A Pilot Study of Train-of-Four and Post-Tetanic Count Monitoring with the TetraGraph Electromyograph Compared to the TwitchView Monitor Electromyograph

AbstractBackgroundQuantitative twitch monitoring is recommended for avoiding residual neuromuscular blockade. Electromyograph twitch monitors are a form of quantitative twitch monitoring. The TwitchView electromyograph has been previously validated against “gold standard” mechanomyography, and may serve as a comparator for other monitors. We have previously shown that the GE electromyograph monitor overcounted twitches, frequently misinterpreting noise as a twitch. This is a pilot study to evaluate the performance of the TetraGraph electromyograph in comparison to the TwitchView electromyograph.MethodsTwitchView and TetraGraph electrodes were applied to opposite arms of patients prior to induction of anesthesia. Post-tetanic count, train-of-four count and train-of-four ratio were then measured approximately every 5 minutes during an unrestricted general anesthetic. Measurements were not made for 10 minutes following neuromuscular blocking drugs or reversal agents.ResultsEight patients were enrolled. The mean baseline train-of-four ratio was 1.02 (SD=0.04) for the TwitchView and 0.99 (SD=0.03) for the TetraGraph (p=0.22). Bland Altman analysis of all of the train-of-four ratio data found that average TwitchView train-of-four values were larger with a bias of 0.10. Train-of-four counts and train-of-four ratios were generally less when measured with TetraGraph than when measured with TwitchView.In 83% (209/253) of data pairs, the result from TetraGraph was less than the result from TwitchView and in 6% (16/253) of data pairs, the result from TetraGraph was greater than the result from TwitchView (p<0.0001). In 11% (28/253) of data pairs, the result from TetraGraph was the same as TwitchView [95%CI 7.35% 16.0%]. Evaluation of individual patient results confirmed the overall results. In some cases there were large discrepancies, such as 4 twitches reported by the TwitchView when the TetraGraph reported a post-tetanic count.ConclusionsUsers of the TetraGraph electromyograph should be aware that significant underestimation of post-tetanic-count, train-of-four count and train-of-four ratio may occur. This could result in administration of unnecessary reversal agents, excessive doses of reversal agents, or delay in extubation. We are undertaking a comparison of the TetraGraph monitor to mechanomyography to confirm the results of this pilot study.

Download Full-text

Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

10.21203/rs.2.9529/v1 ◽

2019 ◽

Author(s):

Gonzalo Domenech ◽

Matias Kampel ◽

Maria Eugenia Garcia Guzzo ◽

Delfina Sanchez Novas ◽

Sergio Terrasa ◽

...

Keyword(s):

Neuromuscular Blockade ◽

Multivariable Analysis ◽

Perioperative Period ◽

University Hospital ◽

Exclusion Criterion ◽

Adductor Pollicis Muscle ◽

Residual Neuromuscular Blockade ◽

Reversal Agents ◽

Elective Surgical Procedures ◽

Train Of Four

Abstract Background: Current neuromuscular blockade (NMB) management techniques cannot completely prevent residual NMB (RNMB) during the postoperative period. Evidently, compliance to NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. We have not found publications that report the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. Methods: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit. Scheduled recovery in the intensive care unit was the only exclusion criterion. The primary outcome was the presence of RNMB, defined as a train-of-four ratio of <0.9. The secondary outcomes were the associations between RNMB and potentially related variables. Results: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P<0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. Conclusions: The results of the present study suggest that quantitative intra-operative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

Download Full-text

Comparison between radial artery tonometry pulse analyzer and pulsed-Doppler echocardiography derived hemodynamic parameters in cardiac surgery patients: a pilot study

PeerJ ◽

10.7717/peerj.4132 ◽

2017 ◽

Vol 5 ◽

pp. e4132 ◽

Cited By ~ 9

Author(s):

Rashad Zayat ◽

Andreas Goetzenich ◽

Ju-Yeon Lee ◽

HeeJung Kang ◽

So-Hyun Jansen-Park ◽

...

Keyword(s):

Pilot Study ◽

Radial Artery ◽

Pearson Correlation ◽

Hemodynamic Parameters ◽

Altman Analysis ◽

Limits Of Agreement ◽

Bland Altman Analysis ◽

Number Of Patients ◽

The Mean ◽

Lower Limits

BackgroundBedside non-invasive techniques, such as radial artery tonometry, to estimate hemodynamic parameters have gained increased relevance as an attractive alternative and efficient method to measure hemodynamics in outpatient departments. For our pilot study, we sought to compare cardiac output (CO), and stroke volume (SV) estimated from a radial artery tonometry blood pressure pulse analyzer (BPPA) (DMP-Life, DAEYOMEDI Co., Gyeonggi-do, South Korea) to pulsed-wave Doppler (PWD) echocardiography derived parameters.MethodsFrom January 2015 to December 2016, all patients scheduled for coronary artery bypass (CABG) surgery at our department were screened. Exclusion criteria were, inter alia, moderate to severe aortic- or Mitral valve disease and peripheral arterial disease (PAD) > stage II. One hundred and seven patients were included (mean age 66.1 ± 9.9, 15 females, mean BMI 27.2 ± 4.1 kg/m2). All patients had pre-operative transthoracic echocardiography (TTE). We measured the hemodynamic parameters with the BPPA from the radial artery, randomly before or after TTE. For the comparison between the measurement methods we used the Bland-Altman test and Pearson correlation.ResultsMean TTE-CO was 5.1 ± 0.96 L/min, and the mean BPPA-CO was 5.2 ± 0.85 L/min. The Bland-Altman analysis for CO revealed a bias of −0.13 L/min and SD of 0.90 L/min with upper and lower limits of agreement of −1.91 and +1.64 L/min. The correlation of CO measurements between DMP-life and TTE was poor (r = 0.501,p < 0.0001). The mean TTE-SV was 71.3 ± 16.2 mL and the mean BPPA-SV was 73.8 ± 19.2 mL. SV measurements correlated very well between the two methods (r = 0.900,p < 0.0001). The Bland-Altman analysis for SV revealed a bias of −2.54 mL and SD of ±8.42 mL and upper and lower limits of agreement of −19.05 and +13.96 mL, respectively.ConclusionOur study shows for the first time that the DMP-life tonometry device measures SV and CO with reasonable accuracy and precision of agreement compared with TTE in preoperative cardiothoracic surgery patients. Tonometry BPPA are relatively quick and simple measuring devices, which facilitate the collection of cardiac and hemodynamic information. Further studies with a larger number of patients and with repeated measurements are in progress to test the reliability and repeatability of DMP-Life system.

Download Full-text

Neuromuscular Blockers and Reversal Agents

10.2310/anes.18225 ◽

2019 ◽

Author(s):

Kristen Flight ◽

Jennifer J Yang ◽

Lindsay M Urben ◽

Michael J Schontz

Keyword(s):

Neuromuscular Blockade ◽

Neuromuscular Transmission ◽

Muscle Relaxation ◽

Neuromuscular Blocking ◽

Neuromuscular Monitoring ◽

Clinical Effects ◽

Duration Of Action ◽

Residual Neuromuscular Blockade ◽

Neuromuscular Blocking Drugs ◽

Reversal Agents

Neuromuscular blocking drugs, which include depolarizing and nondepolarizing drugs, are used to facilitate intubation and provide skeletal muscle relaxation during surgery and in the intensive care unit. The agents differ in their mechanism, duration of action, side-effect profile, and metabolism. Succinylcholine is the only depolarizing agent in clinic use and is typically used for emergent control of the airway, rapid sequence intubations, and short surgical procedures. The risk of hyperkalemia in certain clinical conditions and risk of malignant hyperthermia in susceptible individuals limit the use of succinylcholine in specific patient populations. Nondepolarizing agents vary in their duration of action, but all provide muscle relaxation for a longer duration than succinylcholine. Clinical effects of neuromuscular blocking drugs can be assessed with neuromuscular monitoring, although there is significant variability among providers in the regular use of neuromuscular monitoring. Reversal agents are used to restore neuromuscular transmission, as residual neuromuscular blockade after extubation has been associated with multiple adverse events, including hypoxemia, atelectasis, and aspiration. Sugammadex is an encapsulating agent capable of immediately reversing the effects of rocuronium-induced neuromuscular blockade that will likely impact the way many providers administer rocuronium and may decrease the future use of succinylcholine. This review contains 4 figures, 6 tables, and 41 references. Keywords: hyperkalemia, neuromuscular monitoring, neuromuscular transmission, nondepolarizing neuromuscular blocking agents, residual neuromuscular blockade, reversal agents, succinylcholine sugammadex, sugammadex

Download Full-text

Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs

Anesthesiology ◽

10.1097/aln.0000000000002946 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1036-1045 ◽

Cited By ~ 3

Author(s):

Dan M. Drzymalski ◽

Roman Schumann ◽

Frank J. Massaro ◽

Agnieszka Trzcinka ◽

Ruben J. Azocar

Keyword(s):

Interrupted Time Series ◽

Neuromuscular Blocking ◽

General Anesthetics ◽

Interrupted Time Series Analysis ◽

Reversal Agent ◽

Reversal Agents ◽

Respiratory Events ◽

Train Of Four ◽

Acquisition Costs ◽

Adverse Respiratory Events

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors’ hypothesis was that sugammadex use and associated costs would decrease. Methods A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. Results Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). Conclusions Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

Download Full-text

Early Reversal of Profound Rocuronium-induced Meeting Abstracts by Sugammadex in a Randomized Multicenter Study

Anesthesiology ◽

10.1097/01.anes.0000265152.78943.74 ◽

2007 ◽

Vol 106 (5) ◽

pp. 935-943 ◽

Cited By ~ 133

Author(s):

Harald J. Sparr ◽

Karel M. Vermeyen ◽

Anton M. Beaufort ◽

Henk Rietbergen ◽

Johannes H. Proost ◽

...

Keyword(s):

Neuromuscular Blockade ◽

Venous Blood ◽

Neuromuscular Blocking ◽

Population Pharmacokinetic ◽

Dependent Manner ◽

Male Adult ◽

Blocking Effects ◽

Train Of Four ◽

Blood And Urine Samples ◽

The Mean

Background Sugammadex reverses the neuromuscular blocking effects of rocuronium by chemical encapsulation. The efficacy, safety, and pharmacokinetics of sugammadex for reversal of profound rocuronium-induced neuromuscular blockade were evaluated. Methods Ninety-eight male adult patients were randomly assigned to receive sugammadex (1, 2, 4, 6, or 8 mg/kg) or placebo at 3, 5, or 15 min after 0.6 mg/kg rocuronium. Patients were anesthetized with propofol and fentanyl. The primary endpoint of the study was the time to achieve a recovery of train-of-four ratio to 0.9. Neuromuscular blockade was measured using acceleromyography. Concentrations of rocuronium and sugammadex were determined in venous blood and urine samples. A population pharmacokinetic model using NONMEM (GloboMax LLC, Hanover, MD) was applied. Results The mean time to recovery of the train-of-four ratio to 0.9 after dosing at 3, 5, and 15 min decreased from 52.1, 51.7, and 35.6 min, respectively, after administration of placebo to 1.8, 1.5, and 1.4 min, respectively, after 8 mg/kg sugammadex. Sugammadex was safe and well tolerated. However, 20.4% of patients showed signs of inadequate anesthesia after its administration. The median cumulative excretion of rocuronium in the urine over 24 h was 26% in the placebo group and increased to 58-74% after 4-8 mg/kg sugammadex. The mean plasma clearances of sugammadex and rocuronium were 0.084 and 0.26 l/min, respectively. Conclusions In male subjects, sugammadex safely reversed profound neuromuscular blockade induced by 0.6 mg/kg rocuronium in a dose-dependent manner. Sugammadex enhanced the renal excretion of rocuronium, and its clearance is approximately one third that of rocuronium.

Download Full-text

Considerations in Neuromuscular Blockade in the ICU: A Case Report and Review of the Literature

Case Reports in Critical Care ◽

10.1155/2020/8780979 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Jessica D. Workum ◽

Stephanie H.V. Janssen ◽

Hugo R.W. Touw

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neuromuscular Blockade ◽

Distress Syndrome ◽

Neuromuscular Blocking ◽

Review Of The Literature ◽

Residual Neuromuscular Blockade ◽

Prolonged Effect ◽

Train Of Four ◽

Prolonged Neuromuscular Blockade

Neuromuscular blocking agents are regularly used in the intensive care unit (ICU) to facilitate mechanical ventilation in patients with acute respiratory distress syndrome and patient-ventilator dyssynchronies. However, prolonged neuromuscular blockade is associated with adverse effects like ICU-acquired weakness. Residual neuromuscular blockade is, however, not routinely monitored in the intensive care unit, and as such, this phenomenon might be unrecognized and underreported. We report a case in which an unusual prolonged effect of neuromuscular blockade was seen after cessation of the drug, which illustrates the complexity of neuromuscular blockade in the ICU. We advocate for the use of train-of-four measurements in the ICU, recommend to choose cisatracurium over rocuronium in critically ill patients due to their pharmacokinetics when continuous neuromuscular blockade is considered, and propose a subsequent strategy once the choice has been made to start neuromuscular blockade.

Download Full-text

Postoperative Residual Neuromuscular Paralysis at an Australian Tertiary Children’s Hospital

Anesthesiology Research and Practice ◽

10.1155/2015/410248 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 4

Author(s):

Thomas Ledowski ◽

Brendan O’Dea ◽

Luke Meyerkort ◽

Mary Hegarty ◽

Britta S. von Ungern-Sternberg

Keyword(s):

Acute Care ◽

Postoperative Outcome ◽

Tracheal Extubation ◽

Neuromuscular Blocking ◽

Prospective Audit ◽

Residual Neuromuscular Blockade ◽

Train Of Four ◽

Acute Care Unit ◽

Neuromuscular Paralysis ◽

Pediatric Center

Purpose. Residual neuromuscular blockade (RNMB) is known to be a significant but frequently overlooked complication after the use of neuromuscular blocking agents (NMBA). Aim of this prospective audit was to investigate the incidence and severity of RNMB at our Australian tertiary pediatric center.Methods. All children receiving NMBA during anesthesia were included over a 5-week period at the end of 2011 (Mondays to Fridays; 8 a.m.–6 p.m.). At the end of surgery, directly prior to tracheal extubation, the train-of-four (TOF) ratio was assessed quantitatively. Data related to patient postoperative outcome was collected in the postoperative acute care unit.Results. Data of 64 patients were analyzed. Neostigmine was given in 34 cases and sugammadex in 1 patient. The incidence of RNMB was 28.1% overall (without reversal: 19.4%; after neostigmine: 37.5%; n.s.). Severe RNMB (TOF ratio < 0.7) was found in 6.5% after both no reversal and neostigmine, respectively. Complications in the postoperative acute care unit were infrequent, with no differences between reversal and no reversal groups.Conclusions. In this audit, RNMB was frequently observed, particularly in cases where patients were reversed with neostigmine. These findings underline the well-known problems associated with the use of NMBA that are not fully reversed.

Download Full-text

Residual Neuromuscular Blockade in the Critical Care Setting

AACN Advanced Critical Care ◽

10.4037/aacnacc2018384 ◽

2018 ◽

Vol 29 (1) ◽

pp. 15-24 ◽

Cited By ~ 1

Author(s):

Nicole Stawicki ◽

Patty Gessner

Keyword(s):

Neuromuscular Blockade ◽

Acute Care ◽

Care Setting ◽

Recovery Process ◽

Neuromuscular Blocking ◽

Advanced Practice ◽

Acute Care Setting ◽

Residual Neuromuscular Blockade ◽

Reversal Agents

Residual neuromuscular blockade is a widespread challenge for providers in the acute care setting that, if left unrecognized or untreated, places patients at higher risk for morbidity and mortality. The condition is estimated to occur in 26% to 88% of patients undergoing general anesthesia. The role of the advanced practice nurse in the acute care setting is to facilitate a safe recovery process by identifying early signs of deterioration and supporting the patient until full muscular strength has returned. This article discusses the prevalence of residual neuromuscular blockade and associated complications and patient risk factors. A review is included of the current uses for neuromuscular blockade, pathophysiology of the neuromuscular junction, pharmacologic characteristics of neuromuscular blocking agents (including drug-drug interactions), monitoring modalities, and effectiveness of reversal agents. Treatment recommendations pertinent to residual neuromuscular blockade are outlined.

Download Full-text

The Safety and Antimicrobial Properties of Stabilized Hypochlorous Acid in Acetic Acid Buffer for the Treatment of Acute Wounds—a Human Pilot Study and In Vitro Data

The International Journal of Lower Extremity Wounds ◽

10.1177/15347346211015656 ◽

2021 ◽

pp. 153473462110156

Author(s):

Ewa A. Burian ◽

Lubna Sabah ◽

Klaus Kirketerp-Møller ◽

Elin Ibstedt ◽

Magnus M. Fazli ◽

...

Keyword(s):

Pilot Study ◽

Hypochlorous Acid ◽

Treatment Time ◽

Donor Site ◽

Antimicrobial Properties ◽

Prolonged Treatment ◽

Wound Irrigation ◽

The Mean ◽

And Performance

Acute wounds may require cleansing to reduce the risk of infection. Stabilized hypochlorous acid in acetic buffer (HOCl + buffer) is a novel wound irrigation solution with antimicrobial properties. We performed a first-in-man, prospective, open-label pilot study to document preliminary safety and performance in the treatment of acute wounds. The study enrolled 12 subjects scheduled for a split-skin graft transplantation, where the donor site was used as a model of an acute wound. The treatment time was 75 s, given on 6 occasions. A total of 7 adverse events were regarded as related to the treatment; all registered as pain during the procedure for 2 subjects. One subject had a wound infection at the donor site. The mean colony-forming unit (CFU) decreased by 41% after the treatment, and the mean epithelialization was 96% on both days 14 (standard deviation [SD] 8%) and 21 (SD 10%). The study provides preliminary support for the safety, well-tolerance, and efficacy of HOCl + buffer for acute wounds. The pain was frequent although resolved quickly. Excellent wound healing and satisfying antimicrobial properties were observed. A subsequent in vitro biofilm study also indicated good antimicrobial activity against Pseudomonas aeruginosa with a 96% mean reduction of CFU, when used for a treatment duration of 15 min ( P < .0001), and a 50% decrease for Staphylococcus aureus ( P = .1010). Future larger studies are needed to evaluate the safety and performance of HOCl + buffer in acute wounds, including the promising antimicrobial effect by prolonged treatment on bacterial biofilms.

Download Full-text

Mucosa plication reinforced colorectal anastomosis and trans-anal vacuum drainage: a pilot study with preliminary results

Updates in Surgery ◽

10.1007/s13304-021-01105-4 ◽

2021 ◽

Author(s):

Alexander Ferko ◽

Juraj Váňa ◽

Marek Adámik ◽

Adam Švec ◽

Michal Žáček ◽

...

Keyword(s):

Pilot Study ◽

Povidone Iodine ◽

Anal Verge ◽

Colorectal Anastomosis ◽

Stapled Anastomosis ◽

Neoadjuvant Radiotherapy ◽

Lower Upper ◽

Registration Number ◽

The Mean ◽

Diversion Rate

AbstractDehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019–October 2020. The mean age of patients was 61 years (lower–upper quartiles 54–69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower–upper quartiles 3.00–4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien–Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation.Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.

Download Full-text