last skin stitch is rarely more than 15 minutes, the potential for postoperative residual neuromuscular weakness is considerable. Continuous maintenance of deep NMB during laparoscopic surgery should be performed only in settings where clinicians have access to sugammadex, which should be given in doses of 4.0 mg/kg or greater. However, monitoring of neuromuscular function is essential, and because sugammadex is expensive, maintenance of deep block has economic considerations, especially when the actual benefits of deep block may be nonexistent.Little or no evidence suggests that using deep NMB as opposed to a moderate block for laparoscopic surgery will improve surgical operating conditions. Even if deep block is maintained, surgeons will not automatically ask for lower inflations pressures. At this point, in settings where sugammadex is not available and deep NMB is not routinely used for laparoscopic surgery, current practices do not need to be changed. COMMENTThis interesting and provocative article, in my opinion, should be read by all clinicians who administer anesthesia-and surgeons, too! The current authors, who have considerable expertise in the area of NMBs, reviewed the relevant literature to determine whether deep blockade with NMBs is helpful during laparoscopic surgery. They found little or no evidence to support that deep block (as opposed to moderate block) for laparoscopic surgery improves operating conditions. Moreover, even when deep block is maintained, surgeons will not necessarily ask for lower inflation pressures. Importantly, reversal of deep block with an acetylcholinesterase inhibitor is very slow and incomplete, and the likelihood of postoperative residual neuromuscular weakness in these circumstances is high. Therefore, the authors maintain, continuous maintenance of deep block during laparoscopic surgery should only be considered by clinicians who have access to sugammadex, which is not available in the United States and costs approximately $100 per 200-mg single-dose vial.From my perspective, the 2 most important messages promulgated by this article are that monitoring of neuromuscular function is absolutely mandatory when one is administering NMBs and that deep NMB is not a prerequisite for satisfactory muscle relaxation, at least not in the adequately anesthetized patient. 1,2 Comment by Kathryn E. McGoldrick, MD, FCAI(Hon) Disclosure: The author declares no conflict of interest.
Noma (cancrum oris) is a disease of poverty and malnutrition, which predominantly affects children younger than 10 years in developing countries. Although the majority of sufferers die of sepsis at the time of the initial infection, or of subsequent starvation due to severe trismus and an inability to eat, a small minority of patients survive and require reconstructive surgery for severe facial scarring and deformity. These patients present significant problems to the anesthesiologist with regard to airway management. We present a series of 26 patients undergoing primary and subsequent reconstructive surgery, with particular focus on airway management. We show that airway management, while challenging, can be performed safely and successfully by using individualized airway plans but may require advanced techniques and equipment. Traditional tests focusing on the anterior/superior airway are helpful in assessing patients with facial deformity due to noma.
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