Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial

Abstract

PurposeThe use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery.MethodsThe use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission.ResultsIn our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups.ConclusionOur clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Comparison of Sugammadex Dose for Intraoperative Neuromonitoring in Thyroid Surgery: A Randomized Controlled Trial

“…For nerve sparing, meaningful qualified IONM should be performed during thyroid surgery, as well as the prevention of unwanted intraoperative bucking movement. The signals of V1 and R1 in the patients who received 1 mg/kg sugammadex in the present study were similar to those reported in previous studies in which 2 mg/kg sugammadex was used for reversal of neuromuscular blockade 2,3 . Additionally, the surgeon evaluated the quality of IONM in patients of the group I as good while assessing the EBSLN response in the present study.…”

“…Unsuccessful IONM has been reported to occur at a rate of 3.8% to 23% in previous studies, 7–10 and one of the common reasons for unsuccessful IONM could be failure of neuromuscular blockade recovery. In general, 0.6 mg/kg rocuronium combined with 2 mg/kg sugammadex has been recommended for optimal conditions for both tracheal intubation and high‐quality IONM 2–4 . However, we occasionally observed intraoperative bucking when we used 2 mg/kg sugammadex, and 35.3% of patients in group II had bucking in this study.…”

“…However, the laryngeal muscle shows faster recovery characteristics from neuromuscular blockade than the adductor pollicis muscle 17,18 . In fact, a previous study showed that a sufficient EMG response was achieved with vagal stimulation during thyroid surgery, while the TOFr did not recover >90% 3 . In this study, the EBSLN was checked first among the other nerves, and all patients had a strong or intermediate EBSLN response, and there was no difference in the quality of EBSLN monitoring between the two groups, although seven patients in group I and five patients in group II had TOFr <90% on EBSLN stimulation.…”

“…The signals of V1 and R1 in the patients who received 1 mg/kg sugammadex in the present study were similar to those reported in previous studies in which 2 mg/kg sugammadex was used for reversal of neuromuscular blockade. 2,3 Additionally, the surgeon evaluated the quality of IONM in patients of the group I as good while assessing the EBSLN response in the present study. Therefore, 1 mg/kg sugammadex should be comparable to 2 mg/kg in terms of the quality of IONM.…”

“…An excessive dose of sugammadex can induce rigorous patient movement during surgery, while vocal cord movement can not recover adequately for qualified IONM when the dose is insufficient. Several studies have suggested 2 mg/kg as an effective dose of sugammadex for qualified IONM, [2][3][4] however, these studies focused on complete reversal of neuromuscular blockade. The side effects of excessive doses of sugammadex have not been investigated.…”