Investigation of potential neuropharmacological activity of neostigmine‐glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Abstract

Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine‐glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle‐twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine‐glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine‐glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine‐glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine‐glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.

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

“…This may explain the recent clinical finding by Oh et al. ( 19 ) showing the feasibility of neostigmine reversal of rocuronium in monitored thyroid surgery.…”

“…Since merely partial reversal of NMB is sufficient for IONM, it may be possible to use the non-specific reversal agent neostigmine as an alternative to the selective binding reversal agent sugammadex ( 19 ). Neostigmine is also a broad-spectrum reversal agent for all non-depolarizing NMBAs.…”

“…Neostigmine may be an alternative option for IONM. Recently, neostigmine has been successfully used to facilitate IONM under rocuronium-induced NMB ( 19 ).…”

Response to "A novel use of neostigmine reversal for intraoperative neural monitoring during thyroid surgery"

“…the authors' interest in our paper. 1 Neostigmine does not directly degrade or chelate the effect of neuromuscular blocking agents (NMBAs), but indirectly reverses their effect by inhibiting acetylcholinesterase and increasing acetylcholine at the neuromuscular junction. Increased acetylcholine can overcome the competitive inhibition of NMBAs.…”

“…Lastly, our study included patients who were indicated for use of rocuronium, thus those with renal insufficiency were automatically excluded. Although we investigated the efficacy of neostigmine in our study, 1 we usually use sugammadex after rocuronium administration to apply IONM for patients with renal disease during thyroid surgery in the clinical setting. A recent systematic review article with a meta-analysis showed that sugammadex may effectively and safely reverse rocuronium-induced neuromuscular blockade in patients with end-stage renal disease.…”