Neuromuscular Blockade Research Articles

Is Quantitative Neuromuscular Monitoring Mandatory after Administration of the Recommended Dose of Sugammadex? A Prospective Observational Study

BackgroundSome anaesthetists wonder whether confirming a train-of-four ratio (TOFR) ≥0.9 is necessary when using sugammadex to antagonise neuromuscular blockade (NMB). In this study, we aimed to determine whether using sugammadex at the recommended dose under neuromuscular monitoring (NMM) would ensure complete recovery, even without further NMM. MethodsThis prospective observational study included 51 patients who underwent robot-assisted surgery under general anaesthesia between March and May 2023. At the end of surgery, sugammadex was administered (2 mg/kg for a train-of-four (TOF) count ≥1 and 4 mg/kg for a TOF count = 0 and a post-tetanic count ≥1). NMM was discontinued, and subsequent recovery was completed at the discretion of the attending anaesthetist. TOFR was measured twice immediately upon admission to the post-anaesthesia care unit (PACU). The primary outcome was the incidence of a non-normalised TOFR (nTOFR) <0.9 upon arrival in PACU. The secondary outcomes were the incidences of a nTOFR <0.7 or 1.0, symptoms/signs of residual NMB (diplopia, dyspnoea, and desaturation) and recovery profiles in PACU. ResultsThe incidence of a nTOFR <0.9 upon arrival in PACU was 5.9% (3/51 patients). No patient had a nTOFR <0.7, and 47.1% (24 patients) had a nTOFR <1.0, but no patients showed clinical symptoms/signs of residual NMB. ConclusionsWhen the recommended dose of sugammadex was administered under qualitative NMM, residual NMB at the time of PACU arrival occurred frequently, indicating that quantitative NMM is necessary to ensure adequate recovery. RegistrationClinicalTrials, NCT 05760560.

Intrathecal Pethidine Plus Dexamethasone Versus Intrathecal Bupivacaine in Lower Extremity Orthopedic Surgeries: A Randomized Clinical Trial

Background: Spinal anesthesia remains the preferred technique for lower abdominal and orthopedic procedures. Objectives: This study compares the effects of an intrathecal injection of pethidine combined with dexamethasone versus intrathecal bupivacaine alone in patients undergoing lower extremity orthopedic surgeries. Methods: In this prospective, randomized, controlled, double-blinded study, 46 participants scheduled for elective lower extremity orthopedic surgeries were randomly allocated into two groups. Group PD (n = 23) received an intrathecal injection of 1 mg/kg preservative-free pethidine combined with 4 mg dexamethasone, diluted with 0.9% sodium chloride saline to a total volume of 3 mL. Group B (n = 23) received an intrathecal injection of 3 mL (15 mg) of 0.5% hyperbaric bupivacaine alone. The primary outcome measured was the time to the first need for rescue analgesia. Secondary outcomes included spinal anesthesia characteristics, intraoperative hemodynamic stability, and incidence of perioperative adverse events. Results: The time to first need for rescue analgesia was significantly longer in Group PD (7.76 ± 0.79 hours) compared to Group B (4.48 ± 0.63 hours). Differences in the onset of sensory and motor blocks between Group PD (6.39 ± 1.12 and 10.09 ± 2.23 minutes, respectively) and Group B (6.43 ± 1.99 and 9.96 ± 2.33 minutes, respectively) were statistically non-significant. However, the regression time for sensory and motor blocks was significantly shorter in Group PD compared to Group B (146.74 ± 15.35 and 119.56 ± 14.13 minutes vs. 188.44 ± 6.84 and 168.04 ± 5.25 minutes, respectively). Incidence of hypotension and shivering was also less frequent in Group PD than in Group B. Conclusions: Intrathecal administration of 1 mg/kg pethidine plus 4 mg dexamethasone provided improved spinal anesthesia, with extended postoperative analgesia, minimal intraoperative hemodynamic disturbances, and reduced incidence of shivering compared to bupivacaine alone in patients undergoing lower extremity orthopedic surgeries. This approach may be particularly beneficial for patients with hypersensitivity to ester or amide local anesthetics, offering a cost-effective alternative to standard local anesthetics.

The effect of intravenous lidocaine infusion on subarachnoid anesthesia in patients undergoing total knee replacement: a randomised controlled trial.

Intravenous lidocaine is a non-opioid analgesic adjunct for perioperative pain relief. The aim of our study was to explore whether concurrent administration of intravenous lidocaine prolongs the duration of sensory block during total knee replacement (TKR) under spinal anaesthesia. This prospective randomized double blind controlled trial was conducted on 28 patients (14 in lidocaine group and 14 in the control group) undergoing unilateral TKR under spinal anesthesia. In the lidocaine group, intravenous lidocaine 1.5mg·kg-1 followed by an infusion of 1.5mg·kg-1·h-1 was administered intraoperatively after spinal anesthesia. The primary outcome was the duration of sensory block of spinal anesthesia. Secondary outcomes included onset time of sensory and motor block, duration of motor block, time to first postoperative analgesic, postoperative visual analog scale (VAS) scores and postoperative analgesia requirement in 24h after surgery. The duration of sensory and motor block was longer in the lidocaine group (Mean ± SD; 112.50 ± 5.80min versus 78.21 ± 9.12min;p < 0.001 and 237.14 ± 9.14min versus 215.00 ± 10.12min;p < 0.001, respectively). Time to requirement of first rescue analgesia was 184.29 ± 9.38min in the lidocaine group and 127.14 ± 23.35min in the control group (p < 0.001). VAS scores were lower in the lidocaine group at 4, 8, 12 and 24h after surgery (p < 0.00001, p < 0.00001, p < 0.00006, p = 0.032, respectively). Requirement of additional analgesia in the first 24h was higher in the control group. There were no clinical signs to suggest lidocaine toxicity in any patient. During unilateral TKR under spinal anaesthesia, concurrent use of intravenous lidocaine prolonged sensory block and reduced postoperative analgesic requirements.

Spontaneous breathing-induced lung injury in mechanically ventilated patients.

Recent experimental and clinical studies have suggested that spontaneous effort can potentially injure the lungs. This review summarizes the harmful effects of spontaneous breathing on the lungs during mechanical ventilation in ARDS and suggests potential strategies to minimize spontaneous breathing-induced lung injury. Recent clinical and experimental studies have shown that vigorous spontaneous breathing during mechanical ventilation can potentially injure the lungs due to high transpulmonary pressure, the Pendelluft phenomenon, increased pulmonary perfusion, and patient-ventilator asynchrony. A definitive approach to minimize spontaneous breathing-induced lung injury is the systemic use of neuromuscular blocking agents; however, there is a risk of muscle atrophy. Alternatively, partial paralysis, bilateral phrenic nerve blockade, and sedatives may be useful for decreasing force generation from the diaphragm while maintaining muscle function. A higher positive end-expiratory pressure (PEEP) and prone positioning may reduce force generation from the diaphragm by decreasing neuromechanical efficiency. Several potential strategies, including neuromuscular blockade, partial paralysis, phrenic nerve blockade, sedatives, PEEP, and prone positioning, could be useful to minimize spontaneous breathing-induced lung injury.

Comparative Study to Evaluate the Efficacy of Dexmedetomidine and Magnesium Sulfate as Adjuvants to 0.5% of Hyperbaric Bupivacaine in Patient Undergoing Abdominal Hysterectomy by Spinal Anesthesia: A Randomized, Double-blind Study

Abstract Objective: Abdominal hysterectomy is a common gynecological procedure. While spinal anesthesia offers pain relief, its short analgesic effect is limiting. In this context, there are not many research that examined magnesium sulfate, dexmedetomidine, and 0.5% hyperbaric bupivacaine. Our research addresses this gap as “Comparing Dexmedetomidine and Magnesium Sulfate as Adjuvants to Hyperbaric Bupivacaine for Abdominal Hysterectomy”. Methods: Ninety patients with the American Society of Anesthesiologists Classification I and II, aged 30–60, planned for abdominal hysterectomy were randomized to either dexmedetomidine or magnesium sulfate or control group as adjuvants to hyperbaric bupivacaine. The primary objective was to find the effectiveness of the anesthesia in terms of both sensory and motor blocks (onset, duration, and severity), with the secondary objective was to find out any other associated complications. Results: In comparison to the magnesium sulfate group, the dexmedetomidine group’s anesthetic effect began significantly more immediately and persisted much longer (P &lt; 0.001). The groups did not vary statistically significant in terms of side effects or hemodynamic instability. Conclusion: Adjuvants such as dexmedetomidine or magnesium sulfate along with hyperbaric bupivacaine, for abdominal hysterectomy under spinal anesthesia, provide effective anesthesia. Dexmedetomidine (10 μg) and magnesium sulfate (100 mg) both showed safe intrathecal adjuvant usage. Remarkably, dexmedetomidine surpasses magnesium sulfate by swiftly inducing sensory and motor blocks, extending their duration, and enhancing analgesia. Notably, both adjuncts yield no adverse effects. Overall, these findings underscore the potential of dexmedetomidine as a more effective adjuvant in spinal anesthesia protocols for abdominal hysterectomy procedures.

Effect of dural puncture epidural technique combined with programmed intermittent epidural bolus on labor analgesia: A randomized, double-blind, parallel-group, controlled clinical trial.

Labor analgesia can be achieved by different approaches. The efficacy and safety of combined dural puncture epidural (DPE) with program intermittent epidural bolus (PIEB) are not well characterized. This study aimed to compare the efficacy and safety of DPE combined with PIEB vs epidural (EP) combined with PIEB for labor analgesia. We performed a prospective, randomized, double-blind, parallel-group, controlled clinical trial. Eligible pregnant nulliparous women received either DPE combined with PIEB (group D) or epidural combined with PIEB (group E) for labor analgesia. Analgesia was initiated with 0.1% ropivacaine + 0.3 µg/mL sufentanil and maintained with PIEB at 12 mL/h. Primary outcome was the proportion of women with adequate analgesia within 10 minutes after the initiation of analgesics. Secondary outcomes (time to achieve analgesia, time to first request for additional analgesic, proportion of women required additional analgesic or epidural catheter adjustment and resetting, total labor duration, total analgesic consumption, level of anesthesia, and motor block), side effects, and patient satisfaction were also documented. Out of 174 enrolled women, 160 were included in the analysis. Baseline characteristics were comparable. The proportion of women who achieved adequate analgesia in group D was significantly greater than that in group E (38.8% vs 20.0%, P < .05). Compared with group E, group D also showed advantages in faster adequate analgesic achievement, more likely to reach adequate analgesia, a longer time to maintain analgesia, lesser requirements for additional analgesic, and better sensory blocks. There were no significant inter-group differences in other outcome measures. Compared with epidural and PIEB mode, DPE and PIEB mode achieved better analgesia without increasing maternal or neonatal side-effects during labor.

The Efficacy and Adverse Effects of Sugammadex and Neostigmine in Reversing Neuromuscular Blockade Inpatients with Obesity Undergoing Metabolic and Bariatric Surgery: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

Background and Objectives: Metabolic and bariatric surgery (MBS) is practiced worldwide. Sugammadex was proven to have multiple benefits in reversing neuromuscular blockade (NMB) for patients with obesity undergoing MBS, but its effects on complications of various systems are not clear and concrete. Materials and Methods: This systematic review and meta-analysis was conducted as per the PRISMA guidelines and registered on the PROSPERO database (CRD42023491171). A systematic search was conducted in multiple databases for studies comparing sugammadex with neostigmine in MBS. Continuous data are reported as mean differences (MDs) and 95% confidence intervals (CIs). Dichotomous data are reported as relative risks (RRs) and 95% CIs. A two-sided p &lt; 0.05 was considered statistically significant. Trial sequential analysis (TSA) was performed to evaluate the reliability of the conclusions. Results: Nine studies with 633 patients met the inclusion criteria. Compared with those from the neostigmine group, patients from the sugammadex group were characterized by a significantly shorter recovery time from the administration of the study drug to a train-of-four (TOF) ratio of ≥90% (MD [95% CI]: −15.40 [−26.64; −4.15]; I2 = 96.6%; p = 0.0073; n = 380; random effects model), a lower risk of postoperative residual curarization (PORC) (RR [95% CI]: 0.18 [0.09; 0.38]; p &lt; 0.0001; I2 = 27.9%; n = 344; common effect model), postoperative nausea and vomiting (PONV) (RR [95% CI]: 0.67 [0.48; 0.93]; p = 0.0164; I2 = 0%; n = 335; common effect model), and cardiovascular complications (RR [95% CI]: 0.48 [0.26; 0.88]; p = 0.0186; I2 = 14.7%; n = 178; common effect model). TSA confirmed the conclusions regarding the recovery time and PORC risk. Conclusions: In conclusion, our systemic review and meta-analysis with TSA revealed that sugammadex provided a faster and more reliable choice to reverse NMB in patients with obesity undergoing MBS, with a lower risk of PORC. Sugammadex reduced the risk of cardiovascular complications and postoperative nausea and vomiting. However, the conclusions were not confirmed, and, so, further studies may be necessary.

A Phase I Study of the Pharmacokinetics, Pharmacodynamics, and Safety of Liposomal Bupivacaine for Sciatic Nerve Block in the Popliteal Fossa for Bunionectomy.

This trial assessed the pharmacokinetics, pharmacodynamics, and safety of liposomal bupivacaine given via ultrasound-guided popliteal sciatic nerve block with or without immediate-release bupivacaine hydrochloride in adults having bunionectomies. Forty-five adults were enrolled into four sequential cohorts: (1) liposomal bupivacaine 266 mg with bupivacaine hydrochloride 50 mg; (2) liposomal bupivacaine 133 mg with bupivacaine hydrochloride 50 mg; (3) liposomal bupivacaine 266 mg; or (4) bupivacaine hydrochloride 100 mg. Outcomes included pharmacokinetics (e.g., bupivacaine maximum plasma concentration [Cmax]), onset and duration of motor and sensory nerve block, and safety. Liposomal bupivacaine admixed with bupivacaine hydrochloride produced biphasic bupivacaine plasma disposition profiles with two distinct peaks. Geometric mean Cmax of the early peak ranged from 235 to 421 ng/mL and the geometric mean of the late Cmax was ∼30%-50% lower than the early peak. Median time to sensory block onset was 18 to 29 min in all cohorts. Sensory blocks lasted about twice as long with liposomal bupivacaine (median, 119-167 h) than with bupivacaine hydrochloride alone (median, 67 h). There were no serious adverse events. In conclusion, liposomal bupivacaine provided prolonged sensory nerve block when given as popliteal sciatic nerve blocks with or without bupivacaine hydrochloride, and bupivacaine plasma concentrations were well below the lower bound of the toxicity threshold of 2000 ng/mL for all cohorts.

COMPARISON OF ANESTHETIC EFFECT OF PLAIN ROPIVACAINE VERSUS DEXMEDETOMIDINE AS AN ADJUVANT TO ROPIVACAINE IN USG-GUIDED SUPRACLAVICULAR BLOCK FOR UPPER LIMB SURGERIES

Objectives: Perioperative pain management is very important to achieve patient satisfaction. The objectives of the current study were to compare the anesthetic effects of dexmedetomidine and plain ropivacaine as an adjuvant to ropivacaine for upper limb surgeries in the supraclavicular brachial plexus block in terms of hemodynamic responses, quality, onset, and duration of sensory and motor block, post-operative pain management and side effects/complications if any. Methods: Sixty adult patients scheduled for upper limb surgeries were randomized into Group A and Group B of 30 patients each. Patients in Group A received 0.5% Ropivacaine 20 mL+5 mL normal saline and Group B received 0.5% ropivacaine 20 mL+0.5 mL (50 μg) dexmedetomidine+4.5 mL normal saline. The primary objective of our study was to compare the groups in terms of quality of block, onset, and duration of sensory and motor block and post-operative pain management. The secondary objective was to compare the intraoperative hemodynamic changes and post-operative adverse effects. Results: Time taken in the onset of the sensory as well as motor block in both the groups was statistically significantly more in Group A compared to Group B. The duration of the sensory as well as the motor block was much higher in Group B compared to Group A with a statistically significant difference. The total duration of analgesia was slightly higher in Group A compared to Group B. The mean numerical rating scale was significantly lower in Group B compared to Group A at all-time intervals till 24 h. No major side effects were observed with study drugs. Conclusion: The study confirmed that dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block hastens the onset of the sensory as well as motor block and prolongs the duration of the sensory as well as the motor block in the upper limb surgeries.

Assessing the efficacy of sugammadex based on ideal body weight for reversal of moderate neuromuscular blockade in obstetric patients across different BMI categories: A prospective study

Background: This investigation aimed to evaluate the effectiveness of administering 2 mg/kg intravenous (IV) sugammadex, dosed according to the ideal body weight (IBW) of obstetric patients across three different BMI groups, for the reversal of neuromuscular blockade caused by rocuronium.Materials and Method: A total of ninety female patients, who were categorized as American Society of Anesthesiologists (ASA) II and were 18 years or older, participated in this study. These patients were all scheduled to undergo elective cesarean sections under general anesthesia, providing a well-defined cohort for our investigation. Participants were separated into three groups according to their BMI: Group 1 (n=30) consisted of patients with a BMI less than 30 kg/m², Group 2 (n=30) included those with a BMI ranging from 30 to 39.9 kg/m², and Group 3 (n=30) comprised patients with a BMI over 40 kg/m². At the end of the surgery, each patient received intravenous sugammadex at 2 mg/kg based on ideal body weight, with additional doses as needed, while recording the total amount administered and the times for extubation, motor responses, and first breastfeeding.Results: The total sugammadex dose was found to be notably higher in Group 3 (p=0.002). The time required to reach a Train of Four (TOF) ratio greater than 90% was similar across the groups (p=0.120). However, the recorded durations between sugammadex administration and extubation, accurate motor response, and the time to first breastfeeding significantly differed between the groups.Conclusions: We found that IV sugammadex 2 mg/kg, administered according to the IBW of patients, was effective for reversing moderate neuromuscular blockade in patients of weight categories. However, administering a sugammadex dose of IBW+25% appears to be safer for class III obese patients.

How does intravenous ondansetron affect motor and sensory block in spinal anesthesia administered with intrathecal levobupivacaine? A prospective randomized controlled study

Background: Spinal anesthesia is commonly performed in surgical procedures, and ondansetron, frequently used as an antiemetic, is often administered to manage postoperative nausea and vomiting. Given their frequent co-administration, we sought to investigate the potential effects of intravenous ondansetron on the block characteristics of spinal anesthesia performed with levobupivacaine.Materials and Method: In this prospective, randomized controlled study, forty patients were divided into two groups: Group L (spinal anesthesia with levobupivacaine) and Group OL (spinal anesthesia with levobupivacaine plus intravenous ondansetron).Results: Our findings showed that while motor block duration was similar between the groups (p&gt;0.05), sensory block duration was significantly shorter in the ondansetron group (p&lt;0.05). There were no significant differences in patient demographics or hemodynamic parameters between the groups (p&gt;0.05).Conclusions: The shortened sensory block with ondansetron administration may be clinically undesirable as it could limit the intended duration of anesthesia. We recommend administering ondansetron at the end of surgery to avoid this effect. Further studies are required to confirm these findings and clarify the mechanisms involved.

Sub-Tenon's anesthesia in equine cataract surgery and vitrectomy: a retrospective case series (2018-2022).

A retrospective data analysis was performed on 17 eyes from 13 horses which underwent a sub-Tenon's injection to facilitate phacoemulsification or pars plana vitrectomy under general anesthesia between 2018 and 2022. All procedures were performed by the same veterinary ophthalmologist. Seven eyes received a sub-Tenon's dose of 7 ml lidocaine (XylocainÒ, 2 % lidocaine hydrochloride, Germany, Aspen Germany GmbH), and 10 eyes received 7 ml mepivacaine (MepinaestÒ purum 2 %, mepivacaine hydrochloride, Switzerland, Gebro Pharma GmbH). Statistical analysis compared onset and duration of globe centralization and pupil mydriasis between the two groups. Intraoperative and postoperative complications were also assessed. Mepivacaine had a significantly later onset of action regarding globe centration and mydriasis (8,9 minutes vs. 6 minutes), but also a significantly longer duration of globe centration than lidocaine (31,5 minutes vs. 15,6 minutes). There were no statistically relevant differences between solutions regarding duration of pupil dilation (40,4 minutes for 2 % lidocaine vs. 69,2 minutes for 2 % mepivacaine). Chemosis occurred in all 17 eyes. Surgical complications included corneal epithelial defects (5), retinal detachment (5), lens opacification (5), temporary blindness during recovery (3) and glaucoma (2). Sub-Tenon's anesthesia is a feasible alternative to systemic neuromuscular blockade and retrobulbar block anesthesia for surgical procedures on the equine globe. A controlled prospective in vivo study is needed to further evaluate effects and risks.

Neuromuscular blockade monitoring in pediatric patients.

The administration of neuromuscular blocking agents (NMBAs), the cornerstone of pediatric anesthesia, facilitates intubation and muscle relaxation during surgery. However, NMBAs can also lead to serious complications including respiratory depression, residual paralysis, and prolonged recovery. Neuromuscular monitoring (NMM) in pediatric patients is therefore essential, as it is in adults, to ensure adequate paralysis during surgery and prompt recovery from NMBA-induced paralysis. This article aimed to provide a comprehensive overview of NMM in pediatric anesthesia including the various available methods, their advantages and disadvantages, and the importance of a standardized NMM approach.

Sugammadex for our little ones: a brief narrative review.

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.

The Effect of the Application of Adductor and Infiltration of Local Anesthetic Between the Popliteal Artery and Capsule of the Knee (IPACK) Block to Patients on Postoperative Recovery and Sleep Quality Following Total Knee Arthroplasty: a Randomized, Controlled Study

Aim: The adductor canal block (ACB) and IPACK (Infiltration of local anesthetic between the popliteal artery and capsule of the knee) block are motor protective blocks that provide effective analgesia and allow early ambulation. The aim of this study was to investigate the effect on postoperative recovery and sleep quality of patients applied with ACB and IPACK for total knee arthroplasty (TKA). Material and Method: This prospective, double-blinded, randomized, controlled study included 80 patients who underwent unilateral TKA under spinal anesthesia. The patients were separated as those applied with ACB+IPACK (Group ACB+IPACK, n=40) and a control group (Group C, n=40). The primary outcome was the postoperative first-day quality of recovery scale (QoR-15). Secondary outcomes were postoperative first and second-day Timed-Up-and-Go (TUG) test and range of motion (ROM), the total amount of rescue opioid drugs required, pain scales at different time points in the first 48 hours postoperatively, sleep evaluation on the postoperative and 6 following nights, and evaluation of sleep quality for 1 month using the Pittsburgh Sleep Quality Index (PSQI). Results: The QoR on postoperative days 1 and 7 were better in the ACB+ IPACK group than in the control group (p= 0.001, p= 0.002, respectively). On postoperative days 1 and 2, the TUG (p= 0.035, p= 0.019, respectively) and ROM (p=0.003, p=0.000) values were higher in the ACB+ IPCAK group. Postoperative opioid consumption was lower in the ACB+IPACK group (p= 0.012). The PSQI values at 1 month postoperatively were similar in both groups (p =0.095). Conclusion: The study results demonstrated that ACB+IPACK applied with ultrasound for TKA postoperative analgesia provided effective analgesia, higher QoR and physical performance, and reduced postoperative opioid consumption. However, there was no effect on postoperative sleep quality.

The Utility of Electroencephalograhy in Guiding General Anesthesia in Children.

Traditional pediatric anesthetic dosing using pharmacokinetic estimates based on age and weight is often imprecise, frequently leading to oversedation. Intraoperative electroencephalography (EEG) allows visualization of the brain's response to anesthetic agents in real time, facilitating precise titration of anesthetic drug doses optimized for the individual child. The goal of EEG-guided anesthesia management is to maintain an optimal state of hypnosis during various stages of the procedure while minimizing hemodynamic instability and other adverse effects of anesthesia. This is especially important in children with less predictable anesthetic requirements, such as children with atypical neurodevelopment, altered levels of consciousness before anesthesia, or those receiving total intravenous anesthesia, neuromuscular blockers, or a combination of anesthetic agents with different mechanisms of actions. Children with limited cardiorespiratory reserves and those undergoing high-risk procedures such as cardiopulmonary bypass also benefit from EEG guidance as they have a narrower therapeutic window for optimal anesthetic dosing. Various processed EEG (pEEG) monitors are available for intraoperative monitoring in children. These monitors display a pEEG index based on the manufacturer's algorithm, purportedly indicating the patient's hypnotic state. Due to differences in developmental neurophysiology and EEG dynamics in children, pEEG indices may not always reliably indicate the hypnotic state, especially in neonates and infants. Learning to interpret nonproprietary EEG parameters including the raw EEG, spectral-edge frequency 95% (SEF95), and density spectral array can prevent overreliance on pEEG indices. This review provides an overview of the advantages of EEG guidance during clinical anesthesia, including potential reduction in anesthetic dosage, prevention of EEG suppression, and reduction in peri-operative adverse events. We describe the use of nonproprietary EEG parameters in guiding anesthesia in children for various clinical end points including laryngoscopy, surgical incision, and maintenance of anesthesia, as well as sedation. We illustrate these principles with various case examples commonly encountered during pediatric anesthesia. Lastly, we discuss strategies to expand intraoperative EEG monitoring in children through education and training programs, as well as advocate for further research to assess clinical outcomes associated with EEG guidance to support its routine use in clinical care.

A Comparative Study of Magnesium Sulfate, Lignocaine, and Propofol for Attenuating Hemodynamic Response During Functional Endoscopic Sinus Surgery Under General Anaesthesia: A Prospective Randomized Trial.

This study functional endoscopic sinus surgery (FESS) is a surgical procedure requiring minimal bleeding to optimize the surgical field. This study aimed to evaluate the effectiveness of magnesium sulfate, lignocaine, and propofol in attenuating hemodynamic response. The primary objective of this study was to compare the efficacy of these agents in reducing hemodynamic response. The secondary objectives included assessing the quality of the surgical field, recovery time, and total neuromuscular dose. We randomly allocated 105 patients scheduled for FESS into three groups: lignocaine, propofol, and magnesium sulfate. Heart rate and mean arterial pressure were recorded every 5 min for the first 30 min, followed by measurements every 10 min at the end of the procedure. Moreover, recovery time, total neuromuscular blocking dose, and surgical field score were noted upon completion of the procedure. Statistical analysis was conducted using the number cruncher statistical systems version 9.0.8 software. All three groups showed comparable hemodynamic response and surgical field scores. The recovery time was notably longer in the magnesium sulfate group [10.94 min (2.45)] than in the lignocaine [4.37 min (1.03)] [95% confidence interval (CI) -7.32, -5.83; P=0.000] and propofol groups [4.60 min (0.60)] (95% CI 5.60, 7.095; P=0.000). Moreover, the total neuromuscular blocking agent used was significantly lower in the magnesium sulfate group [5.89 mg (0.47)] than in the lignocaine [6.26 mg (0.56)] (95% CI 0.66, 0.03; P=0.035). Propofol, magnesium sulfate, and lignocaine exerted equal efficacy in attenuating hemodynamic responses during surgery and ensuring a satisfactory surgical field. However, magnesium sulfate led to significantly longer recovery times compared with propofol and lignocaine. In addition, magnesium sulfate required a significantly lower total dose of neuromuscular blocking agents than lignocaine.

ClC-1 Inhibition as a Mechanism for Accelerating Skeletal Muscle Recovery After Neuromuscular Block in Rats

Neuromuscular blocking agents are used commonly to induce skeletal muscle relaxation during surgery. While muscle relaxation facilitates surgical procedures and tracheal intubation, adequate recovery of muscle function after surgery is required to support pulmonary function, and even mild residual neuromuscular block increases the risk of severe postoperative pulmonary complications. While recovery of muscle function after surgery involving neuromuscular blocking agents can be monitored and, in addition, be accelerated by use of current antagonists (reversal agents), there is a clear clinical need for a safe drug to antagonize all types of neuromuscular blocking agents. Here, we show that inhibition of the skeletal muscle-specific chloride ion (Cl-) channel, the ClC-1 channel, markedly accelerates recovery of both single contraction (twitch) and, important physiologically, sustained (tetanic) contractions in a rat model mimicking neuromuscular blocking agent-induced muscle block used during surgery. This suggests ClC-1 inhibition as a mechanism for fast and efficacious recovery of neuromuscular function induced by any neuromuscular blocking agents.

A Comparison of Different Doses Efficacy of Isobaric Ropivacaine 0.5% in Spinal Anesthesia in Cesarean Section

Background: Cesarean delivery is a standard surgical procedure in women. Thus, a practical, affordable, and low-risk anesthetic technique is essential for mother and infant safety. Spinal anesthesia is a popular and efficient technique for anesthesia during cesarean delivery. However, other local anesthesia drugs with negligible side effects should be considered. The most selective medication for this purpose is bupivacaine (marcaine), which creates optimal anesthesia at doses of 10 to 12 mg. Objectives: The most available medicine for spinal anesthesia during cesarean delivery is a 0.5% marine solution. However, ropivacaine for spinal anesthesia can occasionally be accessed as a long-acting amide local anesthetic agent used as an alternative to marcaine during the cesarean delivery. The ropivacaine's advantage over marcaine is its less neurotoxicity and cardiotoxicity, as well as the more stable hemodynamical condition of the patients. So far, no proper therapeutic dose of 0.5% isobaric ropivacaine has been proposed to be used during the cesarean delivery. Any increase in the dose may ensure the block performance, but, by contrast, some side effects may arise, including hypotension, bradycardia, vomiting, and nausea. Herewith, the likelihood of maximum block and most minor side effects was attempted to be assessed at the tiniest doses of this anesthetic agent. Methods: This randomized clinical trial was conducted on C-section candidates. Patients were categorized into three groups receiving 22.5, 25, and 20 mg of the 0.5% isobaric ropivacaine solution. Systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, the rate of using supplementary drugs, block breakdown, and the patient's satisfaction with the anesthesia were measured and recorded. The collected data were analyzed using IBM SPSS Statistics. Results: No significant difference was found between demographic characteristics. Likewise, there was no significant difference in systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, and the rate of using supplementary drugs between the three groups. The most significant block breakdown and use of supplementary drugs were found in the first group (20 mg), with a significant difference between the three groups. Conclusions: The three doses used did not result in meaningful differences between the three groups. However, the differences were significant for the block breakdown, with the higher block breakdown and supplementary drug use observed when using 20 mg of the 0.5 ropivacaine solution.

Infraclavicular versus supraclavicular nerve block for upper limb surgeries: A meta-analysis.

The impact of infraclavicular versus supraclavicular nerve block on the analgesia for upper limb surgeries is unclear. This meta-analysis and systematic review aims to study the analgesic efficacy of infraclavicular versus supraclavicular nerve block for upper limb surgeries. We searched several databases including PubMed, EMbase, Web of science, EBSCO and Cochrane library databases from inception to December 2023, and randomized controlled trials (RCTs) assessing the effect of infraclavicular versus supraclavicular nerve block for upper limb surgeries were included. We excluded studies reporting other nerve block approaches. The methodological quality of the included studies was evaluated by the modified Jadad scale. Standard mean difference with 95% confidence interval (CI) was used to assess continuous outcomes. This meta-analysis was conducted by the fixed-effect model or random-effect model based on the heterogeneity. Eight RCTs and 725 patients were included in this meta-analysis. Compared with supraclavicular nerve block for upper limb surgeries, infraclavicular nerve block was able to significantly increase duration of motor block (SMD = 0.34; 95% CI = 0.12 to 0.56) and decrease readiness for surgery (SMD = -0.43; 95% CI = -0.77 to -0.10), but showed similar duration of sensory block (SMD = 0.17; 95% CI = -0.05 to 0.39), block performance time (SMD = -0.14; 95% CI = -0.51 to 0.22), onset of sensory blockade (SMD = -0.13; 95% CI = -0.59 to 0.33) and onset of motor blockade (SMD = -0.17; 95% CI = -0.26 to 0.12). No high heterogeneity was seen among the included studies. Infraclavicular nerve block may be superior to control the analgesia for upper limb surgeries than supraclavicular nerve block.