Rocuronium-induced Neuromuscular Block Research Articles

Low-dose sugammadex reverses moderate rocuronium-induced neuromuscular block in horses.

Neuromuscular block (NMB) during general anaesthesia has an implicit risk of inadvertent residual NMB during recovery. Reversal of NMB is commonly encouraged to decrease this risk, and has historically been performed with neostigmine/atropine, two agents with important cardiac and gastrointestinal side effects. Sugammadex is a new selective relaxant binding agent that can reverse rocuronium-induced NMB efficiently and without these complications. Recommended doses are possibly cost-prohibitive. To measure the recovery time from rocuronium-NMB after administration of low-dose sugammadex, compared with spontaneous recovery. Nonrandomised in vivo experiments. Fourteen adult horses undergoing different research procedures were anaesthetised with detomidine and isoflurane. All horses received NMB with rocuronium 0.3 mg/kg IV. Neuromuscular function was measured with acceleromyographic train-of-four (TOF) ratio. Recovery occurred spontaneously in five horses weighing (median [range]) 548 (413-594) kg and was enhanced with sugammadex 200 mg (total dose) in nine horses (433 [362-515]) kg. Recovery time from moderate NMB to a TOF ratio 1.0, and total duration of NMB were compared between groups. Cases of recurarisation (decrease in the TOF ratio <0.9 after recovery) were identified within 30 min after sugammadex. The dose of sugammadex was 0.46 (0.39-0.55) mg/kg. The recovery period lasted 21 (17-39) minutes for spontaneous and 4 (3-7) minutes for sugammadex. Total duration of NMB was 58 (41-70) minutes for spontaneous and 36 (21-43) for sugammadex (both p ≤ 0.003). There were no instances of recurarisation. Small sample size. A dose of sugammadex of approximately 0.5 mg/kg substantially shortened the recovery period from rocuronium-induced NMB from a median of 21 to 4 min, when given at a moderate depth of NMB. No recurarisation was observed within the next 30 min.

Phase III clinical trial comparing the efficacy and safety of adamgammadex with sugammadex for reversal of rocuronium-induced neuromuscular block

BackgroundPreliminary clinical trials of adamgammadex, a new cyclodextrin-based selective reversal agent, have demonstrated its efficacy in reversing neuromuscular block by rocuronium. MethodsThis multicentre, randomised, double-blind, positive-controlled, non-inferiority phase III clinical trial compared the efficacy and safety of adamgammadex and sugammadex. We randomised 310 subjects to receive adamgammadex (4 mg kg−1) or sugammadex (2 mg kg−1) at reappearance of the second twitch of the train-of-four (TOF), and standard safety data were collected. ResultsFor the primary outcome, the proportion of patients with TOF ratio ≥0.9 within 5 min was 98.7% in the adamgammadex group vs 100% in the sugammadex group, with a point estimate and 95% confidence interval (CI) of 1.3% (–4.6%, +1.3%); the lower limit was greater than the non-inferiority margin of –10%. For the key secondary outcome, the median (inter quartile range) time from the start of administration of adamgammadex or sugammadex to recovery of TOF ratio to 0.9 was 2.25 (1.75, 2.75) min and 1.75 (1.50, 2.00) min, respectively. The difference was 0.50 (95% CI: 0.25, 0.50); the upper limit was lower than the non-inferiority margin of 5 min. In addition, there were no inferior results observed in secondary outcomes. Adamgammadex had a lower incidence of adverse drug reactions compared with sugammadex (anaphylactic reaction, recurarisation, decreased heart rate, and laryngospasm; P=0.047). ConclusionsAdamgammadex was non-inferior to sugammadex with a possible lower incidence of adverse drug reactions compared with sugammadex. Adamgammadex may have a potential advantage in terms of its overall risk–benefit profile. Clinical trial registrationChinese Clinical Trial Registry, ChiCTR2000039525. Registered October 30, 2020. https://www.chictr.org.cn/showproj.html?proj=56825

Sugammadex for reversal of moderate-to-deep rocuronium block in a clinical setting: A retrospective report of 10 dogs

ObjectiveTo compare recovery times of sugammadex with spontaneous recovery from rocuronium-induced neuromuscular block (NMB) in dogs. Study designRetrospective, unmatchedcase-control study. AnimalsA total of 10 dogs administered sugammadex and 10 dogs recovering spontaneously from rocuronium-induced NMB. MethodsFiles of dogs administered rocuronium between March and August 2023 were inspected. The train-of-four (TOF) count at the time of sugammadex administration and the time between administration and TOF ratio >90% (recovery time) were recorded. The recovery time for those not administered reversal agents was considered from the first TOF value >0 until TOF ratio >90%. The dose of sugammadex and the cumulative dose of rocuronium were recorded. Rocuronium doses and recovery times were compared using Mann–Whitney tests. The coefficient of determination (R2) between the cumulative rocuronium dose and sugammadex dose and the recovery time were calculated. ResultsDogs in the sugammadex and spontaneous recovery groups were administered intravenously (IV) 0.76 (0.4–2.6) and 0.61 (0.3–2.9) mg kg–1 of rocuronium, respectively (p = 0.325). Recovery time after 3.9 (2.9–5.5) mg kg–1 of sugammadex IV was 1 (1–3) minutes and was 20 (10–35) min for spontaneous recovery (p < 0.0001). The R2 for rocuronium and sugammadex doses and recovery times were 0.19 (p = 0.2) and 0.012 (p = 0.758). Conclusions and clinical relevanceSugammadex 2.9–5.5 mg kg–1 reversed moderate (TOF count 1–3) or deep (TOF count 0) rocuronium-induced NMB within 3 minutes, substantially faster than spontaneous recovery.

Influence of the Pringle maneuver during partial hepatectomy on the neuromuscular block induced by intermittent and continuous dosing of rocuronium.

The Pringle maneuver (PM) is a common procedure in hepatectomy that is known to interrupt drug elimination. The purpose of this study was to examine the influence of PM on the duration of action of rocuronium administered by intermittent bolus dosing, the continuous rocuronium infusion dose required for maintenance of a moderate neuromuscular block, and changes in plasma concentrations of rocuronium. Twenty-seven adult patients undergoing partial hepatectomy with PM were enrolled in this study. The duration of action of 0.2mg/kg rocuronium boluses (DUR), and the continuous rocuronium infusion dose required for maintenance of the height of the first twitch of the train-of-four (T1) at 10-20% of the control value (%T1), respectively, were electromyographically monitored on the adductor digiti minimi muscle. The effects of PM on DUR, %T1, and the plasma concentration of rocuronium were measured. The DUR was significantly prolonged during PM [mean: 42.2 (SD: 8.0) min, P < 0.001] compared to baseline [29.7 (6.3) min]. It was prolonged even after completion of the PM [46.2 (10.5) min, P < 0.001]. The plasma concentration of rocuronium measured at every reappearance of T1 was comparable between before and during PM. %T1 [15.5 (5.6)%] was significantly depressed after the start of PM [6.5 (3.9)%, P < 0.001], with persistence of the depression even after completion of PM. However, there were no significant changes in the plasma concentration of rocuronium. Rocuronium-induced neuromuscular block is significantly augmented during PM. However, the augmentation is not associated with an increase in plasma rocuronium concentration.

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

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

Cardiac output and the pharmacology of general anesthetics: a narrative review

The relationship between cardiac output and anesthetic drugs is important to anesthesiologists, since cardiac output determines the speed with which a drug infused into the bloodstream reaches its target and the intensity of the drug’s effect. But rather than focus on how anesthetic drugs affect cardiac output, this narrative review focuses on how changes in cardiac output affect the pharmacokinetics and pharmacodynamics of general anesthetics during the three phases of anesthesia.&#x0D; At induction, an increase in cardiac output shortens both the onset time of propofol for hypnosis and the neuromuscular blocking effect of rapid-acting neuromuscular blockers, favoring the conditions for rapid sequence intubation.&#x0D; During maintenance, changes in cardiac output are followed by opposite changes in the drug plasma concentration of anesthetic drugs. Thus, an increase in cardiac output followed by a decrease in the plasma concentration of the anesthetic could expose the patient to a real risk of intraoperative awakening, which can be avoided by increasing the dose of hypnotic drugs.&#x0D; At emergence, an increase in cardiac output secondary to an increase in pCO2 allows for a more rapid recovery from anesthesia. The pCO2 can be increased by adding CO2 to the respiratory circuit, lowering the ventilatory rate, or placing the patient on partial rebreathing. Finally, the reversal action of sugammadex for rocuronium-induced neuromuscular block can be shortened by increasing the cardiac output.

Performance of a new auxiliary device based on wrist brace to improve accuracy and feasibility in neuromuscular monitoring with acceleromyography in prone-positioned patients undergoing lumbar spine surgery: a prospective randomized clinical trial.

Accuracy of acceleromyography (AMG) is not be comparable to that of mechanomyography or electromyography (EMG). In particular, the prone position may reduce the accuracy and feasibility of AMG. We developed a new device based on wrist brace to allow free thumb movement and fix the other parts of the hand and wrist. We aimed to test whether the brace applied to the AMG would increase precision of AMG and agreement with the EMG in the prone position. Fifty-seven patients, undergoing lumbar surgery under general anesthesia, were randomly assigned to groups to which AMG was applied with or without (no) brace (29 in group B vs. 28 in group NB). EMG was performed in the contralateral arm. Repeatability coefficients of the first twitch height (T1) and train-of-four (TOF) ratio were assessed from nine consecutive measurements during spontaneous recovery from rocuronium-induced neuromuscular block and the AMGs of the two groups were compared in prone position. The agreement between AMG and EMG in each group was assessed using the Bland-Altman method. In group B, the repeatability coefficient of T1 was significantly lower during the recovery to T1 of 25% and TOF ratio of 0.9 (P = 0.017 and 0.033, respectively), indicating higher precision. The mean differences of bias (95% limits of agreement) between AMG and EMG in TOF ratio of 0.9 were 6.839 (- 26.54 to 40.22) in group NB and 3.922 (- 21.83 to 29.67) in group B. The wide limits of agreement in group NB was slightly narrowed in group B but without significance. Trial registration: registered on the UMIN Clinical Trials Registry in August 2020 (UMIN000041310).

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.

Comparison of the Efficacy and Safety of Adamgammadex with Sugammadex for Reversal of Rocuronium-Induced Neuromuscular Block: Results of a Phase II Clinical Trial

This current phase II clinical trial was to compare the effect and safety of adamgammadex, a new cyclodextrin-based selective relaxant binding agent, with sugammadex to reverse rocuronium-induced neuromuscular block. Patients were randomised to receive adamgammadex (4 or 6 mg kg-1) or sugammadex (2 mg kg-1, as a positive control group) at the reappearance of the second twitch (T2) in response to TOF stimulation. The standard safety data were collected. The 4 mg kg-1 (n = 16) and 6 mg kg-1 (n = 20) adamgammadex- and 2 mg kg-1 (n = 20) sugammadex-induced recovery time of TOF ratio to 0.9 were 2.3, 1.6, and 1.5 min, respectively (p = 0.49). The 4 mg kg -1 adamgammadex-induced median recovery time was longer than that of 2 mg kg-1 sugammadex (p = 0.01), and there was no difference between the 6 mg kg -1 adamgammadex group and 2 mg kg-1 sugammadex group (p = 0.32). Then, the number of patients who experienced adverse events (AEs) was 6, 11, and 14 for adamgammadex at 4, 6 mg kg-1 and sugammadex at 2 mg kg-1, respectively. The treatment emergent AEs that occurred more than twice were detailed as follows: incision site pain, hypotension, emesis, fever, throat pain, blood bilirubin increase, abnormal T-wave of ECG, dizziness, incision site swelling, postoperative fever, expectoration, and nausea. For drug-related AEs, the increased urine acetone bodies and first-degree atrioventricular block were observed in two patients from sugammadex group. Then, the previously reported AEs were not observed in this study, including anaphylaxis, haemorrhage, recurarization, abnormal basic vital signs, or lengthened QRS intervals and QT intervals. Adamgammadex was found to be effective for reversal of rocuronium-induced neuromuscular block as sugammadex.

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

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

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

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

Influence of the amount of skeletal muscle mass on rocuronium-induced neuromuscular block

ObjectiveTo evaluate the effects of skeletal muscle mass on the rocuronium-induced neuromuscular block. DesignA prospective, double-blinded, observational study. SettingA tertiary care university hospital. PopulationOne hundred one patients aged 18–65 years who were scheduled to undergo major surgery lasting more than 1 h under general anaesthesia. MethodsAll participants underwent body composition analysis before anaesthesia and were allocated into two groups; the muscular and non-muscular group, according to skeletal muscle mass. During anaesthesia induction, rocuronium 1.0 mg kg−1 of total body weight was injected followed by neuromuscular monitoring using train-of-four stimulation every 15 s. Main outcome measuresThe onset time of rocuronium included the elapsed time from the rocuronium injection until 95% depression of first twitch (T1) and the time to no response to TOF stimulation. The duration was evaluated as the elapsed time from the rocuronium injection to 25% recovery of the final T1 (TDUR25), and the time to the reappearance of T1 (TTOF1) and T4 (TTOF4). These pharmacologic data were compared between two groups. ResultsThere was no significant difference in the onset time of rocuronium between the two groups. However, TDUR25 (min) was significantly shorter in the muscular group than in the non-muscular group (p = 0.035 and p = 0.014 in males and females, respectively). TTOF1 and TTOF4 were also shorter in the muscular group than in the non-muscular group. ConclusionsTotal body weight-based dosing of rocuronium might prolong the neuromuscular relaxation effect in patients with a small amount of skeletal muscle.

A modified TOF-ratio to assess rocuronium-induced neuromuscular block: a comparison with the usual TOF-ratio

BackgroundThe TOFscan is an acceleromyographic neuromuscular monitor that calculates and displays two measurements: first, a train-of-four (TOF) ratio, or ratio of the fourth twitch in the TOF-sequence, T4, and the first twitch, T1 (T4/T1). In addition, a second, modified ratio is displayed (T4/Tr), which refers to the ratio between T4 and a reference twitch (Tr), calculated as the mean value of the four twitches in a TOF-sequence [Tr = (T1 + T2 + T3 + T4)/4]. T4/Tr is calculated before establishment of neuromuscular block. MethodsThis prospective observational study included 35 adult patients. NMB induced by a rocuronium bolus of 0.6 mg/kg was continuously monitored at the adductor pollicis with the TOFscan and both TOF-ratios were simultaneously assessed. Primary outcome was the comparison of recovery to a TOF-ratio ≥ 0.9 calculated as T4/T1 and T4/Tr. ResultsThe first value of the T4/T1 ≥ 90% was 90.9 (1.1) % and the simultaneously calculated T4/Tr was 69.6 (9.3) %, P < 0.001. The first value of the T4/Tr ≥ 90% was 90.5 (1.1) %, the simultaneously T4/T1 was 97.3 (2.5) %, P < 0.001. Time from injection of rocuronium to a TOF-ratio ≥ 90% was 56.2 ± 17.1 min for the T4/T1 and 65.3 ± 19.3 min for the T4/Tr, P < 0.001. During onset, a TOF ratio ≤ 20% was reached 145.5 (50.5) s after rocuronium when considering T4/T1, and 114.5 (45) s with the T4/Tr, P < 0.001. ConclusionThe present study shows the limitations of the usually determined acceleromyographic TOF ratio (T4/T1) in determining adequate neuromuscular recovery. The T4/T1 ratio significantly overestimates recovery compared with the T4/Tr ratio. Clinical decisions of adequate neuromuscular recovery based on the new T4/Tr ratio may reduce the incidence of residual paralysis and improve patient safety.

A comparison between the adductor pollicis muscle and the abductor digiti minimi muscle using electromyography AF-201P in rocuronium-induced neuromuscular block: a prospective comparative study

BackgroundThe AF-201P, a new electromyography (EMG)-based neuromuscular monitor has been developed recently. The aim of this clinical study was to compare two ulnar nerve innervated muscles: the adductor pollicis (AP) muscle and the abductor digiti minimi (ADM) muscle during the recovery from rocuronium-induced neuromuscular block by using EMG AF-201P.MethodsTwenty patients undergoing surgery with general anesthesia were enrolled in the study. During total intravenous general anesthesia, train-of-four (TOF) and post-tetanic counts (PTC) responses following 0.9 mg/kg rocuronium administration were concurrently monitored at the AP and the ADM muscles with EMG AF-201P on the opposite arms. At the end of the surgery, sugammadex 2 mg/kg was administered when TOF counts of 2 (TOFC2) was observed at both muscles. The primary outcome of the study was time from administration of rocuronium to first appearance of PTC response (first PTC). The secondary outcomes of the study were time from administration of rocuronium to TOF count of 1 (TOFC1), time from first PTC to TOFC1 (PTC-TOF time), time to TOFC2, and time from administration of sugammadex to TOF ratio ≥ 0.9. Agreement between the two muscles was assessed using the Bland–Altman analysis. Data are expressed as mean ± standard deviation.ResultsNineteen patients were included in the analysis. Time to first PTC was significantly faster at the ADM muscle than the AP muscle (24.4 ± 11.4 min vs 32.4 ± 13.1 min, p = 0.006). PTC-TOF time was significantly longer with the ADM muscle than the AP muscle (19.4 ± 7.3 min vs 12.4 ± 10.6 min, p = 0.019). There were no significant differences in time to TOFC2 and sugammadex-facilitated recovery between the two muscles. Bland–Altman analyses showed acceptable ranges of bias and limits of agreement of the two muscles.ConclusionsThe ADM muscle showed a good agreement with the AP muscle during rocuronium-induced neuromuscular block but faster recovery of PTC response when using EMG.Trial registrationUMIN-CTR (Registration No. UMIN000044904). Registered 19 July 2021 -Retrospectively registered, https://center6.umin.ac.jp/cgi-bin/ctr_e/ctr_view.cgi?recptno=R000051290.

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

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

Adamgammadex in patients to reverse a moderate rocuronium-induced neuromuscular block.

The aim of this study was to investigate the effectiveness, safety and pharmacokinetics of adamgammadex in surgical patients. Forty-eight patients aged 18-64 years old were randomized to receive adamgammadex (2, 4, 6, and 8 mg.kg-1 ) or placebo at a ratio of 10:2 for reversal of 0.6mg.kg-1 rocuronium-induced neuromuscular block. Neuromuscular function was monitored by TOF-Watch® SX. When the T2 of train-of-four (TOF) reappeared at the end of surgery, patients received an intravenous administration of adamgammadex or placebo. The recovery time of the TOF ratio to 0.9 decreased significantly from 39.3 [29.5, 50.2] minutes in the group that received placebo to 3.0 [2.3, 3.9] minutes, P < .0001; 2.1 [1.5, 3.0] minutes, P < .0001; 2.1 [1.8, 3.3] minutes, P < .0001; and 1.8 [1.5, 2.2] minutes, P < .0001 in the 2, 4, 6 and 8mg.kg-1 adamgammadex groups, respectively. Then, adamgammadex also showed a shortened recovery time for the TOF ratio recovered to 0.8 and 0.7. Adamgammadex was well tolerated, and no cases of anaphylactic reactions, post-operative bleeding, recurarization, abnormal basic vital signs and prolonged QT intervals were observed. The pharmacokinetics of adamgammadex in plasma increased in dose-dependent manner. The 24-hour cumulative fraction of adamgammadex in urine was 65-83%, and that of rocuronium was increased after using adamgammadex from 15% to about 25-30%. Adamgammadex was found to be effective for reversal of rocuronium-induced neuromuscular block, and it was safe and well tolerated in patients.

“ REVERSAL OF VECURONIUM INDUCED NEUROMUSCULAR BLOCK WITH SUGAMMADEX USING TRAIN OF FOUR MODE IN PATIENTS UNDERGOING SURGERIES UNDER GENERAL ANESTHESIA”

BACKGROUND: Sugammadex is a modied γ-cyclodextrin, “SU” stands for sugar and “gammadex” stands for structural molecule gamacyclodextrin. It can reverse profound neuromuscular blockade and can be given for immediate reversal without waiting for the natural recovery. In a dose of 1.0 mg/kg. It can reverse Rocuronium-induced neuromuscular block which has spontaneously recovered to a train-of-four count of four. In this prospective single arm interventional clinical study, we investigated whether 1mg/kg of Sugammadex can also reverse Vecuronium induced neuromuscular blockade at a similar level of block. METHODS: Thirty one patients of 18-70 years of age who were scheduled to undergo general surgery and gynaecological procedures were enrolled. All patients received standard general anaesthesia with propofol, sevourane, fentanyl, and vecuronium. Neuromuscular function was monitored with acceleromyography (Stimupod xavant technology. Hague, Netherlands). Once the neuromuscular function recovered spontaneously to four twitches in response to train-of-four stimulation, patients were administered 1 mg/kg of Sugammadex I.V. Time from study drug injection to normalized train-of-four ratio 0.9 and the incidence of incomplete reversal within 30min were the primary outcome variables. Secondary outcome was the incidence of reparalysis with normalized train-of-four ratio less than 0.9. RESULTS: We observe that at 0 min, less than 5 percent had complete recovery of neuromuscular function, while at 5th minute, almost 97% of patients had complete recovery which maximizes to 100 percent in 15 minutes. The same total recovery is maintained until 30 minutes without any reparalysis. CONCLUSIONS: Sugammadex in a dose of 1.0mg/kg, reversed a threshold train-of-four count of four in vecuronium induced neuromuscular block without any reparalysis.

A Comparison Between the Adductor Pollicis Muscle Using TOF-Watch SX and the Abductor Digiti Minimi Muscle Using TetraGraph in Rocuronium-Induced Neuromuscular Block: A Prospective Observational Study

The commonly used acceleromyography (AMG)-based neuromuscular monitor TOF-Watch SX is no longer manufactured. Recently, a new portable electromyography (EMG)-based neuromuscular monitor TetraGraph was introduced in clinical anesthesia. The aim of the study was to compare the responses obtained simultaneously from the abductor digiti minimi (ADM) muscle with TetraGraph and the adductor pollicis (AP) muscle with TOF-Watch SX during rocuronium-induced neuromuscular block. Patients undergoing orthopedic surgery with general anesthesia were enrolled in this prospective, observational study. During total intravenous general anesthesia, train-of-four (TOF) responses following 0.9-mg·kg -1 rocuronium administration were monitored at the AP muscle with TOF-Watch SX and the ADM muscle with TetraGraph on the opposite arms. Sugammadex 2 mg·kg -1 was administered when both devices showed TOF counts (TOFCs) = 2. The primary outcome was time from rocuronium administration to first appearance of posttetanic count (PTC) response (first PTC). The secondary outcomes were baseline TOF ratios (TOFRs), onset time, time to first reappearance of TOFC = 1 (time to TOFC1), time to first reappearance of TOFC = 2 (time to TOFC2), and time from sugammadex administration to TOFR ≥0.9 with TetraGraph or to normalized TOFR ≥0.9 with TOF-Watch SX (recovery time). We used paired t test and Wilcoxon signed-rank test to analyze parametric and nonparametric data, respectively. P <.05 defined statistical significance. A total of 20 patients were analyzed. The baseline TOFRs were significantly higher with TOF-Watch SX than with TetraGraph (105 [96-110] vs 100 [98-101]; P = .0002). The time to first PTC (minutes) (31.7 ± 9.6 vs 41.1 ± 12.3; P < .001), time to TOFC1 (minutes) (48.0 ± 12.7 vs 58.8 ± 19.2; P < .001), time to TOFC2 (minutes) (56.2 ± 15.7 vs 74.2 ± 23.7; P < .001), and recovery time (seconds) (61.5 [32-148] vs 75.5 [94-102]); P = .043) were significantly faster with TOF-Watch SX than with TetraGraph. There were no significant differences in onset time. TOF-Watch SX overestimated recovery from rocuronium-induced neuromuscular block compared with TetraGraph.

Sugammadex versus neostigmine for reversal of rocuronium-induced neuromuscular blockade in infants: A prospective randomized pilot study

BackgroundThis study aimed to compare sugammadex and neostigmine for the antagonism of rocuronium-induced neuromuscular block in pediatric patients with biliary atresia and impaired liver function undergoing Kasai operation. MethodsForty pediatric patients below three months of age underwent the Kasai operation. When the surgery ended and the second response (T2) to train-of-four (TOF) stimulation was detected, patients were randomly assigned to receive either 50 µg/kg neostigmine combined with 20 µg/kg atropine, or 2 mg/kg sugammadex. We recorded the time between receiving the neostigmine or sugammadex and reaching corrected TOF ratios of 0.9 and 1.0.We also noted their length of stay in the post-anesthesia care unit (PACU) and any incidents of postoperative recurrence of neuromuscular blockade or other adverse events during recovery. ResultsThe times taken to reach TOF ratios of 0.9 and 1.0 after sugammadex were shorter than after neostigmine (p<0.001). The mean duration of PACU stay was also shorter with the use of sugammadex compared to neostigmine (22.55±5.76 min vs. 40.50±7.93 min; p<0.001). We did not record any incidents of postoperative recurrence of neuromuscular blockade after administration of either treatment .The total number of patients who suffered from post-operative vomiting were statistically lower in the sugammadex group than in the neostigmine group (2 vs. 9; p = 0.03). One patient (5%) in the sugammadex group versus 13 patients (65%) in the neostigmine group developed tachycardia (p<0.001). ConclusionsSugammadex at a dose of 2.0 mg/kg is a safe, quick, and efficacious reversal agent to rocuronium-induced neuromuscular blockade (NMB) in pediatric patients below three months of age undergoing the Kasai operation, with a lower incidence of post-operative tachycardia, vomiting, and shivering than neostigmine.

The train-of-four or double-burst ratios cannot reliably exclude residual neuromuscular block in cats

This study investigated the relationship between train-of-four (TOF) or double burst (DBS) ratios (T4:T1 or B2:B1) and twitch (T1) or burst (B1) magnitudes during the recovery from rocuronium-induced neuromuscular block in dogs and cats. The main hypothesis was that TOF or DBS ratios recover after the recovery of T1 or B1, and hence high ratio levels are sensitive indicators of restoration of the neuromuscular function.Six anesthetized dogs and six anesthetized cats received 0.5 mg/kg of rocuronium intravenously. The amplitudes of T1 or B1 were measured with mechanomyography during neuromuscular block until the neuromuscular function recovered fully. The TOF or DBS ratio was recorded concurrently.In dogs, recovery of T1 and B1 preceded the recovery of the TOF and DBS ratios, and T1 and B1 were always ≥90% of recovery when the respective ratio reached 0.9. In contrast, T1 was still depressed in 5/6 cats when the TOF ratio reached 0.9. At that moment, T1 was 72.5 ± 19.8% of recovery. Similarly, the DBS ratio returned to 0.9 when B1 was still <90% in 3/6 cats of recovery.The TOF and DBS fade in dogs consistently disappeared after the magnitude of T1 or B1 were restored, and hence, ratios ≥0.9 are a sensitive indicator that the neuromuscular function recovered. Our observation in cats however show that the spontaneous recovery of neither the TOF nor the DBS ratio of 0.9 can reliably exclude residual block, as the magnitude of T1 or B1 was still depressed in several instances.