profound neuromuscular blockade and surgery

BACKGROUND: Many anaesthetists use rocuronium in place of suxamethonium for rapid sequence induction (RSI). This is less common in obstetric anaesthesia as the duration of action of an effective dose of rocuronium exceeds most obstetric procedures. Sugammadex offers the possibility of rapidly reversing profound rocuronium neuromuscular blockade at the end of surgery. We aimed to determine whether rocuronium 1.2 mg/kg used for RSI in the obstetric population would provide good intubating conditions at 60 s and would be effectively reversed by sugammadex at the end of surgery...

Neuromuscular blocking agents are widely used in perioperative medicine to aid in endotracheal intubation, facilitate surgery, and in critical care/emergency medicine settings. Muscle relaxants have profound clinical uses in current surgical and intensive care and emergency medical therapy. This article reviews cyclodextrins, development of selective binding agents, clinical development, and future directions of sugammadex.

PURPOSE OF REVIEW: The present review focuses on similarities and discrepancies in the management of emergent and elective unstable cervical spine (C-spine) patients. RECENT FINDINGS: During mobilization, lifting is superior to rolling in limiting spine movements. Before prone position surgery, the transfer of the patient on a rotating table is preferable to rolling. In trauma patients, helical computed tomography (CT) with sagittal reconstruction is the first choice for clearing the C-spine...

OBJECTIVE: To evaluate the post-tetanic count (PTC) for predicting the return of reversible neuromuscular blockade at the n. facialis-m. nasolabialis (nF-mNL) and n. ulnaris-mm. carpi flexorii (nU-mCF) nerve-muscle units (NMUs) during profound vecuronium neuromuscular blockade in halothane-anaesthetized dogs. STUDY DESIGN: Randomized, prospective, experimental study. ANIMALS: Twenty-five dogs (seven male 18 female) undergoing surgery; mean age: 4...

Although antiquated and long targeted for obsolescence, neostigmine and succinylcholine still serve the anesthesia community, decades after their inferior pharmacological profiles have been recognized. The need to quickly establish a good intubation condition with a relaxant that will recover rapidly is fundamental to safe anesthesia practice. So is the need to restore muscle power safely and quickly at the end of surgery, by reversing a residual neuromuscular block. Recent data have shown that sugammadex can safely and rapidly reverse profound neuromuscular block established by rocuronium and vecuronium...

OBJECTIVE: To compare n. facialis-m. nasolabialis (nF-mNL) and n. ulnar-mm. carpi flexorii (nU-mCF) sensitivity to vecuronium during halothane or isoflurane anaesthesia. STUDY DESIGN: Randomized, prospective, experimental study. ANIMALS: Forty-four client-owned dogs (19 male, 25 female) undergoing surgery; mean age: 5.0 years; mean body mass: 24.7 kg. METHODS: Thirty minutes after acepromazine (0.05 mg kg(-1)) and morphine (0...

PURPOSE: Intrathecal morphine is administered to provide profound and prolonged analgesia, and to treat acute postoperative pain. We compared the effectiveness of hyperbaric bupivacaine alone and in combination with morphine for unilateral spinal anesthesia in patients undergoing knee arthroscopy. METHODS: Sixty patients were randomly allocated to two groups to receive either 1.2 ml (6 mg) of 0.5% hyperbaric bupivacaine (group B; n = 30) or 1.2 ml of 0.5% hyperbaric bupivacaine containing 0...

There have been great advancements in cardiac surgery over the last two decades; the widespread use of off-pump aortocoronary bypass surgery, minimally invasive cardiac surgery, and robotic surgery have also changed the face of cardiac anaesthesia. The concept of "Fast-track anaesthesia" demands the use of nondepolarising neuromuscular blocking drugs with short duration of action, combining the ability to provide (if necessary) sufficiently profound neuromuscular blockade during surgery and immediate re-establishment of normal neuromuscular transmission at the end of surgery...

Muscle relaxing agents are clinically in use for general anaesthesia to optimize the conditions to the endotracheal intubation as well as the surgical conditions. Therefore different musclerelaxants with specific pharmacological characteristics are available. Many factors that depend on the condition of the patient and the used musclerelaxant agent influence the duration of the neuromuscular blockade. Rapid reversal of their effects, particularly in cases of profound blockades, proved to be difficult. In cases of postoperative residual paralysis hypoxic complications because of failure of the ventilation increase the morbidity and mortality of the perioperative period...

To achieve spontaneous ventilation after completion of surgery, the nondepolarizing effects on skeletal muscle relaxation are often reversed by administration of an acetylcholinesterase inhibitor. However, these agents increase acetylcholine at both the neuromuscular junction and the muscarinic receptors. Therefore, coadministration of an anticholinergic agent is required to prevent parasympathetic adverse effects. In addition, a relative pharmacologic ceiling effect is seen with inhibition of acetylcholinesterase, necessitating some recovery of neuromuscular function before an acetylcholinesterase inhibitor is administered...

BACKGROUND: Sugammadex is a modified [gamma] cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound residual rocuronium-induced blockade than the commonly used cholinesterase inhibitors, edrophonium and neostigmine. METHODS: Sixty patients undergoing elective surgery procedures with a standardized desflurane-remifentanil-rocuronium anesthetic technique received either sugammadex, 4 mg/kg IV (n = 20), edrophonium, 1 mg/kg IV and atropine, 10 microg/kg IV (n = 20), or neostigmine, 70 microg/kg IV and glycopyrrolate, 14 microg/kg IV (n = 20) for reversal of neuromuscular blockade at 15 min or longer after the last dose of rocuronium using acceleromyography to record the train-of-four (TOF) responses...

BACKGROUND: Post-tetanic count is a valuable method to assess profound neuromuscular blockade. However, subsequent responses to repetitive stimulation might be altered due to post tetanic facilitation (PTF). To avoid PTF, it has been advocated to limit the interval of stimulation from 6 to 10 min. The impact of PTF on 90% recovery of the TOF ratio has not been evaluated. Therefore, we assessed the effect of repetitive PTC stimulation on atracurium blockade with the primary outcome being the time to reach 90% TOF recovery in comparison to classical TOF stimulation...

Ocular microtremor (OMT) is a fine physiologic tremor of the eye related to neuronal activity in the reticular formation of the brainstem. The frequency of OMT is suppressed by propofol and sevoflurane and predicts the response to command at emergence from anesthesia. Previous studies have relied on post hoc computer analysis of OMT wave forms or on real-time measurements confirmed visually on an oscilloscope. Our overall aim was to evaluate an automated system of OMT signal analysis in a diverse patient population undergoing general anesthesia...

Spinal somatosensory evoked potentials (SSEPs) have been used to monitor spinal cord function during corrective scoliosis surgery. We report three cases in which direct epidural stimulation for measurement of SSEPs produced paraspinal muscle contraction, resulting in respiratory and metabolic acidosis. In two of the cases, SSEP-induced acidosis was observed even when only the first twitch of the train-of-four response was detectable after a second dose of muscle relaxant. In one of these two cases, the acidosis was abolished after a sufficient dose of vecuronium to ablate the twitch response...

BACKGROUND: Sameridine, a new substance with both local anesthetic and opioid effects, was administered intrathecally for the first time to humans, i.e. in patients subjected to arthroscopic knee joint surgery. METHOD: A dose-escalating (10, 15, 20 and 25 mg), open study was performed in 33 patients. Only two patients were included in the 25 mg group. RESULTS: Sameridine provided good quality of surgical anesthesia in all patients except those receiving 10 mg...

STUDY OBJECTIVE: To determine if posttetanic twitch following 100-Hz tetanic stimulation enables titration of a nondepolarizing relaxant infusion to a greater depth of block than that achieved with posttetanic twitch following 50 Hz. STUDY DESIGN: Prospective, observational study. SETTING: Operating rooms of a university tertiary care center. PATIENTS: 10 ASA physical status II and III patients free of known neuromuscular disease and undergoing general endotracheal anesthesia for routine elective surgery...

For monitoring of vecuronium profound neuromuscular blockade post-tetanic count (PTC) following tetanic stimulation at frequency of 50 and 100 Hz was employed in 25 ASA I-II patients submitted to elective surgery, to evaluate the differences between the two patterns of stimulation and the possible clinical utility of the latter pattern of stimulation. The drugs employed for anaesthesia were: diazepam 0.15 mg kg-1 in premedication, thiopental 4-5 mg kg-1 for induction, suxamethonium 1.5 mg kg-1 for tracheal intubation...

The purpose of this article is to report the case of a patient who developed prolonged neuromuscular block after a large dose of clindamycin (2400 mg). A 58-yr-old, 65 kg woman with severe rheumatoid arthritis was admitted for wrist arthrodesis. After d-tubocurarine (3 mg) and fentanyl (1.5 micrograms.kg-1), anaesthesia was induced with thiopentone (4 mg.kg-1) followed by succinylcholine (1.5 mg.kg-1) and was maintained with N2O in O2 and isoflurane (0.75-1.0% end tidal) and ventilation was controlled. No further neuromuscular relaxants were given although full return of neuromuscular activity in response to train-of-four and 100 Hz tetanic stimulation was observed after succinylcholine...

Fourteen patients undergoing elective surgery were studied at two levels of gallamine dosage. Seven patients received a single bolus dose of 4 mg/kg, and the remainder received 6 mg/kg. The venous plasma concentration-time data from both groups were characterized in terms of a two-compartment open model. No significant differences in the various pharmacokinetic parameters were noted. However the distribution and clearance terms from these two patient groups were significantly higher than those obtained with a previous group of patients receiving lower (2 mg/kg) single and multiple doses...

The assessment of deep neuromuscular blockade produced by nondepolarizing neuromuscular blocking agents is not possible with the conventional use of the Datex NMT-221 "relaxograph" (Datex NMT-221 monitor, Datex Instrumentarium, Helsinki, Finland), an otherwise useful electromyographic (EMG) monitoring device. A method whereby the relaxograph can be adapted to quantitatively measure posttetanic responses is described here. In anesthetized adult patients, neuromuscular blockade was monitored simultaneously on both hands with two relaxographs...