These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

These practice guidelines are a modular update of the “Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures.” The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

Background Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. We embarked on a professional practice initiative to attain train-of-four (TOF) ratio ≥ 0.90 documentation for all patients for improved patient outcomes through reducing residual paralysis. Methods We utilized equipment trials, educational videos, quantitative monitors in all anesthetizing location, electronic clinical decision support with real time alerts and initiated an ongoing professional practice metric. This was a retrospective assessment (2016-2020) of TOF ratio ≥ 0.9 documentation prior to extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients receiving a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. Results From pre- to post-implementation, more patients were ASA 3-5, fewer were inpatients, rocuronium average dose was higher, and more patients had a pre-reversal TOF count < 4. Manually reviewed anesthesia records (n=2807) had 2/172 (1%) cases with TOF ratio ≥ 0.90 documentation in November 2016 which was less than the 250/269 (93%) cases in December 2020. Post-implementation (2/1/2020-12/31/2020) sugammadex 650/935 (70%), neostigmine 195/935 (21%), and no reversal 90/935 (10%) were used to attain TOF ratio ≥ 0.90 in 856/935 (92%) of patients. In the electronically searched medical charts (n=20181), post-implementation inpatients had a shorter PACU length of stay (7% difference, median minutes [25th, 75th percentile], 73 [55,102] to 68 [49,95], p<0.001), pulmonary complications were less (43% difference, 94/4138 (2.3%) to 23/1817 (1.3%), p=0.010, difference -1.0%, 95% CI -1.7% to -0.3%) and hospital length of stay was less (median days [25th, 75th percentile], 3 [2,5] to 2 [1,4], p<0.001). Conclusions In this professional practice initiative TOF ratio ≥ 0.90 documentation occurred for 93% of patients in a busy clinical practice. Return of strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

Abstract. We report six children, five with acute leukemia and one with aplastic anemia, who during chemotherapy have developed severe aseptic bone necrosis. Although there is no definite proof, our data are highly suggestive of incriminating corticosteroid therapy in large cumulative doses as the main pathogenetic factor.

AIMTo report our one-year experience with computer assisted propofol sedation (CAPS) for colonoscopy as the first United States Medical Center to adopt CAPS technology for routine clinical use.METHODSBetween September 2014 and August 2015, 2677 patients underwent elective outpatient colonoscopy with CAPS at our center. All colonoscopies were performed by 1 of 17 gastroenterologists certified in the use of the CAPS system, with the assistance of a specially trained nurse. Procedural success rates, polyp detection rates, procedure times and recovery times were recorded and compared against corresponding historical measures from 2286 colonoscopies done with midazolam and fentanyl from September 2013 to August 2014. Adverse events in the CAPS group were recorded.RESULTSThe mean age of the CAPS cohort was 59.9 years (48.7% male); 31.3% were ASA I, 67.3% ASA II and 1.4% ASA III. 45.1% of the colonoscopies were for screening, 31.5% for surveillance, and 23.4% for symptoms. The mean propofol dose administered was 250.7 mg (range 16-1470 mg), with a mean fentanyl dose of 34.1 mcg (0-100 mcg). The colonoscopy completion and polyp detection rates were similar to that of historical measures. Recovery times were markedly shorter (31 min vs 45.6 min, P < 0.001). In CAPS patients, there were 20 (0.7%) cases of mild desaturation (< 90%) treated with a chin lift and reduction or temporary discontinuation of the propofol infusion, 21 (0.8%) cases of asymptomatic hypotension (< 90 systolic blood pressure) treated with a reduction in the propofol rate, 4 (0.1%) cases of marked agitation or discomfort due to undersedation, and 2 cases of pronounced transient desaturation requiring brief (< 1 min) mask ventilation. There were no sedation-related serious adverse events such as emergent intubation, unanticipated hospitalization or permanent injury.CONCLUSIONCAPS appears to be a safe, effective and efficient means of providing moderate sedation for colonoscopy in relatively healthy patients. Recovery times were much shorter than historical measures. There were few adverse events, and no serious adverse events, related to CAPS.

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