A Survey of Current Management of Neuromuscular Block in the United States and Europe
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Postoperative residual neuromuscular block is a frequent occurrence. Recent surveys of clinical practice in Europe suggest that neuromuscular blocking drugs are often administered without appropriate monitoring. No comparable survey has been undertaken in the United States (US). From this survey, we compared current clinical neuromuscular practice and attitudes between anesthesia practitioners in the US and Europe.We conducted an Internet-based survey among anesthesia practitioners in the US and Europe. The Anesthesia Patient Safety Foundation and the European Society of Anaesthesiology e-mailed all of their active members, inviting them to anonymously answer a series of questions on a dedicated Internet Protocol address-sensitive website. The survey was available online for 60 days. The chi(2) test and Fisher's exact test were used to compare clinical survey items between the 2 cohorts.A total of 2636 completed surveys were received. Most respondents from the US (64.1%) and Europe (52.2%) estimated the incidence of clinically significant postoperative residual neuromuscular weakness to be <1% (P < 0.0001). Routine pharmacologic reversal was less common in Europe than in the US (18% vs 34.2%, respectively; P < 0.0001), and quantitative monitors were available to fewer clinicians in the US (22.7%) than in Europe (70.2%) (P < 0.0001). However, 19.3% of Europeans and 9.4% of Americans never use neuromuscular monitors. Most respondents reported that neither conventional nerve stimulators nor quantitative train-of-four monitors should be part of minimum monitoring standards.Our results suggest a lack of agreement among anesthesia providers about the best way to monitor neuromuscular function. Efforts to improve awareness by developing formal training programs and/or publishing official guidelines on best practices to reduce the incidence of postoperative neuromuscular weakness and patient morbidity are warranted.Keywords:
Neuromuscular monitoring
S445 Introduction: ORG 9487 is an investigational short-acting nondepolarizing muscle relaxant [1]. However, infusion of ORG 9487 appears to change its clinical effect from that of a short-acting to an intermediate-acting relaxant [2]. Therefore, patients may have prolonged neuromuscular blockade after discontinuation of an infusion of ORG 9487. This study was designed to evaluate the effect of neostigmine reversal on residual neuromuscular blockade after a 1 h infusion of ORG 9487 in adults. Methods: After IRB approval and written informed consent, 20 patients undergoing general surgery with an anticipated duration over 2 hours were studied. Anesthesia was induced with propofol 2.5 mg/kg, fentanyl 2 [micro sign]g/kg, and ORG 9487 1.5 mg/kg. Maintenance of anesthesia consisted of nitrous oxide 60% in oxygen with isoflurane, sevoflurane, desflurane, or propofol infusion. After T1 twitch height return to 5% of baseline, a continuous infusion of ORG 9487 will be started at initial infusion rate of 3 mg/kg/h. The infusion was adjusted to maintain T1 at 10% of baseline for 1 hour and was then discontinued. After surgery, patient with TOF ratio (T4/T1) less than 0.7 received neostigmine 0.05 mg/kg and 0.01 mg/kg glycopyrrolate to reverse the residual effect of ORG 9487. Neuromuscular blockade was assessed by peripheral nerve stimulation using a TOF-GUARD[registered sign] monitor (Organon Teknika NV, Turnhout, Beigium). Accelerometric assessment of TOF responses were recorded on a memory card and the data was analyzed using a software for TOF-GUARD[registered sign] card reader in computer. Results: Eleven patients required reversal of neuromuscular blockade with a T1 of 80 +/- 27 % and T4/T1 was 0.43 +/- 0.22. The time between end of infusion and reversal was 102 +/- 44 min. After reversal with neostigmine, the time for T1 to returned to 90 and 100% was 90 +/- 145 and 103 +/- 177 sec, respectively. Time of TOF ratio return to 0.7, 0.8, 0.9 and 1.0 after reversal was 138 +/- 130, 201 +/- 188, 304 +/- 267, and 449 +/- 397 sec, respectively. No recurarization effects and any airway problems were observed in all the patients after reversal. (Figure 1)Figure 1Discussion: After an infusion of ORG 9487, the residual neuromuscular blockade can be clinical reversed using neostigmine within 3 min.
Neuromuscular monitoring
Muscle relaxant
Vecuronium bromide
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Objective The study is designed to compare the pharmacodynamics of cisatracurium by decreasing continuous infusion and intermittent bolus injection so as to find the best way of administration. Methods 40 ASA I~II patients undergoing elective spinal surgery were randomly divided into 2 groups. Patients in group Ⅰ received cisatracurium by decreasing continuous infusion and in group II by intermittent bolus injection. The responses of adductor pollicis were monitored by train-of-four(TOF) stimulation.The level of neuromuscular blockade and the total dose of cisatracurium were recorded, the average infusion rate was calculated; the recovery time of T1 to 25% and 75%, and recovery index(RI) of the two groups were recorded. Intravenous anesthesia was used for both induction and maintained by sevoflurane inhalation. Neuromuscular blockade was monitored until TOF ratio(T4/T1)≥75%. The patients were extubated when spontaneous breath recovered. Results The average infusion rate was significantly slower in group I than that in group II(P0.05); the recovery time of T1 to 25% and 75% was significantly faster in group I than that in group II(P0.05); There were no significant differences in the recovery index in both groups(P0.05). Conclusion Decreasing continuous infusion of cisatracurium can reduce the dose of cisatracurium used in the surgery and obtain a more stable neuromuscular blockade, and the spontaneous recovery from neuromuscular block is faster than that by intermittent bolus injection.
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Spontaneous recovery
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Target controlled infusion
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To compare the effects of sevoflurane and propofol-remifentanil anesthesia on neuromuscular blockade produced by continuous cisatracurium infusion.Forty ASA I or II patients undergoing selective surgery were randomly divided into sevoflurane and propofol-remifentanil anesthesia groups (n=20). Neuromuscular blockade was monitored using train-of-four (TOF) stimulation by recording the contraction force of the adductor pollicis muscle with a muscle relaxation monitor. A bolus dose of cisatracurium of 0.15 mg/kg was administered to facilitate endotracheal intubation, followed by continuous infusion adjusted manually to maintain the first twitch (T1) < or = 5% of the control level. The following variables were recorded including the infusion rate, total amount of cisatracurium, spontaneous recovery index (RI), and the time interval from termination of infusion cisatracurium to recovery of TOF ratio (TOFR) to 0.9.With the maintenance of a 95%-99% neuromuscular blockade, the infusion rate was significantly lower in sevoflurane group than in propofol-remifentanil group (P<0.05), and stabilized in both groups after 120 min. No significant differences were found in RI or the time to TOFR of 0.9 between the two groups (P>0.05).During the maintenance of stable neuromuscular blockade by continuous cisatracurium infusion, both sevoflurane and propofol-remifentanil anesthesia can time-dependently enhance the effect of cisatracurium without producing significant differences in the recovery properties.
Adductor pollicis muscle
Neuromuscular monitoring
Bolus (digestion)
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Fifteen patients who were undergoing major ophthalmic surgery were anaesthetized using controlled ventilation with nitrous oxide, oxygen, midazolam and fentanyl after induction with thiopentone. Each was then given a bolus dose of 0.6 mg kg-1 atracurium followed immediately by an infusion of the drug at the rate of 0.6 mg kg-1 h-1, neuromuscular function being monitored throughout. Even slight movement can jeopardize the success of this type of surgery but good control of neuromuscular blockade was achieved without inhalational supplementation. The mean duration of the atracurium infusion was 118 min (range 30-247 min). The mean time from stopping the infusion to recovery of the first twitch of the train of four (TOF) to 20% was 25 min (range 11-44 min). Atropine (1.2 mg) and 5.0 mg neostigmine were then given in divided doses and a rapid and complete recovery was achieved. This technique can be used safely even in bad-risk patients but the infusion should be discontinued about 25 min before the end of surgery.
Midazolam
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Atracurium besilate
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Objective To compare the effects of sevoflurane and isoflurane on the neuromuscular blockade produced by continuous infusion of cisatracurium in elderly patients.Methods Sixty geriatric patients scheduled for ear-nose-throat surgeries or maxillofacial surgeries under general anesthesia were randomly divided into three groups. Group S and Group I were maintained with inhalation of one minimum alveolar concentration (MAC) of sevoflurane and isoflurane, respectively, while Group C was maintained with target controlled infusion of propofol (target plasma concentration 2-3 μg/ml). Neuromuscular blockade was maintained with continuous cisatracurium infusion in three groups and was monitored using train-of-four (TOF) stimulation by recording the contraction force of adductor pollicis muscle with a TOF-Watch SX monitor to maintain T1, the first twitch in the TOF, at 10% of baseline. The onset time, the infusion rate of cisatracurium, the spontaneous recovery index (T1 25% to 75%), and the time interval from T1 at 10% of baseline to recovery of TOF ratio of 0.9 were recorded.Results Thirty minutes after cisatracurium administration, the infusion rate in Group S and Group I was reduced compared with Group C (P0.05). Forty-five minutes after cisatracurium administration, the infusion rate in Group I was greater than that in Group S (P0.05).Conclusion Equivalent concentration of either sevoflurane or isoflurane can potentiate the neuromuscular blockade by continuous infusion of cisatracurium in elderly patients.
Adductor pollicis muscle
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Continuous Infusion
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We investigated the effect of midazolam pre-medication on rocuronium-induced neuromuscular blockade during sevoflurane anaesthesia. Twenty-two patients scheduled for elective surgery were randomly divided to receive either no pre-medication (control group) or pre-medication with 0.1 mg/kg midazolam intramuscularly (midazolam group). Anaesthesia was induced with fentanyl and propofol, and maintained with sevoflurane and nitrous oxide in oxygen. Neuromuscular responses were monitored using acceleromyography. The onset and clinical duration of action, time to recovery of first twitch of train-of-four (TOF) response to 75% of control, recovery index and time for TOF recovery to 25% and 50% were recorded. Patient-related data were similar in both groups. The parameters recorded were not significantly different between the groups. Midazolam pre-medication does not influence the time-course of action of rocuronium during sevoflurane anaesthesia.
Midazolam
Neuromuscular monitoring
Rocuronium Bromide
Elective surgery
Muscle relaxant
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서 론 Sevoflurane은 혈역학적 안정성, 낮은 혈액/가스 용해도로 인한 빠른 마취 유도 및 각성, 기도 자극이 적다는 점등으 로 인해 소아마취에서 널리 사용되는 흡입마취제이다.흡입 마취제가 다양한 기전을 통하여 비탈분극성 근이완제의 신 경근 차단 효과를 강화시킨다는 것을 잘 알려진 사실이다.이전의 연구에 의하면, sevoflurane은 aminosteroid계 근이완 제 rocuronium의 신경근 차단 역가를 증가시켜 용량-반응 곡선을 좌측으로 변위시키고, 유사한 정도의 근이완을 만들 어내기 위해
Rocuronium Bromide
Neuromuscular monitoring
Sugammadex
Muscle relaxant
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Objective To observe the residual neuromuscular blockade caused by different administration ways of cisatracurium(continuous infusion and intermittent bolus injection). Methods Eighty ASA Ⅰ orⅡ patients,aged from 18to 70,undergoing selective spinal surgery with general anesthesia,were equally randomized into four groups(n=20).Patients received cisatracurium by continuous infusion with 1.5μg·kg-1·min-1in group A1and 0.75μg·kg-1·min-1 in group A2, patients received intermittent bolus injection with 0.1 mg·kg-1·h-1 in group B1 and 0.05 mg·kg-1·h-1 in group B2.The cisatracurium consumption and TOFr recovered to 25%,50%,75%, 90%,extubation time,continuing look up 5stime,tidal volume and respiratory rate before and after anesthesia were recorded.Results Compared with group A2,time of TOFr recovery to 25%,50%in gourp A1were significantly increased(P0.05).Compared with group B1,time of TOFr recovery to 25%in group A1was significantly increased(P0.05).Compared with group B2,time of TOFr recovery to 50%,75%in group A2were significantly increased(P0.05);time of TOFr recovery to 50%,75%,90%in group B1were significantly increased(P0.05).Compared with group A2,time of muscle strength recovery to Ⅳ-Ⅴ and continuing look up 5swere significantly increased(P 0.05).Conclusion Cisatracurium continuous infusion and intermittent bolus injection have no influence on the residual effect of muscle relaxant,but continuous infusion may effect on the time of muscle relaxant.
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Bolus (digestion)
Neuromuscular monitoring
Continuous Infusion
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Neuromuscular transmission
Rocuronium Bromide
Muscle relaxation
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The purpose of this study was to compare the mivacurium infusion requirements and neuromuscular recovery in adults and children during propofol/opioid and sevoflurane anesthesia.Seventy-five adult and 75 pediatric patients were randomized to receive propofol/opioid 0.5 or 1.0 minimum alveolar anesthetic concentration (MAC) (age-related) sevoflurane anesthesia. Plasma cholinesterase (PChE) activity was measured. Neuromuscular blockade was monitored by train-of-four (TOF) stimulation every 10 s and adductor pollicis electromyography. A bolus of 2 x the 95% effective dose of mivacurium (0.25 mg/kg) was followed by an infusion titrated to maintain 90%-95% blockade. Mivacurium doses were recorded every 5 min. At the end of surgery, the infusion was stopped, and recovery from mivacurium was monitored until TOF >or=to0.7. PChE concentrations were within the normal range (adults 4-12 KU/L, children 6-16 KU/L) and correlated with mivacurium dose. Mivacurium infusion rates were higher in children than in adults: at 30 min, the rates in children were 13.1 +/- 6.4, 8.1 +/- 4.7, and 5.2 +/- 2.9 [micro sign]g [center dot] kg-1 [center dot] min-1 at 0, 0.5, and 1.0 MAC sevoflurane, respectively; the corresponding rates in adults were 5.9 +/- 3.1, 4.3 +/- 1.7, and 2.9 +/- 0.7 [micro sign]g [center dot] kg-1. min-1 (P < 0.01). Sevoflurane decreased mivacurium requirements, maximal decreases at 45 min in children and 10 min in adults, and delayed neuromuscular function recovery. Children recovered twice as quickly as adults, achieving TOF >or=to 0.7 at 9.8 +/- 2.5, 11.4 +/- 2.8, and 19.6 +/- 6.3 min compared with 19.9 +/- 5.4, 26.4 +/- 8.3, and 32.9 +/- 9.8 min in adults (P < 0.0001). In conclusion, mivacurium requirements were correlated with PChE, were greater in children than in adults, and were reduced by sevoflurane. Neuromuscular recovery occurred more rapidly in children and was delayed by sevoflurane. Implications: The mivacurium infusion requirement to maintain constant 90%-95% neuromuscular block during anesthesia is correlated with plasma cholinesterase activity. It is increased in children and reduced by the inhaled anesthetic sevoflurane. Despite the larger dose administered to children, recovery from block occurred more rapidly in children than in adults and was delayed by sevoflurane. (Anesth Analg 1998;87:772-8)
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