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The neuromuscular junction is a complex structure consisting of the muscle cell, the nerve terminal of a motor neuron and the synaptic cleft. It is the site of action for neuromuscular blocking drugs, which are a cornerstone of anaesthetic practice. These drugs can be divided into depolarizing and non-depolarizing drugs; the latter can be further subdivided into benzylisoquinolinium and aminosteroid compounds. Reversal agents are also discussed. The pharmacology of neuromuscular blocking drugs and reversal agents is discussed including mechanism of action, metabolism, factors influencing choice of drug as well as adverse effect profile. [ABSTRACT FROM AUTHOR]

Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium‐induced anaphylaxis. Life‐threatening anaphylaxis can be immunoglobulin E–mediated or non–immunoglobulin E‐mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: To compare using deep neuromuscular blockade during low abdominal insufflation pressure (DNMB/LAIP; n = 67) to conventional blockade and pressure (CNMB/CAIP; n = 68) for laparoscopic cholecystectomy and to evaluate the speed and efficacy of NMB recovery using sugammadex (SGX) as assessed by the Postoperative Quality Recovery Scale. Patients & Methods: Rocuronium initiation and maintenance doses were 0.6 and 0.15 mg/Kg, respectively, and neostigmine or SGX was used as reverse agent for CNMB and DNMB, respectively. Abdominal insufflation was terminated at 15 and 8-mmHg, for CAIP and LAIP, respectively. The study outcome is the surgical feasibility under DNMB/LAIP, as judged by the frequency of shift-to-CAIP, surgical field visibility and operative time. Results: The frequency of shift-to-CAIP was 2.9% due to surgeons' inconvenience of LAIP. DNMB allowed significant control of intraoperative (IO) hemodynamic response to surgical manipulations. SGX allowed 3.2 times faster NMB-reversal with significantly higher percentages of patients returned to baseline physiologic statuses. The percentage of patients free of pain and nausea was significantly higher after DNMB/LAIP. At hospital discharge and day-7 PO, 86.6% and 98.5% of patients regained normalcy of their overall perspectives after DNMB/LAIP with a significant difference than after CNMB/CIAP. At 2-week PO, the frequency of shoulder-tip pain (STP) was significantly lower and surgeons' satisfaction rate was significantly with DNMB/LAIP. Conclusion: Laparoscopic cholecystectomy under DNMB/LAIP procedure is feasible and safe with lower incidence and severity of STP and high surgeons' satisfaction. Sugammadex hastened the recovery of DNMB 3.2 times that of neostigmine-induced recovery of CNMB. Registration NO: RC.3.9.2023. [ABSTRACT FROM AUTHOR]

Background & objective: Sugammadex is a drug used to reverse the muscle relaxation effect of rocuronium. Its use is still limited in preterm neonates. The aim of this study was to compare the efficacy of Sugammadex with that of neostigmine in reversing rocuronium-induced muscle relaxation in preterm neonates and to evaluate the safety of its use in this age group. Patients and methods: This randomized clinical trial was carried out on Sixty preterm neonates, planned for elective inguinal hernia repair under general anaesthesia. The patients were divided into two equal groups. Group N used neostigmine and group S used Sugammadex as the reversal agent for rocuronium. Results: In Sugammadex group the mean reversal time (1.15 ± 0.42) min and the mean recovery time (17 ± 6.64) min were significantly shorter than in the neostigmine group (8.9 ± 1.6) min and (27.16 ± 9.26) min respectively, with p value <0.001. The patients in the Sugammadex group showed significantly lower heart rate than those in neostigmine group but showed no significant difference as regard mean blood pressure at 3, 6, 9,12,15 and 18 min after drug injection. There were no significant complications noted in both group. Conclusion: Sugammadex is well tolerated in the Preterm neonates with shorter recovery and reversal time when compared to neostigmine. [ABSTRACT FROM AUTHOR]

Survivors of sexual assault may receive levonorgestrel, also known as Plan B, as a first-line oral emergency contraceptive pill. Sugammadex, a neuromuscular blockade antagonist commonly used in anesthesia, binds to hormonal contraceptives and decreases serum progesterone concentrations. Levonorgestrel acts as a synthetic progesterone, inhibiting ovulation, with peak effectiveness when given during the pre-ovulation stage. Anesthesia professionals must identify at-risk patients and potential drug interactions that can alter emergency contraception efficacy. [ABSTRACT FROM AUTHOR]

Sugammadex is a direct reversal agent of aminosteroid muscle relaxants, particularly rocuronium, with promptly and completely reverse of deep neuromuscular block (NMB), which allows better surgical conditions. Sugammadex exhibits advantages over indirect reversal agent acetylcholinesterase inhibitor neostigmine with less adverse effects. In this retrospective review, we compared the incidence of postoperative vomiting (POV), postoperative urinary retention (POUR), and hemodynamic changes between sugammadex and neostigmine/glycopyrrolate in reversal of muscular blockade. Sugammadex showed superior in all three aspects. The heart rate was 7.253 lower (P < 0.0001) and mean arterial pressure was 5.213 lower (P < 0.0001) in sugammadex group. The POV of neostigmine/glycopyrrolate group was 3.16 times more than sugammadex group (OR = 3.16, p < 0.0001), and POUR of neostigmine/glycopyrrolate group was 4.291 times more than sugammadex group (OR = 4.291, p < 0.0001). Sugammadex showed better hemodynamic stability, and lower incidence of POV and POUR than neostigmine/glycopyrrolate. [ABSTRACT FROM AUTHOR]

• Lingering rocuronium effects affect perceived patient neurologic status. • Rocuronium lingering effects can be prolonged in acute neurosurgical patients. • Rocuronium reversal can drastically impact neurosurgical decision making. • Sugammadex can serve as a useful tool in acute neurosurgical settings. Sugammadex reversal of neuromuscular blocking agents (NMBAs) is usually performed postoperatively. A scarcity of literature exists exploring sugammadex use for timely neurological examination of neurosurgical patients. NMBAs, like rocuronium, are used in the Emergency Department during intubation and their unpredictable duration of action often impedes timely and accurate assessment of patient neurological status. We aim to explore the role of sugammadex in evaluating patients in need of acute neurosurgical care. Retrospective assessment of patients presenting with traumatic brain injury or intracranial hemorrhage was conducted at our level 1 trauma center. Patients of interest were those for whom sugammadex reversal of rocuronium neuromuscular blockade, from intubating doses, was pursued to ensure timely neurologic assessment. Nine patients were identified for whom GCS pre-/post-sugammadex, rocuronium dosing, elapsed time between rocuronium administration and reversal, and clinical course data were retrieved. Arrival GCS was 5.2 ± 3.2, with intubation accomplished within 10 ± 2.5 min of presentation. Rocuronium dosing was consistent between patients, average single dose of 1.2 ± 0.3 mg/kg. Lingering neuromuscular blockade ranged from 28 to 132 min (87.3 ± 34.3 min). All patients exhibited a GCS of 3 T upon initial neurosurgical evaluation, prior to reversal. Post-reversal GCS rose to 6.0 T ± 2.2. Sugammadex facilitated more accurate clinical decision making in 8 of 9 patients, including prevention of unnecessary invasive procedures. Two of 9 patients were eventually discharged home or to a rehabilitation facility. Rocuronium neuromuscular blockade can linger beyond pharmacokinetic predictions, thus delaying timely and precise neurologic assessment. Our data suggests sugammadex may be a useful addition to the clinician's armamentarium for acute neurologic assessment in the neurosurgical population. Sugammadex may impact clinical decision-making in certain patients and allow for more informed decision-making by families and physicians alike. Prospective studies are needed to definitively assess the impact of sugammadex on outcomes in acute neurosurgical settings. [ABSTRACT FROM AUTHOR]

Postoperative myasthenic crisis with respiratory failure is a potentially lethal complication, warranting careful perioperative planning and extended postoperative surveillance of patients. Data on the incidence of postoperative respiratory failure and optimal management of patients after robotic-assisted thymectomy are limited. The objective of this study was to evaluate the incidence of respiratory complications and the need for intensive care unit (ICU) capacities after robotic-assisted thymectomy in patients with myasthenia gravis. Retrospective cohort study. Single University hospital in Vienna, Austria, from January 2014 to December 2019. The authors included adult patients who underwent robotic-assisted thymectomy due to myasthenia gravis. Of 72 patients, 4 patients (5.6%) developed postoperative respiratory failure, needing noninvasive ventilation/intubation. Respiratory failure occurred within the first hours after extubation when patients still were under surveillance in the recovery room or in the ICU. One patient (1.4%) suffered from worsened myasthenic symptoms several days after surgery, and was treated with plasmapheresis. Sixty-five patients (90.3%) were extubated in the operating room, 35 of these (48.6%) were transferred to the ICU, and 30 patients (41.7%) primarily were transferred to the recovery room. Fourteen patients (19.4%) were transferred to the surgical ward after extended observation in the recovery room. Furthermore, after implementation of a standardized perioperative algorithm in 2020, a reduction of ICU admissions was achieved. After careful patient selection, planning, and postoperative patient evaluation, robotic-assisted thymectomy can be performed safely without postoperative surveillance in an ICU. [ABSTRACT FROM AUTHOR]

Sugammadex produces recovery from neuromuscular blockade more rapidly and reliably than neostigmine. We sought to determine if sugammadex is associated with improved perioperative efficiency when compared to traditional neuromuscular blockade reversal with neostigmine, potentially offsetting the higher medication cost. This retrospective analysis involved patients receiving either neostigmine or sugammadex for reversal of neuromuscular blockade at a single academic tertiary care hospital. The final propensity-matched groups consisted of 4060 in each group (neostigmine or sugammadex). The primary outcome measured was total time in the operating room. Secondary outcomes included specific measures of perioperative efficiency as well as postoperative pulmonary failure. The average operating room time for patients was 169.59 [1.27] minutes for neostigmine and 157.06 [1.33] minutes for sugammadex (P < 0.001). The difference was primarily accounted for by shorter surgical times (121.45 [1.18] vs 109.62 [1.22] minutes, P < 0.011). Sugammadex was also associated with a shorter post-anesthesia care unit length of stay (102.47 [1.04] vs 98.67 [1.02] minutes, P < 0.001). For 8120 patients, sugammadex use was associated with shorter operating room and surgical durations as well as shorter post-anesthesia care unit stay. The favorable pharmacodynamic profile of sugammadex may improve surgical and perioperative efficiency and offset higher medication cost. [ABSTRACT FROM AUTHOR]

This study aimed to compare the effect of sugammadex and neostigmine on neuromuscular block reversal and the incidence of postoperative pulmonary complications in patients undergoing lung cancer resection. A double-blind, randomized, prospective study. A single major urban teaching and university hospital. One hundred adult patients underwent elective radical resection of lung cancer under general anesthesia. Patients were assigned into neostigmine (0.05 mg/kg) + atropine 0.02 mg/kg group and sugammadex (2 mg/kg) group. The primary outcomes were the incidence of any postoperative pulmonary complications, and the time to achieve 90% of train-of-four (TOF) after the administration of sugammadex or neostigmine. The secondary endpoints were the number of patients with TOF ratio (TOFr) <0.9 at the time of tracheal extubation, the incidence of readmission 30 days after discharge, and specific postoperative pulmonary complications. Results showed that the average time of recovery to TOFr ≥0.9 with sugammadex was 164.5 ± 27.7 seconds versus 562.9 ± 59.7 seconds with neostigmine + atropine treatment. Fewer sugammadex-treated patients did not achieve TOFr of 0.9 at the time of tracheal extubation than did neostigmine-treated participants. Patients in the sugammadex group had lower incidence of postoperative lung complications, and shorter durations of postanesthesia care unit stay and postoperative hospital stay than those in the neostigmine group. There was no significant difference in the incidence of readmission between the 2 groups. Administration of sugammadex provided faster recovery of rocuronium-induced neuromuscular block when compared with neostigmine. Moreover, for patients undergoing lung cancer resection, administration of sugammadex could reduce the incidence of postoperative pulmonary complications and duration of postoperative hospital stay. [ABSTRACT FROM AUTHOR]

Herein, we designed a dual-response shape transformation and charge reversal strategy with chemo-photodynamic therapy to improve the blood circulation time, tumor penetration and retention, which finally enhanced the anti-tumor effect. In the system, hydrophobic photosensitizer chlorin e6 (Ce6), hydrophilic chemotherapeutic drug berberrubine (BBR) and matrix metalloproteinase-2 (MMP-2) response peptide (PLGVRKLVFF) were coupled by linkers to form a linear triblock molecule BBR-PLGVRKLVFF-Ce6 (BPC), which can self-assemble into nanoparticles. Then, positively charged BPC and polyethylene glycol-histidine (PEG-His) were mixed to form PEG-His@BPC with negative surface charge and long blood circulation time. Due to the acidic tumor microenvironment, the PEG shell was detached from PEG-His@BPC attributing to protonation of the histidine, which achieved charge reversal, size reduction and enhanced tumor penetration. At the same time, enzyme cutting site was exposed, and the spherical nanoparticles could transform into nanofibers following the enzymolysis by MMP-2, while BBR was released to kill tumors by inducing apoptosis. Compared with original nanoparticles, the nanofibers with photosensitizer Ce6 retained within tumor site for a longer time. Collectively, we provided a good example to fully use the intrinsic properties of different drugs and linkers to construct tumor microenvironment-responsive charge reversal and shape transformable nanoparticles with synergistic antitumor effect. The nanoparticle with transformable shape and reversible charge, PEG-His@BPC, conquered the drug delivery challenge of tumor targeting, cellular uptake, tumor penetration and tumor retention, which successfully amplified chemo-photodynamic therapy of breast cancer and obviously inhibited the growth of the tumor. [Display omitted] [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to evaluate the effects of sugammadex and neostigmine used in general anesthesia on postoperative mucociliary clearance. PATIENTS AND METHODS: This prospective, randomized and double-blind study was performed on 60 non-smokers with ASA I-III underwent inguinal hernia repair under general anesthesia. Mucociliary clearance was assessed by nasal saccharine transit time (STT). After the preoperative STT measurement, the patients were taken to the operating room, and divided into two equal groups as group 1 and 2 (n= 30 for each group). Midazolam, propofol, and rocuronium were used in all patients. Anesthesia was maintained by sevoflurane at a flow rate of 6 lt/min (50% O2 - 50% N2O) with a minimum alveolar concentration of 1.3-1.5. After the surgical procedure, atropine-neostigmine (20 mcg/kg - 50 mcg/kg) and sugammadex (2 mg/kg) were administered to group 1 and group 2, respectively, and then the patients were extubated. The postoperative STT was measured in postoperative period. RESULTS: The mean age of the patients was 53 (±16) years, and 56 (93%) of them were male. There were no differences between the groups in terms of age, gender, height, weight, ASA score, and duration of anesthesia, duration of surgery, postoperative period, preoperative STT, and postoperative STT. However, when each group was evaluated separately, there was a statistically significant increase in the postoperative STT compared to the preoperative STT in both groups (p=0.005 for group 1, p<0.001 for group 2). CONCLUSIONS: The effects of sugammadex and neostigmine used in general anesthesia on postoperative mucociliary clearance are similar, and postoperative mucociliary clearance is delayed. [ABSTRACT FROM AUTHOR]

The use of sugammadex at a lower dose after a routine reversal dose of neostigmine may prevent residual neuromuscular blockade (rNMB). Our goal was to investigate the effects of the use of half-dose sugammadex for reversing rNMB after administration of neostigmine, and compare these effects to a routine full-dose of neostigmine. Prospective, single-blinded, randomized trial. Ninety-eight patients having lower abdominal tumor resection surgery under general anesthesia were randomized into two groups. Group N (Neostigmine) (n = 48) patients received standard reversal dose of intravenous neostigmine 0.05 mg/kg and atropine 0.02 mg/kg before extubationl Group N + S (Neostigmine + Sugammadex) (n = 50) patients received 1 mg/kg of intravenous sugammadex three minutes after a standard neostigmine reversal dose. The primary end-point was the incidence of a train-of-four (TOF) ratio less than 0.9 at tracheal extubation. Secondary end-points were periods between the start of administration of reversal agents and extubation or operating room discharge in minutes to achieve recovery of TOF ratio < 0.9 to 0.7 and TOF ratio ≥ 0.9. The demographic data were not different between the two groups (P >.005). The incidence of rNMB presented as TOF ratio < 0.9 to 0.7 was present in 52% of Group N patients compared to 8% in Group N + S patients (P <.0001). The time to recovery between administering reversal and extubation as well as operating room discharge in Group N were; 18.52 ± 6.34 minutes and 23.27 ± 6.95 minutes, respectively, whereas; in Group N + S, they were; 12.86 ± 5.05 and 17.82 ± 4.99 minutes, respectively. (P <.0001, P <.0001, respectively). Adverse events were similar between groups (P >.05). A half-dose sugammadex (1 mg/kg) after full-dose reversal of neostigmine provides a lower incidence of rNMB and shorter recovery times as compared to full-dose neostigmine reversal agent. This practice is safe and effective in case of rNMB. [ABSTRACT FROM AUTHOR]

The popularity of looking younger has been facilitated by the availability of botulinum toxin (BoNT) injection. In 2019, over 7.7 million injections of BoNT occurred, making it the number one minimally invasive cosmetic procedure in the United States. With the ease of patients obtaining BoNT in an outpatient setting, coupled with the fact that it is considered a minimally invasive procedure, most patients do not disclose the use of BoNT during the preoperative anesthesia evaluation. This case report involves a female whose recent BoNT injections interfered with neuromuscular (NM) monitoring during anesthesia. Neuromuscular monitoring was performed using the orbicularis oculi muscle with repeated train-of-four (TOF) 0/4. It was not until completion of procedure when the arms were accessible that the adductor pollicis muscle was assessed with a TOF of 2/4. During postoperative follow up, the patient revealed she had received BoNT injections prior to surgery. A review of BoNT pharmacology, barriers to NM monitoring and use of sugammadex are discussed. This case demonstrates the importance of ascertaining BoNT injection history in any case in which access to the ulnar nerve or tibial nerve is not available. [ABSTRACT FROM AUTHOR]

The purpose of this quality improvement project was to improve consistency of discharge teaching in women who used progesterone-containing hormonal contraceptive medications and received sugammadex during general anesthesia, as there is a risk of unintended pregnancy for 1 week after administration of sugammadex. This project used a predesign and postdesign using two separate sample groups of patients and postanesthesia care unit (PACU) nurses. The sample consisted of 31 total women of childbearing age and 59 PACU nurses. Simplification of sugammadex discharge instructions was achieved by incorporating evidence-based recommendations for electronic discharge instructions and nursing education. PACU nurses were educated and surveyed before and after regarding frequency of discharge teaching, clarity, and comprehension of the after-visit summary and knowledge of sugammadex. Patients were called via telephone postoperatively to assess recall of sugammadex discharge teaching. Postoperative patient phone calls identified a small increase in patient recall of discharge instructions from 5 of 14 patients (35.7%) before implementation to 7 of 17 after implementation (41.2%). PACU nurse surveys indicated an increase in self-reported frequency of sugammadex discharge teaching (34.8% vs 64.2%, P =.024) and that new discharge instructions contained more clear, comprehensive information as compared with previous instructions (29.4% vs 75.5%, P =.001). This quality improvement project successfully implemented more consistent and comprehensive discharge instructions for women who receive sugammadex intraoperatively. Limitations of the project included a small sample size and short implementation intervals. As a result of switching to uniform discharge instructions, more patients received important discharge teaching from PACU nurses, and the percentage of patients who recalled this information increased. [ABSTRACT FROM AUTHOR]

T2DM is a chronic disorder with progressive neuromuscular alterations. L-arginine (ARG) is the most common semi-essential amino acid having several metabolic functions. to investigate the impact of L-arginine in combating diabetic-induced neuromyopathy and its possible mechanisms. 24 rats were divided into CON, CON+ARG, DC, DC+ARG. Behavioral tests, Body weight (BW), fasting blood glucose (FBG), insulin, total antioxidant capacity (TAC), malondialdehyde (MDA), plasminogen activator inhibitor-1 (PAI-1), and irisin were done. Creatine kinase-MM (CK-MM), interleukin 4 (IL-4), interleukin 6 (IL-6), TAC, MDA, expression of microRNA-29a mRNA & light chain 3 protein were determined in muscle. Histological and NF-κβ immunohistochemical expression in muscle and nerve were assessed. ARG supplementation to diabetic rats improved altered behavior, significantly increased BW, insulin, TAC, irisin and Il-4, decreased levels of glucose, microRNA-29a, NF-κβ and LC3 expression, PAI-1, CK-MM and restored the normal histological appearance. ARG supplementation potently alleviated diabetic-induced neuromuscular alterations. [Display omitted] • ARG improved neuromuscular abnormalities in diabetic rats. • ARG reduced inflammation and oxidative stress. • ARG reduced PAI-1, microRNA-29a, NF-κβ and LC3 expression. • ARG increased serum Irisin in diabetic rats. [ABSTRACT FROM AUTHOR]

To compare postoperative arterial blood gas samples and requirement for respiratory support between patients who received sugammadex versus neostigmine reversal before extubation after congenital cardiac surgery. Retrospective, cross-sectional study. Single-center, university-based, tertiary care hospital. Patients with congenital heart disease undergoing surgery with cardiopulmonary bypass. Chart review. The first postoperative arterial blood gas measurements were abstracted from electronic medical records, and reintubation or use of positive- pressure respiratory support within the first 24 postoperative hours was documented. Of the 237 charts reviewed, 111 (47%) patients received sugammadex reversal and 126 (53%) received neostigmine. Multivariate models showed that patients with 2-ventricle congenital heart disease who received sugammadex had lower postoperative arterial carbon dioxide partial pressure (PaCO 2) values (coefficient –3.1, 95% confidence interval [CI] –5.9 to –0.4; p = 0.026) and required less- noninvasive positive- pressure ventilation (odds ratio 0.3, 95% CI 0.1–0.8; p = 0.021). Single-ventricle congenital heart disease patients who received sugammadex had higher postoperative pH values (coefficient 0.04, 95% CI 0.01-0.06; p = 0.01) and lower PaCO 2 values (coefficient –5.2, 95% CI –9.6 to –0.8; p = 0.021). Sugammadex reversal was associated with lower postoperative PaCO 2 values. In addition, sugammadex reversal was associated with less need for noninvasive positive- pressure ventilation in 2-ventricle patients. The magnitude of the effect appears modest, therefore the clinical significance remains unclear. Additional studies focused on investigating particular patient populations, such as infants, single-ventricle congenital heart disease, or patients with pulmonary hypertension, are needed to identify whether these patients appreciate a greater benefit from sugammadex reversal. [ABSTRACT FROM AUTHOR]

O sugamadex é uma substância farmacológica alternativa capaz de reverter o bloqueio neuromuscular sem as limitações apresentadas pelos anticolinesterásicos. Entretanto, há relatos de transtornos de coagulação relacionados ao tratamento com sugamadex sem que mecanismos exatos de seus efeitos sobre a coagulação sejam totalmente compreendidos. O objetivo da presente pesquisa foi avaliar os efeitos do rocurônio, sugamadex e do complexo rocurônio‐sugamadex sobre a coagulação em um modelo experimental com ratos. Este é um estudo randomizado experimental animal. Ratos Wistar foram aleatoriamente designados aos seguintes grupos: grupo controle; Grupo Ssal – 0,5 mL de solução salina intravenosa; Grupo sugamadex – sugamadex intravenoso (100 mg.kg‐1); e Grupo rocurônio‐sugamadex – solução intravenosa com rocurônio (3,75 mg.kg‐1) e sugamadex (100 mg.kg‐1). A anestesia foi realizada utilizando‐se isoflurano com ventilação controlada. Os fatores de coagulação foram medidos 10 minutos após o final do preparo pré‐operatório e 30 minutos após a administração de drogas de acordo com os grupos escolhidos. Contagem de plaquetas, tempo de protrombina e tempo de tromboplastina parcial ativada foram semelhantes entre os grupos e entre os momentos dentro de cada grupo. Houve redução nos níveis de fibrinogênio plasmático entre os tempos 1 e 2 no grupo rocurônio‐sugamadex (p = 0,035). O complexo rocurônio‐sugamadex promoveu reduções na contagem de fibrinogênio plasmático, apesar de os níveis continuarem dentro dos limites normais. Sugammadex is an alternative pharmacological drug capable of reversing neuromuscular blockades without the limitations that are presented by anticholinesterase drugs. Coagulation disorders that are related to treatment with sugammadex were reported. The exact mechanism of the effects on coagulation are not fully understood. The objective of this research is to evaluate the effects of rocuronium, sugammadex and the rocuronium‐sugammadex complex on coagulation in an experimental model in rats. This is an experimental randomized animal study. Wistar rats were randomly assigned into the following groups: the Control Group; the Ssal Group – 0.5 mL of intravenous saline; the Sugammadex Group – intravenous sugammadex (100 mg.kg‐1); and the Rocuronium‐Sugammadex Group – intravenous solution with rocuronium (3.75 mg.kg‐1) and sugammadex (100 mg.kg‐1). Anesthesia was performed by using isoflurane with controlled ventilation. Coagulation factors were measured 10 minutes after the end of the preoperative preparation and 30 minutes after the administration of the drugs in accordance with the chosen groups. Platelet counts, prothrombin times and activated partial thromboplastin times were similar between the groups and between the moments within each group. There were reductions in the plasma fibrinogen levels between sample times 1 and 2 in the Rocuronium‐Sugammadex group (p = 0.035). The rocuronium‐sugammadex complex promoted reductions in plasma fibrinogen counts, although the levels were still within normal limits. [ABSTRACT FROM AUTHOR]

Sugammadex é uma gama‐ciclodextrina modificada que reverte os efeitos de agentes de bloqueio neuromuscular aminoesteroides. Da mesma forma, algumas moléculas esteroides, como toremifene, ácido fusídico e flucloxacilina, podem ser encapsulados pelo sugammadex. A metilprednisolona, esteroide sintético usado geralmente para a profilaxia de edema de vias aéreas, também pode ser encapsulada pelo sugammadex. O objetivo do estudo foi comparar os tempos de recuperação do sugammadex na reversão de bloqueio neuromuscular moderado induzido pelo rocurônio em pacientes em que foi administrado 1 mg.kg‐1 de metilprednisolona ou solução salina no período intraoperatório. Este estudo prospectivo, randomizado, controlado, unicêntrico incluiu 162 pacientes adultos (idades de 18‐65, ASA I‐II, IMC abaixo de 30 kg.m‐2, e não usando medicação esteroide) submetidos à anestesia geral para procedimento eletivo de otorrinolaringologia com propofol, remifentanil, rocurônio e sevoflurano. A monitorização neuromuscular foi realizada usando aceleromiógrafo calibrado. O grupo controle (Grupo C) recebeu 5 mL de solução salina, enquanto o grupo metilprednisolona (Grupo M) recebeu 1 mg.kg‐1 de metilprednisolona em 5 mL de solução salina logo após a indução. Ao término da cirurgia, em relação à contagem do número de respostas à sequência de quatro estímulos (TOFc), dois pacientes mostraram recuperação espontânea e todos os pacientes receberam 2 mg.kg‐1 de sugammadex. A recuperação da razão T 4 /T 1 (TOFr) para 0,9 foi registrada nos dois grupos, e o desfecho primário do estudo foi o tempo estimado de recuperação, momento em que a razão TOFr alcançou o valor de 0,9 (TOFr = 0.9). O tempo mediano para TOFr = 0,9 foi 130 s (29‐330) para o Grupo C e 181s (100‐420) para o Grupo M (p < 0,001). As diferenças entre os dois grupos foi estatisticamente significante. Pacientes que receberam 1 mg.kg‐1 de metilprednisolona no intraoperatório apresentaram tempo de recuperação mais prolongado após o uso de 2 mg.kg‐1 de sugammadex para reverter o bloqueio neuromuscular induzido pelo rocurônio. Sugammadex is a modified gamma‐cyclodextrin that reverses the effects of aminosteroidal neuromuscular blocking agents. Likewise, some steroid molecules, such as toremifene, fusidic acid, and flucloxacillin, can also be encapsulated by sugammadex. Methylprednisolone, which is a synthetic steroid used commonly for airway oedema prophylaxis, can also be encapsulated by sugammadex. The objective of this study was to compare the recovery times of sugammadex for reversing rocuronium‐induced moderate neuromuscular blockade in those who received intraoperative 1 mg.kg‐1 methylprednisolone or saline. This single‐centered, randomized, controlled, prospective study included 162 adult patients undergoing elective ear‐nose‐throat procedures (aged from 18‐65, an ASA physical status I‐II, a BMI less than 30 kg.m‐2, and not taking steroid drug medication) with propofol, remifentanyl, rocuronium and sevoflurane. Neuromuscular monitoring was performed using calibrated acceleromyography. The Control Group (Group C) received 5 mL of saline, while the Methylprednisolone Group (Group M) received 1 mg.kg‐1 of methylprednisolone in 5 mL of saline just after induction. After the completion of surgery, regarding the TOF count, two reappeared spontaneously and 2 mg.kg‐1 sugammadex was administered to all patients. Recovery of the TOF ratio to 0.9 was recorded for both groups, and the estimated recovery time to reach a TOF ratio (TOFr) of 0.9 was the primary outcome of the study. Median time to TOFr = 0.9 was for 130.00 s (range of 29‐330) for Group C and 181.00 s (100‐420) for Group M (p < 0.001). The differences between the two groups were statistically significant. When using 2 mg.kg‐1 of sugammadex to reverse rocuronium‐induced neuromuscular blockade in patients who received 1 mg.kg‐1 of intraoperative methylprednisolone, demonstrated delayed recovery times. [ABSTRACT FROM AUTHOR]

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This process-improvement project improved postoperative education for female patients by facilitating the development of a topic-specific education program to improve knowledge and confidence among perianesthesia nurses in a military treatment facility. An educational program was developed and presented which reviewed the impact sugammadex has on steroidal contraceptive efficacy, evidence-based postoperative teaching strategies, and specific patient education recommendations for female sugammadex-exposed patients taking steroidal contraceptives. Effectiveness was measured by comparing nurses' baseline knowledge and confidence scores before and immediately after presentation of the educational program. These results were then compared with 2-week reassessments to determine if lasting improvements were achieved. Statistically significant increases in knowledge and confidence were achieved upon both postintervention assessments. Interactive evidence-based educational interventions can effectively create sustained increases in knowledge and confidence among health care professionals which translates into improved postoperative patient education. [ABSTRACT FROM AUTHOR]

Background: Sugammadex is a selective relaxant binding agent for antagonism of prolonged rocuronium-induced neuromuscular blockade. The recommended dose is 2 mg/kg. Based on the pharmacological characteristics of sugammadex in obese patients, the calculated lean body mass (CLBM) should be used to determine the dose to reverse moderate neuromuscular blockade induced by rocuronium. Objective: A study was undertaken to prove that sugammadex can be used according to CLBM to reverse moderate neuromuscular blockade in obese female patients. Methods: This is a prospective, non-randomised, observational study. Sugammadex was used at the end of bariatric surgery on obese patients with a body mass index > 32 kg/m2. The dose was calculated according to the lean body mass. Muscle blockade was assessed using train-of-four monitoring. Results: Twenty women were included in this study. All patients were female and ASA 2. The age of patients ranged between 20 and 50 years with a mean age of 35.74 (±10) years. The mean CLBM was 50 kg. The mean time from administration of sugammadex to reverse neuromuscular blockade from two responses of TOF to T4/T1 > 90% was 167.25 seconds (2.8 minutes) (60-285 seconds). Conclusion: It is concluded that the calculated lean body mass can be used to calculate the dose of sugammadex for obese female patients to reverse moderate neuromuscular blockade induced by rocuronium. [ABSTRACT FROM AUTHOR]

Postlaparotomy management for elderly patients with underlying comorbidities is always a challenge because of poor cardiorespiratory reserves and prolonged effect of anesthetic drugs. For these reasons, such patients usually require intensive care unit (ICU) admission in the postoperative period. We report a case of an 85-year-old chronic smoker with controlled diabetes mellitus who needed an emergency laparotomy for a perforated gastric ulcer. Unfortunately, there was a shortage of ICU backup. With the successful conduct of an early surgery using combined general and regional anesthesia, the use of sugammadex (Bridion, Merck Sharp & Dohme Corp, Oss, the Netherlands) as a reversal agent, a skilled surgeon, and good postanesthesia care, the patient did not require ICU admission. He recovered fast and was discharged home 4 days after surgery. This case study aims to contribute to the literature on experience of a successful conduct of anesthesia in a high-risk geriatric patient when ICU facilities are limited. [ABSTRACT FROM AUTHOR]

Resumo O transplante cardíaco é um procedimento frequente no tratamento da disfunção cardíaca em estágio final. Portanto, essa população de pacientes também será exposta com mais frequência a outros procedimentos cirúrgicos mais comuns após o transplante. Em sua avaliação, o anestesiologista deve ter em mente algumas questões específicas relacionadas à história de transplante cardíaco desses pacientes, tais como a reversão do bloqueio neuromuscular. Vários estudos relataram que os inibidores da colinesterase, como a neostigmina, podem produzir uma bradicardia dose‐dependente que ameaça a vida em receptores de transplante cardíaco, enquanto um estudo relatou o uso seguro de neostigmina. A reversão do bloqueio neuromuscular com sugamadex é outra possibilidade, mas os dados na literatura são escassos. Descrevemos cinco casos nos quais a reversão bem‐sucedida do bloqueio neuromuscular foi realizada com sugamadex em receptores pediátricos de transplante cardíaco sem deixar sequelas e discutimos a reversão do bloqueio neuromuscular nessa população de pacientes. Heart transplantation is a frequent procedure in the treatment of end‐stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose‐dependent life‐threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequelae and discuss the reversal of neuromuscular block in this patient population. [ABSTRACT FROM AUTHOR]

Copyright of Cukurova Medical Journal / Çukurova Üniversitesi Tip Fakültesi Dergisi is the property of Cukurova University, Faculty of Medicine and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Neuromuscular blockers have long been an intricate part of the anesthesia regimen. The scientific progress in pharmacology and physiology has strengthened their clinical relevance, has helped to delineate with precision their medical role, and has enhanced the safety and effectiveness of their use. New frontiers in research will define further the role of these agents in modern anesthesia practice and guide their expanding and discrete clinical applications. [ABSTRACT FROM AUTHOR]

Congenital muscular dystrophies are characterised by progressive skeletal muscle weakness from birth or early infancy. Maternal respiratory compromise, joint contractures and presence of spinal instrumentation or fusion are some of the anaesthetic challenges that may be encountered in the obstetric setting. The choice of anaesthetic technique for surgical delivery needs to be considered on an individual basis. Multidisciplinary involvement is paramount to optimise peripartum care and outcomes. In this case report, we present the use of dexmedetomidine, humidified high-flow nasal oxygen, rocuronium and sugammadex in the anaesthetic management of a wheelchair-bound, non-invasive bilevel positive airway pressure ventilation-dependent parturient with congenital muscular dystrophy, who was presenting for caesarean section. [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivos Os parâmetros de peso para o uso de sugamadex em pacientes com obesidade mórbida ainda precisam ser definidos. Métodos Um ensaio clínico prospectivo foi feito com 60 participantes com índice de massa corporal ≥ 40 kg.m −2 , submetidos a cirurgia bariátrica, randomizados em três grupos: peso ideal (PI), peso corrigido em 20% (PC20) e peso corrigido em 40% (PC40). Todos os pacientes receberam anestesia intravenosa total. Rocurônio foi administrado em dose de 0,6 mg.kg −1 para intubação traqueal pelo peso ideal, seguido de infusão (0,3 a 0,6 mg.kg −1 .h −1 ). A sequência de quatro estímulos (TOF) foi usada para monitorar a profundidade do bloqueio. Após recuperação espontânea da segunda resposta do TOF no fim da cirurgia, 2 mg.kg −1 de sugamadex foi administrado. O desfecho primário foi o tempo de reversão do bloqueio neuromuscular até obter TOF ≥ 0,9. O desfecho secundário foi a ocorrência de curarização residual pós‐operatória na sala de recuperação pós‐anestésica, avaliaram‐se a capacidade do paciente de passar do leito cirúrgico para o de transporte, a adequação da oxigenação, o padrão respiratório, a habilidade para deglutir saliva e a clareza de visão. Resultados Os grupos foram homogêneos quanto a gênero, idade, peso corporal total, peso corporal ideal, índice de massa corporal, tipo e tempo de cirurgia. Os tempos de reversão (segundos) foram (média ± desvio‐padrão) 225,2 ± 81,2, 173,9 ± 86,8 e 174,1 ± 74,9, respectivamente, nos grupos PI, PC20 e PC40 ( p = 0,087). Conclusões Não foram observadas diferenças entre os grupos quanto ao tempo de reversão do bloqueio neuromuscular e frequência de curarização residual pós‐operatória. Concluímos que o peso corporal ideal pode ser usado para calcular a dose de sugamadex para reverter o bloqueio neuromuscular moderado em pacientes com obesidade mórbida. Background and objectives The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. Methods A prospective clinical trial was conducted with sixty participants with body mass index ≥ 40 kg.m −2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6 mg.kg −1 of Ideal weight for tracheal intubation, followed by infusion of 0.3–0.6 mg.kg −1 .h −1 . Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF‐count 2 at the end of surgery, 2 mg.kg −1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF ≥ 0.9. Secondary outcome was the occurrence of postoperative residual curarization in post‐anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. Results Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean ± standard deviation) 225.2 ± 81.2, 173.9 ± 86.8 and 174.1 ± 74.9 respectively, in the IW, CW20 and CW40 groups ( p = 0.087). Conclusions No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients. [ABSTRACT FROM AUTHOR]

Resumo Objetivos As reduções da atividade do diafragma estão associadas ao desenvolvimento de atelectasia no período pós‐operatório. A reversão com neostigmina também está associada ao aumento de atelectasia. Avaliamos os efeitos de neostigmina, sugamadex e da reversão espontânea sobre a ventilação pulmonar regional e o fluxo aéreo. Métodos Seis ratos Sprague‐Dawley foram paralisados com rocurônio e mecanicamente ventilados até a recuperação da sequência de quatro estímulos atingir relação 0,5. Administramos neostigmina (0,06 mg.kg −1 ), sugamadex (15 mg.kg −1 ) ou solução salina (n = 2 por grupo). As tomografias foram feitas durante o ciclo respiratório. Modelos tridimensionais dos lobos pulmonares foram gerados com a tecnologia de imagem funcional respiratória e os volumes lobares foram calculados durante o ciclo respiratório. A superfície diafragmática foi segmentada para as varreduras expiratória final e inspiratória final. A alteração total no volume foi relatada pela alteração do volume pulmonar da varredura expiratória final para a varredura inspiratória final. O movimento da parede torácica foi definido como a variação do volume pulmonar menos a alteração no volume resultante da excursão do diafragma. Resultados Os dois ratos que receberam neostigmina apresentaram uma contribuição relativa menor do movimento do diafragma para a alteração total do volume pulmonar em comparação com os dois ratos que receberam sugamadex ou solução salina (contribuição da parede torácica (%): 26,69 e 25,55 para neostigmina; −2,77 e 15,98 para sugamadex; 18,82 e 10,30 para solução salina). Conclusão Este estudo piloto com ratos demonstrou uma contribuição relativa aumentada de expansão da parede torácica após neostigmina em comparação com sugamadex ou solução salina. Essa contribuição relativa menor de movimento do diafragma pode ser explicada por uma redução induzida por neostigmina na atividade do nervo frênico ou por receptores de acetilcolina permanecerem ocupados após a administração de neostigmina. Objectives Reductions in diaphragm activity are associated with the postoperative development of atelectasis. Neostigmine reversal is also associated with increased atelectasis. We assessed the effects of neostigmine, sugammadex, and spontaneous reversal on regional lung ventilation and airway flow. Methods Six Sprague–Dawley rats were paralysed with rocuronium and mechanically ventilated until recovery of the train‐of‐four ratio to 0.5. We administered neostigmine (0.06 mg.kg −1 ), sugammadex (15 mg.kg −1 ), or saline ( n = 2 per group). Computed tomography scans were obtained during the breathing cycle. Three‐dimensional models of lung lobes were generated using functional respiratory imaging technology, and lobar volumes were calculated during the breathing cycle. The diaphragmatic surface was segmented for the end‐expiratory and end‐inspiratory scans. The total change in volume was reported by the lung volume change from the end‐expiratory scan to the end‐inspiratory scan. Chest wall movement was defined as the lung volume change minus the volume change that resulted from diaphragm excursion. Results The two rats that received neostigmine exhibited a smaller relative contribution of diaphragm movement to the total change in lung volume compared with the two rats that received sugammadex or saline (chest wall contribution (%): 26.69 and 25.55 for neostigmine; −2.77 and 15.98 for sugammadex; 18.82 and 10.30 for saline). Conclusion This pilot study in rats demonstrated an increased relative contribution of chest wall expansion after neostigmine compared with sugammadex or saline. This smaller relative contribution of diaphragm movement may be explained by a neostigmine‐induced decrease in phrenic nerve activity or by remaining occupied acetylcholine receptors after neostigmine. [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivos O objetivo de nosso estudo foi comparar os efeitos de sugamadex e neostigmina, usados para o antagonismo do bloqueio neuromuscular em náusea e vômito no pós‐operatório (NVPO). Métodos O estudo foi concluído com 98 pacientes de risco ASA I‐II, submetidos à intubação traqueal sob anestesia geral. Ao final da cirurgia, os pacientes foram aleatoriamente divididos em dois grupos que receberam 2 mg kg −1 de sugamadex (Grupo A) ou 50 μg kg −1 de neostigmina mais 0,2 mg kg −1 de atropina (Grupo N). Os tempos de monitoração e registro foram definidos como uma hora de pós‐operatório e de 1‐6, 6‐12 e 12‐24 horas. As quantidades administradas de antieméticos foram registradas. Resultados Na primeira hora de pós‐operatório, 13 pacientes do Grupo N (27%) e 4 do Grupo S (8%) apresentaram náusea e/ou vômito e a diferença foi estatisticamente significativa ( p = 0,0016). Não houve diferença significativa na incidência e gravidade de NVPO ( p > 0,05) durante as 24 horas de monitoração, porém o número de pacientes que receberam ondansetron para o tratamento de NVPO no Grupo N foi estatística e significativamente maior que o número de pacientes no Grupo S (16 e 6, respectivamente, p < 0,011). Conclusões Ao final do estudo quando comparamos neostigmina com sugamadex para o antagonismo do bloqueio neuromuscular descobrimos que sugamadex apresentou menor incidência de NVPO na primeira hora de pós‐operatório e consumo menor de antiemético em 24 horas de monitoração. Background and objectives The aim of our study is to compare the effects of sugammadex and neostigmine, used for neuromuscular blockage antagonism, on postoperative nausea and vomiting (PONV). Methods Our study was completed with 98 ASA I‐II risk patients undergoing endotracheal intubation under general anesthesia. At the end of the surgery patients were randomly allocated into two groups given 2 mg kg −1 sugammadex (Group S) or 50 μg kg −1 neostigmine plus 0.2 mg kg −1 atropine (Group N). Monitoring and recording times were set as 1 hour postoperative and from 1–6, 6–12, and 12–24 hours. The anti‐emetic amounts administered were recorded. Results In the first postoperative hour 13 patients in Group N (27%) and 4 in Group S (8%) were observed to have nausea and/or vomiting and the difference was statistically significant ( p = 0.0016). During the 24 hours of monitoring there was no significant difference in the incidence and severity of PONV ( p > 0.05), however the number of patients given ondansetron for PONV treatment in Group N was significantly higher than the number in Group S (16 in Group N, 6 in Group S, p < 0.011). Conclusions At the end of our study comparing neostigmine with sugammadex for neuromuscular blockage antagonism, we found use of sugammadex had lower incidence of PONV in the postoperative 1 st hour and less anti‐emetic use in 24 hours of monitoring. [ABSTRACT FROM AUTHOR]

Sugammadex is a cyclodextrin specifically designed to reverse the action of rocuronium through encapsulation. Theoretically, it is possible that sugammadex can encapsulate cortisone. The primary outcome of the present study is to investigate any possible alteration in the efficacy of sugammadex as a reversal of rocuronium due to dexamethasone injection in children undergoing strabismus surgery. The secondary outcome is to assess any possible side effects of sugammadex in these groups of patients. Methods Patients were randomly divided by a closed envelope method into 2 groups 40 patients each. All children were subjected to standard controlled general anesthesia with ETT. Intravenous (IV) dexamethasone 0.5 mg·kg −1 after induction of GA was given in group I (dex group), while IV metoclopramide 0.25 mg·kg −1 was given for group II (met group) as prophylactic antiemetics. Measurements Duration after sugammadex injection to reach 90% TOF ratio was measured by TOF watch SX acceleromyography. Clinical duration of extubation after sugammadex injection was measured. Any signs of residual curarization, respiratory insufficiency or muscle weakness were recorded in the PACU for two hours postoperatively. Results Time to reach 90% TOF was statistically significantly higher in the dex group (60.11 ± 1.98 s) than the met group (23.11 ± 2.36 s) with a P value of 0.001. Clinical time of extubation after sugammadex was higher in the dex group (72.8 ± 2.23 s) than the met group (37.61 ± 2.45 s) with a P value of 0.0001. Conclusions The present study demonstrated that the interaction between sugammadex and dexamethasone may have a clinical effect on the duration of reversal of rocuronium. [ABSTRACT FROM AUTHOR]

• Seventy-three pregnant women received sugammadex in non-obstetric surgery. • Sugammadex was not associated with miscarriage or preterm labor within four weeks. • Missing data may have obscured potential adverse outcomes from sugammadex exposure. • The findings do not exclude sugammadex-related adverse pregnancy outcomes. The influence of sugammadex exposure during pregnancy on progesterone withdrawal and miscarriage is unknown. We aimed to compare the fetal outcomes in pregnant patients who had undergone non-obstetric surgery with and without sugammadex. We retrospectively reviewed the medical charts of pregnant women who underwent non-obstetric surgery at three tertiary perinatal care centers in Japan from January 2013 to December 2020. The women were divided into those who received general anesthesia with sugammadex (GA with SGX) and those who received general anesthesia without sugammadex (GA without SGX). We compared miscarriages and preterm births within four weeks after surgery. Among the 124 women, 73 and 51 were included in the GA with SGX and GA without SGX groups, respectively. The two groups showed no differences in the rate of miscarriages or preterm births (3.0 % vs 4.3 %; odds ratio 1.42, 95 % confidence interval 0.19 to 10.47; P = 1.00). The SGX and no SGX groups were missing outcomes for 8.2 % and 7.8 % of cases, respectively. Having GA with SGX or GA without SGX did not result in different rates of miscarriage or preterm birth within four weeks after the procedure. These findings do not exclude a potential association between sugammadex exposure during pregnancy and adverse pregnancy outcomes. Missing data may have obscured possible adverse outcomes from sugammadex exposure. [ABSTRACT FROM AUTHOR]

Introduction Sugammadex is an efficient reversal agent at any time, after neuromuscular blockade. It provides complete reversal for light or deep block facilitating rapid airway control and decreases anesthesia recovery period in outpatient surgeries in children. Patient and methods After ethical committee approval, informed consent and sample size calculation, 70 patients planned for outpatient total bilateral tonsillectomy were divided randomly into 2 groups. Group S ( n = 35) received 2 mg/kg sugammadex to reversing NMB achieved by rocuronium. Group N ( n = 35) received 0.05 mg/kg neostigmine and atropine sulfate 0.01 mg/kg, and extubation time (time from administration of reversal agent to time of extubation), train-of-four ratio, time to reach train-of-four >0.9, and side effects were recorded. Results There was no significant difference in demographic variables. TOF ratio after reversing was a statistically less in group S than in group N ( p < 0.05). The time when TOF rate exceeded 0.9 and extubation time were less in group S than in group N with significant difference ( p < 0.05). No adverse effect was recorded in both groups. Conclusions Sugammadex has created a novel rapid, effective and reliable retrieval from NMB with rocuronium in children undergoing tonsillectomy with no side effects. [ABSTRACT FROM AUTHOR]

Resumo Justificativa A injeção intra‐arterial de medicamentos pode causar isquemia aguda e grave e resultar em morbidade e mortalidade. Não há informações na literatura que avaliem os efeitos endoteliais arteriais de sugamadex e dexmedetomidina. A hipótese de nosso estudo foi que dexmedetomidina e sugamadex causariam alterações histológicas na estrutura endotelial arterial quando administrados por via intra‐arterial. Método Os coelhos foram randomicamente divididos em quatro grupos: grupo controle (n = 7), sem intervenção; grupo cateter (n = 7), uma cânula foi inserida na artéria central da orelha e medicamentos não foram administrados; grupo sugamadex (n = 7), receberam 4 mg/kg de sugamadex na artéria central da orelha; grupo dexmedetomidina (n = 7), receberam 1 μg/kg de dexmedetomidina na artéria central da orelha. Após 72 horas, as orelhas foram amputadas e histologicamente examinadas. Resultados Não houve diferença significativa entre os grupos controle e cateter referente aos escores histológicos. Os escores do dano causado ao endotélio e à membrana e fibra elásticas, da hipertrofia do músculo liso e do aumento do tecido conjuntivo foram significativamente maiores nos grupos dexmedetomidina e sugamadex do que nos grupos controle e cateter (p < 0,05). Não houve diferença significativa entre os grupos dexmedetomidina e sugamadex nos escores histológicos. Conclusão A administração de sugamadex e dexmedetomidina a coelhos por via intra‐arterial causou danos arteriais histológicos. Para entender as alterações histológicas causadas por sugamadex e dexmedetomidina com mais clareza, estudos experimentais adicionais são necessários. Background Intra‐arterial injection of medications may cause acute and severe ischemia and result in morbidity and mortality. There is no information in the literature evaluating the arterial endothelial effects of sugammadex and dexmedetomidine. The hypothesis of our study is that sugammadex and dexmedetomidine will cause histological changes in arterial endothelial structure when administered intra‐arterially. Methods Rabbits were randomly divided into 4 groups. Group Control ( n = 7); no intervention performed. Group Catheter ( n = 7); a cannula inserted in the central artery of the ear, no medication was administered. Group Sugammadex ( n = 7); rabbits were given 4 mg/kg sugammadex into the central artery of the ear, and Group Dexmedetomidine ( n = 7); rabbits were given 1 μg/kg dexmedetomidine into the central artery of the ear. After 72 h, the ears were amputated and histologically investigated. Results There was no significant difference found between the control and catheter groups in histological scores. The endothelial damage, elastic membrane and elastic fiber damage, smooth muscle hypertrophy and connective tissue increase scores in the dexmedetomidine and sugammadex groups were significantly higher than both the control and the catheter groups ( p < 0.05). There was no significant difference found between the dexmedetomidine and sugammadex groups in histological scores. Conclusion Administration of sugammadex and dexmedetomidine to rabbits by intra‐arterial routes caused histological arterial damage. To understand the histological changes caused by sugammadex and dexmedetomidine more clearly, more experimental research is needed. [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivo Sugamadex é o primeiro agente de ligação relaxante seletivo. Após a administração de sugamadex, os tempos de despertar e de recuperação dos pacientes são menores, em comparação com neostigmina. Neste estudo, a hipótese foi que um despertar mais rápido e claro dos pacientes submetidos à anestesia geral tem efeitos positivos sobre as funções cognitivas no pós‐operatório imediato. Métodos Após a aprovação do Comitê de Ética local, 128 pacientes foram incluídos neste estudo prospectivo, randômico, controlado e duplo‐cego. Os pacientes foram designados para o grupo sugamadex (Grupo S) ou grupo neostigmina (Grupo N). O desfecho primário do estudo foi a recuperação cognitiva no pós‐operatório imediato, de acordo com a mensuração da Avaliação de Montreal da Função Cognitiva (MoCA) e com o Mini Exame do Estado Mental (MMSE), após a avaliação inicial 12‐24 h antes da operação. Após a operação, quando o escore de recuperação de Aldrete modificado era ≥ 9, o teste MMSE e, uma hora depois, o teste MoCA foram repetidos. Resultados Embora tenha havido uma redução nos escores de MoCA e MMSE tanto no Grupo S quanto no Grupo N, entre os escores pré‐ e pós‐operatório não houve diferença estatisticamente significativa nas reduções (p > 0,05). O tempo para atingir TOF 0,9 foi de 2,19 min no Grupo S e de 6,47 min no Grupo N (p < 0,0001). O tempo de recuperação foi de 8,26 min no Grupo S e de 16,93 min no Grupo N (p < 0,0001) Conclusão Mostramos que o procedimento cirúrgico e/ou procedimento anestésico de acompanhamento pode causar uma regressão temporária ou permanente da função cognitiva no pós‐operatório imediato. No entanto, um desempenho cognitivo melhor não pode ser provado no grupo sugamadex em comparação com o grupo neostigmina. Background and objective Sugammadex is the first selective relaxant binding agent. When compared with neostigmine, following sugammadex administration patients wake earlier and have shorter recovery times. In this study, we hypothesized that fast and clear awakening in patients undergoing general anesthesia has positive effects on cognitive functions in the early period after operation. Methods Approved by the local ethical committee, 128 patients were enrolled in this randomized, prospective, controlled, double‐blind study. Patients were allocated to either Sugammadex group (Group S) or the Neostigmine group (Group N). The primary outcome of the study was early postoperative cognitive recovery as measured by the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE). After baseline assessment 12–24 h before the operation. After the operation, when the Modified Aldrete Recovery Score was ≥9 the MMSE and 1 h later the MoCA tests were repeated. Results Although there was a reduction in MoCA and MMSE scores in both Group S and Group N between preoperative and postoperative scores, there was no statistically significant difference in the slopes ( p > 0.05). The time to reach TOF 0.9 was 2.19 min in Group S and 6.47 min in Group N ( p < 0.0001). Recovery time was 8.26 min in Group S and 16.93 min in Group N ( p < 0.0001). Conclusion We showed that the surgical procedure and/or accompanying anesthetic procedure may cause a temporary or permanent regression in cognitive function in the early postoperative period. However, better cognitive performance could not be proved in the Sugammadex compared to the Neostigmine. [ABSTRACT FROM AUTHOR]

Resumo Objetivos O paciente queimado representa um desafio para o anestesiologista, pois se submete a várias intervenções cirúrgicas durante sua hospitalização e necessita de anestesia geral e relaxamento muscular na maior parte delas. Apresenta sistema respiratório comprometido e uma resposta aos relaxantes musculares que difere do paciente sadio; portanto, um monitoramento correto e reversão tornam‐se imprescindíveis. Avaliamos a eficácia e segurança do sugamadex nessa população. Material e métodos Estudo descritivo com caráter prospectivo que inclui quatro pacientes, todos eles considerados grandes queimados, submetidos a escarectomia com anestesia geral e relaxamento neuromuscular. Como variável principal tomou‐se o tempo de recuperação de TOF superior a 0,9 após a administração de sugamadex antes de extubação. Resultados O tempo médio de recuperação de uma razão TOF superior a 0,9 após a administração de sugamadex foi de 4,95 minutos (IC95% 3,25‐6,64; p = 0,53). Conclusões A reversão do relaxamento neuromuscular com sugamadex parece ser eficaz e segura no paciente queimado. Seriam necessários mais estudos analíticos, comparativos e de maior população para confirmar esses dados. Objectives The burn patient is a challenge for the anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. They have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. Material and methods Prospectively descriptive study including four patients, all of them considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. Results Mean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95 minutes 95% CI (3.25‐6.64, p = .53); Conclusions The reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies, of larger populations would be necessary to confirm this data. [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivos Os inibidores da acetilcolinesterase podem causar curarização residual no pós‐operatório quando usados para reverter o bloqueio neuromuscular. Sugamadex reverte o bloqueio neuromuscular por encapsulação química e não está associado aos efeitos colaterais que podem ocorrer com o uso de agentes anticolinesterase. Devido ao aumento dos procedimentos cirúrgicos ambulatoriais. A curarização residual e a rápida recuperação no pós‐operatório são muito importantes para a população de pacientes pediátricos. O objetivo deste estudo foi comparar a eficácia de sugamadex e neostigmina na reversão do bloqueio neuromuscular em pacientes pediátricos submetidos a procedimentos cirúrgicos ambulatoriais. Métodos 80 pacientes, com idades entre 2‐12 anos, programados para cirurgias ambulatoriais foram incluídos neste estudo prospectivo e randomizado. O bloqueio neuromuscular foi obtido com 0,6 mg kg −1 de rocurônio e monitorizado com a interpretação da sequência de quatro estímulos. O Grupo RN ( n = 40) recebeu 0,03 mg kg −1 de neostigmina e o Grupo RS ( n = 40) recebeu 2 mg kg −1 de sugamadex para a reversão de rocurônio. O tempo de extubação (tempo desde a reversão do bloqueio neuromuscular até a extubação), a razão da sequência de quatro estímulos durante esse tempo, o tempo para atingir uma sequência de quatro estímulos > 0,9 e as complicações prováveis foram registrados. Resultados Não houve diferença significativa entre as características dos pacientes. Os tempos de extubação e para atingir uma sequência de quatro estímulos > 0,9 foram significativamente maiores no Grupo RN ( p = 0,001, p = 0,002). A sequência de quatro estímulos no momento da injeção de neostigmina/sugamadex foi significativamente maior no Grupo RN que no Grupo RS ( p = 0,020). A razão entre extubação e sequência de quatro estímulos foi significativamente menor no Grupo RN ( p = 0,002). Conclusão Sugamadex proporciona extubação mais segura com um tempo de recuperação mais curto que o de neostigmina em pacientes pediátricos submetidos a procedimentos cirúrgicos ambulatoriais. Background and objectives Acetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures. Methods 80 patients, aged 2–12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6 mg kg −1 rocuronium and monitorized with train‐of‐four. Group RN ( n = 40) received 0.03 mg kg −1 neostigmine, Group RS ( n = 40) received 2 mg kg −1 sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train‐of‐four ratio during this time, time to reach train‐of‐four > 0.9, and probable complications were recorded. Results There was no significant difference between the patients’ characteristics. Extubation time and time to reach train‐of‐four > 0.9 were significantly higher in Group RN ( p = 0.001, p = 0.002). Train‐of‐four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group ( p = 0.020). Extubation train‐of‐four ratio was significantly lower in Group RN ( p = 0.002). Conclusion Sugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures. [ABSTRACT FROM AUTHOR]

Abstract: The current prospective comparative study aimed at the clinical outcome of sugammadex reversal of neuromuscular blockade (NMB) and the evaluation of its impact on the frequency of critical respiratory events during sevoflurane anesthesia. Patients and methods: The study included 100 male patients with mean age of 33.1±7.5years; 67 patients of ASA grade I, 27 patients of ASA grade II and 6 patients of ASA grade III. Patients were randomly allocated to two equal groups: Group N received reversal of NMB using intravenous (IV) neostigmine (6μg/kg) and Group S received IV sugammadex (2mg/kg). After induction of anesthesia, NM function was monitored, at the wrist; using the TOF-Watch-SX. At the end of the surgery, the reversal of NMB assigned for each group was administered at least after 15min after the last dose of atracurium and NM monitoring was continued until recovery of the TOF T4/T1 ratio to 0.9. Time since injection of the reversal drug till recovery to TOF ratio of 0.9 was recorded and critical respiratory events (CRE) were monitored. Results: Both groups showed non-significant difference as regards the frequency of patients required top doses of NMBD or the mean number of top doses of NMBD. Time till achievement of TOF ratio of 0.9 was significantly shorter with sugammadex compared to neostigmine. Moreover, mean time to achieve TOF ratio of 0.9 was 2.76±1.5min with sugammadex, but was 9.78±2min with neostigmine with significant difference in favor of sugammadex. CRE were recorded in 5 patients (5%); 3 patients with neostigmine (6%) and 2 patients (4%) with sugammadex. Conclusion: NMB reversal using sugammadex allowed significantly earlier achievement of TOF ratio of 0.9 in significantly higher number of patients with minimally and acceptable respiratory events at PACU in comparison with neostigmine. [Copyright &y& Elsevier]

Abstract: Objective: Sinonasal surgery is one of the shared airway surgeries that are not uncommonly complicated intra or postoperatively. The proper anesthetic management of these cases plays a crucial role creating a bloodless field. Sugammadex is a new selective relaxant binding drug as it provides a rapid decrease in free rocuronium in the plasma and at nicotinic receptor that help proper awakening of these patients which is extremely important for minimizing the postoperative respiratory complications. The aim of this study is to compare recovery profile in sinonasal surgery in patients reversed by conventional anticholine esterase (Neostigmine) versus those reversed by Sugammadex. Methods: This study included 40 patients ASA physical status I and II aged 20–45years with chronic sinusitis undergoing endoscopic sinus surgery with or without septoplasty, hypotensive anesthesia to maintain MAP (50–60mmHg), muscle relaxation throughout the procedure at 1–2 posttetanic count (PTCs) by rocuronium infusion, and anesthetic depth maintained using BIS (50–60). Patients were allocated randomly into two equal groups to receive either Sugammadex 4mg/kg (group I) or Neostigmine 0.05mg/kg and atropine 0.02mg/kg (group II) as a reversal agent, and assessment of postoperative respiratory complications was performed using the Postoperative Respiratory System Evaluation Score (PRSES) at 1st and 5th minutes after extubation. Results: The reversal time showed highly significant difference between the two groups. Patients in the Sugammadex group could reach a TOF of 0.9 in a mean time 2.47 (0.51)min versus 24.21 (4.7)min for the Neostigmine group; postoperative respiratory complications, the Sugammadex group and the Neostigmine group did not differ statistically; however, more patients in Neostigmine group showed respiratory complications at 1st and 5th minutes after extubation as shown by PRSES Scoring System. Conclusion: This study showed that the use of Sugammadex in reversing rocuronium induced neuromuscular block in patients undergoing functional endoscopic surgery is superior to Neostigmine. Further studies are required to weigh the cost benefit relationship of the use of Sugammadex in routine clinical practice. [Copyright &y& Elsevier]

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