Recovery Of Neuromuscular Block Research Articles

Pediatric Intraoperative Electromyographic Responses at the Adductor Pollicis and Flexor Hallucis Brevis Muscles: A Prospective, Comparative Analysis.

Peripheral nerve stimulation with a train-of-four (TOF) pattern can be used intraoperatively to evaluate the depth of neuromuscular block and confirm recovery from neuromuscular blocking agents (NMBAs). Quantitative monitoring can be challenging in infants and children due to patient size, equipment technology, and limited access to monitoring sites. Although the adductor pollicis muscle is the preferred site of monitoring, the foot is an alternative when the hands are unavailable. However, there is little information on comparative evoked neuromuscular responses at those 2 sites. Pediatric patients undergoing inpatient surgery requiring NMBA administration were studied after informed consent. Electromyographic (EMG) monitoring was performed simultaneously in each participant at the hand (ulnar nerve, adductor pollicis muscle) and the foot (posterior tibial nerve, flexor hallucis brevis muscle). Fifty patients with a mean age of 3.0 ± standard deviation (SD) 2.9 years were studied. The baseline first twitch amplitude (T1) of TOF at the foot (12.46 mV) was 4.47 mV higher than at the hand (P <.0001). The baseline TOF ratio (TOFR) before NMBA administration and the maximum TOFR after antagonism with sugammadex were not different at the 2 sites. The onset time until the T1 decreased to 10% or 5% of the baseline value (T1) was delayed by approximately 90 seconds (both P =.014) at the foot compared with the hand. The TOFR at the foot recovered (TOFR ≥0.9) 191 seconds later than when this threshold was achieved at the hand (P =.017). After antagonism, T1 did not return to its baseline value, a typical finding with EMG monitoring, but the fractional recovery (maximum T1 at recovery divided by the baseline T1) at the hand and foot was not different, 0.81 and 0.77, respectively (P =.68). The final TOFR achieved at recovery was approximately 100% and was not different between the 2 sites. Although this study in young children demonstrated the feasibility of TOF monitoring, interpretation of the depth of neuromuscular block needs to consider the delayed onset and the delayed recovery of TOFR at the foot compared to the hand. The delay in achieving these end points when monitoring the foot may impact the timing of tracheal intubation and assessment of adequate recovery of neuromuscular block to allow tracheal extubation (ie, TOFR ≥0.9).

Evaluation of a three-axial acceleromyography monitor in dogs compared with mechanomyography

ObjectiveTo compare the ratio of the train-of-four (TOF) and double burst stimulation (DBS) obtained with three-axial acceleromyography (AMG) and mechanomyography (MMG) in dogs during recovery from a rocuronium-induced neuromuscular block. Study designProspective, randomized, experimental study. AnimalsA total of six intact healthy adult male Beagle dogs, weighing 9.1 ± 1.9 kg and aged 3–5 years. MethodsDogs were anesthetized with intravenous (IV) dexmedetomidine and propofol, and isoflurane in oxygen. Neuromuscular function was measured with AMG and MMG in the contralateral thoracic limbs. Rocuronium (0.5 mg kg–1) was administered IV, and the TOF and DBS ratios measured. During neuromuscular block offset, MMG values were recorded when AMG first reached ratios of 0.9 and 1.0. True recovery from neuromuscular block was determined as MMG ratio ≥ 0.9. The false-positive (AMG ≥ 0.9 or 1.0, and MMG ratio < 0.9) rate was determined. Paired values were compared, and bias and limits of agreement were calculated. Receiver operating characteristic (ROC) curves were created. ResultsWhen AMG first reached 0.9 and 1.0 during recovery, MMG values were lower (p < 0.040). When AMG reached 0.9, the false-positive rate was 29% with TOF and 27% with DBS. It decreased to 12% (TOF) and 11% (DBS) when a ratio of 1.0 was used. AMG values were higher than paired MMG values (p < 0.001). The AMG overestimated MMG by 24% and 22% for TOF and DBS, respectively. Areas under the ROC curves (95% confidence interval) were 0.91 (0.89, 0.94) and 0.86 (0.81, 0.94) for TOF and DBS, respectively. Conclusionsand clinical relevance The three-axial AMG monitor overestimated neuromuscular function and, in some cases, indicated adequate recovery despite the MMG ratio being < 0.9. A TOF or DBS ratio of at least 1.0 should be considered when monitoring recovery of neuromuscular block with this AMG device.

Comparison of two electromyography-based neuromuscular monitors, AF-201P and TetraGraph, in rocuronium-induced neuromuscular block: A prospective comparative study

BackgroundThe study aimed to compare the responses obtained simultaneously from the newly developed electromyography (EMG)-based neuromuscular monitors, AF-201P and TetraGraph™, during rocuronium-induced neuromuscular block. MethodsTwenty patients were enrolled in this study. During total intravenous general anesthesia, train-of-four (TOF) responses following 0.9-mg/kg-rocuronium administration were monitored at the abductor digiti minimi muscle with AF-201P and TetraGraph on the contralateral arms. Sugammadex 2 mg/kg was administered when both devices showed TOF counts (TOFC) = 2. The primary outcome was time from rocuronium administration to the first appearance of the post-tetanic count (PTC) response (first PTC). The secondary outcomes were supramaximal current, baseline compound muscle action potential, onset time, time to TOFC = 1, time to TOFC = 2, and time from sugammadex administration to TOF ratio ≥ 0.9. We used the paired t-test and Wilcoxon signed-rank test to analyze parametric and non-parametric data, respectively. P < 0.05 defined statistical significance. ResultsA total of 19 patients were analyzed. The supramaximal current was significantly lower with AF-201P than TetraGraph (31.7 ± 13.2 vs. 43.2 ± 8.2, p = .002). The time to first PTC (24.9 ± 9.4 vs. 27.3 ± 8.9 min, p = .026), time to TOFC = 1 (42.3 ± 9.0 vs. 45.1 ± 10.4 min, p = .03), and time to TOFC = 2 (52.0 ± 10.5 vs. 54.6 ± 11.7 min, p = .014) were significantly faster with AF-201P than with TetraGraph. There were no significant differences in the other outcomes between the devices. ConclusionsAF-201P showed faster recovery of rocuronium-induced neuromuscular block compared with TetraGraph.

A comparison between cisatracurium and rocuronium-induced neuromuscular block on laryngeal electromyography recovery after neostigmine reversal in a porcine model.

BackgroundInducing and reversing neuromuscular block is essential to a positive outcome of thyroid surgery, with intraoperative neuromonitoring (IONM) being used to decrease recurrent and superior laryngeal nerve injuries and improve vocal outcome. Neostigmine is a non-specific broad-spectrum and inexpensive reversal agent for neuromuscular blocking agents (NMBAs). The aim of this porcine study was to explore the effect of neostigmine on electromyography (EMG) signal recovery profile following the commonly used NMBAs, cisatracurium and rocuronium.MethodsTwelve piglets were allocated into two groups with six piglets in each group. When stable baseline EMG signals were obtained, a neuromuscular block was induced by intravenous cisatracurium 0.2 mg/kg (group C) or rocuronium 0.6 mg/kg (group R) for each piglet. We compared laryngeal EMG tracing with spontaneous recovery (control) and neostigmine (0.04 mg/kg) reversal for each group. The time course of real-time laryngeal EMG signals was observed for 30 min from NMBA injection. Effects of neostigmine on EMG signal were assessed at 50% EMG recovery and by the maximum neuromuscular block recovery degree from the baseline value.ResultsNeostigmine shortened the recovery time to 50% EMG amplitude in both group C (16.5 [2.5] vs. 29.0 [2.0] min, P<0.01) and group R (16.5[2.5] vs. 26.5 [1.5] min, P<0.05) compared to spontaneous recovery, respectively. Neostigmine reversal also enhanced the maximum degree of EMG amplitude recovery in both group C (83.6 [5.1] vs. 47.2 [6.1] %, P<0.01) and group R (85.6 [18.2]vs. 57.1 [6.3] %, P<0.05) compared to spontaneous recovery, respectively. The reversal effect of neostigmine did not differ significantly between cisatracurium and rocuronium.ConclusionsThis porcine model demonstrated that neostigmine provides an adequate and timely IONM signal suppressed by both cisatracurium and rocuronium. These results can potentially expand the options for precision neuromuscular block management during IONM to improve vocal outcomes in thyroid surgery patients.

Retraction Note to: Delayed recovery of vecuronium neuromuscular block in diabetic patients during sevoflurane anesthesia.

Retraction Note to: Delayed recovery of vecuronium neuromuscular block in diabetic patients during sevoflurane anesthesia.

Sugammadex Versus Neostigmine for Neuromuscular Block Reversal and Postoperative Pulmonary Complications in Patients Undergoing Resection of Lung Cancer

This study aimed to compare the effect of sugammadex and neostigmine on neuromuscular block reversal and the incidence of postoperative pulmonary complications in patients undergoing lung cancer resection. A double-blind, randomized, prospective study. A single major urban teaching and university hospital. One hundred adult patients underwent elective radical resection of lung cancer under general anesthesia. Patients were assigned into neostigmine (0.05 mg/kg)+atropine 0.02 mg/kg group and sugammadex (2 mg/kg) group. The primary outcomes were the incidence of any postoperative pulmonary complications, and the time to achieve 90% of train-of-four (TOF) after the administration of sugammadex or neostigmine. The secondary endpoints were the number of patients with TOF ratio (TOFr) <0.9 at the time of tracheal extubation, the incidence of readmission 30 days after discharge, and specific postoperative pulmonary complications. Results showed that the average time of recovery to TOFr ≥0.9 with sugammadex was 164.5 ± 27.7 seconds versus 562.9 ± 59.7 seconds with neostigmine+atropine treatment. Fewer sugammadex-treated patients did not achieve TOFr of 0.9 at the time of tracheal extubation than did neostigmine-treated participants. Patients in the sugammadex group had lower incidence of postoperative lung complications, and shorter durations of postanesthesia care unit stay and postoperative hospital stay than those in the neostigmine group. There was no significant difference in the incidence of readmission between the 2 groups. Administration of sugammadex provided faster recovery of rocuronium-induced neuromuscular block when compared with neostigmine. Moreover, for patients undergoing lung cancer resection, administration of sugammadex could reduce the incidence of postoperative pulmonary complications and duration of postoperative hospital stay.

Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study

Study objectiveQuantitative neuromuscular monitoring is traditionally evaluated at the adductor pollicis muscle. By contrast, the TOF-Cuff compressomyograph evaluates neuromuscular block (NMB) at the upper arm. However, compressomyography has not been fully validated against other monitoring entities. This study evaluates the agreement between NMB measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle during various levels of neuromuscular block in patients with and without obesity. InterventionsNMB was measured at the upper arm by compressomyography (TOF-Cuff) and by electromyography (GE-NMT) at the adductor pollicis. DesignProspective, multicenter, observational study. SettingSecondary and tertiary care hospitals' operating theatres. Patients200 non-obese and 50 obese patients. MeasurementsDuring onset and offset of deep (post-tetanic-count 1–15 twitches), moderate (Train-of-Four-count 1–3 twitches) and shallow (Train-of-Four-ratio 0.01–1.0) depths of NMB were measured in obese and non-obese patients. The bias and limits of agreement of both devices were calculated using a Bland-Altman analysis for repeated measurements. Data obtained during spontaneous recovery (i.e. without the use of reversal agents) were used in the primary analyses. Main resultsData from enrolled patients yielded 942 paired post-tetanic-counts, 1175 paired train-of-four-counts and 1574 paired train-of-four ratios during spontaneous recovery. In non-obese patients, mean bias (95% CI) between the two devices was 3.405 (2.294 to 4.517) during deep NMB; −0.023 (−0.205 to 0.160) during moderate NMB and 0.312 (0.287 to 0.338) during shallow NMB. In obese patients, bias was −0.170 (−2.872 to 2.531); 0.178 (−0.202 to 0.558); 0.384 (0.299 to 0.469) for deep, moderate and shallow NMB respectively. ConclusionsThere is variable disagreement between the level of NMB measured at the upper arm by compressomyography and at the adductor pollicis muscle measured by electromyography, throughout the various stages of NMB in obese and non-obese patients. Recovery of NMB on compressomyography preceded recovery on electromyography, which may have consequences for reversal and extubation decisions in clinical practice.

Extravascular leakage of induction doses of rocuronium: four cases in which both depth of neuromuscular block and plasma concentration of rocuronium were assessed.

The duration of action of extravasated rocuronium varies depending on the patient's comorbidities. In patients who receive high doses of non-depolarizing neuromuscular blocking agents subcutaneously, anesthesiologists should be aware of unexpected prolongation of the progress and recovery of neuromuscular block. In such cases, the depth and recovery of neuromuscular block should be objectively monitored to avoid residual neuromuscular block and recurarization.

Cysatracurium dosing in gynecological laparoscopic surgery in obese patients

Aim. Substantiation of cisatracurium dosing in routine gynaecological laparoscopic surgery in obese patients based on comparative development time and duration of the neuromuscular block.Materials and methods. The assay included 24 women with class II-III obesity and routine laparoscopic gynaecological surgery divided into two cohorts. In cohort 1, cisatracurium was dosed at 0.15 mg/kg ideal body weight estimated with the Lorentz formula. In cohort 2, cisatracurium dosing was 0.15 mg/kg real body weight.Results. Tracheal intubation and total operation doses of the relaxant were higher when rated for real body weight. Time between cysatracurium administration and maximal neuromuscular transmission inhibition was less in cohort 2, and recovery time of the first response to stimulation — in cohort 1. Neuromuscular block recovery time to 25% TOF count and the recovery index did not differ significantly between the cohorts.Conclusion. Cysatracurium dosage rated for ideal body weight resulted in a better controlled course of the neuromuscular block, whilst rating for real body weight resulted in a dose-dependent increase of the duration of action and total consumption rate of the relaxant.

Precision Neuromuscular Block Management for Neural Monitoring During Thyroid Surgery

Introduction Titration of neuromuscular block (NMB) plays a key role in intraoperative recurrent laryngeal nerve monitoring during thyroid surgery. The combination of neuromuscular blocking agent and timely partial reversal of NMB was investigated in both animal experiments and clinical neuro-monitored thyroidectomy. Methods In animal experiments, 8 piglets received sugammadex to assess the laryngeal EMG recovery after rocuronium-induced NMB. In clinical monitored thyroidectomy, 40 patients each were allocated to conventional group and sugammadex group. Conventional group received rocuronium 0.3 mg/kg at anesthesia induction, while sugammadex group received partial NMB recovery protocol- 0.6 mg/kg of rocuronium at anesthesia induction and 0.5 mg/kg of sugammadex. Main outcome was assessed by first (V1) and final (V2) EMG signal induced by vagal stimulation. Results In the porcine model, 50% recovery of laryngeal EMG amplitude was achieved at 16.8 ± 1.9 and 6 ± 2.7 minutes respectively after 0.5 and 1 mg/kg of sugammadex (p < 0.01). In monitored thyroidectomy, EMG amplitudes at V1 in group S and group C were 1214 ± 623 and 915 ± 476 μV, respectively (p = 0.02). Positive and adequately high EMG amplitudes were observed at the early surgical stage for all patients. Sugammadex groups were superior to conventional group in EMG tube placement (p < 0.001). Conclusion Both porcine model and clinical application showed that precise NMB management by low-dose sugammadex was effective for intraoperative neural monitoring (IONM). The regimen ensured optimal conditions for tracheal intubation and timely neuromuscular function restoration for high-quality EMG signal.

Systematic Review on Rocuronium Continuous Infusion for Deep Neuromuscular Blockade.

Rocuronium is a muscle relaxant with increased use due to its binding relation with the reversal agent sugammadex. The purpose of this review entails the investigation of its use for the maintenance of Deep Neuromuscular Block (NMB) via continuous infusion. Based on PRISMA systematic search guidelines, databases included PubMed, ISI Web of Science, Cochrane Library and Google Scholar. This comprehensive search addresses surgical patients under deep muscle relaxation via continuous rocuronium infusion. The main indicators were the rocuronium administration, NMB monitoring approaches and effects in order to maintain the deep level of relaxation, as well as reversal time after a standard dose of sugammadex. Despite the variance in approaches found in the literature, findings show the overall maintenance of deep NMB requires approximately 0.758 mg.kg-1h-1 of rocuronium (according to the PTC target of 0-10, 0-5 and 1-2, mean estimates are 0.445, 0.65 and 0.833 mg.kg-1h-1 respectively), suggesting that a lower range and a smaller maximum of PTC response require higher amount of rocuronium for its maintenance. The standard dose of sugammadex (4 mg/kg), administered at the end of the surgery takes longer [2.85 (1.17) min] than when they are administered after moderate NMB recovery [1.68 (0.47) min]. Continuous infusion for deep NMB presents inherent advantages in terms of maintenance and stability of muscle relaxation. Monitoring and rocuronium administration approaches are fundamental and intrinsically connected to provide a stable and improved maintenance of deep NMB.

Philips Intellivue NMT module: precision and performance improvements to meet the clinical requirements of neuromuscular block management.

The variability or inaccuracy of acceleromyographic measurements could interfere with the interpretation of the train-of-four (TOF) ratio during neuromuscular block (NMB) recovery. This study evaluated the precision and performance of the Philips Intellivue NMT module (NMT) before (part 1) and after (part 2) several technical upgrades (i.e., firmware upgrade, new cable, and hand adapter) that were recently available. Two cohorts of 30 patients who were scheduled to undergo rhino/septoplasty under general anesthesia were included in the study. TOF ratios were recorded simultaneously every 15s on both hands with the NMT and a TOF-Watch SX installed inside a SL TOF-Tube (TWX). Before rocuronium was administered and once final responses were stabilized, the average of the four successive measurements that determined the baselines and repeatability coefficients were compared using a z test. Simultaneous measurements were recorded at different NMB stages: onset, depth of NMB after intubation, when TWX recovered TOF count 2, TOF ratios 0.5 and 0.9, and when NMT recovered TOF ratio 0.9. The results were compared using a Student t test; p < 0.05 was considered significant. The NMT repeatability coefficients obtained in part 1 were significantly higher than with the TWX, they were significantly lower in part 2. Initially, the NMT significantly overestimated NMB recovery at every stage. Conversely, in the second part of the study, no difference reached statistical significance. With the recent upgrades and the new hand adapter, the NMT provided similar results compared with the TWX, Their implementation should be recommended in clinical practice.

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial.

PurposeThe use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery.MethodsThe use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission.ResultsIn our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups.ConclusionOur clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Grip strength can be used to evaluate postoperative residual neuromuscular block recovery in patients undergoing general anesthesia.

Background:Residual postoperative neuromuscular blockade is an important clinical issue. Neuromuscular monitoring is usually used to evaluate neuromuscular recovery in patients undergoing general anesthesia. However, this procedure is inconvenient and not widely adopted. We aimed to examine the correlation between grip strength and train-of-four ratio (TOFr) to examine whether assessing grip strength can be used clinically to monitor residual neuromuscular blockade.Methods:One hundred twenty patients with ASA I or II scheduled for laparoscopic cholecystectomy under general anesthesia were enrolled in this study. All patients were randomly selected to receive standard anesthesia induction with either 0.6 mg·kg−1 rocuronium or 0.2 mg·kg−1 cisatracurium. Grip strength was tested in all patients using an electronic device before anesthesia and when TOFr values of 0.7, 0.8, and 0.9, and an hour later of TOFr value of 0.25. The time required for a change in TOFr values from 0.25 to 0.75 and 0.9 was evaluated. Spearman rank correlation analysis was performed to determine correlations between grip strength and TOFr.Results:Spearman rank correlation analysis indicated that there was a significant correlation between grip strength and TOFr during patient recovery from general anesthesia (correlation coefficient for grip strength recovery [rs] = 0.886). Subgroup analysis revealed that there were no differences in mean maximum grip value recovery between patients treated with rocuronium and those treated with cisatracurium when TOFr was 0.7, 0.8, and 0.9 or when the TOFr was 0.25 after 60 minutes (all P >.05). Recovery of TOFr from 0.25 to 0.75 and from 0.25 to 0.9 was longer in patients treated with rocuronium than in those treated with cisatracurium (both P <.001).Conclusion:There was a strong correlation between grip strength and TOFr during recovery from general anesthesia. Evaluation of grip strength can be used as an additional strategy to evaluate postoperative residual neuromuscular blockade.

Effects of two levels of partial neuromuscular block with atracurium on the ventilatory response to hypercapnia in anesthetized Beagles.

OBJECTIVE To evaluate effects of 2 levels of partial neuromuscular block on the ventilatory response to a hypercapnic challenge in anesthetized dogs and to evaluate effects of edrophonium for reversing partial neuromuscular block. ANIMALS 6 healthy adult Beagles. PROCEDURES Each dog was anesthetized twice with propofol and dexmedetomidine. End-tidal partial pressure of CO2 (Petco2), tidal volume (Vt), and peak inspiratory flow (PIF) were measured during breathing at rest. Maximal Vt and PIF (VtMAX and PIFMAX, respectively) in response to a hypercapnic challenge consisting of 10% CO2 inhaled for 1 minute were measured. Variables were measured before administration of atracurium (baseline), during moderate (train-of-four [TOF] ratio, 0.3 to 0.5) and mild (TOF ratio, 0.6 to 0.8) atracurium-induced neuromuscular block, and after neuromuscular block recovery (TOF ratio, ≥ 0.9) following administration of edrophonium or saline (0.9% NaCl) solution. Dogs for which any variable returned to < 80% of the baseline value were identified. RESULTS Partial neuromuscular block increased Petco2; it impaired Vt at rest and VtMAX but not PIF at rest and PIFMAX. All variables except Petco2 returned to baseline values when the TOF returned to ≥ 0.9. After recovery from neuromuscular block, significantly more dogs had a VtMAX < 80% of the baseline value when edrophonium was not administered. CONCLUSIONS AND CLINICAL RELEVANCE Partial neuromuscular block in anesthetized Beagles decreased spontaneous ventilation at rest and impaired the response to a hypercapnic challenge. Response to hypercapnic challenge might remain partially impaired after recovery of the TOF ratio to ≥ 0.9.

Recurrent Laryngeal Nerve Monitoring and Rocuronium: A Selective Sugammadex Reversal Protocol.

The use of neuromuscular blocking agents may affect intraoperative neuromonitoring during thyroid surgery. A selective neuromuscular recovery protocol was evaluated in a retrospective cohort study during human thyroid neural monitoring surgery. One hundred and twenty-five consecutive patients undergoing thyroidectomy with intraoperative neuromonitoring followed a selective neuromuscular block recovery protocol-single intubating dose of rocuronium followed by sugammadex if needed at the first vagal stimulation (V1). Data from 120 of 125 patients could be analysed. Fifteen (12.5%) patients needed sugammadex reversal to obtain an EMG response at the first vagal stimulation (V1). In the remaining 105 patients, spontaneous recovery of rocuronium-induced neuromuscular block was sufficient for a successful first vagal stimulation (V1). In patients undergoing thyroid surgery, routine reversal of rocuronium block with sugammadex is not mandatory for reliable intraoperative neuromonitoring. A selective neuromuscular block recovery approach may be a valuable and more cost-efficient alternative to routine reversal.

Sugammadex Efficacy for Rapid Reversal of Rocuronium Induced Neuromuscular Blockade in Pediatric Rigid Bronchoscopy Regardless the Depth of Anesthesia

Background: Bronchoscopy may be either rigid or flexible. Rigid bronchoscopy is usually done for diagnosis and treatment of intra and/or extra luminal obstruction in the airway for adults and children, anaesthesia for bronchoscopy poses unique challenges for the anaesthesiologist. This procedure needs specific technical precision because both the anaesthesiologist and operator share the same working space, that is, the airway. Pediatric rigid bronchoscopy needs a deep level of general anesthesia with a good (profound) muscle relaxation for a short time, with the modern anesthetic muscle relaxant rocuronium Bromide and its unique rapid onset it gives chance to be used in challenging airway procedures like rigid bronchoscopy and with the its newly advent of selective reversal, sugamadex, encourage its use in pediatric rigid bronchoscopy as it is usually performed for Foreign body removal. Aim: The aim of this study is to compare the efficacy of sugammadex and neostigmine for reversal of neuromuscular blockade induced by rocuronium for facilitating interventional rigid bronchoscopy and having awake child with good adequate muscle power and good ability to protect airway reflexes. Methods: This study was done on 100 patients ASA1-11 underwent rigid bronchoscopy for foreign body aspiration, we compared the efficiency of both neostigmine and the newly selective reversal agent; sugamadex in recovery of the patients, hemodynamics, and the presence of any side effects. Results: Our results showed that no significant changes between two groups in Table 1, Table 2, Table 3 i.e. heart rate, arterial blood pressure and O2 saturation (%) during all period of study i.e. Base line, Strating study drug, 2 min, 5 min, 10 min. But in Table 4, Table 5, Table 6 i.e. Time (in min) from administration at study drug until recovery (TOF>0.9) , extubation time in min (from administration at study drug until extubation), Recovery time (from administration at study drug until Aldrete score more than 9) the time was significantly shorter in group (1) when compared with group (2) which was (3.6 ± 2.6, 3.9 ± 2.6 and 7.3 ± 1.9) in group (1) and (15.12 ± 1.85, 15.85 ± 1.85 and 19.59 ± 2.3) in group (2). In Table 7, there was no significant difference in the side effects between both groups. Conclusion: Sugammadex achieved significantly faster recovery of rocuronium-induced neuromuscular block when compared with neostigmine regardless the depth of anesthesia. Serious adverse events were less than 1% of patients in both sugammadex and neostigmine, and data showed no differences in risk of serious adverse events between groups. sugammadex was well tolerated.

Retraction Note to: Assessment of neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles.

We studied neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles in anesthetized patients. Fifty-four adult patients undergoing air–oxygen–sevoflurane–fentanyl and epidural anesthesia were randomly divided into orbicularis oris, corrugator supercilii, and adductor pollicis groups of 18 patients each. In the three groups, the degree of neuromuscular block caused by rocuronium 0.6 mg/kg was monitored at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles acceleromyographically. Onset of neuromuscular block did not significantly differ among the three groups [157 ± 60, 186 ± 73, and 148 ± 45 s; mean ± standard deviation (SD)]. Minimum value of 1st stimulation in train-of-four (T1)/control at the corrugator supercilii group was significantly higher than in the orbicularis oris and adductor pollicis groups (0.108 ± 0.066 vs. 0.021 ± 0.024 and 0.002 ± 0.007; P < 0.001). T1/control at the orbicularis oris group was significantly higher than at the adductor pollicis group 30 min after rocuronium (P < 0.05). T1/control at the corrugator supercilii group was significantly higher than at the orbicularis oris and adductor pollicis groups 10–30 and 10–40 min, respectively, after rocuronium (P < 0.05). Train-of-four ratios at the orbicularis oris and corrugator supercilii groups were significantly higher than at the adductor pollicis group 40–120 min after rocuronium (P < 0.05). The corrugator supercilii muscle is more resistant to rocuronium than the orbicularis oris and adductor pollicis muscles. Recovery of neuromuscular block at the orbicularis oris muscle is slower than that at the corrugator supercilii muscle but was faster than that at the adductor pollicis muscle.

Retraction Note to: Nicorandil accelerates recovery of neuromuscular block caused by vecuronium

Retraction Note to: Can J Anesth 2001; 1: 28–33, DOI 10.1007/BF03019810. To our readers: Further to the Expression of Concern (http://www.springer.com/medicine/anesthesiology/journal/12630) posted online, it is with considerable regret that the Canadian Journal of Anesthesia hereby retracts the above-cited article by Dr. Yoshitaka Fujii as a result of: 1) overwhelming evidence of fabrication relating to the fact that the distribution of many variables reported by Dr. Fujii in this study are exceedingly unlikely; and 2) the inability of Dr. Fujii’s institution to attest to the integrity of the study and/ or the data conducted under its auspices, as set out in the Joint Editors-in-Chief Request for Determination of April 9, 2012.

Comparison of neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients.

Background and Aims:Obese patients are more vulnerable to residual neuromuscular block (NMB) and its associated complications in the post-operative period. This study was carried out to compare neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients, objectively using neuromuscular (NM) monitoring.Methods:Twenty female patients each belonging to normal weight, overweight and obese, based on body mass index, requiring general anaesthesia were recruited for this prospective cross sectional study. NMB was induced with vecuronium (0.1 mg/kg) dose based on patient's real body weight (RBW) and monitored using acceleromyographic train of four (TOF). All patients received neostigmine 40 μg/kg and glycopyrrolate 10 μg/kg at 25% of spontaneous recovery of first twitch height (T1) of TOF (DUR 25%) and were allowed to recover to TOF ratio of 0.9. Statistical analysis was done using analysis of variance test.Results:Recovery of TOF ratio to 0.5 was comparable in all three groups. Recovery of TOF ratio to 0.7 was delayed in obese (9.82 ± 3.21 min) compared with normal weight group (7.50 ± 2.52 min). Recovery of TOF to 0.9 was significantly delayed in both overweight (12.18 ± 4.29 min) and obese patients (13.78 ± 4.30 min). DUR 25% was significantly longer in overweight (mean, standard deviation [range]; 30.10 [19–40 min]) and obese (28.8 [12–45 min]) compared with normal weight patients (22.75 [16–30 min]).Conclusion:In overweight and obese patients, when vecuronium induction dose is based on RBW, neostigmine induced recovery of NMB is delayed in late phases (TOF 0.7-0.9), which may result in vulnerability for associated complications of incomplete recovery. Ensuring safe recovery thus requires objective NM monitoring.