Antidote Research Articles

Naloxone Online Information Exceeds the Recommended Reading Level for Patient Education Materials.

The opioid epidemic claimed 68,630 lives in 2020 in the United States. It reached record levels during the COVID-19 pandemic. Public comprehension of naloxone, the reversal agent for opioid overdoses, is necessary for its broad uptake and the prevention of opioid-related deaths. This study assesses whether online patient education materials for naloxone meet national readability guidelines. It further compares the readability of naloxone materials to that of cardiopulmonary resuscitation (CPR) materials, given that the latter is an established and widespread life-saving procedure. We searched Google in March 2022 for three terms: "naloxone," "Narcan," and "CPR." The top 15 websites for each term were retrieved, processed, and inputted into a readability calculator to generate six validated reading scale scores. Statistical analyses were performed to compare the readability of naloxone/Narcan online information against national standards and the readability of CPR online information. The average readability of naloxone/Narcan websites was grade 11.2 ± 2.3, and none of the websites met the recommended sixth-grade reading level for patient education materials. In comparison, the average readability of CPR websites was 7.8 ± 1.5. Of the naloxone/Narcan websites, only 17% (4/24) had a readability at or below the eighth-grade level, the average reading level of U.S. adults. In comparison, 80% (12/15) of the CPR websites had a readability at or below the eighth-grade level. Naloxone online information exceeds the recommended reading level and that of CPR materials. Online information about naloxone should be simplified to broaden educational access to this life-saving medication.

Comparison of neostigmine and sugammadex for hemodynamic parameters in neurointerventional anesthesia.

Hemodynamic stability is important during neurointerventional procedures. However, ICP or blood pressure may increase due to endotracheal extubation. The aim of this study was to compare the hemodynamic effects of sugammadex and neostigmine with atropine in neurointerventional procedures during emergence from anesthesia. Patients undergoing neurointerventional procedures were allocated to the sugammadex group (Group S) and the neostigmine group (Group N). Group S was administered IV 2 mg/kg sugammadex when a train-of-four (TOF) count of 2 was present, and Group N was administered neostigmine 50 mcg/kg with atropine 0.2 mg/kg at a TOF count of 2. We recorded heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure (MAP), and peripheral arterial oxygen saturation during administration of the reverse agent and at 2, 5, 10, 15, 30, 120 min, and 24 h thereafter. The primary outcome was blood pressure and heart rate change after the reversal agent was given. The secondary outcomes were systolic blood pressure variability standard deviation (a measure of the amount of variation or dispersion of a set of values), systolic blood pressure variability-successive variation (square root of the average squared difference between successive blood pressure measurements), nicardipine use, time-to-TOF ratio ≥0.9 after the administration of reversal agent, and time from the administration of the reversal agent to tracheal extubation. A total of 31 patients were randomized to sugammadex, and 30 patients were randomized to neostigmine. Except for anesthesia time, there were no significant differences in any of the clinical characteristics between the two groups. The results demonstrated that the increase in MAP from period A to B was significantly greater in Group N than in Group S (regression coefficient = -10, 95% confidence interval = -17.3 to -2.7, P = 0.007). The MAP level was significantly increased from period A to B in the neostigmine group (95.1 vs. 102.4 mm Hg, P = 0.015), but it was not altered in Group S. In contrast, the change in HR from periods A to B was not significantly different between groups. We suggest that sugammadex is a better option than neostigmine in interventional neuroradiological procedures due to the shorter extubation time and more stable hemodynamic change during emergence.

Effects of sugammadex versus neostigmine on postoperative nausea and vomiting after general anesthesia in adult patients:a single-center retrospective study

We aimed to compare the effect of sugammadex to that of neostigmine with respect to the occurrence of postoperative nausea and vomiting (PONV) during the first 24 h following general anesthesia. This retrospective cohort study included patients who underwent elective surgery under general anesthesia in 2020 at an academic medical center in Seoul, South Korea. The exposure groups were determined according to whether the patient received sugammadex or neostigmine as a reversal agent. The primary outcome was PONV occurrence during the first 24 h postoperatively (overall). The association between the type of reversal agent and primary outcome was investigated using logistic regression while adjusting for confounding variables using stabilized inverse probability of treatment weighting (sIPTW). Of the 10,912 patients included in this study, 5,918 (54.2%) received sugammadex. Sugammadex was associated with a significantly lower incidence of overall PONV (15.8% vs. 17.7%; odds ratio, 0.87; 95% confidence interval [CI], 0.79–0.97; P = 0.010) after sIPTW. In conclusion, compared with neostigmine/glycopyrrolate, sugammadex use has a lower risk of PONV during the first 24 h following general anesthesia.

Direct Oral Anticoagulants: How Do These Drugs Work, How to Monitor, and What Is Their Role in Orthopaedic Surgery.

Postoperative venous thromboembolism is a major adverse event associated with orthopaedic surgery. With the addition of perioperative anticoagulation and antiplatelet therapy, the rates of symptomatic venous thromboembolism have dropped to 1% to 3%, and as such, practicing orthopaedic surgeons must be familiar with these medications, including aspirin, heparin, or warfarin, and the use of direct oral anticoagulants (DOACs). DOACs are increasingly being prescribed due to their predictable pharmacokinetics and increased convenience, as they do not require routine monitoring, and 1% to 2% of the general population is currently anticoagulated. Although the introduction of DOACs has yielded additional treatment options, this has also led to confusion and uncertainty regarding treatment, specialized testing, and when and what reversal agents are appropriate. This article provides a basic overview of DOAC medications, their suggested use in the perioperative setting, effects on laboratory testing, and consideration for when and how to use reversal agents in orthopaedic patients.

Annals for Hospitalists - April 2023

Annals for Hospitalists - April 2023

Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study

IntroductionNMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity.ObjectiveTo investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00).MethodsWe performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old.ResultsWe included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB.ConclusionsThe rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

Molecular and supramolecular engineering on lipopeptide-based hole-punching nanotoxins to trigger multimodal death of drug-resistant tumors: Apoptosis, necrosis and autophagy

Discovering bioactive and efficient new agents for broad-spectrum multidrug resistance reversal is a worldwide challenge in the biomedical field. Herein, bioactive nanomaterials assembled from specially-designed lipopeptides are developed as a novel type of hole-punching nanotoxins to trigger multimodal tumor death for multidrug resistance reversal in vitro and in vivo. The dendritic arginine-rich peptides as hydrophilic parts could incorporate with multivalent scaffolds and multiple-interaction residues to boost membrane-binding intensity, and cholesterol as hydrophobic blocks are hopeful to improve and ameliorate membrane-targeting/inserting ability against drug-resistant tumor membranes. The amphiphilic lipopeptides are designed to drive supramolecular self-assembly into nanostructures for improving hole-punching potential and stability. As envisaged, these lipopeptide-based nanotoxins could maintain high stability, obtain strong hole-punching activity and trigger multimodal tumor death with 80.3% TUNEL-positive apoptotic cells, 97.8% PARP-positive necrotic cells and 71.0% LC3-positive autophagic cells for multidrug resistance reversal in vivo. This work opens a new opportunity to develop new-style toxins for antitumor treatment, and the lipopeptide-based nanotoxins are expected to be a candidate agent for dealing with multidrug resistance.

Reversal agents for current and forthcoming direct oral anticoagulants

Over the past 20 years, there has been a shift from vitamin K antagonists to direct oral anticoagulants (DOACs), which include the thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban, edoxaban, and rivaroxaban. Although DOACs are associated with less serious bleeding than vitamin K antagonists, bleeding still occurs with DOACs, particularly in the elderly and in those with comorbidities. Reversal of the anticoagulant effects of the DOACs may be needed in patients with serious bleeding and in those requiring urgent surgery or intervention. Reversal can be effected with specific agents, such as idarucizumab for dabigatran and andexanet alfa for apixaban, edoxaban, and rivaroxaban, or with non-specific agents, such as prothrombin complex concentrates, activated prothrombin complex concentrate, and recombinant activated factor VII. This paper (i) provides an update on when and how to reverse the DOACs, (ii) describes new reversal agents under development, and (iii) provides a strategic framework for the reversal of the factor XI inhibitors currently under investigation in phase three clinical trials.

When and How to Use Reversal Agents for Direct Oral Anticoagulants?

Our objective is to describe currently available reversal agents for direct oral anticoagulants (DOACs), their target population, the available clinical practice recommendations and future directions. Specific (idarucizumab for dabigatran and andexanet alfa for direct factor Xa inhibitors) and non-specific (prothrombin complex concentrates) reversal agents are effective in neutralizing the anticoagulant effect of DOACs. New investigational antidotes such as ciraparantag and VMX-C001 offer an alternative to andexanet alfa in reversing the anticoagulant activity of direct oral factor Xa inhibitors, but more clinical data are needed before they could be licensed for use. Specific reversal agents are recommended for use in clinical situations within their licensed indications (i.e.: reversal of DOACs in patients with severe uncontrolled or life-threatening bleeding or in need of emergency surgery or other invasive procedures), while non-specific reversal agents may be used when specific antidotes are not available or indicated.

Structure-Kinetics Relationships of Opioids from Metadynamics and Machine Learning Analysis.

The nation's opioid overdose deaths reached an all-time high in 2021. The majority of deaths are due to synthetic opioids represented by fentanyl. Naloxone, which is a FDA-approved reversal agent, antagonizes opioids through competitive binding at the μ-opioid receptor (mOR). Thus, knowledge of the opioid's residence time is important for assessing the effectiveness of naloxone. Here, we estimated the residence times (τ) of 15 fentanyl and 4 morphine analogs using metadynamics and compared them with the most recent measurement of the opioid kinetic, dissociation, and naloxone inhibitory constants (Mann et al. Clin. Pharmacol. Therapeut. 2022, 120, 1020-1232). Importantly, the microscopic simulations offered a glimpse at the common binding mechanism and molecular determinants of dissociation kinetics for fentanyl analogs. The insights inspired us to develop a machine learning approach to analyze the kinetic impact of fentanyl's substituents based on the interactions with mOR residues. This proof-of-concept approach is general; for example, it may be used to tune ligand residence times in computer-aided drug discovery.

5-Oxohexahydroquinolines bearing 4-pyridyl methyl carboxylate as P-glycoprotein inhibitors and multidrug resistance reversal agents in cancer cells

Multidrug resistance (MDR) limits the therapeutic effect of conventional chemotherapeutic agents as well as novel targeted anticancer drugs. An important mechanism of MDR is the overexpression of ATP-binding cassette (ABC) transporters in cancer cells, among which P-glycoprotein (P-gp) has one of the highest contributions to drug resistance. In this study, 10 novel 5-oxo-hexahydroquinoline (5-oxo-HHQ) derivatives bearing 4-pyridyl methyl carboxylate moiety (G1-G10) were synthesized and examined for their MDR reversal activity in P-gp overexpressing MES-SA-DX5 cells. Moreover, all synthesized compounds were evaluated for their cell growth inhibitory effect in several cancer cell lines. Most of the tested compounds significantly enhanced the intracellular accumulation of rhodamine 123, a P-gp substrate, in MDR cells, some of them showing better results than verapamil, a well-established P-gp inhibitor. Moreover, most compounds, especially G2, G3, G7, and G8, bearing 2-chlorophenyl, 3-bromophenyl, 3-nitrophenyl and pyridin-4-yl moieties were effective in reversing resistance to doxorubicin when co-incubated with this chemotherapeutic agent in MES-SA-DX5 cells. Our results also showed that compounds G3 and G7 exhibited considerable cytotoxic effects against leukemia and colon cancer cells. In silico docking analysis also confirmed the interaction of compounds G2, G3, G7, and G8 with the drug-substrate binding site of P-gp. Molecular dynamic simulation study was performed to gain insight into the binding mode of compound G3 with P-gp. According to the results, hydrophobic interactions played a more prominent role than hydrogen-binding interactions. Taken together, our findings showed that designed 5-oxo-HHQ compounds are promising MDR reversal agents.

The acceptability of overdose alert and response technologies: introducing the TPOM-ODART framework

BackgroundOpioids were implicated in approximately 88,000 fatal overdoses (OD) globally. However, in principle all opioid OD are reversible with the timely administration of naloxone hydrochloride. Despite the widespread availability of naloxone among people who use opioids (PWUO), many who suffer fatal OD use alone, without others present to administer the reversal agent. Recognising this key aspect of the challenge calls for innovations, a number of technological approaches have emerged which aim to connect OD victims with naloxone. However, the acceptability of OD response technologies to PWUO is of key concern.MethodsDrawing on the Technology People Organisations Macroenvironment (TPOM) framework, this study sought to integrate acceptability-related findings in this space with primary research data from PWUO, affected family members and service providers to understand the factors involved in harm reduction technology acceptability.A qualitative study using a focus group methodology was conducted. The participant groups were people with lived experience of problem opioid use, affected family members and service providers. Data analysis followed a multi-stage approach to thematic analysis and utilised both inductive and deductive methods.ResultsThirty individuals participated in one of six focus groups between November 2021 and September 2022. The analysis generated six major themes, three of which are reported in this article—selected for their close relevance to PWUO and their importance to developers of digital technologies for this group. ‘Trust—in technologies, systems and people’ was a major theme and was closely linked to data security, privacy and confidentiality. ‘Balancing harm reduction, safety and ambivalence’ reflects the delicate balance technological solutions must achieve to be acceptable to PWUO. Lastly, ‘readiness—a double bind’ encapsulates the perception shared across participant groups, that those at the highest risk, may be the least able to engage with interventions.ConclusionEffective digital strategies to prevent fatal OD must be sensitive to the complex relationships between technological, social/human, organisational and wider macroenvironmental factors which can enable or impede intervention delivery. Trust, readiness and performance are central to technology acceptability for PWUO. An augmented TPOM was developed (the TPOM-ODART).

Clinical and economic outcomes of pharmacological stress tests in patients with a history of COVID-19.

Despite millions of COVID-19 cases in the United States, it remains unknown whether a history of COVID-19 infection impacts the safety of pharmacologic myocardial perfusion imaging stress testing (pharmacologic MPI). The aim of this study was to assess if a prior COVID-19 infection was associated with a higher risk of complications during and following pharmacologic MPI testing. This retrospective cohort analysis included 179 803 adults (≥18 years) from the PharMetrics® Plus claims database who underwent pharmacologic MPI between March 1, 2020 and February 28, 2021. Patients with a history of COVID-19 infection (COVID-19 group) were compared with propensity-score matched no-COVID-19 history group for reversal agent use, 30-day resource use, and post-MPI cardiac events/procedures. The most commonly used stress agent was regadenoson (91.7%). The COVID-19 group (n = 6372; 3.5%) had slightly higher: reversal agent use (difference 1.13% [95% confidence interval [CI]: 0.33, 1.92]), all-cause costs (difference USD $128 [95% CI: $73-$181]), and office visits (81.5% vs. 77.0%) than the no-COVID-19 group. Prior COVID-19 infection did not appear to impact subsequent cardiac events/procedures. COVID-19 history was associated with slightly higher reversal agent use, all-cause costs, and office visits after pharmacologic MPI; however, the differences were not clinically meaningful. Concerns for use of stress agents in patients with prior COVID-19 do not appear to be warranted.

The pattern of brain oxygen response induced by intravenous fentanyl limits the time window of therapeutic efficacy of naloxone

Opioids induce respiratory depression resulting in coma or even death during overdose. Naloxone, an opioid antagonist, is the gold standard reversal agent for opioid intoxication, but this treatment is often less successful for fentanyl. While low dosing is thought to be a factor limiting naloxone's efficacy, the timing between fentanyl exposure and initiation of naloxone treatment may be another important factor. Here, we used oxygen sensors coupled with amperometry to examine the pattern of oxygen responses in the brain and periphery induced by intravenous fentanyl in freely moving rats. At both doses (20 and 60 μg/kg), fentanyl induced a biphasic brain oxygen response—a rapid, strong, and relatively transient decrease (8–12 min) followed by a weaker and prolonged increase. In contrast, fentanyl induced stronger and more prolonged monophasic oxygen decreases in the periphery. When administered before fentanyl, intravenous naloxone (0.2 mg/kg) fully blocked the hypoxic effects of moderate-dose fentanyl in both the brain and periphery. However, when injected 10 min after fentanyl, when most of hypoxia had already ceased, naloxone had minimal effect on central and peripheral oxygen levels, but at a higher dose, it strongly attenuated hypoxic effects in the periphery with only a transient brain oxygen increase associated with behavioral awakening. Therefore, due to the rapid, strong but transient nature of fentanyl-induced brain hypoxia, the time window when naloxone can attenuate this effect is relatively short. This timing limitation is critical, making naloxone most effective when used quickly and less effective when used during the post-hypoxic comatose state after brain hypoxia has already ceased and harm for neural cells already done.

Ginsenoside Rb1 for overcoming cisplatin-insensitivity of A549/DDP cells in vitro and vivo through the dual-inhibition on two efflux pumps of ABCB1 and PTCH1

BackgroundThe multi-drug resistance is an inherent weakness in the chemotherapeutics of non-small cell lung cancer occurring frequently all over the world. Clinically, ginseng and Chinese medicinal prescriptions including ginseng usually used as anti-tumor adjuncts due to its characteristic of qi-invigorating, which could improve the curative effect of chemotherapy drugs and reduce their toxic side effects. Triterpenoid saponins are the crucial active ingredients in Panax ginseng, and Ginsenoside Rb1 is of the highest quantities. However, the research on the tumor drug-resistance reversal effect and mechanism of ginsenoside Rb1 is still not clear. PurposeThis study aimed to systematically estimate the reversal activity of Ginsenoside Rb1 on cisplatin-insensitivity of A549/DDP cells and to reveal its prospective molecular mechanism. MethodsMTT assay were conducted to evaluate the reversal activity on cisplatin-insensitivity of A549/DDP cells of Ginsenoside Rb1in vitro, and the behavior was also studied by establishing a subcutaneous transplanted tumor model of A549/DDP in BALB/c-nu mice. In addition, P-gp ATPase activity assay, cisplatin accumulation assay, Annexin V-FITC apoptosis assay, real-time qPCR analysis and western blotting analysis were used to clarify the potential mechanism. ResultsGinsenoside Rb1 could effectively reverse the cisplatin-resistance of A549/DDP in vitro and vivo. And after the co-treatment of Ginsenoside Rb1 plus cisplatin, the accumulation of cisplatin increased in A549/DDP cells, which was accompanied with the down-regulation of the mRNA and protein expression levels of ABCB1, SHH, PTCH1 and GLI2. Besides, the apoptosis-inducing ability of cisplatin improved by the relative regulation on the protein expression level of Bax and Bcl-2. Far more importantly, the changes of CYP3A4 mRNA and protein levels were not significant. ConclusionGinsenoside Rb1 could increase the concentration of intracellular cisplatin and improve the insensitivity for cisplatin on A549/DDP cells. Even better, there was perhaps no unpredictable CYP3A4-mediated pharmacokinetic interactions after the combination of Ginsenoside Rb1 plus cisplatin. Ginsenoside Rb1 was a probable reversal agent for the cisplatin-insensitivity of A549/DDP cells, with a bifunction of inhibiting the efflux of two drug pumps (P-gp and PTCH1) by targeting ABCB1 and Hedgehog (Hh) pathway. In general, this research laid the groundwork for the development of a new reversal agent for the cisplatin-insensitivity of NSCLC.

Adrenaline auto-injector injuries: Practical considerations in emergency management in a tertiary hand surgery unit.

Adrenaline auto-injectors are the first line treatment for anaphylaxis in the community setting. Both anaphylaxis and auto-injector carriage are increasing in prevalence. Adrenaline auto-injector injuries are common and most often involve the hand or digits. Such injuries carry a risk of ischemic necrosis due to profound vasoconstriction, especially if there is undying vascular pathology such as Raynaud's disease. The effects can be readily reversed with local infiltration of phentolamine. A survey was circulated to 40 clinicians working in the emergency and hand surgery departments of a major urban center. Knowledge of adrenaline duration of action and its reversal (agent, dose and location in the hospital) was assessed. All clinicians working within the two departments were eligible for participation. Only 25% of clinicians surveyed were aware of the duration of action of adrenaline. Half were aware of the correct reversal agent and only 20% knew the correct dose. Only one person was aware of phentolamine's location within the hospital. There is relatively poor clinician knowledge surrounding adrenaline reversal and a lack of easily accessible information available about dosing and drug location within the hospital. Given the time dependent nature of adrenaline auto-injector injuries Emergency Departments should consider stocking phentolamine in an emergency drugs fridge within the department along with a dosing guide. This is likely to greatly reduce time from presentation to treatment and thus the chances of digital ischemia progressing to necrosis.

Enhancing HIV-1 latency reversal through regulating the elongating RNA Pol II pause-release by a small-molecule disruptor of PAF1C.

The polymerase-associated factor 1 complex (PAF1C) is a key, post-initiation transcriptional regulator of both promoter-proximal pausing and productive elongation catalyzed by RNA Pol II and is also involved in transcriptional repression of viral gene expression during human immunodeficiency virus-1 (HIV-1) latency. Using a molecular docking-based compound screen in silico and global sequencing-based candidate evaluation in vivo, we identified a first-in-class, small-molecule inhibitor of PAF1C (iPAF1C) that disrupts PAF1 chromatin occupancy and induces global release of promoter-proximal paused RNA Pol II into gene bodies. Transcriptomic analysis revealed that iPAF1C treatment mimics acute PAF1 subunit depletion and impairs RNA Pol II pausing at heat shock-down-regulated genes. Furthermore, iPAF1C enhances the activity of diverse HIV-1 latency reversal agents both in cell line latency models and in primary cells from persons living with HIV-1. In sum, this study demonstrates that efficient disruption of PAF1C by a first-in-class, small-molecule inhibitor may have therapeutic potential for improving current HIV-1 latency reversal strategies.

Changes in bispectral index and patient state index during sugammadex reversal of neuromuscular blockade under steady-state sevoflurane anesthesia

Few studies have investigated the changes in patient state index (PSI) and bispectral index (BIS) in response to abrupt increase in electromyographic (EMG) activity. These were performed using intravenous anesthetics or reversal agents for neuromuscular blockade (NMB) other than sugammadex. We compared the changes in BIS and PSI values caused by the sugammadex reversal of NMB during steady-state sevoflurane anesthesia. We enrolled 50 patients with American Society of Anesthesiologists physical status 1 and 2. At the end of the surgery, we administered 2 mg kg−1 sugammadex while maintaining sevoflurane for a 10-min study period. The changes in BIS and PSI from baseline (T0) to train of four ratio of 90% were not significantly different (median difference 0; 95% CI − 3 to 2; P = 0.83), neither were the changes in BIS and PSI values from T0 to their maximum values (median difference 1; 95% CI − 1 to 4; P = 0.53). Maximum BIS and PSI were significantly higher than their baseline values (median difference 6; 95% CI 4–9; P < 0.001 and median difference 5; 95% CI 3–6; P < 0.001, respectively). We found weak positive correlations between BIS and BIS-EMG (r = 0.12, P = 0.01), as well as PSI and PSI-EMG (r = 0.25, P < 0.001). Both PSI and BIS were affected to some extent by EMG artifacts after sugammadex administration.

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.