Feasibility of Intraoperative Neuromonitoring during Thyroid Surgery after Administration of Sugammadex for Reversal of Neuromuscular Blockade

Abstract Background Neuromuscular blocking agent (NMB) dosage suggested in current intraoperative neural monitoring (IONM) clinical guideline might cause operational difficulty during thyroid surgery. This study evaluated the feasibility of sugammadex with an enhanced NMB recovery protocol. Methods Complete IONM data for 57 patients who had normal cord mobility were investigated: 32 patients received rocuronium 0.6 mg/kg at anesthesia induction and sugammadex 2 mg/kg at vagus nerve exposure (group S) and 25 received rocuronium 0.3mg/kg with 0.9% NaCl 2mL/kg instead (group R). Electromyography (EMG) signals were obtained from the vagus nerve and RLN before and after resection of the thyroid lobe and were defined as V1, V2 and R1, R2 signals, respectively. The train-of-four ratio (TOFr) was used for continuous quantitative monitoring of neuromuscular transmission. Results Mean EMG in Group S (vagus nerve: 722.728 ± 160.11μV, RLN: 1028.64 ± 180.34μV) was greater than Group R (568.884 ± 135.15, 776.66 ± 145.91μV) from first minute after administration of sugammadex (P <0.05). The time for tracheal intubation was 102.97±64.5 seconds in group S with high dose rocuronium, while 195.12±68.9 seconds in group R (p < .001). Conclusions Rocuronium 0.6 mg/kg can greatly shorten the tracheal intubation time and reduce the difficulty of surgery, and employment sugammadex can reverse residual muscle relaxation of rocuronium and optimize IONM conditions.

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Intraoperative Neuromonitoring During Thyroid Surgery: The Effect of Surgical Positioning

Surgical Innovation ◽

10.1177/1553350618799786 ◽

2018 ◽

Vol 26 (1) ◽

pp. 77-81

Author(s):

Jason E. Crowther ◽

Daniah Bu Ali ◽

Jeremy Bamford ◽

San-Wook Kang ◽

Emad Kandil

Keyword(s):

Vagus Nerve ◽

Thyroid Surgery ◽

Intraoperative Neuromonitoring ◽

Neurological Injury ◽

Neural Recordings ◽

Surgical Positioning ◽

Ultrasound Measurements ◽

Before And After ◽

Recurrent Laryngeal Nerves ◽

Proper Interpretation

Intraoperative neuromonitoring during thyroid surgery has been used to successfully prevent permanent neurological injury by early identification of anatomical variants. Proper interpretation of neuromonitoring data requires knowledge of what factors might affect the data. In this study, we examined the effect of surgical positioning on the latency and amplitude of neural recordings made from the vocalis muscle during thyroid surgery. A retrospective review was performed of 145 patients who underwent thyroid surgery. Eighty-three had open cervical procedures, and 62 had robotic-assisted transaxillary procedures. Intraoperative neuromonitoring recordings were made by stimulation of the vagus and recurrent laryngeal nerves for both groups. Ultrasound measurements were made of a subset of the transaxillary patients immediately before and after arm positioning. Groups differed only on right-sided recordings. Patients with transaxillary surgeries had significantly shorter latencies evoked from the vagus nerve. We found that vagus nerve–evoked latencies were also correlated to ultrasound measurements of the nerves. Surgical positioning during thyroid surgery is a factor that may affect intraoperative neuromonitoring data and should be taken into account by the surgeon during interpretation.

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Involvement of 5-HT3 receptors in the initiation of pharyngeal reflex

AJP Regulatory Integrative and Comparative Physiology ◽

10.1152/ajpregu.1994.266.5.r1652 ◽

1994 ◽

Vol 266 (5) ◽

pp. R1652-R1658

Author(s):

M. Yoshioka ◽

Y. Goda ◽

T. Ikeda ◽

H. Togashi ◽

T. Ushiki ◽

...

Keyword(s):

Superior Laryngeal Nerve ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Laryngeal Nerve ◽

Nucleus Ambiguus ◽

High Dose ◽

Nodose Ganglia ◽

Bilateral Vagotomy ◽

Pharyngeal Branch ◽

Pharyngeal Reflex

Activation of peripheral serotonin (5-HT) receptors, classified as 5-HT3, was shown to elicit the pharyngeal reflex in anesthetized rats. Intravenous bolus injection of 5-HT (6.25-50 micrograms/kg) evoked rhythmic bursts in the efferent pharyngeal branch of the vagus nerve in a dose-related manner, whereas afferent superior laryngeal nerve activity was not altered by even a high dose of 5-HT. The pharyngeal branch response was blocked by pretreatment with a selective 5-HT3-receptor antagonist YM060 (1 and 10 micrograms/kg). A 5-HT3-receptor agonist, 2-methyl-5-HT, also produced a rhythmic burst in the pharyngeal branch, and this effect was blocked by YM060. Intrapharyngeal pressure was rhythmically increased by both 5-HT (12.5-50 micrograms/kg) and 2-methyl-5-HT (6.25-50 micrograms/kg) in a dose-related manner. Both of these effects were antagonized by YM060 (10 micrograms/kg). In addition, a neuromuscular blocking agent vecuronium (1 mg/kg iv) completely inhibited the 5-HT-induced increase in pharyngeal pressure. After a bilateral vagotomy was performed below the nodose ganglia, the 5-HT-induced increase in pharyngeal branch activity was abolished, whereas a bilateral sectioning of the superior laryngeal nerve did not alter the 5-HT-induced increase in pharyngeal branch activity. Retrograde tracing with fluorescent dye (fast blue) was used to identify the cell bodies of the pharyngeal branch. Pharyngeal motoneuron cell bodies were distributed along the entire length of the nucleus ambiguus. Our results suggest that exogenous 5-HT-induced increases in pharyngeal branch activity and intrapharyngeal pressure may be initiated by the peripheral 5-HT3-receptors of the vagal nervous system and that this may be a viscerosomatic reflex.

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Management of traumatic brain injury

10.1093/med/9780199600830.003.0343 ◽

2016 ◽

Author(s):

Alistair A. Gibson ◽

Peter J. D. Andrews

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

External Ventricular Drain ◽

Young Male ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Moderate Hypothermia ◽

High Dose ◽

Thromboembolism Prophylaxis

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and although young male adults are at particular risk, it affects all ages. TBI often occurs in the presence of significant extracranial injuries and immediate management focuses on the ABCs—airway with cervical spine control, breathing, and circulation. Best outcomes are achieved by management in centres that can offer comprehensive neurological critical care and appropriate management for extracranial injuries. If patients require transfer from an admitting hospital to a specialist centre, the transfer must be carried out by an appropriately skilled and equipped transport team. The focus of specific TBI management is on the avoidance of secondary injury to the brain. The principles of management are to avoid hypotension and hypoxia, control intracranial pressure and maintain cerebral perfusion pressure above 60 mmHg. Management of increased intracranial pressure is generally by a stepwise approach starting with sedation and analgesia, lung protective mechanical ventilation to normocarbia in a 30° head-up position, maintenance of oxygenation, and blood pressure. Additional measures include paralysis with a neuromuscular blocking agent, CSF drainage via an external ventricular drain, osmolar therapy with mannitol or hypertonic saline, and moderate hypothermia. Refractory intracranial hypertension may be treated surgically with decompressive craniectomy or medically with high dose barbiturate sedation. General supportive measures include provision of adequate nutrition preferably by the enteral route, thromboembolism prophylaxis, skin and bowel care, and management of all extracranial injuries.

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Anesthesia in a patient with Charcot-Marie-Tooth disease with pneumothorax: a case report

Journal of International Medical Research ◽

10.1177/0300060519881239 ◽

2019 ◽

Vol 47 (11) ◽

pp. 5896-5902

Author(s):

Jae Won Kim ◽

Goo Kim ◽

Tae Woo Kim ◽

Woong Han ◽

Jin Hyun Maeng ◽

...

Keyword(s):

Wedge Resection ◽

Muscle Relaxation ◽

Sensory Neuropathy ◽

Blocking Agent ◽

Relaxation Mechanism ◽

Neuromuscular Blocking ◽

Charcot Marie Tooth ◽

Charcot Marie Tooth Disease ◽

Upper And Lower Extremities ◽

Tooth Disease

A 21-year-old man underwent wedge resection for treatment of pneumothorax. This patient had been diagnosed with Charcot-Marie-Tooth disease (CMTD) and had a history of surgical treatment of scoliosis, pneumothorax, foot deformity, and arm dislocation. Additionally, the patient showed signs of muscle weakness and atrophy in the upper and lower extremities. CMTD is genetically associated with motor and sensory neuropathy and reportedly has an association with malignant hyperthermia or a delayed muscle relaxation mechanism. In the present case, total intravenous anesthesia was performed with a combination of propofol and remifentanil, and rocuronium was administered as a neuromuscular blocking agent. Surgery was performed without delayed muscle relaxation or any other specific intraoperative adverse events.

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The Nonrecurrent Laryngeal Nerve Without Abnormal Subclavian Artery: Report of Two Cases and Review of the Literature

Ear Nose & Throat Journal ◽

10.1177/01455613211056547 ◽

2021 ◽

pp. 014556132110565

Author(s):

Ying Lu ◽

ChengHui Deng ◽

Ning Lan ◽

PinXiu Wang ◽

HuaZe Xi ◽

...

Keyword(s):

Carotid Artery ◽

Vagus Nerve ◽

Subclavian Artery ◽

Thyroid Surgery ◽

Laryngeal Nerve ◽

Inferior Laryngeal Nerve ◽

Review Of The Literature ◽

Nonrecurrent Inferior Laryngeal Nerve ◽

Nonrecurrent Laryngeal Nerve ◽

Neural Monitoring

As a variant of recurrent inferior laryngeal nerve (RILN), the nonrecurrent inferior laryngeal nerve (NRILN) is closely related to the occurrence of abnormal subclavian artery (ASA). The nonrecurrent inferior laryngeal nerve has been found in patients without arterial abnormalities, which is seen in the coexistence of NRILN and RILN, but it is easily confused with sympathetic-inferior laryngeal anastomosis branch (SILAB). We encountered 2 right NRILN patients without ASA during thyroid surgery. This article summarizes the characteristics of these cases and proposes methods to distinguish the coexistence of NRILN and RILN from SILAB. So far, 11 articles have reported 16 cases of NRILN without arterial abnormalities. In patients without artery abnormality, the vagus nerve could send out a descending branch NRILN at the bifurcation of the carotid artery and enter the larynx after anastomosis with RILN. Adequate dissection of the carotid sheath may avoid confusion with SILAB, and neural monitoring is also expected to provide a reference for the identification.

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Fazadinium - a new neuromuscular blocking agent

Drug and Therapeutics Bulletin ◽

10.1136/dtb.16.23.90 ◽

1978 ◽

Vol 16 (23) ◽

pp. 90-92

Keyword(s):

Tracheal Intubation ◽

Endotracheal Intubation ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agent ◽

Convulsive Therapy ◽

Muscular Relaxation ◽

Electro Convulsive Therapy

Fazadinium bromide (Fazadon - Duncan, Flockhart) is a new non-depolarising neuromuscular blocking agent which is intended for both tracheal intubation at the start of surgery and muscular relaxation during the operation. The only available quick-acting drugs, suxamethonium (Anectine; Brevidil M), and suxethonium (Brevidil E) are depolarising agents whose effect cannot be reversed with anticholinesterases; they also occasionally have troublesome unwanted effects, which are well summarised in textbooks. Suxamethonium is used mainly to facilitate endotracheal intubation, bronchoscopy, electro-convulsive therapy and short-lasting surgical or orthopaedic procedures requiring relaxation. Its rapid breakdown prevents persistent block. Longer-acting non-depolarising drugs like tubocurarine, gallamine and pancuronium are used to produce relaxation during surgery.

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