Residual Curarization Research Articles

Evaluation of postoperative residual curarization: a prospective clinical study

Background: Reversal of neuroblockade in general anesthesia is important to prevent possible complications. Currently, neostigmine and sugamedex are the agents of choice. The reversibility of blockade is evaluated by TOF (train-of-four ) as well as clinical observation. Our goal is to research and evaluate both agents in terms of complications and residual blockade. Materials and Methods: Our prospectively designed work included 100 cases operated under general anesthesia. demographic data, OF values, and complications were recorded. Results: A total of 100 patients, 63 neostigmine and 37 sugammedex, were consisted of in the search. The mean age of the sufferers was 41.9±16.9 years. When age was compared between the groups, it was found that the neostigmine (N) group was younger (p=0.027). There was a likeness between the groups in terms of surgical time, BMI (body mass index), Spo2, heart rate, mean arterial pressure, and total rocuronium consumption. The TOF value of the group N was 1(0.87-1), while that of the group sugamedex (S) was 1(0.91-1) and was found to be significant (p=0.045). There was no difference in TOF between cases who received an additional dose of rocuronium and those who did not receive an additional dose of rocuronium. Conclusions: As a result of the TOF values we obtained, we found that both agents were effective in removing the blockade, but the residual rate was statistically significantly lower in the sugamedex group, although not clinically significant. We did not encounter any complications in our study and we think that sugamedex is safer in terms of residual blockade.

Comparison of Postoperative Muscle Strength Recovery Between Cisatracurium and Rocuronium.

Background Neuromuscular blocking agents are crucial for anesthesia but can cause reversible paralysis, leading to risks like postoperative residual dysfunction. Undetected paralysis in thepost-anesthesia care unit (PACU) jeopardizes patient safety by impairing airway function and increasing complications. Effective reversal, assessed clinically or via nerve stimulation, is critical to prevent residual postoperative curarization (RPOC), which is linked to significant morbidity and mortality. Evaluating agents like rocuronium and cisatracurium helps optimize anesthesia outcomes and patient recovery. Methodology The study included 100American Society of Anaesthesiologists (ASA) I and II patients approved by the Institutional Review Board of Kasturba Medical College, Mangalore, India. Patients were briefed about the study, provided written informed consent, and underwent pre-anesthetic evaluations, including discussions on anesthetic procedures and associated risks. They were instructed to fast overnight after consenting. Results The study compared 100 ASA I and II patients receiving rocuronium or cisatracurium during anesthesia, analyzing age distribution (p=0.429), gender (p=0.839), ASA status (p=0.228), and physical characteristics (height, weight, BMI, p>0.05). Recovery parameters such as hand grip, sustained head lift, and double burst stimulation (DBS) twitch response showed no significant differences between groups (p=0.538 for hand grip and sustained head lift; p=0.220 for DBS. Late recovery rates at 15 minutes were observed with 16% for hand grip, 14% for sustained head lift, and 26% for DBS in the rocuronium group; compared to 14%, 10%, and 16%, respectively, in the cisatracurium group. Conclusion The study found significant postoperative residual curarization in both groups, emphasizing the need for intraoperative and PACU peripheral nerve stimulation for effective assessment. Further research on intraoperative variables could improve understanding of residual paralysis in PACU, guiding better anesthesia management.

Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach.

Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results. We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.

Effect of coadministration of 10 mg/kg calcium chloride and neostigmine on extubation time: A randomized controlled trial

Introduction and objectivesSome studies investigating the effect of calcium on neostigmine-induced recovery of neuromuscular blockade have shown that this combination promotes neuromuscular recovery, but does not significantly affect the incidence of postoperative residual curarization and time to extubation. This study aimed to evaluate the effects of 10 mg/kg calcium chloride co-administered with neostigmine on early recovery and time to extubation. Patients and methodsThis prospective, randomized, double-blinded, placebo-controlled study included 88 ASA I–II patients aged between 18 and 65 years who were scheduled for elective surgery lasting at least 1 h under general anaesthesia in which 10 mg/kg of calcium chloride or the same volume of normal saline was co-administered with 5 μg/kg of neostigmine at the end of surgery. Time to extubation (time from neostigmine administration to extubation), time from neostigmine administration to TOF ratio (TOFr) 0.9 (neuromuscular recovery), and the incidence of residual neuromuscular blockade (RNMB) and other adverse effects were recorded. ResultsMedian (Q1, Q3) extubation time was significantly shorter in the calcium group vs. the placebo group (6.5 min [5.52–7.43] vs. 9.78 min [8.35–11]), P < .001. Median neuromuscular recovery time in the calcium group was 5 min vs. 7.1 min in the placebo group, P < .001. Patients in the calcium group had significantly higher TOFr and lower incidence of RNMB at 5 and 10 min vs. the placebo group, and no significant side effects. ConclusionCalcium chloride at a dose of 10 mg/kg co-administered with neostigmine promotes early neuromuscular recovery and reduces time to extubation by about 32%.

Comparison of Different Weight Scalars to Dose Sugammadex for the Reversal of Neuromuscular Blockade in Morbidly Obese Patients: A Systematic Review.

This systematic review was conducted to evaluate the optimal weight scalar to dose sugammadex in a morbidly obese (MO) patient population (BMI≥40 kg/m2). The primary outcome was recovery time from moderate neuromuscular blockade (NMB) or deep NMB. Secondary outcomes included time to extubation and incidence of postoperative residual curarization (PORC). Eight randomized controlled trials (RCTs) involving 645 participants were included. The different dose scalars included were total body weight (TBW), ideal body weight (IBW), 20% corrected body weight (CBW) and 40% CBW). A dose of 2 mg/kg of sugammadex based on 40% CBW and a 4 mg/kg dose of sugammadex based on 40% CBW provide a reliable and timely reversal of moderate and deep NMB respectively in the MO patients.

Postoperative residual curarisation in geriatric patients: a prospective, observational cohort study.

To evaluate the occurrence and potential risk factors of residual curarisation after surgery and the subsequent acute respiratory events in elderly patients. The prospective, cohort study was conducted at Ankara City Hospital from July to December 2021, and comprised data of geriatric patients undergoing elective surgery under general anaesthesia using moderate-acting nondepolarising muscle relaxants. Postoperative acute respiratory events in the post-anaesthesia care unit were subsequently noted. Data was analysed using SPSS 25. Of the 185 patients aged >65 years evaluated, 174(94%) were included; 88(50.6%) females and 86(49.4%) males. The incidence of residual curarisation was in 6(3.4%) patients. Postoperative residual curarisation was significantly associated with smooth recovery process (p<0.05). The recovery was associated with intraoperative bleeding, total dose of neuromuscular blocker, and the length of time from the last dose of neuromuscular blocker to antagonist administration (p<0.05). Postoperative critical respiratory events were more common in patients with postoperative residual curarisation (p< 0.001). The length of stay in post-anaesthesia care unit was 1.57 times longer in such patients (p=0.001). Postoperative residual curarisation increased length of hospital stay and respiratory complications.

An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia

BackgroundThe incidence of postoperative residual curarisation remains unacceptably high. We assessed whether an educational intervention on perioperative neuromuscular block management can reduce it. MethodsIn this multicentre, cluster randomised crossover trial, centres were allocated to receive an educational intervention either in a first or a second period. The educational intervention consisted of a lecture about neuromuscular management key points, including quantitative neuromuscular monitoring and use of reversal agents. The lecture was streamed to allow repetition. Additionally, memory cards were distributed in each operating theatre. The primary outcome was postoperative residual curarisation in the PACU. Secondary outcomes were frequency of quantitative neuromuscular monitoring, use of reversal agents, and incidence of postoperative pulmonary complications during hospital stay. Measurements were performed before randomisation and after the first and the second period. The effect of the educational intervention was estimated using multivariable mixed effects logistic regression models. ResultsWe included 2314 subjects in 34 Spanish centres. Postoperative residual curarisation incidence was not affected by the educational intervention (odds ratio [OR] 0.90 [95% confidence interval {CI}: 0.51–1.58]; P=0.717 and 1.30 [0.73–2.30]; P=0.371] for first and second time-period interaction). The educational intervention increased the quantitative neuromuscular monitor usage (OR 2.04 [95% CI: 1.31–3.19]; P=0.002), the use of reversal agents was unchanged (OR 0.79 [95% CI: 0.50–1.26]; P=0.322), and the incidence of postoperative pulmonary complications decreased (OR 0.19 [95% CI: 0.10–0.35]; P<0.001). ConclusionsAn educational intervention on perioperative neuromuscular block management did not reduce the incidence of postoperative residual curarisation nor increase reversal, despite increased quantitative neuromuscular monitoring. Sugammadex reversal was associated with reduced postoperative residual curarisation. The educational intervention was associated with a decrease in postoperative pulmonary complications. Clinical trial registrationNCT03128151.

Coadministration of intravenous calcium along with neostigmine for rapid neuromuscular blockade recovery: A systematic review and meta-analysis.

Postoperative residual curarization (PORC) and the impact of the coadministration of intravenous calcium along with an acetylcholinesterase inhibitor on it are not well addressed. Extensive electronic database screening was done until October 7, 2022 after enlisting the protocol of this systematic review in PROSPERO (CRD42021274879). Randomized controlled trials (RCTs) evaluating the impact of intravenous calcium and neostigmine coadministration on neuromuscular recovery were included in this meta-analysis. Our search retrieved four RCTs with a total of 266 patients. The application of calcium shortened the neuromuscular recovery time (SMD = -2.13, 95% confidence interval [CI]: -2.66 to -1.59, I2 = 66%) and reduced the risk of PORC at 5 min (odds ratio [OR] = 0.21, 95% CI: 0.10-0.46, I2 = 0%), with an improved train-of-four (TOF) ratio at 5 min (mean difference [MD] = 9.28, 95% CI: 4-14.57, I2 = 66%). However, neither significant reduction in PORC at 10 min (OR = 0.41, 95% CI: 0.15-1.09, I2 = 0%) nor a better TOF ratio was associated with coadministration of calcium (MD = 0.40, 95% CI: -1.3-2.11). Coadministration of calcium along with neostigmine during the early period of neuromuscular blockade reversal can be used to enhance neuromuscular recovery.

Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study

IntroductionFor thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. Patients and methodsIn this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg−1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 μV. If not, sugammadex (2 mg.kg−1) was administered. The dissection began when the signal was positive. ResultsFrom January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/− 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DiscussionThis prospective study shows that the use of 0.5 mg.kg−1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.

REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study).

Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value &lt; 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.

Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta-Analysis.

To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery. PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database. Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no-deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions. the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications [including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV)]. Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded. Four articles with 242 patients were identified for analysis. The results indicated that compared with no-deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio [RR]=1.29, 95% CI: 1.07-1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR=0.32; 95% CI: 0.21-0.49) (lower incidence of vocal fold movement [1.85% vs. 34%; RR=0.08, 95% CI: 0.02-0.41] and coughing [15.53% vs. 38.78%; RR=0.42, 95% CI: 0.27-0.66]). There were no differences in the overall incidence of postoperative complications (RR=2.10, 95% CI: 0.12-36.40). Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications. 1 Laryngoscope, 133:2055-2065, 2023.

Occurrence of butyrylcholinesterase polymorphisms in patients undergoing surgery in Slovakia.

Post-operative residual curarization is a persisting problem, characterized by muscle fatigue, exhaustion or paresis, caused by the use of neuromuscular blocking agents with prolonged postoperative effect. Genetically, determined changes in cholinesterase activity can be a major reason for persistent muscle blockade after administration of muscle relaxants. Regarding the subsistence of polymorphisms in the plasma cholinesterase gene causing change in enzyme activity and metabolism of applied drugs, we investigated the frequency of two polymorphisms known to reduce its activity significantly in patients undergoing surgery. Primary results show a relatively high occurrence of plasma cholinesterase K risk allele (18.75%). Characterization of the lacking information about genetic background of changes in plasma cholinesterase activity within Slovakia may allow for easier decision-making in clinical practice when selecting alternative neuromuscular blocking and also reversal agents.

Evaluation of the vasorelaxant effect of Sugammadex on the arterial smooth muscle in rats

Although NMBAs (Neuro Muscular Blocking Agents) have been used for a long time, postoperative residual curarization is still a significant problem. Nowadays, an agent named Sugammadex is used for the reversal of curarization. It has been presented as a safer agent than its predecessor, neostigmine. The main purpose of this study is to investigate the effects of Sugammadex on rat thoracic aorta and enlighten the mechanism of action and potential benefits in surgical operations with general anesthesia. Twenty Wistar albino rats were used for the experiments. Thoracic aorta segments have been removed and mounted to the organ bath. Contraction and relaxation responses were presented as a percentage of phenylephrine (3x10-5 M) contraction. After recording contractile responses of Sugammadex (10-8-10-4 M), relaxation responses of Sugammadex (10-8-10-4 M) have been recorded both in the presence and absence of L-NAME (3x10-5 M) (Potent Nitric Oxide Sentase Inhibitor). Finally, relaxation responses of sugammadex-rocuronium have been recorded. Sugammadex caused slightly noticeable and concentration-dependent contraction on isolated thoracic aorta strips. Sugammadex also caused potent and concentration-dependent relaxation on isolated rat thoracic aorta. The relaxation response caused by Sugammadex has been diminished significantly in the presence of L-NAME. Administration of rocuronium with Sugammadex did cause neither relaxation nor any additional contractile effect on isolated rat thoracic aorta strips. Sugammadex is a promising agent in reversing rocuronium-induced neuromuscular block. Although the adverse effects of this agent are not studied in detail, it seems Sugammadex is safer than neostigmine. The side effects of anesthetic agents are one of the main problems of surgical procedures, including neurosurgery, gynecology, and obstetrics. Especially acute hypotension may be fatal in neurosurgery and gynecological operations. Sugammadex should be used carefully in adjusted and individualized doses to avoid hypotension-related adverse effects.

Highly Water-Soluble Cucurbit[8]uril Derivative as a Broad-Spectrum Neuromuscular Block Reversal Agent.

Broad-spectrum agents for the reversal of residual curarization induced by neuromuscular blocking agents are of great significance. Here, we report a highly water-soluble cucurbit[8]uril (CB[8]) derivative as a broad-spectrum neuromuscular block reversal agent induced by both benzylisquinolinium and aminosteroid neuromuscular block agents by the supramolecular sequestration strategy. The UV/Vis competition titration assays suggest the high binding affinity of the CB[8] derivative toward both benzylisquinolinium-type cisatracurium besylate and aminosteroid-type rocuronium, vecuronium, and pancuronium, at the level of 107 M-1. In vivo studies demonstrate that the administration of the CB[8] derivative could significantly accelerate the recovery time compared to the placebo or neostigmine groups. The reversal activity of the CB[8] derivative is comparable to or higher than that of clinically approved sugammadex. Acute toxicity evaluations reveal that the CB[8]-derivative displays outstanding biocompatibility, with the maximum tolerance dose as high as 960 mg kg-1.

Advances of Diaphragm Ultrasound in Anesthesia Management

Diaphragm excursion,diaphragm thickness,and diaphragmatic thickening fraction are three indicators for evaluating the two hemidiaphragms by ultrasound.Diaphragm ultrasound has been widely applied in clinical practice including anesthesia management.It can help to diagnose postoperative residual curarisation and identify patients at a high risk of suffering from postoperative pulmonary complications.It can serve to recognize patients with diaphragm paralysis due to surgical or anesthetic factors as early as possible.Moreover,diaphragm ultrasound plays a role in preoperative pulmonary function assessment for special sufferers with chronic obstructive pulmonary disease,adolescent idiopathic scoliosis,or neuromuscular disease.Apart from these,diaphragm ultrasound can give anesthesiologists and colleagues in intensive care unit an important clue for extubation and weaning from mechanical ventilation of patients.

Evaluation of Postoperative Residual Curarisation after Administration of Neostigmine or Sugammadex by Diaphragmatic Ultrasonography:A Randomized Double-blind Controlled Trial

Objective To evaluate and compare the incidence of postoperative residual curarisation (PORC) after administration of neostigmine or sugammadex by diaphragmatic ultrasonography.Methods A total of 100 patients with American Society of Anesthesiologists grade Ⅰ or Ⅱ who underwent elective joint replacement surgery from March to August in 2021 were randomly enrolled into the neostigmine+atropine group(N+A group,n=51) and sugammadex group(SUG group,n=49) according to a random number table.Muscle relaxation was monitored by train of four(TOF) stimulation of adductor pollicis muscle during anesthesia.The patients in N+A group were administrated with neostigmine 50 μg/kg + atropine 15 μg/kg and those in SUG group with sugammadex 2 mg/kg for reversing muscle relaxation.Endotracheal tube was removed only when TOF ratio≥0.9. Diaphragmatic ultrasonography was performed before surgery,10 min and 30 min after extubation.The right diaphragm excursion during deep breathing(DE-DB) and the diaphragm movement velocity during sniffing(V-S) were measured,with the low-frequency probe placed at the intersection of the right midclavicular line and the right costal margin.The diaphragmatic thickening fraction during deep breathing(TF-DB) was measured with the high-frequency probe placed at zone of apposition.The incidence of PORC was taken as the primary outcome,and DE-DB,TF-DB,and V-S as the secondary outcomes.Results When PORC was defined as TF-DB≤36%,the incidence of PORC in the SUG group was lower than that in the N+A group 10 min(4.3% vs.31.1%;χ2=11.541,P=0.001) and 30 min(0 vs.17.6%;P=0.001) after extubation.When PORC was defined as TF-DB≤36% or DE-DB≤4 cm,the incidence of PORC in the SUG group was also lower than that in the N+A group 10 min(8.2% vs.33.3%;χ2=9.543,P=0.002) and 30 min(0 vs.19.6%;χ2=8.608,P=0.003) after extubation.The DE-DB in the SUG group was higher than that in the N+A group 10 min[(6.5±1.6) cm vs.(5.6±1.4) cm;t=-3.185,P=0.002] and 30 min[(6.9±1.5) cm vs.(6.1±1.4) cm;t=-2.712,P=0.008] after extubation.The TF-DB in the SUG group was also higher than that in the N+A group 10 min[(60.1±18.8)% vs.(49.1±20.0)%;t=2.739,P=0.007] and 30 min[(65.0±20.1)% vs.(49.9±19.1)%,t=-3.686,P<0.001] after extubation.Conclusion Compared with neostigmine,sugammadex can significantly improve the postoperative diaphragm movement and decrease the incidence of PORC.

Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial

BackgroundPostoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively.Methods/designIn this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively.DiscussionElimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting.Trial registrationClinicalTrials.gov NCT05040490. Registered on 3 September 2021

Postoperative Residual Curarization in Difficult Environment for the Practice of General Anesthesia: Inventory of the Yaounde/Essos Hospital Center

Postoperative Residual Curarization in Difficult Environment for the Practice of General Anesthesia: Inventory of the Yaounde/Essos Hospital Center

Non-intubated Thoracoscopic Surgery-Pros and Cons.

Pulmonary resection by video-assisted thoracoscopic surgery with single-lung ventilation has become a standardized modality over the last decades. With the aim to reduce surgical stress during operation procedures, some have adopted a uniportal approach in pulmonary resection as an alternative to multiportal VATS. The ERAS program has been widely spread to achieve even better outcomes. In 2004, Pompeo reported the resection of pulmonary modules by conventional VATS under intravenous anesthesia without endotracheal intubation. Within less than a decade thereafter, complete VATS pulmonary resections under anesthesia without endotracheal intubation had been reported for a range of thoracoscopic procedures. Avoiding tracheal intubation under general anesthesia can reduce the incidence of complications such as intubation-related airway trauma, residual neuromuscular blockade, ventilation-induced lung injury, impaired cardiac performance, and postoperative nausea. Numerous studies can be found especially from Asian countries, focusing on comparison of intubated and non-intubated procedures showing that non-intubated VATS could reduce the rate of postoperative complications, shorten hospital stay and decrease the perioperative mortality rate, indicating that non-intubated VATS is a safe, effective and feasible technique for thoracic disease. However, if we look closely at all studies, it is obvious that there are no significant differences between intubated and non-intubated surgery in terms of the standard procedures and maneuvers. In non-intubated procedures it can be less comfortable for the surgeon to manipulate in the thoracic cavity, but the procedural steps remain the same. All the differences between the intubated and non-intubated operation procedure are found in perioperative management of the patient. The patient is still in deep anesthesia during the procedure and hypecapnia can occur. It is easier to manage this if the patient is intubated. In addition, if a complication occurs during the operation and intubation is required, this can cause an emergent situation, which means that not all patients are suitable for such a procedure, especially those with severe emphysema, obese patients and those with a problematic oropharyngeal configuration-Mallampati score. Moreover, studies on non-intubated thoracic surgery point to shortened hospitalization, faster recovery etc. But there are also studies on intubated uniportal VATS procedures in combination with ERAS protocol showing shortened hospitalization and better outcome for patients. Currently, especially with the use of optical intubation canylas, totally intravenous anesthesia (TIVA), BIS and relaxometer, anesthesia is safe for avoiding airway injury, hypercapnia, and there is minimal risk of residual curarization as well as one of the postoperative lung complications such as microaspiration and atelectasis. In addition, the patient recovers rapidly from anesthesia and can be verticalised and mobilized a couple of hours after the operation. It is desirable to take into consideration what type of patient and what lung disease is suitable for non-intubated technique and what is more convenient for intubation.

Peri-operative diaphragm ultrasound as a new method of recognizing post-operative residual curarization

BackgroundThis study sought to evaluate the diagnostic accuracy of peri-operative diaphragm ultrasound in assessing post-operative residual curarization (PORC).MethodsPatients undergoing non-thoracic and non-abdominal surgery under general anaesthesia were enrolled from July 2019 to October 2019 at Peking Union Medical College Hospital. A train-of-four ratio (TOFr) lower than 0.9 was considered as the gold standard for PORC. Diaphragm ultrasound parameters included diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) during quiet breathing (QB) and deep breathing (DB). The diaphragm excursion fraction (DEF) was calculated as the DE-QB divided by the DE-DB. The diaphragm excursion difference (DED) was defined as DE-DB minus DE-QB. Receiver operating characteristic curve analysis was used to determine the cut-off values of ultrasound parameters for the prediction of PORC.ResultsIn total, 75 patients were included, with a PORC incidence of 54.6%. The DE-DB and DED were positively correlated with the TOFr, while the DEF was negatively correlated with the TOFr. The DE-DB cut-off value for predicting PORC was 3.88 cm, with a sensitivity of 85.4% (95% confidence interval [CI]: 70.1–93.9%), specificity of 64.7% (95% CI: 46.4–79.7%), positive likelihood ratio of 2.42 (95% CI 1.5–3.9), and negative likelihood ratio of 0.23 (95% CI: 0.1–0.5). The DED cut-off value was 1.5 cm, with a specificity of 94.2% (95% CI: 80.3–99.3%), sensitivity of 63.4% (95% CI: 46.9–77.9%), positive likelihood ratio of 10.78 (95% CI: 2.8–42.2), and negative likelihood ratio of 0.39 (95% CI: 0.3–0.6).ConclusionsPeri-operative diaphragm ultrasound may be an additional method aiding the recognition of PORC, with DED having high specificity.