Reversal Of Residual Neuromuscular Blockade Research Articles

The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial

BackgroundGlycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly patients. Therefore, this study aimed to compare the cardiovascular effects of G/N and A/N for the reversal of NMB in elderly patients.MethodsElderly patients aged 65–80 years who were scheduled for elective non-cardiac surgery under general anesthesia were randomly assigned to the glycopyrrolate group (group G) or the atropine group (group A). Following the last administration of muscle relaxants for more than 30 min, group G received 4 ug/kg glycopyrrolate and 20 ug/kg neostigmine, while group A received 10 ug/kg atropine and 20 ug/kg neostigmine. HR, mean arterial pressure (MAP), and ST segment in lead II (ST-II) were measured 1 min before administration and 1–15 min after administration.ResultsHR was significantly lower in group G compared to group A at 2–8 min after administration (P < 0.05). MAP was significantly lower in group G compared to group A at 1–4 min after administration (P < 0.05). ST-II was significantly depressed in group A compared to group G at 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, and 15 min after administration (P < 0.05).ConclusionsIn comparison to A/N, G/N for reversing residual NMB in the elderly has a more stable HR, MAP, and ST-II within 15 min after administration.

Comparison of three scoring criteria to assess recovery from general anesthesia in the postanesthesia care unit in the indian population.

Different discharge criteria are available for shifting patients out from postanesthesia care room following surgery. This study was done to compare the three-scoring system namely traditional time-based criteria, Fast track criteria and modified Aldrete score, in Indian population patients who recover after general anesthesia in postanesthesia care unit (PACU). Three hundred and seventy-five patients scheduled for general anesthesia were included in this study. Induction of anesthesia was done with intravenous (IV) propofol and maintained with sevoflurane inhalation with oxygen and nitrous oxide. Reversal of residual neuromuscular blockade was done with IV neostigmine and glycopyrrolate. Patients were shifted to PACU following tracheal extubation and recovery was assessed using the traditional time-based criteria, fast track criteria, and modified Aldrete score. As per modified Aldrete score, mean time of shift out is 19 min with median of 15 min and standard deviation of 21.7 min. As per fast-track score, mean time of shift out is 187 min with median of 30 min and standard deviation of 243.7 min. As per the time-based criteria, mean time of shift out is 222 min with median of 240 min and standard deviation of 136.8 min. While using modified Aldrete score, majority of patients had a shorter stay in PACU and faster time to shift out as compared to fast-track criteria and traditional time-based criteria. Modified Aldrete score when compared to fast-track scoring and time-based criteria shows early recovery and reduces the length of stay in PACU.

Effect of reversal of residual neuromuscular blockade on the amplitude of motor evoked potentials: a randomized controlled crossover study comparing sugammadex and placebo.

To compare the amplitude changes in motor evoked potentials (MEP) with reversal of residual neuromuscular blockade using sugammadex or placebo in patients with cervical myelopathy. In this prospective randomized double-blind, placebo-controlled crossover trial, 38 patients with cervical myelopathy undergoing posterior cervical decompression and fusion were randomized to either sugammadex (2mg/kg) or placebo. The primary outcome measure was the increase in amplitude of the MEP in the first dorsal interossei (FDI) muscle at 3 min. Mann-Whitney U test was used to analyze the primary outcome measure. There was a significant increase in the amplitude of MEP at 3 min with sugammadex when compared to placebo group. The median (IQR) increase in MEP amplitude (μV) at 3 min from the left FDI in sugammadex and placebo group was 652.9 (142:1650) and 20.6 (-183.5:297.5) (p <0.001), respectively. Corresponding values from right FDI were 2153.4 (1400:4536.8) and 55(-65.2:480.8) (p=<0.001). Our study showed that there was a 200% increase in the MEP amplitude in the first dorsal interosseous muscle at 3 min following reversal of residual neuromuscular blockade with sugammadex. By ensuring that maximal MEP amplitude is recorded at baseline, early commencement of neuromonitoring can be achieved. The study was registered at http://clinicaltrials.gov , ID NCT03087513, Feb 5th 2018.

This Month in Anesthesiology

This Month in Anesthesiology

Comparative evaluation of morphine and fentanyl for emergence following supratentorial craniotomy

Abstract Background: The emergence from anaesthesia is a very crucial aspect in neurosurgical patients due to the need for evaluation of neurological status in the immediate post-operative period. The present study evaluates the emergence characteristics following administration of morphine as compared to shorter-acting opioid, fentanyl in patients undergoing supratentorial craniotomy. Methods: A total of 84 patients were included in the study. The patients either received morphine 0.1 mg/kg before induction or fentanyl 2 mcg/kg body weight at induction, 1 mcg/kg before skin incision and at the beginning of dural closure. Doses of both opioids were repeated as judged clinically during surgery. Following surgery, the trachea was extubated after reversal of residual neuromuscular blockade, and the emergence characteristics of patients in the two groups were compared. Results: The mean time to emergence was 8.5 ± 3.7 min in morphine group whereas it was 7.8 ± 5.1 min in fentanyl group (P = 0.11). Conclusions: Morphine appears similar to fentanyl for facilitating early emergence in patients undergoing an elective supratentorial craniotomy.

Comparative evaluation of morphine and fentanyl for emergence following supratentorial craniotomy

Background: The emergence from anaesthesia is a very crucial aspect in neurosurgical patients due to the need for evaluation of neurological status in the immediate post-operative period. The present study evaluates the emergence characteristics following administration of morphine as compared to shorter-acting opioid, fentanyl in patients undergoing supratentorial craniotomy. Methods: A total of 84 patients were included in the study. The patients either received morphine 0.1 mg/kg before induction or fentanyl 2 mcg/kg body weight at induction, 1 mcg/kg before skin incision and at the beginning of dural closure. Doses of both opioids were repeated as judged clinically during surgery. Following surgery, the trachea was extubated after reversal of residual neuromuscular blockade, and the emergence characteristics of patients in the two groups were compared. Results: The mean time to emergence was 8.5 ± 3.7 min in morphine group whereas it was 7.8 ± 5.1 min in fentanyl group ( P = 0.11). Conclusions: Morphine appears similar to fentanyl for facilitating early emergence in patients undergoing an elective supratentorial craniotomy.

Retrospective investigation of postoperative outcome after reversal of residual neuromuscular blockade

Postoperative residual neuromuscular blockade (RNMB) is associated with significant morbidity. The aim of this retrospective data analysis was to investigate the influence of the method of RNMB reversal on postoperative outcome. Tertiary teaching hospital in Western Australia. With Ethics Committee approval, data from 1444 patients who received at least one dose of a non-depolarising muscle relaxant intraoperatively during 2011 were analysed. Endpoints included unwanted events in the postanaesthesia care unit (PACU); symptoms of pulmonary complications within 7 postoperative days (0 to 100 outcome score based on 'temperature >38°C', 'leucocyte count >11 × 10 l', 'physical examination consistent with pneumonia' and 'shortness of breath'); PACU turnover time; and length of hospital stay. Data from 1444 patients (722 sugammadex, 212 neostigmine and 510 no-reversal) were analysed. The incidence of postoperative nausea and vomiting (PONV) in PACU was higher in neostigmine-reversed than sugammadex-reversed patients (21.5 vs. 13.6%; P <0.05). No differences were found regarding other PACU incidents, length of PACU stay or hospital stay. Pulmonary outcome deteriorated significantly (outcome score increased) with age and American Society of Anesthesiologists (ASA) physical status. This was observed particularly in ASA 3/4 patients more than 60 years of age in neostigmine-reversed or non-reversed patients, but almost no detrimental effect of age on pulmonary outcome was found in the sugammadex group (P <0.05). RNMB reversal with sugammadex was associated with the lowest rate of PONV and may reduce the risk of pulmonary complications in elderly ASA 3/4 patients. Australian New Zealand Clinical Trials Registry: ACTRN12612000087853.

Acute sialadenitis of parotid gland: Anaesthesia mumps

Acute sialadenitis of parotid gland: Anaesthesia mumps

A47 Does Morphine prolong Emergence in Neurosurgical Patients

Background and Goal of Study: One of the major concerns in neurosurgical patients is emergence. The idea is to allow early neurological examination and reintervention if necessary. More than two decades of quest for an ideal anaesthetic agents to fast track recovery has not yielded conclusive results. Long acting opoids like morphine are not popular for use in neurosurgical patients and the acceptability is for short acting opioids. However there is paucity of data which compares morphine and short acting opioids with regards to their emergence profile in neurosurgical patients. This study was done to evaluate the emergence characteristics of morphine when compared to fentany in patients undergoing elective neurosurgery. Methods: The data of two major tertiary health care institutes of India were compared . One institute predominantly uses morphine while the other uses fentanyl for perioperative analgesia in patients undergoing neurosurgery. The patients who underwent elective supratentorial craniotomy and followed similar emergence technique (low dose propofol along with nitrous oxide in oxygen) were included in the study. The dose of opioids were based on the protocol of individual institution. The patients of morphine group (Group M) received single dose morphine 0.1mg/kg prior to induction. The fentany group (Group F) received 2 ug/kg of fentanyl at induction, 1ug/kg prior to skin incision and at beginning of dural closure. In both groups Fentanyl 1ug/kg was given as additional dose if required. Following surgery, the trachea was extubated after reversal of residual neuromuscular blockade once the patients opened eyes or responded to verbal commands. The emergence chararacteristic among the two groups were compared. Results: A total of eighty four patients qualified for inclusion in the study. There were thirty-seven patients in Group M while Group F had forty-seven patients. The mean time to emergence (time from cessation of anaesthesia to extubation) was 8.5 ± 3.7 minutes in group M and 7.8 ± 5.1 minutes in group F ( p = 0.11). The patients who had early emergence (< 15 minutes following cessation of anaesthesia) were 35 (94%) in group M while it were 43(91%) in group F (p= 0.69). Conclusion: When used judiciously, morphine appears acceptable and similar to fentany for facilitating early emergence in patients undergoing elective supratentorial craniotomy.

Intra-operative change of gastric pH during laparotomic cholecystectomy under general anaesthesia: A prospective case-control study

Background:Gastric decompression by suctioning often shows greenish/greenish-yellow-coloured gastric aspirates following cholecystectomy under general anaesthesia (GA). Possible intraoperative regurgitation of duodenal contents into stomach because of surgical manipulation may be the reason for such alteration in colour of the gastric secretions.Aim:We conducted this study to determine whether there were any pH changes of gastric secretions during laparotomic cholecystectomy operation to confirm our hypothesis of regurgitation of duodenal contents into the stomach.Settings and Designs:Prospective observational controlled study in the Department of Anaesthesiology and Critical Care in a tertiary care university teaching hospital.Methods:Fifty adult ASA I and II patients scheduled for open cholecystectomy operation under GA were included in the study group and another 50 non-abdominal surgical patients without any gall bladder disease were taken as controls. Three to five milliliters of gastric secretions were aspirated just after intubation and also before reversal of residual neuromuscular blockade for analysis of pH.Statistical Analysis:Analysis of variance test and Chi-square test with Fisher's exact correction were used for statistical analysis. Differences were significant when the P value was <0.05.Results:Post-operative values of pH in the study group were significantly higher than their pre-operative values (2.40±1.10 vs. 4.04±1.6, P≤0.001). Forty-nine patients (98%) in the study group had altered coloured post-operative gastric aspirations, while no patient in the control group had such changes (P<0.001).Conclusions:A significant change in gastric pH takes place during laparotomic cholecystectomy due to reflux of duodenal content into the stomach.

The Effect of Residual Neuromuscular Blockade on the Speed of Reversal with Sugammadex

Sugammadex is a modified gamma cyclodextrin compound which encapsulates rocuronium resulting in rapid reversal of residual neuromuscular blockade. We performed a post hoc analysis of data from a multicenter study designed to mimic standard clinical practice which would test the hypothesis that the presence (versus the absence) of a twitch response to neuromuscular stimulation at the time of reversal drug administration would influence the speed and completeness of the reversal effect of sugammadex. One-hundred-seventy-one consenting patients undergoing general anesthesia with a volatile-based anesthetic technique were enrolled in a multicenter observational study. All patients received rocuronium, 0.6 mg/kg i.v. for tracheal intubation and maintenance boluses of 0.15 mg/kg i.v. as needed during surgery. The degree of rocuronium-induced blockade was assessed during anesthesia using a TOF-Watch-SX acceleromyograph to record the train-of-four (TOF) responses on a laptop computer from induction of anesthesia until the TOF ratio returned to > or = 0.9 after completion of the surgical procedure. The patients received sugammadex, 4 mg/kg i.v., for reversal of neuromuscular blockade > 15 min after the last dose of rocuronium. Recovery data were compared in patients with either no (0) (n = 89) or > or = 1 twitch (n = 82) in response to TOF stimulation at the time of reversal drug administration. The patients without a twitch response were more likely to be female (60% vs 40%) and had a shorter time interval between the last bolus dose of rocuronium and the administration of the reversal drug (31+/-18 vs 45+/-23 min, P < 0.05). The time to achieve a TOF ratio of 0.9 was prolonged in the 0 twitch group compared with the > or = 1 twitch response group (173+/-162 vs 104+/-73 s, P < 0.05). Overall, 84% of the patients in the 0 twitch group recovered to a TOF of 0.9 in < or = 5 min compared to 91% of the patients in the group with > or = 1 twitch (P < 0.05). The times to achieve a TOF of 0.9 varied from 0.8 to 22.3 and 0.7 to 8.5 min in the 0 twitch and > or = 1 twitch groups, respectively. Reversal of rocuronium-induced neuromuscular blockade by sugammadex was influenced by the degree of residual blockade at the time the reversal drug was administered. Despite the wide variability, reversal of the TOF ratio to 0.9 occurred < or = 5 min in more than 80% of the patients regardless of the number of twitches at the time of reversal drug administration.

Urgent Usage of Sugammadex to Treat Residual Neuromuscular Blockade in the PACU

To the Editor: Lenz et al. (1) describe a case wherein sugammadex was used urgently to rapidly restore full neuromuscular function in a patient with apparent inadequate reversal of residual neuromuscular blockade upon leaving the operating room. Vecuronium was used intraoperatively despite the fact that the patient had severe renal failure in which context vecuronium could be expected to have a prolonged half-life (2). After reversal with neostigmine and glycopyrrolate, “four twitches” were present, and the patient was noted to have “small tidal volumes.” Although sugammadex was quite effective, it is not yet an approved drug, and the authors justify its use under provisions of the IRB for emergency use of an investigational drug on a one-time only basis. We have a concern about the use of sugammadex in this situation. The patient was still tracheally intubated and the simplest management would have been sedation and mechanical ventilation until fully intact neuromuscular function could be verified. Although sugammadex appears to be a safe drug, exposing the patient to an investigational drug without informed consent when there is a very effective and simple alternative needlessly places the patient at increased risk (however small the risk may be). We are also perplexed that the authors discharged the patient home after only 2 h when he had been given an investigational drug whose pharmacokinetics have not been elucidated in patients with severe renal failure. Although sugammadex binds avidly to rocuronium and vecuronium, the risk of recurarization in the context of severe renal failure is currently unknown, and it would have been prudent to monitor the patient for a longer period of time. The accompanying editorial (3) states that using an investigational drug outside of a clinical trial is only appropriate when “immediate use of the investigational drug is required to preserve the life of the patient and time is insufficient for an independent physician to certify the decision before treatment” (emphasis ours). In this situation, immediate use of sugammadex was not required to preserve the life of the patient, and this case could have been managed in a simpler, and possibly safer, fashion. Philip M. Jones, MD, FRCPC Timothy P. Turkstra, MD, FRCPC Department of Anesthesia and Perioperative Medicine University Hospital London Health Sciences Centre London, Ontario Canada

Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Comparison with Neostigmine???Glycopyrrolate and Edrophonium???Atropine

Sugammadex is a modified [gamma] cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound residual rocuronium-induced blockade than the commonly used cholinesterase inhibitors, edrophonium and neostigmine. Sixty patients undergoing elective surgery procedures with a standardized desflurane-remifentanil-rocuronium anesthetic technique received either sugammadex, 4 mg/kg IV (n = 20), edrophonium, 1 mg/kg IV and atropine, 10 microg/kg IV (n = 20), or neostigmine, 70 microg/kg IV and glycopyrrolate, 14 microg/kg IV (n = 20) for reversal of neuromuscular blockade at 15 min or longer after the last dose of rocuronium using acceleromyography to record the train-of-four (TOF) responses. Mean arterial blood pressure and heart rate values were recorded immediately before and for 30 min after reversal drug administration. Side effects were noted at discharge from the postanesthesia care unit. The three groups were similar with respect to their demographic characteristics and total dosages of rocuronium prior to administering the study medication. Although the initial twitch heights (T1) at the time of reversal were similar in all three groups, the time to achieve TOF ratios of 0.7 and 0.9 were significantly shorter with sugammadex (71 +/- 25 and 107 +/- 61 s) than edrophonium (202 +/- 171 and 331 +/- 27 s) or neostigmine (625 +/- 341 and 1044 +/- 590 s). All patients in the sugammadex group achieved a TOF ratio of 0.9 < or =5 min after reversal administration compared with none and 5% in the edrophonium and neostigmine groups, respectively. Heart rate values at 2 and 5 min after reversal were significantly higher in the neostigmine-glycopyrrolate group compared with that in sugammadex. Finally, the incidence of dry mouth was significantly reduced in the sugammadex group (5% vs 85% and 95% in the neostigmine and edrophonium groups, respectively). Sugammadex, 4 mg/kg IV, more rapidly and effectively reversed residual neuromuscular blockade when compared with neostigmine (70 microg/kg IV) and edrophonium (1 mg/kg IV). Use of sugammadex was associated with less frequent dry mouth than that with the currently used reversal drug combinations.

Difficult Retrograde Endotracheal Intubation: The Utility of a Pharyngeal Loop

Difficult Retrograde Endotracheal Intubation: The Utility of a Pharyngeal Loop

Parasympathetic nervous activity after administration of atropine and neostigmine using heart rate spectral analysis.

Recently, heart rate spectral analysis has become recognized as a powerful tool for quantitatively evaluating autonomic nervous system activity. The purpose of this study was to analyze parasympathetic nervous activity by heart rate spectral analysis after administration of atropine and neostigmine for reversal of residual neuromuscular blockade. For our study, 36 female patients (26-37 years of age), ASA physical status (PS) I, who were scheduled for laparoscopic examination, were randomly allocated to one of the following four groups: In group A (1∶1), 9 patients received 1.0mg atropine followed 4 min later by 1.0 mg neostigmine. In group B (1∶2), 9 patients received 0.5 mg atropine followed 4 min later by 1.0 mg neostigmine. In group C (1∶2.5), 9 patients received 1.0 mg atropine followed 4 min later by 2.5 mg neostigmine. In group D (1∶2 mix), 9 patients received a mixed solution of atropine 0.5 mg and neostigmine 1.0mg. After finishing the laparoscopic examination, additional anesthesia was maintained with 70% nitrous oxide, 30% oxygen, and 0.5% isoflurane. The control data were obtained 10 min after finishing the laparoscopic examination. After that, the data on atropine were obtained between 2 and 4min after administration of atropine, and the data on neostigmine were obtained between 5 and 7 min after administration of neostigmine. We selected power spectral density of the high-frequency component (HF-p) in heart rate spectral analysis as an index to assess parasympathetic activity. In groups A, B, and C, the HF-p decreased after administration of atropine. In groups B and C, the HF-p increased after administration of neostigmine as compared to the control. In group A, the HF-p increased after neostigmine but did not differ from the control. The difference between groups D and B was not statistically significant. From the results of this study, we concluded that the muscarinic effect of neostigmine could not be sufficiently blocked by atropine at 1/2 dosages of neostigmine, but could be sufficiently blocked by atropine at equivalent dosages of neostigmine, under light isoflurane anesthesia.

Comparison of Rocuronium and Mivacurium to Succinylcholine During Outpatient Laparoscopic Surgery

Tracheal intubating conditions and neuromuscular effects of succinylcholine, rocuronium, and mivacurium were studied in 100 healthy women undergoing outpatient laparoscopic surgery. After a standardized fentanyl-thiopental induction, tracheal intubation was facilitated with succinylcholine 1 mg/kg in Groups I (n = 23) and II (n = 25), rocuronium 0.6 mg/kg in Group III (n = 27), or mivacurium 0.2 mg/kg in Group IV (n = 25). If clinically indicated, bolus doses of rocuronium 5-10 mg (Groups I and III) or mivacurium 2-4 mg (Groups II and IV) were administered during the maintenance period. Anesthesia was maintained with desflurane and nitrous oxide 60% in oxygen. At the end of the surgery, residual neuromuscular block was reversed with edrophonium 0.5 mg/kg and atropine 10 micrograms/kg, if needed. The neuromuscular function was assessed using electromyography with a train-of-four mode of stimulation every 10 s at the wrist. Intubating conditions 90 s after succinylcholine and rocuronium were significantly better than after mivacurium. The onset time (from the end of injection until 95% suppression of the first twitch [T1]) for succinylcholine (63 +/- 21 s and 62 +/- 17 s in Groups I and II, respectively) were significantly shorter than for rocuronium (158 +/- 76 s) or mivacurium (210 +/- 93 s). Moreover, the onset times for rocuronium were significantly shorter than mivacurium. The recovery times (of T1 to 25% of the control value) were significantly shorter with succinylcholine and mivacurium than rocuronium. Significantly fewer patients needed reversal of residual neuromuscular blockade after mivacurium compared to rocuronium. One patient in Group I and six patients in Group IV displayed erythema on the upper body. Postoperative myalgia were experienced by 16% of the patients in Groups I and II compared to none in Groups III and IV. There was on difference in the incidence of postoperative nausea and vomiting among the four groups. In conclusion, rocuronium appears to be an acceptable alternative to succinylcholine for tracheal intubation. However, rocuronium's longer duration of action increases the need for reversal drugs. When rapid tracheal intubation is unnecessary, mivacurium is also an acceptable alternative to succinylcholine and is associated with a more rapid spontaneous recovery than rocuronium.

Vecuronium in the myasthenic patient

The use of vecuronium in six patients with myasthenia gravis undergoing thymectomy is described the train-of-four twitch technique was used to monitor neuromuscular function. The first two patients received an initial dose of 0.02 mg/kg and incremental doses of 4 micrograms/kg, which is in the order of one fifth of that normally used. Satisfactory depression of the first twitch of the train-of-four, however was not obtained and, therefore, in the remaining four patients the doses were doubled. At this dose satisfactory depression of the first twitch was achieved. Neostigmine 5.0 mg produced adequate reversal of residual neuromuscular blockade and the train-of-four twitch response recovered to normal levels. With reduced dosage and with careful neuromuscular monitoring, vecuronium can be used safely in the myasthenic patient.

Clinical comparison of D-Tubocurarine and pancuronium: Dosage schedule based on lean body mass

(1) Pancuronium bromide is associated with a faster onset of neuromuscular blockade than d-tubocurarine in equipotent doses. (2) The use of lean body mass allows a more predictable dose-response relationship in people of extreme body weight. (3) The reversal of residual neuromuscular blockade was adequate and similar in both the pancuronium and d-tubocurarine groups.