Postoperative Residual Curarization Research Articles

Effect of Smoking on Reversing Neuromuscular Block.

Rocuronium is a non-depolarising, intermediate-acting, monoquaternary amino steroid and was brought into clinical use as a potentially ideal muscle relaxant. Post-operative residual curarisation (PORC) results from the prolonged effects of non-depolarising neuromuscular blocking agents. This is a common problem and seriously affects patient safety. No recent study has investigated the effects of sugammadex on smokers, which is often used to restore neuromuscular block and avoid PORC. This study compares the severity of the effects of sugammadex used for antagonising rocuronium bromide and antagonism durations in smokers and non-smokers. This randomised, prospective study included 40 patients scheduled for elective surgery and belonging to classes I and II based the American Society of Anesthesiologists classification, who were either smokers for at least 10 years or non-smokers. Patients underwent routine and neuromuscular monitoring. At induction, 2 mg kg-1 propofol and 1 mcg kg-1 intravenous fentanyl were applied. After the loss of eyelash reflex, 0.6 mg kg-1 intravenous rocuronium was administered. Patients were intubated at train of four (TOF) 2. Anaesthesia was continued with 50% O2+50% air and 2% sevoflurane. Rocuronium, 0.15 mg kg-1, was administered at TOF 2 during the operation. At the end of the operation, 2 mg kg-1 sugammadex was administered. The times until TOF 0.7, 0.8 and 0.9 were recorded. Intubation time was 132.8±46.4 s for smokers and 127.6±32.7 s for non-smokers. After sugammadex administration, the time to TOF 0.7 was 153.3±54.7 s in smokers and 125±67.2 s in non-smokers. The times were 178.4±58.8 and 146.6±72.6 s for TOF 0.8 and 200.8±55.8 s and 170.4±77.8 s for TOF 0.9 in smokers and non-smokers, respectively. Although not statistically significant, the time to reach each TOF was longer for smokers. Larger populations and different perspectives are needed to find if sugammadex use is affected by smoking, which has negative effects on the body.

Postoperative Residual Curarization: A Case Report

Postoperative Residual Curarization: A Case Report

Recovery of laryngeal nerve function with sugammadex after rocuronium-induced profound neuromuscular block

Study ObjectiveThe aim of this study was to evaluate the efficacy of sugammadex in reversing profound rocuronium-induced neuromuscular block at the laryngeal adductor muscles using motor-evoked potentials (mMEPs). DesignA prospective observational study. SettingUniversity surgical center. PatientsTwenty patients with American Society of Anesthesiologists physical class I-II status who underwent propofol-remifentanil anesthesia for the surgery of the thyroid gland. InterventionsPatients were enrolled for reversal of profound neuromuscular block (sugammadex 16 mg/kg, 3 minutes after rocuronium 1.2 mg/kg). To prevent laryngeal nerve injury during the surgical procedures, all patients underwent neurophysiologic monitoring using mMEPs from vocal muscles. At the same time, the registration of TOF-Watch acceleromyograph at the adductor pollicis muscle response to ulnar nerve stimulation was performed; recovery was defined as a train-of-four (TOF) ratio ≥0.9. Measurement and main resultsAfter injection of 16 mg/kg of sugammadex, the mean time to recovery of the basal mMEPs response at the laryngeal adductor muscles was 70 ± 18.2 seconds. The mean time to recovery of the TOF ratio to 0.9 was 118 ± 80 seconds. In the postoperative period, 12 patients received follow-up evaluation of the vocal cords and no lesions caused by the surface laryngeal electrode during electrophysiological monitoring were noted. ConclusionsRecovery from profound rocuronium-induced block on the larynx is fast and complete with sugammadex. In urgent scenarios, “early” extubation can be performed, even with a TOF ratio ≤0.9. However, all procedures to prevent postoperative residual curarization should still be immediately undertaken.

A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients.

The importance of the characteristics of anesthesia and postoperative residual curarization (PORC) in the elderly population should be a growing concern in this century. To investigate the effect of sugammadex on the duration of the recovery from neuromuscular blocking agents and postoperative residual curarization in the young elderly and middle-aged elderly patients who underwent elective laparoscopic cholecystectomy, followed by a train of four (TOF) watch monitorization. Prospective clinical trial study. Sixty patients over the age of 65 with American Society of Anesthesiologists I-III were divided into two groups according to their age (65-74 years old and ≥75 years old). Patients received sugammadex (2.0 mg/kg iv) at the reappearance of the second twitch of the TOF as an agent for reversal of neuromuscular blockage at the end of surgery. Patients were extubated at the time of TOF ≥0.9. The patients' TOF responses were evaluated with regards to PORC in at the 5th minute and were followed up for one hour in the recovery room. Reintubation was applied for those patients who developed PORC and had peripheric oxygen saturation <90% despite being given 6 L oxygen per min with a face mask. The onset time of neuromuscular blocking agent and time from T2 to achieve TOF ratio 90% (the duration of sugammadex effect) or over were found to be longer in the middle-aged elderly group than in the young elderly group. A statistically significant relationship was found between age and the duration of TOF ratio to reach 0.9 in the same direction. The PORC incidence and rate of reintubation were found to be 1.7% in all patients. In our opinion, it is necessary to remember that the duration of sugammadex effect on the recovery period is prolonged for patients who are aged ≥75 years compared to patients aged between 65-74 years. (ClinicalTrials.gov Identifier: ACTRN12615000758505).

Sugammadex for reversal of neuromuscular blockade: a retrospective analysis of clinical outcomes and cost-effectiveness in a single center.

ObjectiveThe aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen for neuromuscular block (NMB) management.MethodsWe conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium–sugammadex) and as rescue therapy after neostigmine reversal (rocuronium–neostigmine–sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen was carried out. To such purpose, two periods were compared: 2011–2012, without sugammadex available; 2013–2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective.ResultsThe introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P<0.001) and were discharged to the surgical ward (P<0.001) more rapidly than controls. The cost-saving of sugammadex as first-choice reversal drug has been estimated to be €2.9/case. Patients receiving sugammadex as rescue therapy after neostigmine reversal (3.2%) showed no difference in time to discharge to the surgical ward (P=0.44) compared to controls. No unplanned intensive care unit (ICU) admissions with rocuronium–neostigmine–sugammadex strategy were observed. The potential economic benefit in avoiding postoperative residual curarization (PORC)-related ICU admission in the 2013–2014 period was estimated at an average value of €13,548 (€9,316–€23,845).ConclusionSugammadex eliminated PORC and associated morbidities. In our center, sugammadex reduced the costs of NMB management and promoted rapid turnover of patients in operating rooms, with total cost-effectiveness that counteracts the disadvantages of its high cost.

,

,

500 Years after Curares Discovery: What has Changed, What has not?

Curares were first discovered in 1500’s by pioneering explorer which were perfectly aware of their use as poisons but completely unaware of their potential as medications; it was to wait until late 1800’s to know some more on them, and only in middle 1940’s some medical applications started, resulting in important evolution towards modern anesthetic techniques, including balanced anesthesia and opportunity for more complex surgical procedures. New molecules, meaning new problems, including Postoperative Residual Curarization (PORC), anesthesia awareness, difficult airway management and related clinical problems. Many advancements have been performed in the last 50 years, new molecules are available and new opportunities for powerful, fast and effective antagonism are available. Nevertheless, curares remain poisons, and their use could be considered safe only in experienced hands, not less than native americans Men of Medicine, and always taking account of situation, strategy and patients characteristics before counting on onset, offset and possibility for reversal. All points showing that in 500 years many things changed and many others they probably remained the same, because in the end, it is not the drug, but the man who gives it.

Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patients undergoing surgery &amp;ndash; a&amp;nbsp;series of 117 cases

PurposeMyasthenia gravis (MG) is an autoimmune disease interfering with neuromuscular transmission. Patients are at risk of postoperative residual curarization (PORC) if nondepolarizing muscle relaxants are used. Clinically inapparent insufficient muscle strength may result in hypoventilation and postoperative bronchopneumonia. We describe a cohort of 117 cases in which sugammadex was used in MG patients undergoing surgery with muscle relaxation with rocuronium.Methods and patientsWe anesthetized 117 patients with MG using rocuronium and sugammadex as neuromuscular blockade reversal agent. One hundred five patients underwent surgical thymectomy and 12 underwent cholecystectomy (five laparotomic and seven laparoscopic). We measured time from sugammadex administration to recovery and to extubation, using the TOF-Watch® (series of four consecutive electrical impulses [the train-of-four] >0.9). We tracked peripheral capillary oxygen saturation (SpO2) <95%, elevation of partial pressure of carbon dioxide (pCO2) >10% above baseline, number of reintubations within the first 48 hours, and number of pneumonias within 120 hours, postoperatively. Results were processed as average, minimum, and maximum values.ResultsThe period needed to reach train-of-four of 0.9 following sugammadex administration was on average 117 seconds (minimum of 105 seconds/maximum of 127 seconds) and differed within deviation <10%. The time to extubation following sugammadex administration was on average 276 seconds (minimum of 251 seconds/maximum of 305 seconds) and differed minimally among patients as well. We observed no SpO2 <95%, no pCO2 elevation >10% above a baseline, no emergent reintubation within the first 48 hours, and no pneumonia diagnosed on clinical basis within 120 hours, postoperatively in all 117 patients.ConclusionIn this cohort of MG patients undergoing surgery using rocuronium and sugammadex, we did not observe any signs of postoperative residual curarization and respiratory depression. The neuromuscular blockade recovery was reliable, predictable, and rapid.

Use of neuromuscular blockers in Brazil

The objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers, focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of neuromuscular blockers. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main neuromuscular blockers used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to neuromuscular blockers were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to neuromuscular blockers. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

Uso de bloqueadores neuromusculares no Brasil

The objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers (NMB), focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of NMB. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main NMB used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to NMB were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to NMB. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

Nov način odmerjanja sugamadeksa za odpravo z vekuronijem povzročene nevromišične blokade

Background and Goal of Study: Sugammadex is a selective binding agent that bindsaminosteroid muscle relaxants. Each molecule of sugammadex binds one molecule of musclerelaxant. To produce the same depth of the neuromuscular block (NMB) much less molecules ofvecuronium are needed than molecules of rocuronium. In theory less sugammadex would beneeded to neutralise the neuromuscular block if vecuronium was used to produce the neuromuscular block. Our aim was to compare reversal of vecuronium induced muscle relaxation between a new way of dosing sugammadex, which takes into account TOF value at the end of the surgery and the amount of vecuronium given during the surgery with neostigmine atropine combination. We also wanted to know how much this dosage regime can save compared to standard per kg dosage.Materials and Methods: 20 adult patients requiring a general anesthesia for surgery were analysed. The first group of 11 patients (SUG) received sugammadex at the end of the surgery according to the table one for NMB reversal. The second group of 9 patients (NEO) received neostigmine and atropine. Train of four (TOF) value was recorded at the end of the surgery and then continuously until the TOF value reached more than 0.9 and the patient was extubated. The time required for the TOF value reaching 0.9 was compared between the groups. For economical evaluation we compared the amount of sugammadex used in the SUG group to standard sugammadex per kg dosage.Results and Discussion: Mean time to recovery to a TOF ratio of 0.9 with sugammadex was 5.12min versus 12.6 min with neostigmine atropine (P &lt; 0.05). No sign of postoperative residual curarisation was observed in the SUG group. For patients in our study 530 mg of sugammadex were used to neutralise the NMB. If standard per kg sugammadex dosing had been used we would have used 2420 mg for the NMB reversal.Conclusion(s): New dosing for sugammadex was successful in neutralising the NMB regardlessof the TOF value at the end of the surgery. The economic impact of the proposed dosing is significant as an average cost for the vecuronium NMB reversal is reduced from around 80 € to 20 € per patient.

Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine.

Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy. We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization. Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization. With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

Target-Controlled Infusion of Remifentanil Without Muscle Relaxants Allows Acceptable Surgical Conditions During Thoracotomy Performed Under Sevoflurane Anesthesia

To test the hypothesis that the use of a nonmuscle relaxant anesthetic technique (NMRT) during thoracotomy would be associated with comparable surgical conditions with the standard use of neuromuscular blocking drugs. A prospective, randomized, single-blind, controlled study. A single university hospital. Sixty-six patients scheduled for open thoracotomy under sevoflurane anesthesia with a target-controlled infusion (TCI) of remifentanil. After ethical approval, patients were randomly assigned to receive cisatracurium or saline (n = 33 for each group) during the entire study period. The four-point ordinal surgical rating scale, the intubating conditions, the use of anesthetics and vasopressors, the incidence of light anesthesia (defined as an episode with state entropy values that exceeded 50 and/or mean arterial blood pressure and heart rate values that exceeded the baseline by 20% and lasted for more than 3 consecutive minutes), and the times to clinical recovery and postanesthesia care unit (PACU) discharge, hospital stays, and postoperative residual curarization (PORC) were recorded. Compared with the use of cisatracurium, the use of NMRT resulted in comparable good-to-excellent surgical rating scales (90.9% v 94.0%, respectively; p = 0.642), good-to-excellent laryngoscopy and endobronchial intubating conditions (93.9% v 100%, respectively; p>0.09), use of anesthetic and vasopressor medications, and hospital stays, together with shorter clinical recovery, extubation times (7.6 [95% CI 6.82 to 8.39] v 19.0 [95% CI 15.76 to 22.23] minutes, respectively; p<0.001), and PACU stays (37.4 [95% CI 35.09 to 39.79] v 70.9 [95% CI 56.90 to 84.91] minutes, respectively; p<0.001). The use of cisatracurium resulted in a nonstatistical number of light anesthesia episodes upon positioning, skin incision, and rib separation (p>0.624,with Fisher's exact test). There were no failed intubations in the 2 groups. No patient received cisatracurium in the NMRT group. Two patients (6.1%) in the cisatracurium group experienced PORC that required tracheal intubation in the PACU. The use of TCI of remifentanil with NMRT offers acceptable laryngoscopy, intubating, and surgical conditions during sevoflurane anesthesia for open thoracotomy, especially when. the anesthesiologists have more than 10 years' experience.

Prevalence and Risk Factors of Postoperative Residual Curarization in Patients Arriving at Postanesthesia Care Unit after General Anesthesia: A Prospective Cohort Study

Background: Postoperative residual curarization (PORC) following the use of neuromuscular blocking drugs (NMBDs) remains a significant problem. The purpose of this study was to determine the prevalence and risk factors of PORC in patients who were admitted to postanesthesia care unit (PACU) after general anesthesia during our routine clinical practice.Methods: This was a prospective, observational cohort study. Patients who were admitted to PACU after general anesthesia were enrolled. Neuromuscular function was monitored using acceleromyography and train-of-four (TOF) stimulation. A TOF ratio of less than 0.9 was defined as having PORC. Multivariate Logistic regression analysis was performed to identify risk factors of PORC.Results: A total of 542 patients completed the study. PORC occurred in 30.6% (166/542) of patients. Increasing age (odds ratio [OR] 1.211, 95% confidence interval [CI] 1.068-1.374, P=0.003), combined use of two different non-depolarizing NMBDs during surgery (OR 1.693, 95% CI 1.138-2.520, P=0.009) and hypothermia at PACU arrival (OR 1.778, 95% CI 1.043-3.032, P=0.035) were associated with increased risk of PORC, whereas administration of neostigmine at the end of surgery (OR 0.341, 95% CI 0.164-0.709, P=0.004) and prolonged time interval from last dose of NMBDs to PACU arrival (OR 0.326, 95% CI 0.215-0.496, P<0.001) were associated with decreased risk of PORC. Patients with PORC at PACU arrival had prolonged PACU stay, increased occurrence of adverse events during PACU stay and increased rate of PORC at PACU discharge.Conclusions: PORC was common in patients who were admitted to PACU after general anesthesia. Increasing age, combined use of two different non-depolarizing NMBDs during surgery and hypothermia at PACU arrival were associated with increased risk of PORC. Citation: Min Xie, Dong-Xin Wang, Zhi-Yu Geng. Prevalence and risk factors of postoperative residual curarization in patients arriving at postanesthesia care unit after general anesthesia: a prospective cohort study. J Anesth Perioper Med 2014; 1: 72-8. doi: 10.24015/JAPM.2014.0012This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Sugammadex versus neostigmina en pacientes pediátricos: estudio prospectivo y aleatorizado

Background and objectivesAcetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures. Methods80 patients, aged 2-12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6mgkg−1 rocuronium and monitorized with train-of-four. Group RN (n=40) received 0.03mgkg−1 neostigmine, Group RS (n=40) received 2mgkg−1 sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train-of-four ratio during this time, time to reach train-of-four >0.9, and probable complications were recorded. ResultsThere was no significant difference between the patients’ characteristics. Extubation time and time to reach train-of-four>0.9 were significantly higher in Group RN (P=.001, P=.002). Train-of-four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group (P=.020). Extubation train-of-four ratio was significantly lower in Group RN (P=.002). ConclusionSugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures.

Pesquisa de curarização residual no pós‐operatório, eventos respiratórios agudos e abordagem de anestesiologistas

Background and objectivesResidual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. MethodsThis observational study included 415 patients who received general anesthesia with intermediate‐acting NMBDs. Anesthesia was maintained by non‐participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90–93% despite receiving 3L/min nasal O2, respiratory rate >20breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8‐question mini‐survey shortly after the study. ResultsThe incidence of PORC was 43% (n=179) for TOFR <0.9, and 15% (n=61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p<0.05). In addition, 66% (n=272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n=126) of the patients receiving neostigmine. ConclusionsWhen routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Sugammadex versus neostigmina em pacientes pediátricos: estudo prospectivo e randomizado

Background and objectivesAcetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures. Methods80 patients, aged 2–12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6mgkg−1 rocuronium and monitorized with train‐of‐four. Group RN (n=40) received 0.03mgkg−1 neostigmine, Group RS (n=40) received 2mgkg−1 sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train‐of‐four ratio during this time, time to reach train‐of‐four>0.9, and probable complications were recorded. ResultsThere was no significant difference between the patients’ characteristics. Extubation time and time to reach train‐of‐four>0.9 were significantly higher in Group RN (p=0.001, p=0.002). Train‐of‐four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group (p=0.020). Extubation train‐of‐four ratio was significantly lower in Group RN (p=0.002). ConclusionSugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists

Background and objectivesresidual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. MethodsThis observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90–93% despite receiving 3L/min nasal O2, respiratory rate >20breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. ResultsThe incidence of PORC was 43% (n=179) for TOFR <0.9, and 15% (n=61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p<0.05). In addition, 66% (n=272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n=126) of the patients receiving neostigmine. ConclusionsWhen routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Sugammadex versus neostigmine in pediatric patients: a prospective randomized study

Background and objectivesAcetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures. Methods80 patients, aged 2–12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6mgkg−1 rocuronium and monitorized with train-of-four. Group RN (n=40) received 0.03mgkg−1 neostigmine, Group RS (n=40) received 2mgkg−1 sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train-of-four ratio during this time, time to reach train-of-four>0.9, and probable complications were recorded. ResultsThere was no significant difference between the patients’ characteristics. Extubation time and time to reach train-of-four>0.9 were significantly higher in Group RN (p=0.001, p=0.002). Train-of-four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group (p=0.020). Extubation train-of-four ratio was significantly lower in Group RN (p=0.002). ConclusionSugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures.

Case Scenario: Residual Curarization in Diabetic Polyneuropathy

Case Scenario: Residual Curarization in Diabetic Polyneuropathy