Residual Neuromuscular Block in HIV-Infected Young Patients: A Prospective Observational Study

Abstract Objectives: Avoidance of residual neuromuscular blockade (RNMB) is crucial to decrease anesthesia-related pulmonary complications. At present, no data are available for HIV-infected patients about the occurrence of RNMB. In this trial, we aim to investigate the incidence of RNMB in such patients. Methods: Data were prospectively collected on 45 normal and 45 HIV-infected patients (18-65 yr). The train-of-four stimulation (TOF-Watch SX) was used to evaluate the level of neuromuscular block from the induction of anesthesia to back to the postanesthesia care unit (PACU) by an assessor, but blind to the anesthesiologist. Primary endpoint was the presence of RNMB at PACU admission, defined as a train-of-four (TOF) ratio < 0.9. The onset time (from application of cisatracurium to maximum depression of T1), no reaction time (from zero of T1 to non-zero), and clinical duration (from application to 25% recovery of T1) were determined for each patient. Results: The incidence of RNMB was 37.5% in HIV- infected patients and 32.5% in normal patients (difference, 5%; 99% CI, −16% to 26 1%; p=0.815). The onset time was no different between two groups (4.05±0.88 min in HIV-infected group vs. 3.85±1.08 min in normal group (p=0.37)). The no reaction time was also similarly between two groups ( 49.83±3.81min in HIV-infected group vs. 48.98±5.12min in normal group (p=0.40)). The clinical duration was 53.78±3.05 min and 52.40±5.02 min in HIV-infected group and normal group, respectively (p=0.14). Conclusion: The odds of RNMB were not significantly different in HIV-infected young patients compared to normal persons.

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Residual Block after Mivacurium with or without Edrophonium Reversal in Adults and Children

Anesthesiology ◽

10.1097/00000542-199602000-00014 ◽

1996 ◽

Vol 84 (2) ◽

pp. 362-367. ◽

Cited By ~ 49

Author(s):

David R. Bevan ◽

Raymond Kahwaji ◽

John M. Ansermino ◽

Eleanor Reimer ◽

Michael F. Smith ◽

...

Keyword(s):

Ulnar Nerve ◽

Neuromuscular Block ◽

Saline Group ◽

Neuromuscular Blocking ◽

Postanesthesia Care Unit ◽

Random Allocation ◽

Train Of Four ◽

Residual Neuromuscular Block ◽

Residual Block ◽

Stimulation Of

Background The rapid recovery from mivacurium- induced neuromuscular block has encouraged omission of its reversal. The purpose of this study was to determine, in children and in adults, whether failure to reverse mivacurium neuromuscular block was associated with residual neuromuscular block on arrival in the postanesthesia care unit. Methods In 50 children, aged 2-12 yr, and 50 adults, aged 20-60 yr, anesthesia was induced and maintained with propofol and fentanyl, and neuromuscular block was achieved by an infusion of mivacurium, to maintain one or two visible responses to train-of-four (TOF) stimulation of the ulnar nerve. At the end of surgery, mivacurium infusion was stopped, and 10 min later, reversal was attempted with saline or 0.5 mg x kg(-1) edrophonium by random allocation. On arrival in the postanesthesia care unit, a blinded observer assessed patients clinically and by stimulation of the ulnar nerve with a Datex electromyogram in the uncalibrated TOF mode. Results Children arrived in the postanesthesia care unit 8.2 +/- 3-4 min after reversal of neuromuscular block and showed no sign of weakness, either clinically or by TOF stimulation. Although TOF ratio was greater in children who had received edrophonium (1.00 +/- 0.05 vs. 0.93 +/- 0.01, P<0.01), TOF was >0.7 in all children. Adults arrived in the postanesthesia care unit 12.9 +/- 5.3 min after reversal of neuromuscular block(P<0.01 vs. children). Six in the saline group demonstrated weakness (two required immediate reversal of neuromuscular block, and TOF was <0.7 in four others), compared with TOF <0.7 in only one of the edrophonium group (P<0.05). Conclusions This study demonstrated that, in adults, failure to reverse mivacurium neuromuscular block was associated with an increased incidence of residual block. Such weakness was not observed in children receiving similar anesthetic and neuromuscular blocking regimens.

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Quantitative Relationships between Pulmonary Function and Residual Neuromuscular Blockade

BioMed Research International ◽

10.1155/2018/9491750 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6

Author(s):

ShuYing Fu ◽

WenDong Lin ◽

XiNing Zhao ◽

ShengJin Ge ◽

ZhangGang Xue

Keyword(s):

Pulmonary Function ◽

Neuromuscular Blockade ◽

Demographic Data ◽

Preoperative Evaluation ◽

Tracheal Extubation ◽

Postanesthesia Care Unit ◽

Predictive Values ◽

Residual Neuromuscular Blockade ◽

Significant Difference ◽

Train Of Four

Background. Neuromuscular blockade is a risk factor for postoperative respiratory weakness during the immediate postoperative period. The quantitative relationships between postoperative pulmonary-function impairment and residual neuromuscular blockade are unknown. Methods. 113 patients who underwent elective laparoscopic cholecystectomy were enrolled in this study. They all had a pulmonary-function test (PFT) during the preoperative evaluation. Predictive values based on demographic data were also recorded. The train-of-four ratio (TOFR) was recorded at the same time as the PFT and at every 5 minutes in the qualified 98 patients in the postanesthesia care unit (PACU). We analyzed the degree of PFT recovery when the TOFR had recovered to different degrees. Results. There was a significant difference (P<0.05) between the preoperative baseline value and the postoperative forced vital capacity at each TOFR point, except at a TOFR value of 1.1. There was also a significant difference (P<0.05) between the preoperative baseline value and the postoperative peak expiratory flow at each TOFR point. Conclusions. Postoperative residual neuromuscular blockade was common (75.51%) after tracheal extubation, and pulmonary function could not recover to an acceptable level (85% of baseline value), even if TOFR had recovered to 0.90. Trial Registration. Chinese Clinical Trial Register is ChiCTR-OOC-15005838.

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Pharyngeal Function and Breathing Pattern during Partial Neuromuscular Block in the Elderly

Anesthesiology ◽

10.1097/aln.0000000000000043 ◽

2014 ◽

Vol 120 (2) ◽

pp. 312-325 ◽

Cited By ~ 37

Author(s):

Anna I. Hårdemark Cedborg ◽

Eva Sundman ◽

Katarina Bodén ◽

Hanne Witt Hedström ◽

Richard Kuylenstierna ◽

...

Keyword(s):

Neuromuscular Block ◽

The Elderly ◽

Pulmonary Complications ◽

Neuromuscular Blocking ◽

Residual Effects ◽

Airway Protection ◽

Healthy Elderly ◽

Increased Risk ◽

Train Of Four ◽

Pharyngeal Function

Abstract Background: Intact pharyngeal function and coordination of breathing and swallowing are essential for airway protection and to avoid respiratory complications. Postoperative pulmonary complications caused by residual effects of neuromuscular-blocking agents occur more frequently in the elderly. Moreover, elderly have altered pharyngeal function which is associated with increased risk of aspiration. The purpose of this study was to evaluate effects of partial neuromuscular block on pharyngeal function, coordination of breathing and swallowing, and airway protection in individuals older than 65 yr. Methods: Pharyngeal function and coordination of breathing and swallowing were assessed by manometry and videoradiography in 17 volunteers, mean age 73.5 yr. After control recordings, rocuronium was administered to obtain steady-state train-of-four ratios of 0.70 and 0.80 followed by spontaneous recovery to greater than 0.90. Results: Pharyngeal dysfunction increased significantly at train-of-four ratios 0.70 and 0.80 to 67 and 71%, respectively, compared with 37% at control recordings, and swallowing showed a more severe degree of dysfunction during partial neuromuscular block. After recovery to train-of-four ratio of greater than 0.90, pharyngeal dysfunction was not significantly different from the control state. Resting pressure in the upper esophageal sphincter was lower at all levels of partial neuromuscular block compared with control recordings. The authors were unable to demonstrate impaired coordination of breathing and swallowing. Conclusion: Partial neuromuscular block in healthy elderly individuals causes an increased incidence of pharyngeal dysfunction from 37 to 71%, with impaired ability to protect the airway; however, the authors were unable to detect an effect of partial neuromuscular block on coordination of breathing and swallowing.

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Optimal neuromuscular blocking effects of remifentanil during tracheal intubation under general anesthesia

Journal of International Medical Research ◽

10.1177/0300060518772227 ◽

2018 ◽

Vol 46 (8) ◽

pp. 3097-3103 ◽

Cited By ~ 1

Author(s):

So Young Kwon ◽

Si Wook Chung ◽

Jin Deok Joo

Keyword(s):

General Anesthesia ◽

Elective Surgery ◽

Neuromuscular Block ◽

Onset Time ◽

Neuromuscular Blocking ◽

Blocking Effects ◽

Train Of Four ◽

The Times ◽

Time Required ◽

Retrospective Comparative Study

Objective This study was performed to determine the effect of the remifentanil dose on the onset time of rocuronium with electromyography. Methods This retrospective comparative study included 75 patients undergoing general anesthesia for elective surgery. Patients received lidocaine (40 mg) and propofol (2 mg/kg) followed by rocuronium (0.6 mg/kg) with either saline infusion (Group S), remifentanil at 0.5 µg/kg/minute (Group R 0.5), or remifentanil at 1.0 µg/kg/minute (Group R 1.0). Neuromuscular block was monitored by train-of-four (TOF) electromyography, and the times taken to reach TOF 0 and TOF ratio (TOFR) 25% were recorded. Results The times taken to reach TOF 0 and TOFR 25% were significantly higher in Groups R 0.5 and R 1.0 than in Group S. The time taken to reach TOF 0 was 130.0 ± 6.4 s in Group S, 142.6 ± 6.0 s in Group R 0.5, and 183.0 ± 11.6 s in Group R 1.0. The time taken to reach TOFR 25% was also higher in Groups R 0.5 and R 1.0 than in Group S. Conclusions As the remifentanil dose increases, the intubation time required to reach TOF 0 also increases. Remifentanil has an effect on the onset of rocuronium.

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Intraoperative Acceleromyography Monitoring Reduces Symptoms of Muscle Weakness and Improves Quality of Recovery in the Early Postoperative Period

Anesthesiology ◽

10.1097/aln.0b013e3182342840 ◽

2011 ◽

Vol 115 (5) ◽

pp. 946-954 ◽

Cited By ~ 92

Author(s):

Glenn S. Murphy ◽

Joseph W. Szokol ◽

Michael J. Avram ◽

Steven B. Greenberg ◽

Jesse H. Marymont ◽

...

Keyword(s):

Muscle Weakness ◽

Subjective Experience ◽

Early Postoperative Period ◽

Postanesthesia Care Unit ◽

Control Group ◽

Time Of Arrival ◽

Residual Neuromuscular Blockade ◽

Quality Of Recovery ◽

Train Of Four

Background The subjective experience of residual neuromuscular blockade after emergence from anesthesia has not been examined systematically during postanesthesia care unit (PACU) stays. The authors hypothesized that acceleromyography monitoring would diminish unpleasant symptoms of residual paresis during recovery from anesthesia by reducing the percentage of patients with train-of-four ratios less than 0.9. Methods One hundred fifty-five patients were randomized to receive intraoperative acceleromyography monitoring (acceleromyography group) or conventional qualitative train-of-four monitoring (control group). Neuromuscular management was standardized, and extubation was performed when defined criteria were achieved. Immediately upon a patient's arrival to the PACU, the patient's train-of-four ratios were measured using acceleromyography, and a standardized examination was used to assess 16 symptoms and 11 signs of residual paresis. This examination was repeated 20, 40, and 60 min after PACU admission. Results The incidence of residual blockade (train-of-four ratios less than 0.9) was reduced in the acceleromyography group (14.5% vs. 50.0% control group, with the 99% confidence interval for this 35.5% difference being 16.4-52.6%, P < 0.0001). Generalized linear models revealed the acceleromyography group had less overall weakness (graded on a 0-10 scale) and fewer symptoms of muscle weakness across all time points (P < 0.0001 for both analyses), but the number of signs of muscle weakness was small from the time of arrival in the PACU and did not differ between the groups at any time. Conclusion Acceleromyography monitoring reduces the incidence of residual blockade and associated unpleasant symptoms of muscle weakness in the PACU and improves the overall quality of recovery.

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Mivacurium Neuromuscular Block at the Adductor Muscles of the Larynx and Adductor Pollicis in Humans

Anesthesiology ◽

10.1097/00000542-199607000-00011 ◽

1996 ◽

Vol 85 (1) ◽

pp. 77-81 ◽

Cited By ~ 33

Author(s):

Benoit Plaud ◽

Bertrand Debaene ◽

Frank Lequeau ◽

Claude Meistelman ◽

Francois Donati

Keyword(s):

Neuromuscular Block ◽

Onset Time ◽

Pressure Change ◽

Peak Effect ◽

Adductor Pollicis ◽

Vocal Cords ◽

Laryngeal Muscles ◽

Time To Peak ◽

Adductor Muscles ◽

Train Of Four

Background Laryngeal muscles must be paralyzed for tracheal intubation. Time to peak effect (onset time) is shorter and intensity of blockade is less at laryngeal muscles compared with the adductor pollicis. The authors' aim in this study was to determine the neuromuscular effects of mivacurium at the laryngeal adductor muscles and the adductor pollicis. Methods In 22 adults, anesthesia was induced and maintained with propofol and alfentanil. The force of contraction of the adductor pollicis was recorded, and the laryngeal response was evaluated by measuring the pressure change in the cuff of a tracheal tube positioned between the vocal cords after train-of-four stimulation. Mivacurium (0.07 mg.kg-1 or 0.14 mg.kg-1) was given intravenously (10s). Results With 0.07 mg.kg-1 mivacurium, onset time was 151 +/- 40 s(mean +/- SD) at the larynx and 241 +/- 79 s at the adductor pollicis, respectively (P < 0.005). Maximum block was 78 +/- 18% and 95 +/- 8%, respectively (P < 0.002), and time to 90% recovery was 11.1 +/- 2.9 min and 23.3 +/- 7.6 min, respectively (P < 0.001). With 0.14 mg.kg-1 mivacurium, onset time also was more rapid at the vocal cords (137 +/- 20 s) than at the adductor pollicis (201 +/- 59 s, P < 0.01). Maximum block was 90 +/- 7% and 99 +/- 1% (P < 0.005), and time to 90% recovery was 16.4 +/- 4.9 min and 27.4 +/- 7.8 min, respectively (P < 0.01). Conclusions With mivacurium, onset and recovery are faster at the laryngeal muscles, but block is less intense than at the adductor pollicis. A dose greater than 0.14 mg.kg-1 mivacurium is necessary to ensure complete relaxation at the vocal cords.

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Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

Anesthesiology ◽

10.1097/aln.0000000000004044 ◽

2021 ◽

Author(s):

Glenn S. Murphy ◽

Sorin J. Brull

Keyword(s):

Neuromuscular Block ◽

Meta Analysis ◽

Blocking Agent ◽

Neuromuscular Blocking ◽

Neuromuscular Monitoring ◽

Postanesthesia Care Unit ◽

Clinical Practices ◽

Residual Neuromuscular Blockade ◽

Quantitative Monitoring ◽

Residual Neuromuscular Block

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

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Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the Postanesthesia Care Unit

Anesthesiology ◽

10.1097/aln.0b013e318182af3b ◽

2008 ◽

Vol 109 (3) ◽

pp. 389-398 ◽

Cited By ~ 183

Author(s):

Glenn S. Murphy ◽

Joseph W. Szokol ◽

Jesse H. Marymont ◽

Steven B. Greenberg ◽

Michael J. Avram ◽

...

Keyword(s):

Neuromuscular Blockade ◽

Anesthetic Management ◽

Arterial Oxygen Saturation ◽

Arterial Oxygen ◽

Postanesthesia Care Unit ◽

Early Recovery ◽

Residual Neuromuscular Blockade ◽

Respiratory Events ◽

Train Of Four ◽

Adverse Respiratory Events

Background Incomplete recovery from neuromuscular blockade in the postanesthesia care unit (PACU) may contribute to adverse postoperative respiratory events. This study determined the incidence and degree of residual neuromuscular blockade in patients randomized to conventional qualitative train-of-four (TOF) monitoring or quantitative acceleromyographic monitoring. The incidence of adverse respiratory events in the PACU was also evaluated. Methods One hundred eighty-five patients were randomized to intraoperative acceleromyographic monitoring (acceleromyography group) or qualitative TOF monitoring (TOF group). Anesthetic management was standardized. TOF patients were extubated when standard criteria were met and no fade was observed during TOF stimulation. Acceleromyography patients had a TOF ratio of greater than 0.80 as an additional extubation criterion. Upon arrival in the PACU, TOF ratios of both groups were measured with acceleromyography. Adverse respiratory events during transport to the PACU and during the first 30 min of PACU admission were also recorded. Results A lower frequency of residual neuromuscular blockade in the PACU (TOF ratio < or = 0.9) was observed in the acceleromyography group (4.5%) compared with the conventional TOF group (30.0%; P < 0.0001). During transport to the PACU, fewer acceleromyography patients developed arterial oxygen saturation values, measured by pulse oximetry, of less than 90% (0%) or airway obstruction (0%) compared with TOF patients (21.1% and 11.1%, respectively; P < 0.002). The incidence, severity, and duration of hypoxemic events during the first 30 min of PACU admission were less in the acceleromyography group (all P < 0.0001). Conclusions Incomplete neuromuscular recovery can be minimized with acceleromyographic monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intraoperative acceleromyography use.

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