Unanticipated Profound Paralysis and Sugammadex Dosing Implications After Videoscopic Thoracic Surgery

A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

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.

Dexmedetomidine versus fentanyl in intraoperative neuromuscular monitoring using propofol based total intravenous anesthesia regimen in kyphoscoliosis correction surgery

Background Intraoperative neuromuscular monitoring (IONM) is used to reduce the risk of postoperative neurological deficit in patients undergoing kyphoscoliosis correction surgery. Somatosensory evoked potentials (SSEPs) are among the several techniques developed by neurophysiologists to increase the sensitivity of intraoperative monitoring. We administered total intravenous anesthesia (TIVA) to 20 patients undergoing kyphoscoliosis deformity correction surgeries: group A: propofol and dexmedetomidine and group B: propofol and fentanyl. The primary objective of our study was to compare the effect of dexmedetomidine and fentanyl on intraoperative hemodynamic parameters and their interference with SSEP’s readings. The secondary objective was to assess the total intraoperative requirement of inhalational anesthetic agents, quality of surgical field, and the cost-effectiveness of either regimen. Results Intraoperative hemodynamic stability, analgesia, surgical field, and cost-effectiveness (due to reduced requirement of sevoflurane) were better with dexmedetomidine than fentanyl. SSEPs were successfully recorded with both the drugs while the requirement of inhalation anesthetic agents was significantly reduced in the dexmedetomidine group than in the fentanyl group. There were no injuries while recording SSEPs. The latency and amplitude of SSEPs were maintained throughout either group. No intraoperative awakening or awareness was noted (bispectral index was maintained in the range of 40 to 60). No postoperative neurological deficit was noted in any patient. Conclusions Both dexmedetomidine and fentanyl can be successfully used in propofol-based TIVA for SSEP monitoring in kyphoscoliosis correction surgeries, but the better analgesic profile, ease of maintaining stable hemodynamics with a significant reduction in inhalational agent requirement, and opioid-sparing effect by dexmedetomidine make it a more desirable agent to be used in propofol-based TIVA.

Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

Background The paucity of easy-to-use, reliable objective neuromuscular monitors is an obstacle to universal adoption of routine neuromuscular monitoring. Electromyography (EMG) has been proposed as the optimal neuromuscular monitoring technology since it addresses several acceleromyography limitations. This clinical study compared simultaneous neuromuscular responses recorded from induction of neuromuscular block until recovery using the acceleromyography-based TOF-Watch SX and EMG-based TetraGraph. Methods Fifty consenting patients participated. The acceleromyography and EMG devices analyzed simultaneous contractions (acceleromyography) and muscle action potentials (EMG) from the adductor pollicis muscle by synchronization via fiber optic cable link. Bland–Altman analysis described the agreement between devices during distinct phases of neuromuscular block. The primary endpoint was agreement of acceleromyography- and EMG-derived normalized train-of-four ratios greater than or equal to 80%. Secondary endpoints were agreement in the recovery train-of-four ratio range less than 80% and agreement of baseline train-of-four ratios between the devices. Results Acceleromyography showed normalized train-of-four ratio greater than or equal to 80% earlier than EMG. When acceleromyography showed train-of-four ratio greater than or equal to 80% (n = 2,929), the bias was 1.3 toward acceleromyography (limits of agreement, –14.0 to 16.6). When EMG showed train-of-four ratio greater than or equal to 80% (n = 2,284), the bias was –0.5 toward EMG (–14.7 to 13.6). In the acceleromyography range train-of-four ratio less than 80% (n = 2,802), the bias was 2.1 (–16.1 to 20.2), and in the EMG range train-of-four ratio less than 80% (n = 3,447), it was 2.6 (–14.4 to 19.6). Baseline train-of-four ratios were higher and more variable with acceleromyography than with EMG. Conclusions Bias was lower than in previous studies. Limits of agreement were wider than expected because acceleromyography readings varied more than EMG both at baseline and during recovery. The EMG-based monitor had higher precision and greater repeatability than acceleromyography. This difference between monitors was even greater when EMG data were compared to raw (nonnormalized) acceleromyography measurements. The EMG monitor is a better indicator of adequate recovery from neuromuscular block and readiness for safe tracheal extubation than the acceleromyography monitor. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New