sugammadex became available, particularly in older children and cases staffed by residents. ETT use declined over the study period.

Sugamadex na reversão da anafilaxia induzida por rocurônio em paciente pediátrico: relato de caso e revisão de literatura

INTRODUCTION: Among neuromuscular blockers (NMB), rocuronium is the most notably cited as a cause of anaphylactic reaction. Rocuronium-induced anaphylaxis is a serious and potentially fatal complication, requiring immediate and effective management. The advent of the specific antagonist, sugammadex, has widely spread its use because it reduces the incidence of residual neuromuscular blockade and is indicated in the protocol for the treatment and reversal of refractory anaphylaxis. This study reports an episode of anaphylaxis induced by rocuronium and successfully reversed after administration of sugammadex. CASE REPORT: A 6-year-old child, weighing 30 kg, scheduled for video-assisted thoracoscopy under general anesthesia presented with tachycardia, severe hypotension, and diffuse skin rash after induction of general anesthesia and administration of rocuronium. All therapeutic measures were immediately taken for the treatment of a severe allergic reaction, however there was no clinical improvement, and the patient progressed to sinus bradycardia. At this point, cardiopulmonary resuscitation maneuvers were initiated, and adrenaline was administered, but without satisfactory clinical response. In this context, the possibility of the causative agent being rocuronium was raised. Sugammadex was administered 16mg/kg, and the patient immediately returned to sinus rhythm and later presented a favorable clinical evolution and no sequelae. DISCUSSION: Sugammadex is a molecule that encapsulates rocuronium and removes it from both plasma and neuromuscular junction, and then excretes it inertly in the urine. Some authors suggest that sugammadex removes rocuronium molecules from the circulation, whether free or IgE-bound. This mechanism is extremely important, especially in grade III and IV anaphylactic reactions, which can lead to death. In view of the scarcity of publications, this report showed the role of sugammadex in the reversal of rocuronium-induced anaphylaxis, refractory to conventional treatment.

Identifying Variation in Intraoperative Management of Brain-Dead Organ Donors and Opportunities for Improvement: A Multicenter Perioperative Outcomes Group Analysis.

Intraoperative events and clinical management of deceased organ donors after brain death are poorly characterized and may consequently vary between hospitals and organ procurement organization (OPO) regions. In a multicenter cohort, we sought to estimate the incidence of hypotension and anesthetic and nonanesthetic medication use during organ recovery procedures. We used data from electronic anesthetic records generated during organ recovery procedures from brain-dead adults across a Multicenter Perioperative Outcomes Group (MPOG) cohort of 14 US hospitals and 4 OPO regions (2014-2020). Hypotension, defined as mean arterial pressure or MAP <60 mm Hg for at least 10 cumulative minutes was the primary outcome of interest. The associations between hypotension and age, sex, race, anesthesia time, OPOs, and OPO case volume were examined using multivariable mixed-effects Poisson regression analyses with robust standard error estimates. We calculated intraclass correlation coefficients (ICCs) to describe the variation between-MPOG centers and the OPO regions in the use of medications, time of the operation, and duration of the operation. We examined 1338 brain-dead adult donors, with a mean age of 42± (standard deviation [SD] 15) years; 60% (n = 801) were males and 67% (n = 891) non-Hispanic White. During the entire intraoperative monitoring period, 321 donors (24%, 95% confidence interval [CI], 22%-26%) had hypotension for a median of 13.8% [quartile1-quartile 3: 9.4%-21%] of the monitoring period and a minimum of 10 minutes to a maximum of 96 minutes [(median: 17, quartile1-quartile 3: 12-24]). The probability having hypotension in donors 35 to 64 years and 65 years and older were approximately 30% less than in donors 18 to 34 years of age (adjusted relative risk ratios, aRR, 0.68, 95% CI, 0.55-0.82, aRR, 0.63, 95% CI, 0.42-0.94, respectively). Donors received intravenous heparin (96.4%, n = 1291), neuromuscular blockers (89.5%, n = 1198), vasoactive medications (82.7%, n = 1108), crystalloids (76.2%, n = 1020), halogenated anesthetic gases (63.5%, n = 850), diuretics (43.8%, n = 587), steroids (16.7%, n = 224), and opioids (23.2%, n = 310). The largest practice heterogeneity observed between the MPOG center and OPO regions was steroids (between-center ICCs = 0.65, 95% CI, 0.62-0.75, between-region ICCs = 0.39, 95% CI, 0.27-0.63) and diuretics (between-center ICCs = 0.44, 95% CI, 0.36-0.6, between-region ICCs = 0.30, 95% CI, 0.22-0.49). Despite guidelines recommending maintenance of MAP >60 mm Hg in adult brain-dead organ donors, hypotension during recovery procedures was common. Future research is needed to clarify the relationship between intraoperative events with donation and transplantation outcomes and to identify best practices for the anesthetic management of brain-dead donors in the operating room.

Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial

BackgroundIt is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique.MethodsPatients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated.ResultsAmong 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5–15], 10 [10–20], and 15 [10–15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10–20] mins for CLB, 20 [15–20] mins for LSB, and 22.5 [15–25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB.ConclusionsLateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice.Trial registrationThis study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).

Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system.

Background: Neuromuscular blocking agents (NMBAs) are primarily used during surgical procedures to facilitate endotracheal intubation and optimize surgical conditions. This study aimed to explore the adverse event signals of NMBAs, providing reference for clinical safety. Methods: This study collected reports of atracurium, cisatracurium, rocuronium, and vecuronium as primary suspect drugs in The US Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2023. The adverse events (AEs) reported in the study were retrieved based on the Preferred Terms (PTs) of the Medical Dictionary for Regulatory Activities. In addition, we conducted disproportionality analysis on relevant reports using the reporting odds ratio (ROR) method and Bayesian confidence propagation neural network (BCPNN) method. A positive signal was generated when both algorithms show an association between the target drug and the AE. Results: A total of 11,518 NMBA-related AEs were reported in the FAERS database. The most AEs of rocuronium were collected. NMBA-related AEs involved 27 different system organs (SOCs), all of the four NMBAs had positive signals in "cardiac disorders," "immune system disorders," "respiratory, thoracic and mediastinal disorders" and "vascular disorders." At the PTs level, a total of 523 effective AEs signals were obtained for the four NMBAs. AEs labled in the instructions such as anaphylaxis (include anaphylactic reaction and anaphylactic shock), bronchospasm, respiratory arrest and hypotension were detected positive signals among all NMBAs. In addition, we also found some new AEs, such as ventricular fibrillation for the four NMBAs, hyperglycaemia for atracurium, kounis syndrome and stress cardiomyopathy for rocuronium, hepatocellular injury for cisatracurium, hyperkalaemia for vecuronium. To further investigated the AEs associated with serious clinical outcomes, we found that cardiac arrest and anaphylaxis were the important risk factors for death due to NMBAs. Conclusion: NMBA-related AEs have a significant potential to cause clinically severe consequences. Our study provides valuable references for the safety profile of NMBAs, and considering the limitations of the FAERS database, further clinical data are needed to validate the findings of this study.

Effect of dexmedetomidine constant rate infusion on the analgesic duration of peripheral nerve blocks in dogs: a randomized clinical study

The aim of this study was to evaluate whether a constant rate infusion of dexmedetomidine could prolong the analgesic effect of peripheral nerve blocks. Twenty client-owned dogs were enrolled and randomly divided into 2 groups. The DEX group received dexmedetomidine infusion at 1 mcg kg−1 h−1, and the NaCl group received an equivalent volume infusion of saline. Infusions were started after securing vascular access and continued for 10 min, after which intravenous (IV) methadone at 0.2 mg kg−1 and propofol to effect were administered. All animals were maintained with isoflurane in 70% oxygen. Sciatic, saphenous and obturator nerve blocks were performed using 0.1 mL kg−1 0.5% ropivacaine/block. Intraoperative fentanyl was administered if the heart rate and/or mean arterial pressure (MAP) increased > 15% from the previous measurement, and vasopressors were administered if MAP was ≤ 70 mmHg. Postoperative pain was assessed every hour using the Glasgow Composite Pain Scale (GCPS) until the first rescue analgesia administration. Postoperative rescue analgesia (methadone (0.2 mg kg−1 IV) and carprofen (2 mg kg−1 IV)) was administered if the pain score was higher than 6/24 or 5/20. Duration of analgesia was defined as the time between the nerve block procedure and initial postoperative rescue analgesia. Ambulation, proprioception, and skin sensitivity were evaluated to assess the duration of the motor and sensory block. A Student T and chi-square test were used to compare groups for duration of postoperative analgesia and intraoperative fentanyl and vasopressor use, respectively (p values ≤ 0.5 considered significant). A greater number of dogs in the NaCl group required fentanyl (5/10 p = 0.03) and vasopressors (8/10, p = 0.02) than did those in the DEX group (0/10 and 2/10, respectively). The duration of postoperative analgesia was significantly longer (604 ± 130 min) in the DEX group than in the NaCl group (400 ± 81 min, p = 0.0005).Dexmedetomidine infusion at 1 mcg kg−1 h−1 delays the time to first administration of rescue analgesia and reduces intraoperative analgesic and vasopressor requirements during Tibial Tuberosity Advancement surgery.