Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution

Green, Michael S.; Venkatesh, Archana Gundigi; Venkataramani, Ranjani

doi:10.1155/2017/8197035

Cited by 9 publications

(8 citation statements)

References 14 publications

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“…Since this is the first clinical trial that proposes, as its primary endpoint, a relative reduction of 30% in the incidence of residual curarization, the necessary sample size has been calculated using the statistical software Epi Info (version 7). This analysis shows that at least 30 patients per group will be necessary, considering that in 5% of subjects TF is not valuable [ 22 , 23 ], and expecting 23–25% of residual curarization with neostigmine 30 min after the extubation vs. 2–4% after the administration of sugammadex (with a 95% confidence interval (CI) and a power of 80%, and assuming equal variance between the two groups). For the secondary outcome, the number needed to treat has been calculated with a CI of 95%.…”

Section: Methodsmentioning

confidence: 99%

Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial

Cappellini

Picciafuochi

Ostento

et al. 2018

Trials

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BackgroundThe extensive use of neuromuscular blocking agents (NMBAs) during surgical procedures still leads to potential residual paralyzing effects in the postoperative period. Indeed, neuromuscular monitoring in an intra-operative setting is strongly advocated. Acetylcholinesterase inhibitors can reverse muscle block, but their short half-life may lead to residual curarization in the ward, especially when intermediate or long-acting NMBAs have been administered. Sugammadex is the first selective reversal drug for steroidal NMBAs; it has been shown to give full and rapid recovery of muscle strength, thus minimizing the occurrence of residual curarization. Acceleromyography of the adductor pollicis is the gold standard for detecting residual curarization, but it cannot be carried out on conscious patients. Ultrasonography of diaphragm thickness may reveal residual effects of NMBAs in conscious patients.Methods/designThis prospective, double-blind, single-center randomized controlled study will enroll patients (of American Society of Anesthesiologists physical status I–II, aged 18–80 years) who will be scheduled to undergo deep neuromuscular block with rocuronium for ear, nose, or throat surgery. The study’s primary objective will be to compare the effects of neostigmine and sugammadex on postoperative residual curarization using two different tools: diaphragm ultrasonography and acceleromyography of the adductor pollicis. Patients will be extubated when the train-of-four ratio is > 0.9. Diaphragm ultrasonography will be used to evaluate the thickening fraction, which is the difference between the end expiratory thickness and the end inspiratory thickness, normalized to the end expiratory thickness. Ultrasonography will be performed before the initiation of general anesthesia, before extubation, and 10 and 30 min after discharging patients from the operating room. The secondary objective will be to compare the incidence of postoperative complications due to residual neuromuscular block between patients who receive neostigmine and those who receive sugammadex.DiscussionPostoperative residual curarization is a topic of paramount importance, because its occurrence can cause complications and increase the length of stay in hospital and the related costs. Diaphragm ultrasound assessment may become a bedside integrative tool in the neuromuscular monitoring field to detect concealed residual curarization in surgical patients who have received paralyzing agents.Trial registrationEudraCT, 2013-004787-62. Registered on 18 June 2014, as “Evaluation of muscle function recovery after deep neuromuscular blockade by acceleromyography of the adductor pollicis or diaphragmatic echography: comparison between sugammadex and neostigmine.”ClinicalTrials.gov, NCT02698969. Registered on 15 February 2016, as “Recovery of Muscle Function After Deep Neuromuscular Block by Means of Diaphragm Ultrasonography and Adductor Pollicis Acceleromyography: Comparison of Neostigmine vs. Sugammadex as Reversal Drugs.”Electronic supplementary materialT...

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Section: Methodsmentioning

confidence: 99%

Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial

Cappellini

Picciafuochi

Ostento

et al. 2018

Trials

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show abstract

“…Mean of residual blockage without reversal 72% timization of surgical conditions. However, there are several risks in the use of neuromuscular blocking agents, the most critical being inadequate recovery of neuromuscular function, leading to complications due to upper airway muscle weakness [11]. Accordingly, reversible agents such as acetylcholinesterase inhibitors and Sugamadex are used to antagonize non-depolarizing muscle relaxant effects and prevent complications due to residual curarization, as observed in this research.…”

Section: Overall Average 89%mentioning

confidence: 89%

Incidence of Residual Neuromuscular Blocking in Oncological Patients in the Anesthetic Rescue Room: Importance of Objective Monitoring in the Foundation Center of Control of Oncology of the State of Amazonas - Fcecon

Pirangy¹,

Melo²,

Pereira³

et al. 2019

Int J Anesthetic Anesthesiol

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The present research project aims to evaluate the incidence of residual neuromuscular block in the post-anesthetic recovery room in patients who underwent general anesthesia with mechanical ventilation. It is known that neuromuscular blockers are drugs that interrupt the transmission of nerve impulses at the neuromuscular junction causing muscle paralysis. In addition, they facilitate endotracheal intubation during anesthetic induction and allow for adequate surgical management.There are several adverse effects resulting from their use, among them: The occurrence of vagolytic and sympatholytic activities that cause cardiovascular alterations or autonomic stimulation. Monitoring the levels of these blockers is of paramount importance because it allows the titration of the drug. By relaxing and paralyzing the muscles, postoperative weakness due to the absence or incomplete performance of the antagonists of this drug is frequent. This situation is known as postoperative residual neuromuscular block.When it comes to the anesthetic practice to evaluate such situation, the patient's clinic is often the only alternative. The safe use of neuromuscular blockers requires monitoring to qualify muscle relaxation by being measured from a known monitor of four stimuli or Train of Four (TOF).The residual neuromuscular blocker influences possible clinical complications that may lead to increased morbidity and mortality in the postoperative period. Thus, this project aims to identify the incidence of residual neuromuscular block in the postanesthetic recovery room in order to reduce the cardiorespiratory complications resulting from the use of the adenos polarizing neuromuscular blockers.

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“…It is conventionally used for reversal of neuromuscular block induced by nondepolarizing neuromuscular blocking drugs at the end of surgery. [6] The use of neostigmine is known to be safe and effective for most patients. However, in recent years several cases of acute pulmonary edema due to the application of neostigmine have been reported.…”

Section: Discussionmentioning

confidence: 99%

Acute noncardiogenic pulmonary edema after neostigmine administration during the recovery period of general anesthesia

et al. 2018

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Although neostigmine is widely used for recovery from neuromuscular block and exhibits satisfactory effect in most cases, there is a potential risk of ANPE in some cases, which is rare but potentially fatal and could affect the patient outcomes. Therefore, it is necessary for anesthetists to closely monitor the vital signs of patients after administration of neostigmine in the perioperative period.

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Management of Residual Neuromuscular Blockade Recovery: Age-Old Problem with a New Solution

Cited by 9 publications

References 14 publications

Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial

Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial

Incidence of Residual Neuromuscular Blocking in Oncological Patients in the Anesthetic Rescue Room: Importance of Objective Monitoring in the Foundation Center of Control of Oncology of the State of Amazonas - Fcecon

Acute noncardiogenic pulmonary edema after neostigmine administration during the recovery period of general anesthesia

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