The Duration of Residual Neuromuscular Block After Administration of Neostigmine or Sugammadex at Two Visible Twitches During Train-of-Four Monitoring

Abstract

Patients with a history of risk factors for stroke and a systolic blood pressure of at least 110 mm Hg were randomly assigned to receive either irbesartan at a target dose of 300 mg once a day or double-blind placebo. The patients were already enrolled in 1 of 2 trials of clopidogrel plus aspirin versus aspirin alone or versus oral anticoagulants. The first coprimary outcome was stroke, myocardial infarction, or death from vascular causes; the second was this composite outcome plus hospitalization for heart failure. Nine thousand sixteen patients were enrolled and followed up for a mean of 4.1 years. The mean reduction in systolic blood pressure was 2.9 mm Hg greater in the irbesartan group than in the placebo group, and the mean reduction in diastolic blood pressure was 1.9 mm Hg greater. The first coprimary outcome happened at a rate of 5.4% per 100 person-years in both groups (hazard ratio with irbesartan, 0.99; 95% confidence interval [CI], 0.91Y1.08). The second coprimary outcome occurred at a rate of 7.3% per 100 person-years among those who received irbesartan and 7.7% per 100 person-years among those who received placebo (hazard ratio, 0.94; 95% CI, 0.87Y1.02). The rates of first hospitalization for heart failure (a prespecified secondary outcome) were 2.7% per 100 person-years among patients who received irbesartan and 3.2% per 100 person-years in those receiving placebo (hazard ratio, 0.86; 95% CI, 0.76Y0.98). Among patients who were in sinus rhythm at baseline, irbesartan was not beneficial in preventing hospitalization for AF or AF recorded on a 12-lead electrocardiogram. There also was no benefit of irbesartan in a subgroup that underwent transtelephonic monitoring. More irbesartan patients than placebo patients had symptomatic hypotension (127 vs 64) and renal dysfunction (43 vs 24). Irbesartan did not lessen cardiovascular events in patients with AF. (Funded by Bristol-Myers Squibb and SanofiAventis; ClinicalTrials.gov no. NCT00249795.)

Sugammadex Always Fast? Probably Yes, but in Liver Transplantation

“…Illman and colleagues found a mean difference of 11.6 minutes between sugammadex and neostigmine, administered when two twitches were detectable, to reach a TOF R >90%. 26 Considering a 1:1 treatment ratio and an expected 5-minute reduction in the sugammadex group, with an alpha level of 0.05 and a power (1-ß) of 90%, the calculated sample size was 16 subjects for each group.…”

Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications

“…27,28 Based on the results from our secondary analysis, we refined this definition as neostigmine administration at doses 60 μg/kg or less after TOF count of 2 or greater. 27,28 Based on the results from our secondary analysis, we refined this definition as neostigmine administration at doses 60 μg/kg or less after TOF count of 2 or greater.…”

“…This does not mean that higher individual doses of NMBAs, either by administration of a large individual dose or by repeated administration of smaller dosages, are not safe when clinically indicated, but rather that judicious use of these drugs should be advocated in the interest of patient safety. 28,49 Despite the growing body of literature to support the use of neuromuscular transmission monitoring, this practice is not consistently used by anesthesia providers. Residual paralysis has been reported to occur in 20 to 45% of cases in which NMBAs are used.…”

“…10 Objective quantitative monitoring of neuromuscular transmission is the only reliable method to exclude residual neuromuscular blockade; however, qualitative, visual, or tactile TOF monitoring is more widespread. 28 Neostigmine does not reverse deep neuromuscular blockade 10,54-56 and should not be given to patients who present with deep neuromuscular blockade [55][56][57] because it can result in incomplete reversal. 49 These exploratory findings suggest that the use of TOF monitoring in tandem with neostigmine administration at doses 60 μg/kg or less is a viable strategy to decrease the incidence of NMBA-induced respiratory complications.…”

Sugammadex versus neostigmine after rocuronium continuous infusion in patients undergoing liver transplantation.

“…Illman and colleagues found a mean difference of 11.6 minutes between sugammadex and neostigmine recovery times, administered when two twitches were detectable and reversal considered as having occurred when TOF R > 90%. 26 Considering a 1:1 treatment ratio and an expected 5-minute reduction in the sugammadex group, with an alpha level of 0.05 and a power (1-ß) of 90%, the calculated sample size was 16 subjects for each group. Taking into consideration a potential dropout of 20% and to increase the statistical significance, we decided to enrol at least 20 subjects per group.…”