Neuromuscular Reversal Agents Research Articles

Obesity and anesthesia.

Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

SUGAMMADEX ANAPHYLAXIS

<h3>Introduction</h3> Sugammadex is a neuromuscular reversal agent used at the conclusion of surgeries to reverse the effects of rocuronium and vecuronium. It was first used in 2008 and the incidence of anaphylaxis has been estimated to be around 0.02%. We report a case of anaphylaxis to sugammadex which manifested abruptly with hypotension, diaphoresis, and dyspnea but with absence of rash. <h3>Case Description</h3> A 71YOF underwent an uncomplicated laparoscopic cholecystectomy. At the end of the procedure, patient received 200mg sugammadex IV and within 3 minutes she became hypotensive, diaphoretic, and dyspneic. She did not have a rash. She never received this medication before. She received IV fluids and she was started on phenylephrine drip. Patient was initially phenylephrine refractory but after 10 minutes her hypotension resolved. The diagnosis was unclear, therefore a repeat laparoscopy to rule out bleeding was performed and intraoperatively transesophageal echocardiogram showed normal left ventricle function, but minimal filling. The blood loss was estimated to be 30 ml. Due to high suspicion, Sugammadex was preemptively listed as an allergy. One hour after her symptoms began, tryptase level was 48.7 mcg/L, followed by 61.5 mcg/L 2.5 hours later. Baseline tryptase was 4.5 mcg/L. At a follow up visit, skin prick testing to sugammadex was positive with a 1:1 concentration and to intradermal testing with a 1:1000 concentration. Skin testing of other agents which were administered prior to sugammadex were negative. <h3>Discussion</h3> Although rare, rapid recognition of possible sugammadex anaphylaxis, despite the lack of rash, is very important for adequate treatment and further testing.

Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery

BackgroundPostoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery.MethodsThree hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed.ResultsTwo hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19–90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18–94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0–10) vs. 3 (0–12) days, p = 0.036), and reduced time to first stool (median 2 (0–10) vs. 3 (0–12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2.ConclusionsPatients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

POSA97 Assessment of the Economic IMPACT in Relation with the Use of Sugammadex in the French Hospitals Setting

This study aims to estimate the impact of sugammadex administration as neuromuscular reversal agents on time spent in the operating room (OR) and post-acute care unit (PACU) and the potential economic impact of faster recovery in patients undergoing colectomy, hysterectomy, or bariatric surgery in France.

Sugammadex versus neostigmine for reversal of rocuronium-induced neuromuscular blockade: A randomized, double-blinded study of thoracic surgical patients evaluating hypoxic episodes in the early postoperative period

Study objectiveThis objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus neostigmine results in a decreased number of hypoxic episodes in the early postoperative period in patients undergoing thoracic surgery with single lung ventilation. DesignSingle-center, randomized, double-blind, two-arm clinical trial. SettingOperating room and postanesthesia care unit. Patients92 subjects aged ≥18, American Society of Anesthesiologists physical status II-IV, and undergoing a thoracic operation necessitating single lung ventilation. InterventionsSubjects received either 2 mg/kg sugammadex or 50 μg/kg neostigmine with 8 μg/kg glycopyrrolate for reversal of moderate neuromuscular blockade. MeasurementsFor the first 90 min postoperatively, all episodes of hypoxia were recorded. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch® SX) and the train of four (TOF) was recorded at 2, 5, 10, and 15 min after administration of the neuromuscular reversal agent. Main resultsSubjects who received neostigmine had a median of 1 episode (interquartile range IQR: 0–2.2) of hypoxia versus subjects who received sugammadex who had a median of 0 episodes (IQR: 0–1) (p = 0.009). The mean time to recovery of TOF ≥ 0.9 was significantly faster with sugammadex at 10 min (95% confidence interval CI: 5–15) compared with neostigmine at 40 min (95% CI: 15–53) (p < 0.001). ConclusionsIn thoracic surgical patients necessitating single lung ventilation, sugammadex provides faster reversal of moderate neuromuscular blockade and results in a decreased number of postoperative hypoxic episodes compared with neostigmine.

Should we Routinely Reverse Neuromuscular Blockade with Sugammadex in Patients with a History of Heart Transplantation?

Cases of cardiac arrest after administration of neostigmine as a neuromuscular reversal agent have been reported in the literature. Sugammadex is a new neuromuscular reversal agent that acts via a different mechanism than acetylcholinesterase inhibitors. Here we reviewed the currently available literature on the use of sugammadex and potential considerations of using sugammadex in patients with a history of heart transplantation. Based on our currently available information, sugammadex administration in heart transplant patients should warrant similar caution and preparation for cardiovascular collapse as acetylcholinesterase inhibitors.

Sedation induced by antiepileptic drugs polytherapy: A note of caution during anesthesia.

Sir, Sedation is a common complaint among patients with epilepsy taking antiepileptic drugs (AEDs). This side-effect is compounded in patients taking multiple AEDs.[123] An 18-year-old male presented with history of seizures (since day 3 of life) refractory to multiple AEDs. He was taking twice daily doses of valproate 500 mg, clonazepam 20 mg, oxcarbazepine 450 mg, and levetiracetam 1500 mg; and zonisamide 100 mg in the morning and 200 mg at bed time. He had no other co-morbidities. The patient was scheduled for vagal nerve stimulation under general anesthesia for diffuse, bilateral, non-localizing seizure foci. In the preoperative period, the patient was oriented to time, place, and person despite periods of mood swings, during which he became restless and aggressive. Baseline laboratory parameters including liver function tests were within normal limits. The patient was advised to continue AEDs on the morning of surgery. On arrival at the operating room (OR), he was deeply sedated and responded only to painful stimuli. The baseline vitals were BP 129/64 mmHg, HR 88/min, and SpO2 99% on room air. The bispectral index (BIS) value was found to be between 77 and 80. Anesthesia was induced with fentanyl 120 μg and propofol 100 mg, and tracheal intubation was facilitated with rocuronium 50 mg. The maintenance of anesthesia was done with O2: air (FiO2 0.5), sevoflurane (0.8–1 Minimum alveolar concentration [MAC]) along with continuous infusions of fentanyl (60 μg/h), and rocuronium (12 mg/h). However, the BIS value started decreasing progressively below 40 [Figure 1]. Accordingly, the sevoflurane dial concentration was tapered, and to our surprise, even at zero end-tidal concentration of sevoflurane and a MAC of 0, the BIS value consistently remained between 40 and 45 with no change in hemodynamic parameters. As a result, sevoflurane was avoided. Infusions of fentanyl and rocuronium were discontinued 45 min prior to completion of surgery. At the end of surgery (160 min), BIS value reached between 50 and 55. After confirming return of spontaneous respiration, neuromuscular reversal agent was administered. However, the patient was not able to follow the verbal commands even though gag and cough reflexes were intact, and spontaneous movement of all four limbs was present. Trachea was extubated at a BIS value of 65. The patient was shifted to the ICU and closely monitored. He showed gradual improvement in sensorium over the next 1 hour and started obeying verbal commands. On interrogation, the patient could not recall any intraoperative event.Figure 1: Shows the trend of bispectral index (BIS) during the intraoperative periodThrough this correspondence, we wish to highlight certain important issues with multiple AED therapy. First, many AEDs have sedation as an important side-effect, particularly at high doses. Our patient received five AEDs on the morning of surgery, and by the time he reached the OR, he was deeply sedated. As informed by his parents, it was a regular phenomenon, and after morning doses, he frequently slept till mid-afternoon. Second, loss of verbal responsiveness as end point of induction with propofol was not possible here. That is why a fixed dose of propofol was administered. Third, we also bring forth the importance of BIS monitoring in such cases to titrate drug doses. Had we not applied BIS monitoring, we would have unnecessarily administered higher concentrations of sevoflurane than required thereby causing further delay in anesthetic recovery. Fourth, one of the classical extubation criteria of obeying to commands by the patient at the end of the surgery was not followed. However, adequate return of spontaneous breathing and airway reflexes along with spontaneous movement of all four limbs were ensured. Moreover, the intraoperative period was uneventful, and no neurological worsening was expected. Finally, the patient could not recollect any intraoperative event in the postoperative period suggesting absence of awareness. Thus, patients taking multiple AEDs should be evaluated thoroughly during pre-anesthetic check-up. The modification of anesthetic drugs and doses should be done, accordingly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients: A Systematic Review of Clinical Studies.

Despite the increasing numbers of obese patients undergoing elective surgery, there is a lack of evidence-based dosing guidelines for peri-operative medications in obesity. The objective was to systematically review the dosing and outcomes of peri-operative medications used in obese elective surgical patients. Medical subject headings and general keywords were used to systematically search multiple databases (PubMed, EMBASE, Cochrane Library and CINAHL). Studies of medications in obese surgical patients were included if they had a non-obese control or comparative dosing scalar group. The National Health and Medical Research Council GRADE tool was used to assess quality of evidence for each drug. Thirty-three studies of six drug classes were identified: anaesthetics (n = 6), muscle relaxants (n = 10), neuromuscular reversal agents (n = 3), analgesics (n = 2), antibiotics (n = 5) and anticoagulants (n = 7). A variety of dose scalars and/or recommendations was observed for various medications. Lean body weight was proposed as a suitable weight scalar for induction of anaesthesia with propofol whereas total body weight for maintenance of anaesthesia with propofol and depolarizing muscle relaxants. Ideal body weight was reported as an appropriate dosing scalar for non-depolarizing muscle relaxants and neuromuscular reversal agents. Both corrected body weight 40% and ideal body weight were reported as suitable weight scalars for post-operative analgesia with morphine. The standard 2-g dose of cefazolin appeared effective in the prevention of surgical site infection. Body mass index stratified dosing of enoxaparin was effective for venous thromboembolism prevention. No drug recommendation achieved an "Excellent" quality of evidence. Limited data suggest that clinicians should consider each individual class of medication when selecting a dose for obese surgical patients. Routine use of fixed-dosing regimens is likely to under- or overdose obese patients thus predisposing them to adverse drug events or treatment failure leading to patient harm.

Abstract PR276

Background & Objectives: Sugammadex is a novel neuromuscular reversal agent, and there are limited number of experience with usage of this agent for infant patient group in literature.1, 2 The objective of this study is to evaluate the efficacy and safety of sugammadex in reversing profound neuromuscular block induced by rocuronium in infant patients. Materials & Methods: This study was approved by Baskent University Institutional Review Board (Project no: KA16/67) and supported by Baskent University Research Fund. Twenty-six ASA I-III infant patients aged 2 to 12 months with a weight range of 3 to 11 kg were studied undergoing meningomyelosele repair, hydrocephalus and spinal fusion surgery with general anesthesia. Anaesthesia was induced with 5 mg/kg thiopental, 1µg/kg fentanil and 0.6 mg/kg rocuronium. Sevoflurane was administered to all patients after intubation.The neuromuscular block was monitored with acceleromyography using TOF stimuli. At the end of surgery, sevoflurane inhalation was interrupted and switched to 100% O2 and TOF monitorization began. If profound neuromuscular block (TOF= 0) persisted at the end of the surgery, 3 mg /kg sugammadex was administered intravenously to evaluate their neurological status at early postoperative period. Results: Our study included a total of 26 patients, of which 10 were male and 16 were female. The mean age of the patients was 6.15 ± 3.52 (2-12) months and their mean weight was7.11 ± 2.33 (3-11) kg. The operative time was found 65.38 ± 24.40 (30-120) minutes and the mean recovery time of the T4/T1 ratio to 0.9 was 112.65 ± 35.60 (60-240) seconds. We did not encounter any complication at extübation period like bradycardia, tachycardia, laringospasm, broncospasm. No clinical evidence of recurarization or residual curarization was observed. A limited number of complications were observed (3 patient for cough and 2 patient for agitation) after extubation. Complications such as nausea, vomiting, bradycardia, tashicardia, rush and hypersensitivity were not observed in any patient after extubation. Conclusion: The efficacy and safety of sugammadex were confirmed in infant surgical patients for reversal of deep neuromusculer block from rocuronium.

Failed Tracheal Intubation During Obstetric General Anaesthesia: A Literature Review

(Int J Obstet Anesth. 2015;24(4):356–374) Failed tracheal intubation guidelines for obstetrics were first developed by Michael Tunstall at Aberdeen Maternity Hospital in the 1970s. Multiple versions of these original guidelines spread through local adaptation. The American Society of Anesthesiologists produced official national guidelines on management of the difficult airway in 1992, and these were last updated in 2013. Similar guidelines were developed by the Difficult Airway Society (DAS) for the United Kingdom in 2004. These do not address issues specific to the obstetric patient, however. Developments in obstetric anesthesia practice that have taken place since Tunstall introduced his guidelines include availability of supraglottic airway devices (SAD), antacid and oral intake protocols during labor, rapid onset nondepolarizing neuromuscular blocking drugs, and rapid neuromuscular reversal agents. Use of neuraxial anesthesia for cesarean section has increased, and up to one third of obstetric general anesthetics are now administered after failed neuraxial anaesthesia. The Obstetric Anaesthetists’ Association (OAA) and DAS have just published stand-alone obstetric failed intubation guidelines. The primary aim of this study was to search the relevant literature for evidence to support these guidelines, with special focus on quantitative data to estimate incidences of difficult airway management, management options, and maternal and neonatal outcomes.

Sugammadex facilitates early recovery after surgery even in the absence of neuromuscular monitoring in patients undergoing laryngeal microsurgery: a single-center retrospective study.

BackgroundIn many countries, routine clinical anaesthesia does not always involve neuromuscular monitoring. In these clinical settings, the efficacy and safety of sugammadex use has not yet been confirmed. We investigated the efficacy and safety of sugammadex in the absence of neuromuscular monitoring.MethodsOne hundred and forty patients who underwent laryngeal microsurgery with the use of rocuronium as a neuromuscular blocking agent, without the use of a neuromuscular monitoring device, were retrospectively investigated. The patients were randomly chosen among all the patients who met the inclusion criteria at a tertiary university hospital between July 2013 and February 2015 and were allocated to group S (sugammadex group) or group P (pyridostigmine group) according to the neuromuscular reversal agent administered. Five patients were excluded from analysis and 135 patients completed the study. Primary outcome was extubation time. Secondary outcomes were anaesthesia time, the correlation between anaesthesia time and extubation time, the total amount of rocuronium, and postoperative adverse events in the post-anaesthesia care unit (PACU).ResultsExtubation time was significantly shorter in group S (6.3 ± 3.9 min) than in group P (9.0 ± 5.4 min). Anaesthesia time was also significantly shorter in group S (30.7 ± 10.3 min) than in group P (35.8 ± 12.6 min). In the patients with an anaesthesia time of 30 min or less, there was a positive correlation between anaesthesia time and extubation time in group P (r = 0.453), but there was no significant relationship in group S. The total amount of rocuronium used was higher in group S (0.62 ± 0.11 mg kg−1) than in group P (0.38 ± 0.14 mg kg−1). Postoperative adverse events in the PACU were comparable between the groups, except for tachycardia events: the incidence of tachycardia was significantly lower in group S (8.0 %) than in group P (17.3 %).ConclusionsSugammadex could shorten anaesthesia and extubation times as well as recovery time in the PACU and reduce postoperative hemodynamic complications in a clinical setting in the absence of neuromuscular monitoring. This may enhance the patients’ recovery in the operating room and PACU while improving the postoperative condition of patients.Trial registrationThe trial was registered in the UMIN clinical trials registry (www.umin.ac.jp/ctr/index/htm; unique trial number: UMIN000016602; registration number: R000019266; principal investigator’s name: Byung Gun Lim; date of registration: February 22, 2015).Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0221-2) contains supplementary material, which is available to authorized users.

Sugammadex Use in a Patient with Wolff-Parkinson-White (WPW) Syndrome.

Wolff-Parkinson-White (WPW) syndrome is a disease associated with episodes of supraventricular tachycardia and ventricular pre-excitation or atrial fibrillation. WPW is characterized by an aberrant electrical conduction pathway between atria and ventricles. The major anesthetic problem connected with WPW syndrome is the risk of tachyarrhythmias due to accessory pathway. Therefore, it has been proposed that the aim of anesthetic management should be the avoidance of tachyarrhythmia and sympathetic stimulation. Sugammadex was administered as a neuromuscular reversal agent in this case. To our knowledge, this is the first case report of sugammadex use in a patient with WPW. This report presents a case of general anesthesia management in a patient with WPW syndrome. We think that it is appropriate to use sugammadex to reverse rocuronium for the prevention of sudden hemodynamic changes in patients with WPW who underwent general anesthesia.

The combination of sugammadex and neostigmine can reduce the dosage of sugammadex during recovery from the moderate neuromuscular blockade.

BackgroundSugammadex is a novel neuromuscular reversal agent, but its associated hypersensitivity reaction and high cost have been obstacles to its widespread use. In the interest of reducing the necessary dosage of sugammadex, the reversal time of the combined use of sugammadex and neostigmine from moderate neuromuscular blockade were investigated.MethodsThe patients enrolled ranged in age from 18 to 65 years old with American Society of Anesthesiologists class 1 or 2. The subjects were randomly assigned into one of the four groups (Group S2, S1, SN, and N; n = 30 per group). The reversal agents of each groups were as follows: S2 - sugammadex 2 mg/kg, S1 - sugammadex 1 mg/kg, SN - sugammadex 1 mg/kg + neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg, N - neostigmine 50 µg/kg + glycopyrrolate 10 µg/kg. The time to recovery of the train-of-four (TOF) ratio was checked in each group.ResultsThe time to 90% recovery of TOF ratio was 182.6 ± 88.9, 371.1 ± 210.4, 204.3 ± 103.2, 953.2 ± 379.7 sec in group S2, S1, SN and N, respectively. Group SN showed a significantly shorter recovery time than did group S1 and N (P < 0.001). However, statistically significant differences between the S2 and SN groups were not be observed (P = 0.291). No hypersensitivity reactions occurred in all groups.ConclusionsFor the reversal from rocuronium-induced moderate neuromuscular blockade, the combined use of sugammadex and neostigmine may be helpful to decrease the recovery time and can also reduce the required dosage of sugammadex. However, the increased incidence of systemic muscarinic side effects must be considered.

Cardiac Arrest and Neuromuscular Blockade Reversal Agents in the Transplanted Heart

CASES OF CARDIAC ARREST after the administration of a neuromuscular reversal agent have been reported in the literature. However, no clear explanation of these near-fatal events has been formulated. In the authors' institution, 2 additional cases of cardiac arrest have been experienced. Therefore, this study reviewed the characteristics of all available patients and, in conjunction with the latest studies on heart transplant patients, speculated on the possible causes of these events.

General anesthesia for electroconvulsive therapy with Brugada electrocardiograph pattern

Brugada syndrome is characterized by an electrocardiograph pattern of right bundle-branch block and has an increased risk for cardiac arrest due to malignant arrhythmia. We describe the successful anesthetic management for electroconvulsive therapy in a patient with Brugada electrocardiograph pattern. Patients with Brugada ECG pattern are not recommended to use neostigmine which augments ST elevation. Sugammadex was administered as a neuromuscular reversal agent in this case. Sugammadex provides rapid reversal of profound rocuronium-induced neuromuscular blockade under propofol anesthesia.

Succinylcholine: A Useful Drug in Bariatric Surgery

To the editor: We read the recent article by Tejirian et al. [1], and as members of our American College of Surgeons Level 1A Center of Excellence management team, we feel that a reply is indicated. Based on a single case, they recommended avoidance of succinylcholine (SCH) in all bariatric patients. At Stanford University, we take an opposite approach and use SCH to facilitate tracheal intubation for all of our morbidly obese patients. With its rapid onset and short duration of action, SCH is ideal for rapid sequence induction of anesthesia. This is particularly important in bariatric patients because hemoglobin desaturation occurs rapidly following apnea and intubation of the trachea must be accomplished quickly [2]. SCH’s onset is fast and its duration of action is short. Therefore, if difficulties are encountered when securing the airway, the immediate return of motor function allows the patient to resume spontaneous ventilation. There is no way to prove or disprove the “clinical” diagnosis that SCH was responsible for their patient’s severe muscle aches. If SCH was the cause, it was an extreme presentation of a complication that is usually mild (if and when present) and of minimal clinical significance, especially in bariatric patients [3]. We have anesthetized hundreds of morbidly obese patients and thousands of other patients using SCH without ever having the serious complications they associated with its use. As the authors’ note, once the neuromuscular reversal agent sugammadex becomes available clinically, a nondepolarizing muscle relaxant such as rocuronium or vecuronium will become a safe option to SCH. With sugammadex, reversal will be obtained immediately, effectively controlling time of paralysis. Until that time, we believe that SCH remains the drug of choice for tracheal intubation in bariatric patients.

Postoperative nausea and vomiting (PONV) in children.

Postoperative nausea and vomiting (PONV) are common and unpleasant complications. The aim of this study was to evaluate possible aetiologies of PONV in children and to formulate measures to reduce its incidence. During four months 780 patients requiring anaesthesia were studied prospectively. Vomiting occurred in 34.4%, nausea in 39.3% of the patients. Patients < 2 years of age and boys > 13 years vomited rarely, whereas girls > 13 years vomited frequently. The use of propofol was associated with a decreased rate of PONV. Administration of drugs for reversal of neuromuscular blockade, postoperative opioids and certain operative procedures were associated with an increased rate of PONV. Patients with a history of motion sickness and or previous PONV also had an increased rate of PONV. The majority of the patients perceived PONV as a very unpleasant experience. Possible measures to reduce its incidence include: administration of prophylactic antiemetic drugs for high-risk patients (3-13 years, girls > 13 years, history of motion sickness and or previous PONV) who are undergoing surgical procedures with a high incidence of PONV. Adjustment of anaesthetic technique as wider use of propofol, NSAIDs or regional analgesia instead of opioids for postoperative pain relief and avoidance of neuromuscular reversal agents if possible.