Tracheal extubation is a risky phase of anaesthesia. Most complications that occur when an endotracheal tube is removed are of minor nature, but those that require critical action can end in serious complications or even death. Patient – A 55-year-old woman was admitted for elective transabdominal hysterectomy and adnexal procedures. Anaesthesia – Standard monitoring. For induction, we used fentanyl, propofol, and rocuronium. The maintenance phase of anaesthesia was without complications. After extubation, the patient presented with severe trismus and mask ventilation was unsuccessful (cannot ventilate) – It was not until 200 mg of succinylcholine was administered that the masseter muscle spasm subsided. Extubation is a process that must always be planned. A routine approach and lack of a contingency plan is responsible for a number of complications related to the period of patient awakening and associated with the removal of the endotracheal tube. Trismus, in response to extubation, is a phenomenon not described in the literature in non-high risk patients.

Background: Electromyography can be used for quantitative neuromuscular monitoring during general anesthesia, mostly using the stimulation train-of-four (TOF) pattern. Relaxometry measures the muscular response of the adductor pollicis muscle to electrical stimulation of the ulnar nerve, which is routinely used in clinical practices for monitoring the neuromuscular block. However, when it is not always possible to be used for all patients, the posterior tibial nerve is a suitable alternative. Objectives: Using electromyography, we compared the neuromuscular block between the ulnar and the posterior tibial nerves. Methods: In this study, the participants were 110 patients who met inclusion criteria and submitted their written consent. Following the administration of cisatracurium intravenously, the patients had relaxometry performed simultaneously on the ulnar and the posterior tibial nerves using electromyography. Results: Eighty-seven patients were included in the final analysis. The onset time was 296 ± 99 s at the ulnar nerve and 346 ± 146 s at the tibial nerve, with a mean difference of -50 s and a standard deviation of 164 s. The 95% limits of agreement ranged from -372 s to 272 s. The relaxation time was 105 ± 26 min at the ulnar nerve and 87 ± 25 min at the tibial nerve, with a mean difference of 18 min and a standard deviation of 20 min. Conclusions: Using electromyography, no statistically significant difference was noticed between the ulnar and the posterior tibial nerve during the neuromuscular block. The onset time and the relaxation time assessed with an electromyogram to compare the stimulation of the ulnar and posterior tibial nerves showed large limits of agreement.

IntroductionNegative pressure pulmonary edema (NPPE) is an uncommon perioperative complication with a potentially fatal outcome. It is most predominant in young healthy men undergoing surgical procedures under general anesthesia. Due to its rare occurrence and uncharacteristic clinical presentation, it poses a potential diagnostic pitfall.AimThe purpose of this article is to present clinical characteristics and management of NPPE.Material and methodsThis paper is based on the available literature and the authors’ experience.Results and discussionClinical presentation of NPPE is uncharacteristic and includes i.e. agitation, tachypnea, tachycardia, cyanosis and pink frothy sputum. Postponed extubation after general anesthesia is believed to be optimal in order to prevent NPPE as it minimizes asynchrony of muscle function reversal and probability of laryngospasm. Differential diagnosis includes and is not limited to pulmonary edema, aspiration pneumonia, anaphylaxis, septic shock, pulmonary embolism or exacerbation of bronchial asthma. Management of NPPE is symptomatic and focuses on symptomatic treatment and maintaining an open airway passage. Endotracheal intubation with low tidal volume ventilation of 6 mL/kg of ideal body weight with a plateau pressure of less than 30 cm H₂O and high positive end-expiratory pressure (PEEP) may improve patients outcomes.ConclusionsIt is crucial for anesthesiologists to familiarize themselves with this phenomenon for early recognition and proper therapeutic decisions. It should be emphasized that under the highest risk of developing NPPE are young male patients and the most common cause is post-extubation laryngospasm.

Introduction: Postoperative residual curarization (PORC) is a common complication but rarely taken into account during the postoperative period. PORC is associated with an increased risk of morbidity and mortality in anesthetized patients. Even small degrees of residual muscle relaxation of the transverse striated muscles can have serious clinical consequences for patients including a decline of upper respiratory tract function or swallowing disorders. Aim: The aim of the work is to discuss the problem of PORC, its risk factors and diagnosis, as well as to identify the most common errors, which can be made even by experienced anesthesiologists and can lead to an increased risk of developing this life-threatening complication. Material and methods: This work is based on the available literature and the authors’ experience. Results and discussion: PORC caused by non-depolarizing neuromuscular blocking agents is a known problem in daily clinical practice. The effects of PORC significantly increase the risk of respiratory complications (hypoxia, pulmonary edema, atelectasis and pneumonia). Patients can report discomfort even with a small degree of residual muscle block above a train of four (TOF) ratio of 0.8. Complete recovery of neuromuscular function does not occur until the TOF ratio is greater or equal to 0.9. Conclusions: The primary strategy to avoid residual neuromuscular block and to improve the safety precautions of patients undergoing anesthesia is not by means of clinical evaluation but consistent monitoring of neuromuscular conduction and extubating the patient when the TOF ratio more than 0.9.