TOF-Watch SX Research Articles

The Effect of Phonomyography Prototype for Intraoperative Neuromuscular Monitoring: A Preliminary Study.

Quantitative neuromuscular monitoring, as extolled by clinical guidelines, is advocated to circumvent the complications associated with neuromuscular blockers (NMBs), such as residual neuromuscular block (rNMB). Nonetheless, the worldwide utilization of such methods remains undesirable. Phonomyography (PMG) boasts the advantages of convenience, stability, and multi-muscle recording which may be a promising monitoring method. The purpose of this preliminary study is conducting a feasibility analysis and an effectiveness evaluation of a PMG prototype under general anesthesia. A prospective observational preliminary study was conducted. Twenty-five adults who had undergone none-cardiac elective surgery were enrolled. The PMG prototype and TOF-Watch SX simultaneously recorded the pharmacodynamic properties of single bolus rocuronium at the ipsilateral adductor pollicis for each patient. For the primary outcome, the time duration to 0.9 TOF ratio of the two devices reached no statistical significance (p > 0.05). For secondary outcomes, the multi-temporal neuromuscular-monitoring measurements between the two devices also reached no statistical significance (p > 0.05). What is more, both the Spearman's and Pearson's correlation tests revealed a strong correlation across all monitoring periods between the PMG prototype and TOF-Watch SX. Additionally, Bland-Altman plots demonstrated a good agreement between the two devices. Thus, the PMG prototype was a feasible, secure, and effective neuromuscular-monitoring technique during general anesthesia and was interchangeable with TOF-Watch SX.

Monitoring of Neuromuscular block during emergency abdominal surgery

Relevance. Sixty percent of cases of residual neuromuscular block (rNMB) were recorded globally, yet this issue of rNMB in critically ill patients remains taboo. To predict any leftover NMB, a train-of-four stimulation (TOF) Watch SX was utilized to track the depth of muscle relaxant in emergency patients both during and after surgery, even when they were transported to the intensive care unit. This study aimed to investigate differences in the variability of neuromuscular block between two distinct surgical procedures: laparoscopic cholecystectomy (the control group) and emergency abdominal surgery (the investigation group). Materials and Methods. Using two different muscle relaxants and assessing their depth using accelerometry notably the TOF Watch SX. A total of 140 patients, aged 18-60 years with a BMI of 18-30 kg/m², participated in the study. Group I underwent planned cholecystectomy (control group), while Group II underwent emergency abdominal surgery (investigation group). The muscle relaxants Ridelat-C, generic of atracurium benzilate (Verofarm OOO, Harabovsk, Russia) and Kruaron, generic of rocuronium bromide (Verofarm OOO, Harabovsk, Russia) were administered, with various monitoring methods, including Drager Fabius, ECG, and lab results, Microsoft Office Professional Plus 2021 advanced with graphs and ANOVA. Results and Discussion. The results demonstrated profound skeletal muscle relaxation for planned cholecystectomy, with TOF 0 achieved at 165.9 ± 95 seconds for Kruaron and 183.3 ± 90 seconds for Ridelat-C. In emergency abdominal surgery, it took 207.1 ± 120 seconds with Kruaron and 255.5 ± 109.5 seconds with Ridelat-C at TOF0. Notably, Kruaron exhibited prolonged effects in Group II, leading to residual neuromuscular block in critically ills even 2.5 hours post-surgery. Conclusion . Neuromuscular blocking agents modestly exacerbated neuromuscular dysfunction, potentially contributing to acquired critical illness polyneuropathy/myopathy, severe sepsis/septic shock, and massive blood loss/haemorrhagic shock. In critically ills, a minimal calculated dose of Kruaron is recommended, while Ridelat-C, which metabolized within the blood plasma without involving the kidneys or liver, might be a better choice. Suggamadex was suggested for reversing Kruaron effects due to its rapid effect as compared to proserine.

The Variation of Muscle Relaxant According to the Circadian Rhythm in Emergency Abdominal Surgery

In the contemporary anesthesiology services, muscle relaxation plays an integral role in emergency abdominal surgery in order to facilitate the work of the surgeons. Circadian rhythms control the behavioral, mental and physical changes of humans on a 24-hour cycle. The term circadian is originated from the Latin word “circa diem” meaning “around a day.” They are regulated by the suprachiasmatic nucleus SCN in the hypothalamus which is the “master clock” of the brain and the body. A study was carried on 50 patients both male and female from eighteen to sixty years old undergoing emergency abdominal surgery. The level of muscle relaxation administered intravenously was monitored using a TOF Watch SX time 08:00 till 14:00 then from 15:00 -20:00. Two different muscle relaxants were used notably “atracurium benzilate and rocuronium bromide” each at a dose of 0.4 mg/kg and 0.5 mg/kg respectively. The time of action for endotracheal intubation, duration and extubation was recorded. As a result, it was demonstrated that there was a significant shorter time of action and shorter duration in surgeries taking place from 15:00 pm-20:00 as compared to 08:00 -14:00 with both relaxants. To conclude, according to the circadian rhythm, effects of muscle relaxants in the evening relatively differed from the morning by having a shorter duration bringing to the fact that the cholinergic system had a role to play.

Validity and Tolerability of Awake Calibration of an Accelerometer Neuromuscular Monitor.

Validity and Tolerability of Awake Calibration of an Accelerometer Neuromuscular Monitor.

Assessment of the New Acceleromyograph TOF 3D Compared with the Established TOF Watch SX: Bland-Altman Analysis of the Precision and Limits of Agreement between Both Devices-A Randomized Clinical Comparison.

The new acceleromyograph TOF 3D was compared with the established TOF Watch SX in patients undergoing elective laparoscopic gynecological surgery. Neuromuscular transmission was assessed by simultaneous recording with both devices. Measurements were performed simultaneously at the left and the right M. adductor pollicis (Group A, 25 patients), or the M. corrugator supercilii (Group CS, 25 patients). The repeatability, time course, and limits of agreement (Bland-Altman) were compared. The primary endpoint was the 90% train-of-four recovery time (TOFR 0.9). Other endpoints included onset time of block, maximum T1 depression, time to 25% T1 recovery, the recovery time course of T1 response, and TOF ratio, respectively. In group CS, the repeatability coefficient of the TOF 3D was lower (4.66 (1.6)) than of the TOF Watch SX (6.02 (1.9); p = 0.026). In group A, the onset of the block was faster when measured by the TOF 3D (98.7 (30) s vs. 112.2 (36) s (mean (SD)); p = 0.032). In group A, time to recovery to a TOFR of 90% was measured earlier by the TOF 3D (bias −0.71 min, limits of agreement from −8.94 to +7.51 min). The TOF 3D provides adequate information with high precision and sensitivity. It is suitable even for measurement sites with small muscle contractions such as the M. corrugator supercilii.

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.

Comparison of the TOFscan and the TOF-Watch SX during pediatric neuromuscular function recovery: a prospective observational study

BackgroundTOFscan is a three-dimensional acceleromyography neuromuscular monitoring device that does not require initial calibration before muscle relaxant injection. This study aimed to compare TOFscan with TOF-Watch SX, the currently widely accepted uni-dimensional acceleromyography, for use among the pediatric population. We aimed to assess the agreement between TOFscan with TOF-Watch SX in the pediatric population’s neuromuscular recovery.MethodsA total of 35 children aged 6–12 years were enrolled. Prior to any muscle relaxant injection, TOFscan and TOF-Watch SX were applied at each opposite arm and monitoring began concurrently throughout neuromuscular recovery. Calibration was performed for TOF-Watch SX, and train-of-four values were recorded every 15 s. Agreement between the two devices was evaluated with Modified Bland-Altman analysis.ResultsThe bias between TOF-Watch SX and TOFscan were all within the 95% limits of agreement. The bias and standard deviation were smaller and the limit of agreement was narrower in the normalized group than in the non-normalized group [normalized bias −0.002 (95% CI, −0.013 to 0.010), standard deviation (SD) 0.111 vs non-normalized bias 0.010 (95% CI, −0.003 to 0.0236), SD 0.127].ConclusionsTOFscan reliably demonstrated lack of bias and good concordance with TOF-Watch SX throughout the neuromuscular recovery, especially when normalized. Despite technical limitations, the two devices were unbiased along the path of spontaneous and pharmacological reversal in pediatric patients.Trial registrationClinicalTrials.gov NCT03775603. Registered on 13 March 2018

English

BACKGROUND Cisatracurium and atracurium are intermediate acting muscle relaxants which do not depend on renal or hepatic metabolism for elimination since they undergo Hofmann elimination. Despite the advantages of cisatracurium such as minimal effects on the cardiovascular system, no accumulative effects, no metabolite toxicity, and metabolic product has no neuromuscular blocking effects, due to slow onset and unsatisfactory intubating conditions, the use of cisatracurium is limited compared with those seen with equipotent doses of other neuromuscular blocking agents. This study was undertaken to find onset time and intubating conditions with 3 × ED95 doses of atracurium versus cisatracurium. METHODS ASA grade 1 or 2 patients, (N = 220) were randomly allocated into 2 groups to receive equipotent doses of either atracurium or cisatracurium. Intubating conditions were assessed using Cooper et al scale and neuromuscular monitoring done using TOF Watch SX. Haemodynamic responses and any adverse effects were noted. RESULTS The onset time was 167.36 ± 75.41 seconds (2.78 ± 1.25 minutes) in atracurium group whereas in cisatracurium group, onset time was 249.26 ± 75.90 seconds (4.15 ± 1.26) and the difference was statistically significant with p value of &lt; 0.001. The difference in intubating conditions between the groups was statistically insignificant. However, atracurium produced a higher incidence of clinically acceptable conditions (excellent in 94.4 %) than cisatracurium (excellent in 87.3 %). The incidence of adverse effects such as erythema, flushing and bronchospasm was greater in Atracurium group though hypotension was observed in both groups. CONCLUSIONS Onset time and intubating conditions are significantly better with equipotent doses of atracurium compared to cisatracurium. But atracurium is associated with higher incidence of adverse effects such as erythema, flushing and bronchospasm, though the potential of cisatracurium to cause anaphylactoid reactions cannot be ignored. KEYWORDS Cisatracurium, Atracurium, Muscle Relaxants, Neuromuscular Blocking Agents, Erythema, Flushing, Bronchospasm, Hypotension, Anaphylactoid Reactions

A comparison of accelerometric monitoring by TOF Watch® SX and electromyographic monitoring by Tetragraph® for recovery from neuromuscular blockade

BackgroundNeuromuscular monitoring has become a standard of care for management of anesthesia. While acceleromyography (AMG) is the most common technology used in clinical practice, guidelines suggest that electromyographic (EMG) devices are ideal for quantitative neuromuscular monitoring. The Tetragraph® is an EMG monitor that has recently been marketed. Study objectiveThe aim of this study is to assess the agreement during recovery from neuromuscular blockade of this new monitor with the TOF Watch® SX, and to compare intraobserver variability for the two devices. DesignSingle-center, prospective, observational clinical study. SettingOperating room. PatientsTwenty-three patients were enrolled and twenty patients were included in the analysis. InterventionA comparison of TOF-ratios measured sequentially from the same hand with the Tetragraph and TOF Watch SX was conducted during spontaneous recovery of neuromuscular function from patients that received rocuronium during surgery. Main outcome measuresWe used Bland-Altman plots for repeated measures to compare TOF-ratios obtained sequentially by the two devices. Subsequent measures with the same device were used to calculate intraobserver variability for each monitor. Main resultsThe bias between AMG and EMG for TOF-ratios range between 0.2 and 1.0 was 0.13 (95% CI 0.08 to 0.18) and the limits of agreement (LoA) were − 0.11 (95% CI -0.20 to −0.06) and 0.37 (95% CI 0.32 to 0.46), respectively. Agreement slightly improved for TOF-ratios higher than 0.8 compared with lower TOF-ratios: the bias was 0.12 (95% CI 0.08 to 0.17) and 0.13 (95% CI 0.08 to 0.19), respectively. EMG relative intraobserver variability was lower compared with AMG (2.0%, IQR 0.0% to 4.5% vs. 3.2%, IQR 1.2% to 6.0%, P = 0.001). ConclusionsBias between the TOF Watch SX and the Tetragraph TOF-ratios is in line with previous results for AMG and EMG monitors.

Actual versus ideal body weight dosing of sugammadex in morbidly obese patients offers faster reversal of rocuronium- or vecuronium-induced deep or moderate neuromuscular block: a randomized clinical trial

BackgroundThis randomized, double-blind trial evaluated sugammadex-mediated recovery time from rocuronium- or vecuronium-induced moderate (M-) or deep (D-) neuromuscular block in morbidly obese adults dosed by actual (ABW) or ideal body weight (IBW).MethodsAdults with BMI ≥40 kg/m2 were randomized to 1 of 5 groups: M-neuromuscular block, sugammadex 2 mg/kg ABW; M-neuromuscular block, sugammadex 2 mg/kg IBW; M-neuromuscular block, neostigmine 5 mg, and glycopyrrolate 1 mg; D-neuromuscular block, sugammadex 4 mg/kg ABW; or D-neuromuscular block, sugammadex 4 mg/kg IBW. Supramaximal train of four (TOF) stimulation of the ulnar nerve (TOF-watch SX®) monitored recovery. Primary endpoint was time to TOF ratio ≥ 0.9 for ABW and IBW groups pooled across neuromuscular blocking agent (NMBA)/blocking depth, analyzed by log-rank test stratified for agent and depth. Prespecified safety outcomes included treatment-emergent bradycardia, tachycardia, and other arrhythmias, and adjudicated hypersensitivity and anaphylaxis.ResultsOf 207 patients randomized, 188 received treatment (28% male, BMI 47 ± 5.1 kg/m2, age 48 ± 13 years). Recovery was 1.5 min faster with ABW vs IBW dosing. The sugammadex 2 mg/kg groups recovered 9-fold faster [time 0.11-fold, 95% CI 0.08 to 0.14] than the neostigmine group. ABW (5.3%) and IBW (2.7%) groups had similar incidences of recovery time > 10 min (95% CI of difference: − 4.8 to 11.0%); 84% for neostigmine group. Re-curarization occurred in one patient each in the 2 mg/kg IBW and neostigmine groups. Prespecified safety outcomes occurred with similar incidences.ConclusionsABW-based sugammadex dosing yields faster reversal without re-curarization, supporting ABW-based sugammadex dosing in the morbidly obese, irrespective of the depth of neuromuscular block or NMBA used.Trial registrationRegistered on November 17, 2017, at ClinicalTrials.gov under number NCT03346070.

A modified train-of-four ratio to assess recovery from depolarizing neuromuscular blockade after succinylcholine, a prospective observational study.

Succinylcholine is still used in clinical practice. Its duration is highly variable and neuromuscular monitoring is recommended to assess its recovery. Unfortunately, depolarizing neuromuscular block cannot be evaluated by train-of-four (TOF) as no fade occurs. Only single twitch (ST) allows to monitor depolarizing block. The TOFScan monitor proposes a modified TOF ratio (T4/Tref) not referring to fade within a TOF series. We hypothesized that the T4/Tref allows to assess recovery from succinylcholine. This observational study aims to compare recovery from depolarizing block simultaneously assessed with T4/Tref and ST. After Ethics Committee approval and written informed consent 45 patients receiving a single dose of succinylcholine were included. ST recovery, measured with TOF-Watch SX, and T4/Tref recovery, measured by TOFScan, were assessed simultaneously. Difference between measurements was compared using Mann-Whitney U test and overall concordance with the intraclass correlation coefficient (ICC). The ICC was 0.85 [95% CI 0.82-0.87]. The first T4/Tref ratio ≥ 90% was 97% [95% CI 93-101%] the corresponding ST value was 91% [95% CI 87-97%]. The first T4/Tref ratio ≥ 100% was 103% [95% CI 102-107%], the corresponding ST value was 104% [95% CI 100-106%]; median [95% confidence interval of the median]. Time to recovery to 90% and 100% of baseline did not differ between ST or T4/Tref. It was10.0 [8.0-13.0] min vs 10.0 [8.0-12.0] min, P = 0.307 and 10.0 [9.0-15.0] min vs 10.0 [8.0-15.0] min, P = 0.546; respectively; median [IQR]. Agreement between both parameters was excellent. The T4/Tref can be used accurately to measure recovery from depolarizing neuromuscular block.

SUGAMMADEX versus neostigmine after ROCURONIUM continuous infusion in patients undergoing liver transplantation

BackgroundRapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation.This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation.MethodsThe TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution’s internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine).ResultsData from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001).ConclusionSugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice.Trial registrationClinicalTrials.govNCT02697929 (registered 3rd March 2016).

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

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

Comparison of the TOFscan and the TOF-Watch SX during Recovery of Neuromuscular Function

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Quantitative neuromuscular monitoring is required to ensure neuromuscular function has recovered completely at the time of tracheal extubation. The TOFscan (Drager Technologies, Canada) is a new three-dimensional acceleromyography device that measures movement of the thumb in multiple planes. The aim of this observational investigation was to assess the agreement between nonnormalized and normalized train-of-four values obtained with the TOF-Watch SX (Organon, Ireland) and those obtained with the TOFscan during recovery from neuromuscular blockade. Twenty-five patients were administered rocuronium, and spontaneous recovery of neuromuscular blockade was allowed to occur. The TOFscan and TOF-Watch SX devices were applied to opposite arms. A preload was applied to the TOF-Watch SX, and calibration was performed before rocuronium administration. Both devices were activated, and train-of-four values were obtained every 15 s. Modified Bland-Altman analyses were conducted to compare train-of-four ratios measured with the TOFscan to those measured with the TOF-Watch SX (when train-of-four thresholds of 0.2 to 1.0 were achieved). Bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at nonnormalized train-of-four ratios between 0.2 and 1.0 were 0.021 and -0.100 to 0.141, respectively. When train-of-four measures with the TOF-Watch SX were normalized, bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at ratios between 0.2 and 1.0 were 0.015 and -0.097 to 0.126, respectively. Good agreement between the TOF-Watch SX with calibration and preload application and the uncalibrated TOFscan was observed throughout all stages of neuromuscular recovery.

Effect of MDR1 gene polymorphisms on neuromuscular block of rocuronium

Objective To evaluate the effect of MDR1 gene polymorphisms on the neuromuscular block of rocuronium. Methods One hundred thirty-five patients, aged 18-50 yr, with body mass index of 18-25 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing gynecologic laparoscopic operation under general anesthesia, were enrolled in the study.Anesthesia was induced with midazolam 0.06 mg/kg, sufentanil 0.7 μg/kg, propofol(target plasma concentration 6 μg/ml)and remifentanil(target plasma concentration 6 ng/ml). After the patients lost consciousness, neuromuscular block was assessed with TOF-Watch SX accelerometer, and rocuronium 0.6 mg/kg was intravenously injected.Anesthesia was maintained by target-controlled infusion of propofol(target plasma concentration 3-5 μg/ml)and remifentanil(target plasma concentration 3-6 ng/ml). Rocuronium 0.15 mg/kg was added when T1 reached 25% of control.The onset time of rocuronium, maintenance time of induction dose, maintenance time of additional dose and recovery index were recorded.Peripheral venous blood samples were collected for MDR1 genotype(MDR1 1236 C>T and 3435 C>T)analysis using polymerase chain reaction-restriction fragment length polymorphism. Results For MDR1 1236 C>T genotype, there were 19 cases of MDR1 1236 CC genotype, 72 cases of MDR1 1236 TT genotype, 44 cases of MDR1 1236 CT genotype.Compared with patients of MDR1 1236 CC, the maintenance time of induction dose, maintenance time of additional dose and recovery index were significantly prolonged in patients of MDR1 1236 TT and CT genotypes(P T genotype, there were 58 cases of MDR1 3435 CC genotype, 55 cases of MDR1 3435 TT genotype, 22 cases of MDR1 3435 TC genotype.There was no significant difference in maintenance time of induction dose, maintenance time of additional dose and recovery index among patients of different MDR1 3435 C>T genotypes(P>0.05). Conclusion MDR1 1236 C>T gene polymorphisms affects the neuromuscular block of rocuronium, and the genetic factor may be one of the reasons contributing to the individual variation in the efficacy. Key words: Polymorphism, single nucleotide; Andristanols; Neuromusclar blockade; Dose-response relationship, drug

Effects of calcium chloride coadministered with neostigmine on neuromuscular blockade recovery: A double-blind randomised study.

Ionised calcium plays an important role in neuromuscular transmission, but its effects on the reversal of nondepolarising neuromuscular blockade have not been fully evaluated. We examined whether calcium chloride coadministered with neostigmine could enhance the rate of neuromuscular recovery. Randomised double-blind trial. A tertiary teaching hospital. In total, 53 patients undergoing elective surgery under general anaesthesia with neuromuscular monitoring by acceleromyography using a TOF-Watch SX monitor. Patients were randomly allocated to receive either 5 mg kg of calcium chloride (calcium group, n = 26) or the same volume of normal saline (control group, n = 27) coadministered with 25 μg kg of neostigmine and 15 μg kg of atropine at the end of surgery. The primary end point was the neuromuscular recovery time [time from neostigmine administration to recovery of the TOF ratio (TOFr) to 0.9]. Secondary end points included the TOFr at 5, 10 and 20 min after neostigmine administration and the incidence of postoperative residual curarisation (PORC), defined as a TOFr less than 0.9 at each time point. The neuromuscular recovery time was significantly faster in the calcium group than in the control group (median [Q1 to Q3]; 5.0 [3.0 to 7.0] vs. 6.7 [5.7 to 10.0] min, respectively; P = 0.007). At 5 min after neostigmine administration, the TOFr was higher [87 (74 to 100) vs. 68 (51 to 81)%, respectively; P = 0.002] and the incidence of PORC was lower (50.0 vs. 81.5%, respectively; P = 0.016) in the calcium group than in the control group. There were no differences between the two groups with respect to the TOFr or incidence of PORC at 10 and 20 min after neostigmine administration. Calcium chloride coadministered with neostigmine enhanced neuromuscular recovery in the early period of nondepolarising neuromuscular blockade reversal.

Effects of sevoflurane and desflurane on pharmacodynamics of rocuronium in children

Objective: To observe the intraoperative influences on pharmacodynamics of rocuronium in children inhaling sevoflurane and desflurane for 40 min balance. Methods: Ninety children (ASAⅠ-Ⅱ) undergoing elective surgery with general anesthesia in Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University from July 2015 to May 2016 were randomly assigned into six groups (n=15): Sevoflurane group (group S1 and S2), Desflurane group (group D1 and D2) and Propofol group (group P1 and P2). Children in group D1, S1 and P1 were allocated to research the dose-effect relationship of rocuronium, children in group D2, S2 and P2 were allocated to research the time-effect relationship of rocuronium. TOF-Watch SX monitor was used to exert a train-of-four stimulation (TOF) at ulnar nerve in wrist, then the adductor pollicis muscle appeared muscle twitch 4 times in turn which was recorded T(1, )T(2, )T(3) and T(4) respectively. After the success of the muscle relaxant calibration, 1.3 MAC sevoflurane and desflurane were inhaled and maintained for 40 min respectively in children in Sevoflurane group (group S1 and S2) and Desflurane group (group D1 and D2), Plasma target controlled infusion of 3.5-4.0 μg/ml propofol was always administered in Propofol group (group P1 and P2). 75 μg/kg rocuronium was injected each time in group S1, D1 and P1 respectively. Maximum inhibited effect of T(1) was recorded after every injection until inhibition of T(1) more than 95% eventually. The method of cumulative dose four times was used to calculate the efficiency curve of rocuronium[median effective dose (ED(50)), 90% effective dose (ED(90)) and 95% effective dose (ED(95))]. 0.6 mg/kg rocuronium was injected respectively through vein in group S2, D2 and P2. The recovery times of muscle relaxant were recorded which including time of T(1) disappeared (onset time), T(1) from 0% to 5% (peak effect time), T(1) from 0% to 25% (clinical effect time), T(1) from 25% to 75% (recovery index), T(1) from 0% to 70% (internal effect time), T(4)/T(1) (TOFr) from 0% to 70% and 90%. Results: ED(50, )ED(90) and ED(95) in group D1 were 128.73, 212.45 and 245.78 μg/kg respectively. ED(50, )ED(90) and ED(95) in group S1 were 132.46, 218.94 and 252.30 μg/kg respectively. ED(50, )ED(90) and ED(95) in group P1 were 230.56, 381.02 and 439.55 μg/kg respectively. ED(50, )ED(90) and ED(95) in group D1 and S1 were significantly lower than those in group P1 (all P<0.05), but there was no significant difference between D1 and S1 group (P>0.05). Compared with group P2, the shorter onset time, the longer peak effect time and clinical effect time was observed in group D2 and S2, the longer recovery index, internal effect time and TOFr from 0% to 70% and 90% was observed in group S2 (all P<0.01). Conclusions: 1.3 MAC sevoflurane and desflurane inhaling for 40 min significantly reduces ED(50) and ED(95) of rocuronium, prolongs the onset time and action time of rocuronium in children. Sevoflurane can significantly prolong the recovery characteristics of rocuronium.

Comparison of clinical applications of single-dose intravenous injection of mivacurium and cisatracurium in adults’ vocalcordpolyps resection under self-retaining laryngoscope

Objective: Through comparing the clinical observation of mivacurium and cisatracurium in vocal polyp extraction, to study the advantage of mivacurium in vocal polyp extraction. Methods: Forty American Society of Anesthesiologists(ASA) physical status I~II patients for vocal polyp extraction, aged 18~60 years old, were randomly divided into two groups as Mivacurium injection group(Group M) and Cis-atracurium injection group(Group C), each group includes 20 subjects. None of the patients are allergic, has serious diseases of cardiovascular system, liver or kidney.None of them has asthma, airway high response, difficult airway or neuromuscular diseases.Those patients who use beta-blockers or calcium channel blockers for a long time were excluded .All the subjects had the same premedication, fasting and fluid fobidden time. All the subjects who get into the operating room get the routine monitoring of electrocardiogram(EEG), blood pressure(BP), heart rate(HR), pulse oxygen saturation(SpO2) and the TOF WATCH SX. Each group gives the same medicine other than the muscle relaxant during induction of general anesthesia to do the vocal polyp extraction by the same experienced operator. Two groups were recorded in each index of anesthesia induction and tracheal intubation conditions, operation conditions, anesthesia, muscle relaxation monitoring. Results: There are no statistically significant in Cormack-Lehane grading system,Cooper’s grading system and operation satifaction(p>0.05). 2. Group A have shorter intubation time than Group B(p 0.05). Conclusion: 1. A single intubating dose of mivacurium can provide similar intubation and surgeon satisfaction for the vocal polyp extraction. 2. Compared with cis-atracurium, mivacurium can shorten the intubation time and the recovery time of anesthesia. The adverse reactions of mivacurium is mild, and it has less Residual muscle relaxation. Therefore mivacurium is more suitable for the vocal polyp extraction than cis-atracurium.

Monitoring of Muscle Relaxation in Routine Anesthesia Practice: Three-year Experience

Neuromuscular block is a really significant component of anesthesia during surgery operations. At this time, individual sensitivity to neuromuscular blocking differs considerably and depends on great number of factors. The main task of conduct of neuromuscular monitoring is exclusion of residual block and recovery of neuromuscular conductivity. We present analysis of three years’ experience of application of monitoring of neuromuscular conductivity. The aim of the research is the estimation of effectiveness of usage of monitoring of neuromuscular conductivity in daily practice of anesthesia service for provision of patients’ security and formation of comfortable conditions for surgeons’ work. Materials and methods. In our research, we included 4459 patients who had operating treatment under general anesthesia. All the patients were divided in two groups. In the first group (2355 patients) during anesthesia there used monitor TOF-Watch SX (Organon, Ireland). In the second group (2104 patients) monitoring of neuromuscular conductivity was not performed. Results. The received results lead to the conclusion that application of monitoring of neuromuscular conductivity allowed to decrease statistically number of incidents connected with insufficient neuromuscular blocking or impaired reversion of neuromuscular block. Absence of statistically considerable differences in quantity of hyperdynamic reactions in the circulatory system connected with intubation, probably, is caused by great quantity of heterogeneous factors of influence on this index. Also, application of monitor of neuromuscular conductivity made it possible to conform to a surgeon’s expectations, ensuring muscular relaxation suitable for surgery conditions. Conclusion. Usage of monitors of neuromuscular conductivity in routine anesthesia practice is necessary and essential for ensuring patients’ security and creation of comfortable conditions for surgeons work.

Incidence of postoperative residual paralysis in a nigerian teaching hospital.

Postoperative residual paralysis (PORP) is a known risk factor after general anesthesia (GA) for critical respiratory events and increased postoperative morbidity. PORP is defined as a train-of-four ratio (TOFR) of <0.9 using acceleromyography (AMG). TOFR <0.9 has been associated with increased risk of aspiration, obstruction of the upper airway and an impaired hypoxic ventilatory response. The aim of this study was to determine the incidence of PORP, associated factors related with its occurrence and critical respiratory events in the postanesthesia recovery room (PAR) at our institution. Forty-one adult patients were scheduled for elective surgeries requiring GA with the use of at least 1 dose of a nondepolarizing neuromuscular blocking drug (NMBD). An independent anesthetist quantitatively measured TOFR of recruited patients postoperatively in the recovery room using the TOF-watch SX acceleromyograph (Organon Teknika) 5 min after arrival. The incidence of PORP was 75.6% (n = 31), with severe PORP (TOFR <0.7) seen in 41.5% (n = 17) of patients. Median time to full recovery in the PAR was 33 min (range 5-164 min). There was no statistical difference in the incidence of PORP related to the choice of NMBD (P = 0.186) or duration of surgery (P = 0.175). No respiratory complications or events were observed in patients with residual blockade. The incidence of PORP is quite high and undetected in our environment. Quantitative monitoring for residual paralysis is advocated as part of routine monitoring with the use of NMBDs for improved patient safety.