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Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four PICO questions (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Envenomations by snakes represent a neglected health problem in tropical and subtropical countries. In South America, Lachesis muta occasionally causes severe human envenomation, with treatment being conditioned to an unspecific antivenom. In this work, we examined the neutralizing ability of Coutarea hexandra stem bark hydroalcoholic extract (Ch‐E), including the commercial phytochemicals coumarin and quinine, on the neuromuscular blockade induced by L. m. muta venom in mouse phrenic nerve‐diaphragm preparation. Biological assays were performed following conventional myographic technique ex vivo. Ch‐E was phytochemically characterized to detect the presence of coumarin and quinine using analytical methods. Ch‐E and commercial phytochemicals were tested separately or combined under pre‐ and post‐venom incubation protocols. Ch‐E attenuated the venom‐induced neuromuscular blockade only under the pre‐venom incubation protocol. Quinine was not detected in Ch‐E. Commercial coumarin and quinine exhibited a concentration‐dependent counteracting effect on the venom‐induced neuromuscular blockade. The pre‐venom incubation protocol showed to be efficient in attenuating the L. m. muta venom–induced neuromuscular blockade, most likely due to the presence of coumarin derivatives and unknown alkaloids in this extract. [ABSTRACT FROM AUTHOR]

Background: High‐flow nasal oxygenation is reported to prolong duration of apnea while maintaining adequate oxygen saturation with the mouth closed. Also, buccal oxygenation is known to have similar effects in obese adults. We compared the effect of these two methods on prolongation of acceptable apnea time in pediatric patients with their mouth open. Methods: Thirty‐eight patients, aged 0–10 years were randomly allocated to either the high‐flow nasal oxygenation group (n = 17) or the buccal oxygenation group (n = 21). After induction of anesthesia including neuromuscular blockade, manual ventilation was initiated until the expiratory oxygen concentration reached 90%. Subsequently, ventilation was paused, and the patient's head was extended, and mouth was opened. The HFNO group received 2 L·min−1·kg−1 of oxygen, and the BO group received 0.5 L·min−1·kg−1 of oxygen. We set a target apnea time according to previous literature. When the apnea time reached the target, we defined the case as "success" in prolongation of safe apnea time and resumed ventilation. When the pulse oximetry decreased to 92% before the target apnea time, it was recorded as "failure" and rescue ventilation was given. Results: The success rate of safe apnea prolongation was 100% in the high‐flow nasal oxygenation group compared to 76% in the buccal oxygenation group (p =.04). Oxygen reserve index, end‐tidal or transcutaneous carbon dioxide partial pressure, and pulse oximetry did not differ between groups. Conclusion: High‐flow nasal oxygenation is effective in maintaining appropriate arterial oxygen saturation during apnea even in children with their mouth open and is superior to buccal oxygenation. Buccal oxygenation may be a good alternative when high‐flow nasal oxygenation is not available. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents are used commonly to induce skeletal muscle relaxation during surgery. While muscle relaxation facilitates surgical procedures and tracheal intubation, adequate recovery of muscle function after surgery is required to support pulmonary function, and even mild residual neuromuscular block increases the risk of severe postoperative pulmonary complications. While recovery of muscle function after surgery involving neuromuscular blocking agents can be monitored and, in addition, be accelerated by use of current antagonists (reversal agents), there is a clear clinical need for a safe drug to antagonize all types of neuromuscular blocking agents. Here, we show that inhibition of the skeletal muscle-specific chloride ion (Cl-) channel, the ClC-1 channel, markedly accelerates recovery of both single contraction (twitch) and, important physiologically, sustained (tetanic) contractions in a rat model mimicking neuromuscular blocking agent-induced muscle block used during surgery. This suggests ClC-1 inhibition as a mechanism for fast and efficacious recovery of neuromuscular function induced by any neuromuscular blocking agents. Reversal agents are intravenous drugs used to accelerate recovery from neuromuscular block post-surgery. We report that inhibition of ClC-1, a skeletal muscle chloride channel, reverses any nondepolarizing blocking agent, providing a novel reversal (antagonism) mechanism. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents (NMBAs), a cornerstone of pediatric anesthesia, facilitate intubation and muscle relaxation during surgery. However, NMBAs can also lead to serious complications including respiratory depression, residual paralysis, and prolonged recovery. Neuromuscular monitoring (NMM) in pediatric patients is therefore essential, as it is in adults, to ensure adequate paralysis during surgery and prompt recovery from NMBA-induced paralysis. This article aimed to provide a comprehensive overview of NMM in pediatric anesthesia including the various available methods, their advantages and disadvantages, and the importance of a standardized NMM approach. [ABSTRACT FROM AUTHOR]

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, sugammadex use was only recently approved for children aged 2 to 17 years, and it remains unapproved for children under 2. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients. [ABSTRACT FROM AUTHOR]

Objective: This study functional endoscopic sinus surgery (FESS) is a surgical procedure requiring minimal bleeding to optimize the surgical field. This study aimed to evaluate the effectiveness of magnesium sulfate, lignocaine, and propofol in attenuating hemodynamic response. The primary objective of this study was to compare the efficacy of these agents in reducing hemodynamic response. The secondary objectives included assessing the quality of the surgical field, recovery time, and total neuromuscular dose. Methods: We randomly allocated 105 patients scheduled for FESS into three groups: lignocaine, propofol, and magnesium sulfate. Heart rate and mean arterial pressure were recorded every 5 min for the first 30 min, followed by measurements every 10 min at the end of the procedure. Moreover, recovery time, total neuromuscular blocking dose, and surgical field score were noted upon completion of the procedure. Statistical analysis was conducted using the number cruncher statistical systems version 9.0.8 software. Results: All three groups showed comparable hemodynamic response and surgical field scores. The recovery time was notably longer in the magnesium sulfate group [10.94 min (2.45)] than in the lignocaine [4.37 min (1.03)] [95% confidence interval (CI) -7.32, -5.83; P=0.000] and propofol groups [4.60 min (0.60)] (95% CI 5.60, 7.095; P=0.000). Moreover, the total neuromuscular blocking agent used was significantly lower in the magnesium sulfate group [5.89 mg (0.47)] than in the lignocaine [6.26 mg (0.56)] (95% CI 0.66, 0.03; P=0.035). Conclusion: Propofol, magnesium sulfate, and lignocaine exerted equal efficacy in attenuating hemodynamic responses during surgery and ensuring a satisfactory surgical field. However, magnesium sulfate led to significantly longer recovery times compared with propofol and lignocaine. In addition, magnesium sulfate required a significantly lower total dose of neuromuscular blocking agents than lignocaine. [ABSTRACT FROM AUTHOR]

Background: Neuromuscular blocking agents (NMBAs) are a crucial component of anesthesia and intensive care through the relaxation of skeletal muscles. They can lead to adverse reactions such as postoperative residual neuromuscular block. Only one agent is capable of an instant block reversal in deep block situations, but is restricted to aminosteroid agents. Among animal models, non‐human primates are an essential model for a great diversity of human disease models. The main objective of this study was to establish a model for NMBA monitoring with current available drugs before testing new reversal agents. Methods: Seven healthy male cynomolgus macaques were randomly assigned to this study. Experiments using macaques were approved by the local ethical committee (CEtEA #44). All animals were anesthetized according to institutional guidelines, with ketamine and medetomidine, allowing IV line placement and tracheal intubation. Anesthesia was maintained with isoflurane. Either rocuronium bromine (with or without sugammadex reversal) or atracurium besylate was evaluated. Monitoring was performed with two devices, TOF‐Watch and ToFscan, measuring the T4/T1 and the T4/Tref ratios, respectively. Nonparametric Mann–Whitney statistical analyses were done when indicated. Results: NMBA monitoring required adaptation compared to humans, such as stimulus intensity and electrode placement, to be efficient and valid in cynomolgus macaques. When administered, both NMBAs induced deep and persistent neuro‐muscular block at equivalent doses to clinical doses in humans. The rocuronium‐induced profound neuromuscular block could be reversed using the cyclodextrin sugammadex as a reversal agent. We report no adverse effects in these models by clinical observation, blood chemistry, or complete blood count. Conclusion: These results support the use of non‐human primate models for neuromuscular block monitoring. This represented the first step before the forthcoming testing of new NMBA‐reversal agents. [ABSTRACT FROM AUTHOR]

OBJECTIVE To investigate whether liver compression (LC) could increase stroke volume (SV) by more than 15% in healthy, anesthetized dogs with hypovolemia and suggest LC as a novel method to evaluate fluid responsiveness. ANIMALS 6 healthy Beagles. METHODS This prospective, nonrandomized experimental study was conducted from November 2023 to February 2024. The dogs were anesthetized with isoflurane and mechanically ventilated under neuromuscular blockade. After instrumentation, the dogs underwent the following 4 experimental stages in a sequential, nonrandomized manner: stage 1, baseline; stage 2, 30% withdrawal of circulating blood volume; stage 3, 50% infusion of the collected blood; and stage 4, the remaining 50% infusion of the collected blood. At each stage, SV via pulmonary artery thermodilution and hemodynamic variables were measured before, during, and after the LC. RESULTS In stage 2, LC significantly increased mean SV by 30%, from 6.9 to 9 mL/beat. Simultaneously, LC significantly increased mean arterial pressure by 11 mm Hg and mean central venous pressure by 2 mm Hg, while pulse pressure variation significantly decreased from 28% to 22%. In stages 1, 3, and 4, LC did not significantly change mean SV, mean arterial pressure, and pulse pressure variation; however, mean central venous pressure significantly increased during stage 3. CLINICAL RELEVANCE This study demonstrates that LC at 22 mm Hg for 1 minute could increase SV more than 15% in anesthetized, hypovolemic dogs and LC could be used as a novel method to evaluate fluid responsiveness. [ABSTRACT FROM AUTHOR]

Purpose Neuromuscular blocking agents (NMBAs) are commonly used during surgery, and restoring neuromuscular function at the end of surgery is vital in preventing complications of residual paralysis. Recent guidelines from the American Society of Anesthesiology recommend using sugammadex over neostigmine; however, sugammadex is significantly more expensive than neostigmine and may increase drug expenditure for pharmacy departments. This review summarizes evidence evaluating sugammadex dose adjustments and the potential of these dose adjustments to lead to cost savings for pharmacy departments. Summary We found evidence suggesting that the manufacturer-recommended sugammadex dose may not be needed in many patients and that dosing based on an adjusted body weight or based on depth of neuromuscular blockade may lead to lower sugammadex usage. Combining sugammadex with neostigmine could also decrease the dose of sugammadex required. We have highlighted the importance of objective neuromuscular monitoring to guide sugammadex dosing and evaluation for residual neuromuscular blockade. Cost savings for pharmacy departments may be realized by these alternative dosing strategies and/or vial-splitting practices. Conclusion Implementing practices related to sugammadex vial splitting and dose adjustment based on body weight and depth of neuromuscular blockade shows potential benefits in terms of sugammadex cost savings. [ABSTRACT FROM AUTHOR]

Efficacy and safety of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) in patients with neuromuscular diseases remains unclear. We summarised the available evidence and evaluated the quality of data reporting and the validity of published reports. We searched for reports (any design) on the usage of sugammadex (any regimen) for the reversal of an NMBA in patients (any age) with any neuromuscular disease. We used a modified CARE checklist (maximum score 23) to assess the quality of data reporting and an original specific validity checklist (maximum score 41) that was developed through a Delphi process. We retrieved 126 observational reports (386 patients). Most dealt with myasthenia gravis patients receiving rocuronium. The train-of-four ratio returned to ≥0.9 in 258 of 265 (97.4%) patients in whom neuromonitoring was used. Adverse events occurred in 14 of 332 (4.2%) patients in whom adverse events were reported as present or absent. In 90 case reports, the median score of the 23-point CARE checklist was 13.5 (inter-quartile range [IQR] 11–16). In all 126 reports, the median score of the 41-point validity checklist was 23 (IQR 20–27). Scores were positively correlated. These uncontrolled observations (of mainly low to moderate quality and validity) do not allow confident assessment of the efficacy and safety of sugammadex for the reversal of NMBAs in patients with neuromuscular diseases. Reporting of observational data should follow established guidelines, include specific information to ensure validity, and emphasise what the new data add to current knowledge. PROSPERO 2019 (CRD42019119924). [ABSTRACT FROM AUTHOR]

Objective Bronchopulmonary dysplasia (BPD) is the most common late morbidity for premature infants. Continuous neuromuscular blockade (CNMB) is suggested for the most unstable phase of BPD, despite no outcome data. We explored the association between duration of CNMB for severe BPD and mortality. Design Medical record review of children <5 years old admitted from 2016 to 2022 with BPD and one or more course of CNMB for ≥14 days. Results Twelve children received a total of 20 episodes of CNMB for ≥14 days (range 14–173 d) during their hospitalization. Most (10/12) were born at <28 weeks' gestation and most (11/12) with birth weight <1,000 g; 7/12 were of Black race/ethnicity. All were hospitalized since birth. Most (10/12) were initially transferred from an outside neonatal intensive care unit (ICU), typically after a >60-day hospitalization (9/12). Half (6/12) of them had a ≥60-day stay in our neonatal ICU before transferring to our pediatric ICU for, generally, ≥90 days (8/12). The primary study outcome was survival to discharge: 2/12 survived. Both had shorter courses of CNMB (19 and 25 d); only one child who died had a course ≤25 days. Just two infants had increasing length Z-scores during hospitalization; only one infant had a final length Z-score > − 2. Conclusion In this case series of infants with severe BPD, there were no survivors among those receiving ≥25 days of CNMB. Linear growth, an essential growth parameter for infants with BPD, decreased in most patients. These data do not support the use of ≥25 days of CNMB to prevent mortality in infants with severe BPD. Key Points This is a case series of neuromuscular blockade for severe BPD. Neuromuscular blockade did not improve linear growth. Ten out of 12 infants who were on prolonged neuromuscular blockade died. [ABSTRACT FROM AUTHOR]

Background: COVID-19 patients may exhibit neurological symptoms due to direct viral damage, systemic inflammatory syndrome, or treatment side effects. Mechanical ventilation in patients with severe respiratory failure often requires sedation and neuromuscular blockade, hindering thorough clinical examinations. This study aimed to investigate neurological involvement through clinical and noninvasive techniques and to detect signs of intracranial hypertension in these patients. Method: We conducted a prospective observational study on mechanically ventilated COVID-19 adult patients admitted to our ICU, following standard of care protocols for ventilation and permissive hypercapnia. Data were collected at three time points: admission day (T1), day seven (T7), and day fourteen (T14). At each time point, patients underwent multimodal noninvasive neurological monitoring, including clinical examination, pupillary reactivity, transcranial color doppler of the middle cerebral artery (MCA), and optic nerve sheath diameter (ONSD) assessed via ultrasound (US). Head computer tomography (CT) was performed at T1 and T14. A limited subset of patients had a follow-up examination six months after ICU discharge. Results: Seventy-nine patients were recruited; most were under deep sedation and neuromuscular blockade at T1. Pupillary size, symmetry, and reactivity were normal, as was the MCA mean velocity. However, ONSD, assessed by both US and CT, appeared enlarged, suggesting raised intracranial pressure (ICP). In a subgroup of 12 patients, increased minute ventilation was associated with a significant decrease in US-ONSD, corresponding to a drop in paCO2. At follow-up, twelve patients showed no long-term neurological sequelae, and US-ONSD was decreased in all of them. Discussion and conclusions: In this cohort, enlarged ONSD was detected during non-invasive neurological monitoring, suggesting a raised ICP, with hypercapnia playing a prominent role. Further studies are needed to explore ONSD behavior in other samples of mechanically ventilated, hypercapnic patients. [ABSTRACT FROM AUTHOR]

Background: Improvements in oxygenation and lung mechanics with prone position (PP) in patients with acute respiratory distress syndrome (ARDS) are inconstant. The objectives of the study were (i) to identify baseline variables, including the recruitment-to-inflation ratio (R/I), associated with a positive response to PP in terms of oxygenation (improvement of the ratio of arterial oxygen partial pressure over the inspired oxygen fraction (PaO2/FiO2) ≥ 20 mmHg) and lung mechanics; (ii) to evaluate whether the response to the previous PP session is associated with the response to the next session. Methods: In this prospective, observational, single-center study in patients who underwent PP for ARDS due to COVID-19, respiratory variables were assessed just before PP and at the end of the session. Respiratory variables included mechanical ventilation settings and respiratory mechanics variables, including R/I, an estimate of the potential for lung recruitment compared to lung overinflation. Results: In 50 patients, 201 PP sessions lasting 19 ± 3 h were evaluated. Neuromuscular blockades were used in 116 (58%) sessions. The PaO2/FiO2 ratio increased from 109 ± 31 mmHg to 165 ± 65 mmHg, with an increase ≥ 20 mmHg in 142 (71%) sessions. In a mixed effect logistic regression, only pre-PP PaO2/FiO2 (OR 1.12 (95% CI [1.01–1.24])/every decrease of 10 mmHg, p = 0.034) in a first model and improvement in oxygenation at the previous PP session (OR 3.69 (95% CI [1.27–10.72]), p = 0.017) in a second model were associated with an improvement in oxygenation with PP. The R/I ratio (n = 156 sessions) was 0.53 (0.30–0.76), separating lower- and higher-recruiters. Whereas PaO2/FiO2 improved to the same level in both subgroups, driving pressure and respiratory system compliance improved only in higher-recruiters (from 14 ± 4 to 12 ± 4 cmH2O, p = 0.027, and from 34 ± 11 to 38 ± 13 mL/cmH2O, respectively, p = 0.014). Conclusions: A lower PaO2/FiO2 at baseline and a positive O2-response at the previous PP session are associated with a PP-induced improvement in oxygenation. In higher-recruiters, lung mechanics improved along with oxygenation. Benefits of PP could thus be greater in these patients. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents (NMBAs) relax skeletal muscles to facilitate surgeries and ease intubation but can lead to adverse reactions, including complications because of postoperative residual neuromuscular blockade (rNMB) and, in rare cases, anaphylaxis. Both adverse reactions vary between types of NMBAs, with rocuronium, a widely used nondepolarizing NMBA, inducing one of the longest rNMB durations and highest anaphylaxis incidences. rNMB induced by rocuronium can be reversed by the synthetic γ-cyclodextrin sugammadex. However, in rare cases, sugammadex can provoke anaphylaxis. Thus, additional therapeutic options are needed. Rocuronium-induced anaphylaxis is proposed to rely on preexisting rocuronium-binding antibodies. To understand the pathogenesis of rocuronium-induced anaphylaxis and to identify potential therapeutics, we investigated the memory B cell antibody repertoire of patients with suspected hypersensitivity to rocuronium. We identified polyclonal antibody repertoires with a high diversity among V(D)J genes without evidence of clonal groups. When recombinantly expressed, these antibodies demonstrated specificity and low affinity for rocuronium without cross-reactivity for other NMBAs. Moreover, when these antibodies were expressed as human immunoglobulin E (IgE), they triggered human mast cell activation and passive systemic anaphylaxis in transgenic mice, although their affinities were insufficient to serve as reversal agents. Rocuronium-specific, high-affinity antibodies were thus isolated from rocuronium-immunized mice. The highest-affinity antibody was able to reverse rocuronium-induced neuromuscular blockade in nonhuman primates with kinetics comparable to that of sugammadex. Together, these data support the hypothesis that antibodies cause anaphylactic reactions to rocuronium and pave the way for improved diagnostics and neuromuscular blockade reversal agents. Editor's summary: Neuromuscular blocking agents (NMBAs) such as rocuronium are used during anesthesia to assist with surgeries and intubations. Although these agents are effective, they are not without risk. Patients can develop postoperative residual neuromuscular blockade, which can be treated with an NMBA reversal agent, and life-threatening anaphylaxis can occur in rare cases. Here, Dejoux et al. isolated and characterized memory B cells from three individuals who developed reactions to NMBA treatment and had serum antibodies to rocuronium. The authors found that IgE antibodies generated from these memory B cells were sufficient to induce anaphylaxis in mice treated with rocuronium, although they were too low affinity to be used as reversal agents. This led the authors to immunize mice with rocuronium to generate antibodies of higher affinity, which were able to reverse neuromuscular blockade in rocuronium-treated nonhuman primates. Together, these data explain why these three patients had a reaction and offer a therapeutic approach to reversing neuromuscular blockade. —Courtney Malo [ABSTRACT FROM AUTHOR]

Background: To investigate feasibility of utilizing enhanced neuromuscular blocking agents with selective recovery protocol during thyroid surgery with intraoperative neuromonitoring (IONM). Methods: Two‐hundred and ninety patients were randomized into two groups: group A 0.3 mg/kg rocuronium and group B 0.6 mg/kg. Sugammadex 2 mg/kg was injected if needed followed initial vagal stimulation (V0). Electromyography signals from vagus and recurrent laryngeal nerves before and after resection were recorded as V1, V2, R1, and R2. Results: In group B, 30 patients (20.7%) had V0 signals <100 μV, compared to 9 (6.2%) in group A. After sugammadex administration, 144 patients (99.3%) in both groups achieved positive V1 signals. Group B demonstrated a shorter surgical time from rocuronium injection to V2 stimulation compared to group A, accompanied by a significantly lower incidence of intraoperative body movement (0 vs. 16 patients). Conclusions: 0.6 mg/kg rocuronium with selective use 2 mg/kg sugammadex for IONM in thyroid surgery can meet both anesthesia and surgery demands. [ABSTRACT FROM AUTHOR]

Abstract Background Sugammadex is a pharmacologic agent that provides rapid reversal of neuromuscular blockade via encapsulation of the neuromuscular blocking agent (NMBA). The sugammadex-NMBA complex is primarily cleared through glomerular filtration from the kidney, raising the possibility that alterations in renal function could affect its elimination. In pediatric patients, the benefits of sugammadex have led to widespread utilization; however, there is limited information on its application in pediatric renal impairment. This study examined sugammadex use and postoperative outcomes in pediatric patients with severe chronic renal impairment at our quaternary pediatric referral hospital. Methods After IRB approval, we performed a retrospective analysis in pediatric patients with stage IV and V chronic kidney disease who received sugammadex from January 2017 to March 2022. Postoperative outcomes studied included new or increased respiratory requirement, unplanned intensive care unit (ICU) admission, postoperative pneumonia, anaphylaxis, and death within 48 h postoperatively, unplanned deferral of intraoperative extubation, and repeat administrations of NMBA reversal after leaving the operating room. Results The final cohort included 17 patients ranging from 8 months to 16 years old. One patient required new postoperative noninvasive ventilation on postoperative day 2, which was credited to hypervolemia. Another patient had bronchospasm intraoperatively resolving with medication, which could not definitively be associated sugammadex administration. There were no instances of deferred extubation, unplanned ICU or need for supplemental oxygen after tracheal extubation identified. Conclusion No adverse effects directly attributable to sugammadex in pediatric patients with severe renal impairment were detected. There may be a role for utilization of sugammadex for neuromuscular reversal in this population.

Study Objective. Sugammadex is a widely used neuromuscular blockade reversal agent. Cost concerns limit use in pediatric patients for, whom recommended doses are often far less than vial quantities. Therefore, we undertook a quality improvement initiative at a pediatric hospital in which sugammadex vials were fractionated. We hypothesized we would see a decrease in administered dose and waste and improved adherence with dosing guidelines. Methods. Sugammadex vials were fractionated into 25, 50, or 100 mg aliquots, which would be distributed to anesthesia staff by pharmacy staff in approximate 2 mg/kg of actual body weight doses (±10%). We analyzed changes in sugammadex waste and dosing practices 1/1/2019 to 3/15/2023 pre/postintervention (4/1/2021). We gauged dose appropriateness using last train of four (TOF) prior to sugammadex administration. Results. 7,889 patients 2–17 years (4,771 with documented TOF), ASA 1–4 receiving general anesthesia with a steroidal NMB medication and sugammadex reversal. Pre‐ and postintervention mean doses were 2.5 mg/kg (SD: 1.2) and 2.4 mg/kg (SD: 0.96), respectively. A smaller proportion of cases received standard 2 or 4 mg/kg doses (pre: 77.6 vs. post: 66.7%). Mean waste per case declined from 4.2 mg/kg (SD: 4.1) to 0.22 mg/kg (SD: 0.38). Among cases with 0 or 1 measured twitches on TOF that should receive at least 4 mg/kg, fewer received at least 3.6 mg/kg (post: 56.7% vs. pre: 66.8%), and a greater proportion received less than 2.2 mg/kg (post: 27.4% vs. pre: 20.7%). Among cases that should have received at least 2 mg/kg by TOF, the proportion of patients receiving more than 3.6 mg/kg declined from 9.5% to 5.2%. Discussion. Fractionating sugammadex vials was associated with decreases in waste, but not dose, and significant underdosing was more likely to occur. While vial fractionation could enable increased access to sugammadex and other costly medications, it may introduce unintended consequences. [ABSTRACT FROM AUTHOR]

Purpose: Pain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring. Methods: This retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients. Results: NOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent's infusion, only NOL properly identified nociception. In the former group, EEG's relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL. Conclusion: NOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them. [ABSTRACT FROM AUTHOR]

Background: We aimed to elucidate the quantitative relationship between the neuromuscular blockade depth and intraoperative motor-evoked potential amplitudes. Methods: This prospective, single-arm, open-label, observational study was conducted at a single university hospital in Seoul, Korea, and included 100 adult patients aged ≥19 years undergoing brain tumor removal surgery under general anesthesia. We measured the neuromuscular blockade degree and motor-evoked potential amplitude in the deltoid, abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles until dural opening. Results: The pharmacokinetic-pharmacodynamic model revealed the exposure-response relationship between the rocuronium effect-site concentration and motor-evoked potential amplitudes. The mean motor-evoked potential amplitudes decreased proportionally with increasing neuromuscular blockade depth. As the mean amplitude increased, the coefficient of variation decreased bi-exponentially. The critical ratio of the first evoked response to the train-of-four stimulation (T1)/control response (Tc) thresholds beyond which the coefficient of variation exhibited minimal change were found to be 0.63, 0.65, 0.68, and 0.63 for the deltoid, abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles, respectively. Conclusions: Our results reveal that the motor-evoked potential amplitude exhibits deterioration proportional to the degree of neuromuscular blockade. In light of the observed bi-exponential decline of the coefficient of variation with the motor-evoked potential amplitude, we recommend maintaining a T1/Tc ratio higher than 0.6 for partial neuromuscular blockade. [ABSTRACT FROM AUTHOR]

Background: Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. Methodology: This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A—Low-pressure group in which pneumoperitoneum pressure was kept low (8–10 mmHg) with deep Neuromuscular blockade (NMB) and Group B—Normal pressure group (12–14 mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24 h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. Results: Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative–pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6 h and 24 h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. Conclusion: Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings. [ABSTRACT FROM AUTHOR]

Background: Prolong effects of non-depolarizing neuromuscular blocking agents after rapid sequence intubation may prevent meaningful neurological examination, delaying appropriate diagnosis and neurosurgical intervention. Sugammadex is indicated for the reversal of neuromuscular blockade induced by rocuronium. Objective: The objective of this study was to evaluate low- (2 mg/kg) vs standard-dose (4 mg/kg) sugammadex for rocuronium-induced deep neuromuscular blockade reversal in the emergency department (ED) by achieving a post-treatment train-of-four (TOF) of 4 to facilitate neurological examination. Methods: This was a single-center, retrospective, cohort study evaluating low-vs standard-dose sugammadex for neuromuscular blockade reversal in the ED. Results: 34 patients were identified within the designated time period, 24 of which were included in the final analysis ([n = 9 low-dose], [n = 15 standard-dose]). Median sugammadex doses were 2.3 mg/kg and 4.1 mg/kg for low- and standard-dose, respectively. The majority of patients presented for intraparenchymal hemorrhage (54.2%). No significant difference in success rate of NMBA reversal was found between low- and standard-dose sugammadex ([100.0% vs 93.3%], P = 1.000). A total of 9 patients had a neurosurgical procedure performed after sugammadex administration. Low-dose sugammadex was associated with significantly less acquisition cost compared to the standard dose (P <.001). Conclusion: Low- (2 mg/kg) and standard-dose (4 mg/kg) sugammadex successfully reversed rocuronium-induced deep neuromuscular blockade in the ED by achieving a post-treatment TOF of 4 to facilitate neurologic examination. Low-dose sugammadex may be a viable option for deep NMBA reversal in the ED and is associated with decreased institutional cost. [ABSTRACT FROM AUTHOR]

Background: Age‐related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta‐analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. Method: We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25–75), and to ≥90% train‐of‐four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25‐75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random‐effects network and pairwise meta‐analyses along with meta‐regression were used to evaluate the results. Results: We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta‐analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25‐75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log‐linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2–11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d–12 M), respectively. We found a negative log‐linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. Conclusions: The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent. [ABSTRACT FROM AUTHOR]

Background: Airway pressure release ventilation (APRV) has become increasingly popular for the management of acute respiratory distress syndrome (ARDS); however, its clinical impact remains a topic of debate. Furthermore, there is a gap between the guidelines and the actual clinical practices in mechanical ventilation management for ARDS. This survey aimed to explore the utilization of APRV and mechanical ventilation strategies for ARDS in Chinese intensive care unit (ICU) clinicians. Methods: A comprehensive 34‐item survey was distributed online platforms amongst ICU clinicians across mainland China from June to August 2019. Results: A total of 420 valid responses were collected, with 57.4% (241) originating from academic hospitals and 42.6% (179) from non‐academic hospitals. Of the respondents, 98.6% (414) recognized the significance of low tidal volume ventilation for ARDS prognosis, 85.2% adhered to a tidal volume below 8 mL/kg predicted body weight, and most (46.4%) selected the initial positive end‐expiratory pressure within the range of 5–10 cmH2O based on experience. Among the respondents, 62.1% (261) reported familiarity with APRV and 41.9% (176) had implemented APRV. Of those who had utilized APRV, 93.2% (164) believed in its effectiveness for ARDS patients and 69.3% (122) advocated for early application of APRV. Substantial variations were noted regarding APRV initiation settings and the preservation of spontaneous breathing during APRV. Academic hospitals exhibited higher usage rates of lung recruitment, neuromuscular blockade, prone ventilation, and acquaintance with and utilization of APRV compared to non‐academic hospitals (all p values ≤ 0.001). Conclusions: Our findings highlight opportunities for improvement in mechanical ventilation management for ARDS, particularly in non‐academic hospitals. Additionally, a significant proportion of clinicians demonstrated limited knowledge of APRV, and there was a lack of consensus on its application. Further training and larger‐scale clinical trials are required to validate the efficacy and utilization of APRV in managing ARDS. [ABSTRACT FROM AUTHOR]

Background: The neuromuscular blocking agent mivacurium can be used during anesthesia to facilitate tracheal intubation. Data on onset time, duration of action, and effect on intubating conditions in patients 80 years and older are however limited. We hypothesized that onset time and duration of action of mivacurium would be longer in elderly patients than in younger adults. Methods: This prospective observational study included 35 elderly (≥80 years) and 35 younger (18–40 years) patients. Induction of anesthesia comprised fentanyl 1–3 μg kg−1 and propofol 1.5–2.5 mg kg−1 and propofol and remifentanil for maintenance. Acceleromyography was used for monitoring neuromuscular blockade. The primary outcome was onset time defined as time from injection of mivacurium 0.2 mg kg−1 to a train‐of‐four (TOF) count of zero. Other outcomes included duration of action (time to TOF ratio ≥0.9), intubating conditions using the Fuchs‐Buder scale and the intubating difficulty scale (IDS), and occurrence of hoarseness and sore throat postoperatively. Results: No difference was found in onset time comparing elderly with younger patients; 219 s (SD 45) versus 203 s (SD 74) (difference: 16 s (95% CI: −45 to 14), p =.30). Duration of action was significantly longer in elderly patients compared with younger patients; 52 min (SD 17) versus 30 min (SD 8) (difference: 22 min [95% CI: 15 to 28], p <.001). No difference was found in the proportion of excellent intubating conditions (Fuchs‐Buder); 31/35 (89%) versus 26/35 (74%) (p =.12) or IDS score (p =.13). A larger proportion of younger patients reported sore throat 24 h postoperatively; 34% versus 0%, p =.0002. No difference was found in hoarseness. Conclusion: No difference in onset time of mivacurium 0.2 mg kg−1 was found comparing elderly and younger patients. However, elderly patients had significantly longer duration of action. No difference was found in intubating conditions. [ABSTRACT FROM AUTHOR]

Our lab is investigating the efficacy profiles of tropine analogs against opioidinduced respiratory depression. The companion manuscript reports that the cellpermeant tropeine, tropine ester (Ibutropin), produces a rapid and sustained reversal of the deleterious actions of fentanyl on breathing, alveolar-arterial (A-a) gradient (i.e., index of alveolar gas exchange), and arterial blood-gas (ABG) chemistry in freely-moving male Sprague Dawley rats, while not compromising fentanyl analgesia. We report here that in contrast to Ibutropin, the injection of the parent molecule, tropine (200 µmol/kg, IV), worsens the adverse actions of fentanyl (75 µg/kg, IV) on ventilatory parameters (e.g., frequency of breathing, tidal volume, minute ventilation, peak inspiratory and expiratory flows, and inspiratory and expiratory drives), A-a gradient, ABG chemistry (e.g., pH, pCO2, pO2, and sO2), and sedation (i.e., the righting reflex), while not affecting fentanyl antinociception (i.e., the tail-flick latency) in freely-moving male Sprague Dawley rats. These data suggest that tropine augments opioid receptor-induced signaling events that mediate the actions of fentanyl on breathing and alveolar gas exchange. The opposite effects of Ibutropin and tropine may result from the ability of Ibutropin to readily enter peripheral and central cells. Of direct relevance is that tropine, resulting from the hydrolysis of Ibutropin, would combat the Ibutropin-induced reversal of the adverse effects of fentanyl. Because numerous drug classes, such as cocaine, atropine, and neuromuscular blocking drugs contain a tropine moiety, it is possible that their hydrolysis to tropine has unexpected/unintended consequences. Indeed, others have found that tropine exerts the same behavioral profile as cocaine upon central administration. Together, these data add valuable information about the pharmacological properties of tropine. [ABSTRACT FROM AUTHOR]

Aims: Residual neuromuscular blockade has been linked to pulmonary complications in the postoperative period. This study aimed to determine whether sugammadex was associated with a lower risk of postoperative pulmonary complications (PPCs) compared with neostigmine. Methods: This retrospective cohort study was conducted in a tertiary academic medical center. Patients ≥18 year of age undergoing noncardiac surgical procedures with general anesthesia and mechanical ventilation were enrolled between January 2019 and September 2021. We identified all patients receiving rocuronium and reversal with neostigmine or sugammadex via electronic medical record review. The primary endpoint was a composite of PPCs (including pneumonia, atelectasis, respiratory failure, pulmonary embolism, pleural effusion, or pneumothorax). The incidence of PPCs was compared using propensity score analysis. Results: A total of 1786 patients were included in this study. Among these patients, 976 (54.6%) received neostigmine, and 810 (45.4%) received sugammadex. In the whole sample, PPCs occurred in 81 (4.54%) subjects (7.04% sugammadex vs. 2.46% neostigmine). Baseline covariates were well balanced between groups after overlap weighting. Patients in the sugammadex group had similar risk (overlap weighting OR: 0.75; 95% CI: 0.40 to 1.41) compared to neostigmine. The sensitivity analysis showed consistent results. In subgroup analysis, the interaction P‐value for the reversal agents stratified by surgery duration was 0.011. Conclusion: There was no significant difference in the rate of PPCs when the neuromuscular blockade was reversed with sugammadex compared to neostigmine. Patients undergoing prolonged surgery may benefit from sugammadex, which needs to be further investigated. [ABSTRACT FROM AUTHOR]

A meta-analysis published in the journal Anaesthesia compared the use of remifentanil with neuromuscular blocking (NMB) drugs for tracheal intubation in adults. The study found that a remifentanil bolus provided comparable rates of successful tracheal intubation compared to NMB drugs. However, this conflicts with the findings of a recent trial that found remifentanil to be statistically inferior to NMB drugs. While the use of NMB drugs is widely recommended, the study suggests that tracheal intubation with high doses of remifentanil may be a safe alternative in certain situations. Further research is needed to investigate the efficacy of tracheal intubation without NMB drugs and to improve patient safety during the procedure. [Extracted from the article]

Summary: There is increasing interest in the use of short‐acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty‐one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5–4.0 μg.kg‐1) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94–1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate‐certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0–4.0 μg.kg‐1) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72–1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate‐certainty of evidence). There was no evidence of an effect between remifentanil (2.0–4.0 μg.kg‐1) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01–13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44–2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low‐certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses. [ABSTRACT FROM AUTHOR]

Background: Suxamethonium is hydrolysed by butyrylcholinesterase (BChE) and a low BChE activity can result in a prolonged duration of action of suxamethonium. The BChE activity is reduced during pregnancy and postpartum period by up to 33%. However, it can also be reduced by mutations in the BChE gene. In this study, we assessed BChE activity and mutations in the BChE gene in pregnant and postpartum patients with prolonged duration of action of suxamethonium. It was hypothesised that at least 30% of patients with a low BChE activity did not have a mutation in the BChE gene. Methods: In this registry study we focused on pregnant and postpartum patients with a history of prolonged duration of action of suxamethonium referred to the Danish Cholinesterase Research Unit (DCRU) between March 2007 and January 2023. Primary outcome was the proportion of patients without a mutation among patients with a low BChE activity. Secondary outcomes were the proportion of patients with a low BChE activity and the proportion of patients with a mutation out of the total number of patients. Results: A total of 40 patients were included and among patients with a low BChE activity, 6% (95% CI: 1%–21%) did not have a mutation. Out of the total number of included patients referred to the DCRU, 90% (95% CI: 76%–97%) had a mutation and 94% (95% CI: 80%–99%) had a low BChE activity. Conclusion: Among pregnant and postpartum patients with a history of prolonged duration of action of suxamethonium and a low BChE activity, 6% did not have a mutation in the BChE gene. Our findings suggest that during pregnancy and postpartum clinically relevant prolonged duration of action of suxamethonium rarely occurs in genotypically normal patients. [ABSTRACT FROM AUTHOR]

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Background: EEG reactivity is a predictor for neurological outcome in comatose patients after cardiac arrest (CA); however, its application is limited by variability in stimulus types and visual assessment. We aimed to evaluate the prognostic value of the quantitative analysis of EEG reactivity induced by standardized electrical stimulation and for early prognostication in this population. Methods: This prospective observational study recruited post-CA comatose patients in Xuanwu Hospital, Capital Medical University (Beijing, China) between January 2016 and June 2023. EEG reactivity to electrical or traditional pain stimulation was randomly performed via visual and quantitative analysis. Neurological outcome within 6 months was dichotomized as good (Cerebral Performance Categories, CPC 1–2) or poor (CPC 3–5). Results: Fifty-eight post-CA comatose patients were admitted, and 52 patients were included in the final analysis, of which 19 (36.5%) had good outcomes. EEG reactivity induced with the electrical stimulation had superior performance to the traditional pain stimulation for good outcome prediction (quantitative analysis: AUC 0.932 vs. 0.849, p = 0.048). When using the electrical stimulation, the AUC of EEG reactivity to predict good outcome by visual analysis was 0.838, increasing to 0.932 by quantitative analysis (p = 0.039). Comparing to the traditional pain stimulation by visual analysis, the AUC of EEG reactivity for good prognostication by the electrical stimulation with quantitative analysis was significantly improved (0.932 vs. 0.770, p = 0.004). Conclusions: EEG reactivity induced by the standardized electrical stimulation in combination with quantitative analysis is a promising formula for post-CA comatose patients, with increased predictive accuracy. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of tetanic stimulation on the time to achieve stabilization of the T1 height, by acceleromyography train-of-four (TOF) ratio monitoring, in patients aged 60 to 80 years. Methods: Randomized, prospective, single-blind, controlled trial in patients aged 60 to 80 years undergoing elective surgery under general anesthesia in two university hospitals in Brazil between December 2019 and March 2022. This trial was performed in accordance with the principles of the Helsinki Declaration and the guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II. Participants were randomly allocated by computer-generated numbers to receive tetanic stimulation (intervention group, n = 25) or not receive tetanic stimulation (control group, n = 25) to achieve T1 height stabilization on TOF ratio monitoring. The primary endpoint was to evaluate the effect of tetanic stimulation on the time to achieve stabilization of the T1 height. We also evaluated the effect on the onset time of rocuronium and time to recover from neuromuscular blockade with a single dose of rocuronium 0.6 mg.kg-1 with spontaneous recovery. Results: There was no statistically significant difference between the groups in the time to T1 height stabilization (intervention: 4.3 [2.0–8.0] min; control: 5.8 [2.0–10.5] min; p = 0.202), onset time of the neuromuscular blocking agent (intervention: 1.9 [±0.7] min; control: 2.2 [±1.0] min; p = 0.219), or neuromuscular blockade recovery times to normalized TOF values of 0.7 (intervention: 106.1 [±37.2] min; control: 91.7 [±27.5] min; p = 0.295), 0.8 (intervention: 114.3 [±40.1] min; control: 97.8 [±28.9] min; p = 0.225), 0.9 (intervention: 126.5 [±44.0] min; control: 106.9 [±30.6] min; p = 0.153), and 1.0 (intervention: 138.3 [±43.4] min; control: 123.8 [±43.5] min; p = 0.425). Conclusion: The results of this study suggest that the recommendation to use tetanic stimulation to shorten the time to T1 height stabilization in neuromuscular monitoring did not alter the stabilization time of the T1 twitch or the pharmacodynamics of neuromuscular blockade with rocuronium in patients aged 60 to 80 years. [ABSTRACT FROM AUTHOR]

OBJECTIVE The Society of Critical Care Medicine released the first guideline for the prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit. METHODS This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS). RESULTS Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4. CONCLUSIONS Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions. [ABSTRACT FROM AUTHOR]

Background: Postoperative gastrointestinal dysfunction (POGD) commonly occurs following gastrointestinal (GI) surgery and is associated with specific anesthetic agents. Cholinesterase inhibitors employed for reversing neuromuscular blockade have been implicated in development of POGD. Sugammadex, a novel reversal agent, is linked with reduced POGD. However, there is a lack of comprehensive comparative review between these agents regarding their impact on POGD following GI surgery. This study aims to systematically review the effects of sugammadex on POGD compared to cholinesterase inhibitors following GI surgery. Methods: MEDLINE, EMBASE, and CENTRAL were searched as of July 2022 to identify articles comparing sugammadex with cholinesterase inhibitors in patients undergoing gastrointestinal surgery, specifically in relation to POGD. Secondary endpoints included length of hospital stay, readmission rates, pulmonary complications, and postoperative morbidity. Results: From 198 citations, 2 randomized controlled trials (RCTs) and 3 retrospective cohorts with 717 patients receiving sugammadex and 812 patients receiving cholinesterase inhibitors were included. Significantly lower rates of prolonged postoperative ileus (OR.44, 95% CI.25-.77, P <.05, I2 = 56%, low certainty evidence) was observed with sugammadex. No significant difference in any other outcome was observed. Narrative review of readmission data demonstrated no significant difference. Conclusion: The use of sugammadex following gastrointestinal surgery is associated with significantly lower rates of prolonged postoperative ileus compared to cholinesterase inhibitors. However, these do not translate into a significant reduction in length of stay, morbidity, or postoperative nausea and vomiting. Results are limited by the numer of studies included and missing data, more robust RCTs are needed before recommendations can be made. [ABSTRACT FROM AUTHOR]

Tetanus is a life-threatening, vaccine-preventable disease caused by an endotoxin produced by Clostridium tetani. We report a case of severe tetanus in an adult male with a history of intravenous drug use. The patient presented with a 1-day history of inability to open his jaw and a right lower extremity necrotic wound. Initial management consisted of tetanus toxoid, human tetanus immunoglobulin, antimicrobials and intermittent lorazepam. Due to progressive symptoms, wound debridement and placement of an advanced airway in the operating room ensued. Episodes of tetany were associated with fever, autonomic instability, acute desaturations and preemptive ventilator triggering despite maximum doses of continuous propofol and midazolam. Neuromuscular blockade with cisatracurium was added, resulting in control of tetany. Despite initial control, NMB could not be weaned due to recurrent spasms. Intravenous dantrolene was therefore sought as an alternative antispasmodic. Following an initial load, patient was successfully liberated from cisatracurium. Dantrolene was therefore converted to enteral to facilitate gradual down-titration of intravenous sedatives with subsequent conversion to oral benzodiazepines. After a prolonged hospital course, the patient was able to be discharged home. Dantrolene was thus effectively utilized as an adjunctive antispasmodic agent to facilitate liberation from cisatracurium and continuous sedation. [ABSTRACT FROM AUTHOR]

The article discusses the need for mandatory training in the management of rare anaesthetic events, specifically focusing on patient deaths caused by unrecognised oesophageal intubation. The authors highlight that despite efforts to prevent such harm, patients continue to die from this preventable error. They argue that regular, multidisciplinary team training should be implemented to improve performance during these rare events. The authors acknowledge that there is currently no proof that this training will improve outcomes, but they believe it is necessary to prioritize patient safety. They suggest that the General Medical Council should enforce mandatory training for anaesthetists, and they reference the example of Australia and New Zealand where similar training is already in place. The authors acknowledge that implementing career-long mandatory training will come with costs, but they emphasize the importance of protecting patients and preventing future tragedies. [Extracted from the article]

This document is a letter published in the journal Systematic Reviews. The letter discusses the optimal dosage of adamgammadex, a reversal agent, for the reversal of rocuronium-induced neuromuscular block. The authors conducted a meta-analysis of three randomized controlled trials comparing different doses of adamgammadex and sugammadex for the reversal of rocuronium-induced neuromuscular blockade. The results suggest that both doses of adamgammadex (4 mg/kg and 6 mg/kg) are effective in reversing neuromuscular blockade, providing flexibility in dosing options for anesthesiologists and surgeons. However, further large-scale trials are needed to confirm these findings and evaluate the safety profile of adamgammadex at different doses. [Extracted from the article]

Abstract Background While awake, flexible bronchoscopic intubation has long been considered the gold standard for managing anticipated difficult airways, the videolaryngoscope has emerged as a viable alternative. In addition, the decision to perform awake intubation or to proceed with airway management after induction of general anesthesia should be grounded in a comprehensive assessment of risks and benefits. Case presentation A 41-year old female patient was scheduled for excision of bilateral, mobile, and pedunculated masses on both aryepiglottic folds, which covered almost the entire upper part of the glottis. We conducted a comprehensive evaluation of the patient’s signs and symptoms, which included neither stridor nor dyspnea in any position, along with the otolaryngologist’s opinion and the findings from the laryngeal fiberscopic examination. Given the potential challenges and risks associated with awake flexible bronchoscopic intubation for this patient, we decided to proceed with gentle tracheal intubation using a videolaryngoscope under general anesthesia. In case of failed mask ventilation and tracheal intubation, we had preplanned strategies, including awakening the patient or performing an emergent tracheostomy, along with preparations to support these strategies. Ensuring that mask ventilation was maintained with ease, the patient was sequentially administered intravenous propofol, remifentanil, and rocuronium. Under sufficient depth of anesthesia, intubation using a videolaryngoscope was successfully performed without any complications. Conclusions Videolaryngoscopic intubation after induction of general anesthesia can be a feasible alternative for managing difficult airways in patients with supraglottic masses. This approachshould be based on a comprehensive preoperative evaluation, adequate preparation, and preplanned strategies to address potential challenges, such as inadequate oxygenation and unsuccessful tracheal intubation.

Quantitative neuromuscular monitoring, as extolled by clinical guidelines, is advocated to circumvent the complications associated with neuromuscular blockers (NMBs), such as residual neuromuscular block (rNMB). Nonetheless, the worldwide utilization of such methods remains undesirable. Phonomyography (PMG) boasts the advantages of convenience, stability, and multi-muscle recording which may be a promising monitoring method. The purpose of this preliminary study is conducting a feasibility analysis and an effectiveness evaluation of a PMG prototype under general anesthesia. A prospective observational preliminary study was conducted. Twenty-five adults who had undergone none-cardiac elective surgery were enrolled. The PMG prototype and TOF-Watch SX simultaneously recorded the pharmacodynamic properties of single bolus rocuronium at the ipsilateral adductor pollicis for each patient. For the primary outcome, the time duration to 0.9 TOF ratio of the two devices reached no statistical significance (p > 0.05). For secondary outcomes, the multi-temporal neuromuscular-monitoring measurements between the two devices also reached no statistical significance (p > 0.05). What is more, both the Spearman's and Pearson's correlation tests revealed a strong correlation across all monitoring periods between the PMG prototype and TOF-Watch SX. Additionally, Bland–Altman plots demonstrated a good agreement between the two devices. Thus, the PMG prototype was a feasible, secure, and effective neuromuscular-monitoring technique during general anesthesia and was interchangeable with TOF-Watch SX. [ABSTRACT FROM AUTHOR]

Background and Objective: Early and smooth extubation following anesthesia is an important concern in patients undergoing transsphenoidal pituitary surgery to permit early neurological evaluation and prevent complications. The aim was to compare the RESPONSE FIRST and REVERSAL FIRST techniques for quality of extubation (QOE) in patients undergoing endoscopic transsphenoidal pituitary surgery. Methods: Fifty-six patients aged 18-60 years, with American Society of Anesthesiologists Physical Statuses I-II, and undergoing transsphenoidal surgery for pituitary tumors were randomized into either the RESPONSE FIRST group, in which neuromuscular reversal was given following the patient's response to oral commands, or the REVERSAL FIRST group, in which reversal of neuromuscular blockade (NMB) was given at the return of spontaneous respiration. QOE was the primary outcome. Hemodynamic response, jugular venous oxygen saturation (SjVO2), time to extubation, and awareness during emergence were assessed as secondary outcomes. Results: The QOE in the RESPONSE FIRST group was significantly better than the REVERSAL FIRST group (mean (interquartile range (IQR)), 18 (17-19) vs 14 (12-14.75), P < 0.001). Heart rate (HR) and mean arterial pressure (MAP) were better in the RESPONSE FIRST group when compared to the REVERSAL FIRST group at the time of extubation, at 5 minutes, and 15 minutes following extubation (P < 0.05). SjVO2values were higher in the REVERSAL FIRST group as compared to the RESPONSE FIRST group during extubation and at 5 minutes after extubation (P < 0.01). There was no significant difference in the time to extubation between the groups (P = 0.73). Conclusion: The RESPONSE FIRST technique is associated with better QOE and preservation of systemic and cerebral hemodynamics during extubation in patients undergoing transsphenoidal pituitary surgery when compared to the REVERSAL FIRST technique. [ABSTRACT FROM AUTHOR]

Background and Objective: Neuromuscular blocking agents are routinely used in laparoscopic surgery to optimize operative conditions. We compared the effect of a deep and moderate neuromuscular blockade (NMB) on surgical conditions and postoperative outcomes in children undergoing major laparoscopic surgery. Methods: Sixty children aged 2–14 years scheduled to undergo major laparoscopic surgery were randomly allocated to deep (post-tetanic count 1–2 twitches) or moderate (train-of-four 1–2 twitches) NMB groups. The anesthesia was maintained with propofol and remifentanil, and the NMB was maintained with a rocuronium continuous infusion. At the end of the operation, the NMB were antagonized with sugammadex. The intra-abdominal pressure, airway pressure, Leiden Surgical Rating Scale, intraoperative hemodynamics, drug usages, duration of surgery, postoperative recovery time, pain, and complications were compared between the groups. Results: The maximum and mean intra-abdominal pressure, the peak inspiratory pressure, and mean airway pressure were significantly lower in the deep NMB group than in the moderate NMB group (p < 0.001). The Leiden Surgical Rating Scale and the dosage of rocuronium were significantly higher in the deep NMB group than the moderate NMB group (p < 0.001). The intraoperative hemodynamics, duration of surgery, post-operative recovery time, pain, and the incidence rate of complications were not significantly different between the groups (p > 0.05). Conclusions: A deep NMB provided better operative conditions and similar recovery profiles compared with a moderate NMB as reversed with sugammadex in children undergoing major laparoscopic surgery. Clinical Trial Registration: Chinese Clinical Trial Registry, No. ChiCTR2100053821. [ABSTRACT FROM AUTHOR]

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Background: Neuromuscular ultrasound has become an important tool in the diagnostic workup of nerve and muscle disorders. Scanning techniques, sonoanatomy, and sonographic appearance of the pathologies of the main upper and lower limb nerves have been extensively described in the literature. The nerve branches and small nerves have also been addressed but to a much lesser extent. The aim of the article is to give an overview of neuromuscular ultrasound of important small nerves including nerve branches and other small nerves. The article provides a summary for machine settings and indications of ultrasound scanning of small nerves. It then discusses each nerve as regards the relevant anatomy, detailed scanning techniques, sonoanatomy, and common pathologies. Conclusion: This article represents a practical guide for scanning important nerve branches and small nerves which can facilitate sonographic assessment of pathologies of such challenging nerves. [ABSTRACT FROM AUTHOR]

Copyright of Hungarian Medical Journal / Orvosi Hetilap is the property of Akademiai Kiado 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.)

Polymyxin-induced neuromuscular blockade is a rare but potentially fatal condition, with majority of cases that were reported between 1962 and 1973. We describe a patient who developed hypercapnic respiratory failure after initiation of polymyxin for multi-drug resistant Escherichia Coli bacteremia, due to polymyxin-induced neuromuscular dysfunction. After cessation of polymyxin, he regained full strength, had complete resolution of ptosis, and was successfully extubated. In light of the renewed use of polymyxin in this era of antimicrobial-resistance, this case aims to raise awareness about this rare but life-threatening condition, which is easily reversible with early recognition and prompt discontinuation of the drug. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia—induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety. [ABSTRACT FROM AUTHOR]

This article discusses the importance of quantitative neuromuscular monitoring in anesthesia practice. It highlights the historical development of neuromuscular blocking drugs and the introduction of sugammadex, which offers the potential for antagonism of neuromuscular block. The article emphasizes the dangers of residual neuromuscular block, including prolonged recovery and postoperative complications. It also addresses the barriers to adopting quantitative monitoring, such as cost and lack of training. The authors argue that the use of quantitative monitoring is essential for optimizing neuromuscular block management and improving patient outcomes. [Extracted from the article]

Administration of succinylcholine to patients with a variant in the butyrylcholinesterase (BChE) gene increases the risk of anesthesia emergence prior to recovery from neuromuscular blockade (NMB). Application of quantitative neuromuscular monitoring (NMM) can identify residual NMB. We present two patients with abnormal BChE gene variants. In the first case, quantitative monitoring was applied too late to prevent awareness, but allowed diagnosis and prevented admission to the intensive care unit. In the second case, monitoring was applied prior to NMB, which enabled early diagnosis and prevented premature awakening from anesthesia. These cases illustrate the importance of quantitative NMM, even in short cases and with short-acting depolarizing agents such as succinylcholine. The clinical implications of this report include a more consistent use of NMM to identify and manage patients with undiagnosed abnormal BChE and to prevent premature anesthesia emergence. [ABSTRACT FROM AUTHOR]