Neuromuscular blockade management for intraoperative neural monitoring

Lu, I‐Cheng; Wu, Sheng‐Hua; Wu, Chien‐Ming

doi:10.1002/kjm2.12153

Cited by 19 publications

(22 citation statements)

References 55 publications

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“…Adequate NMB is necessary for tracheal intubation and muscle relaxation. Timely restoration of neuromuscular function is required for neuromonitoring signals 5 . Various strategies for NMB management include relaxant‐free anesthesia, lower doses of NMB agents, and regular doses of NMB agents with sugammadex 6–8 .…”

Section: Introductionmentioning

confidence: 99%

Investigation of potential neuropharmacological activity of neostigmine‐glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Lee

Won

et al. 2021

The Kaohsiung J of Med Scie

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Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine‐glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle‐twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine‐glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine‐glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine‐glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine‐glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.

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Section: Introductionmentioning

confidence: 99%

Investigation of potential neuropharmacological activity of neostigmine‐glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Lee

Won

et al. 2021

The Kaohsiung J of Med Scie

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“…In previous studies of rocuronium, 1× the ED 95 of rocuronium was recommended to guarantee sufficient recovery of neuromuscular transmission for IONM (15,16,21,22). However, a lower degree of neuromuscular blockade resulted in less favorable intubation conditions (22). Although 2× the ED 95 of rocuronium provided better intubation conditions in one study, positive EMG signals were not obtained for all patients until 55 minutes after administration of this dose of rocuronium (15).…”

Section: Discussionmentioning

confidence: 93%

“…IONM was not affected by dosage (1× ED 95 versus 2× ED 95 ) of cisatracurium in the early stage of the operation. In previous studies of rocuronium, 1× the ED 95 of rocuronium was recommended to guarantee sufficient recovery of neuromuscular transmission for IONM (15,16,21,22). However, a lower degree of neuromuscular blockade resulted in less favorable intubation conditions (22).…”

Section: Discussionmentioning

confidence: 99%

Dosage effect of cisatracurium on intubation and intraoperative neuromonitoring during thyroidectomy: a randomized controlled trial

Li¹,

Zhang²,

Xu³

et al. 2021

Gland Surg

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Background: Intraoperative neuromonitoring (IONM) reduces the risk of recurrent laryngeal nerve (RLN) injury during thyroid surgery. However, the use of neuromuscular blocking agents (NMBAs), which are essential to improve intubation conditions, may hinder the electromyographic response during IONM.The aim of this prospective, double-blind, randomized controlled trial was to explore the optimal dosage of cisatracurium to produce adequate muscle relaxation for tracheal intubation without significantly affecting evoked potentials of IONM during thyroidectomy.Methods: Patients undergoing thyroidectomy with IONM in our institution, with an American Society of Anesthesiologists grade of I-II, aged 18-75 years, and with a body mass index below 32 kg/m 2 were enrolled and randomly assigned (by random numbers) to receive 1× (group C1) or 2× (group C2) the effective dose (ED 95 ) of cisatracurium for tracheal intubation. The patients, surgeons, and anesthesiologists in charge were blinded to group assignment. Anesthesia was induced with sufentanil, propofol, and cisatracurium (0.05 mg/kg in group C1, 0.1 mg/kg in group C2). Ease of intubation was evaluated with the intubation condition score (Cooper score) and the intubation difficulty scale (IDS). Amplitudes of evoked potentials during intermittent IONM were compared between groups. The primary outcomes were the Cooper score, the IDS score, and the evoked potentials of IONM.Results: Fifty-three patients were randomized from October 2019 to November 2020, and 52 were analyzed (with 26 patients in each group). The Cooper score was significantly lower in group C1 [median, 8.0 (interquartile range, 7.0-8.3)] than in group C2 [9.0 (9.0-9.0), P<0.001]. The rate of difficult laryngoscopy without external laryngeal pressure was significantly higher in group C1 than in group C2 (61.5% vs. 11.5%, P<0.001). More patients in group C1 required assistance to complete tracheal intubation (16 vs. 4, P=0.001).The IDS score was significantly higher in group C1 [3.0 (0.0-4.0) vs. 1.0 (0.0-1.0), P=0.045]. There were no significant differences between groups in amplitudes of evoked potentials. No serious adverse events were observed.Conclusions: A dose of 2× ED 95 of cisatracurium provided better intubation conditions and easier tracheal intubation than 1× ED 95 , without disturbing IONM.

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“…H) on the hospital IONM team. Standard procedures for equipment setup, anesthesia and loss of signal troubleshooting were performed by the IONM team of Kaohsiung Medical University Hospital [33][34][35][36] according to the guidelines published by the International Nerve Monitoring Study Group (INMSG) [12][13][14][15].…”

Section: Methodsmentioning

confidence: 99%

Laryngeal Neural Monitoring during Pediatric Thyroid Cancer Surgery—Is Transcartilage Recording a Preferable Method?

Huang

Kim

Dionigi

et al. 2021

Cancers

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The use of transcartilage (TC) intraoperative neuromonitoring (IONM) in a pediatric population has not been reported. This study evaluated the feasibility and the benefit of using TC-IONM for thyroid cancer surgery in a pediatric population. This retrospective single-center study enrolled 33 pediatric patients who had received an IONM-assisted thyroidectomy. Demographic characteristics, standardized IONM laryngeal examinations and stimulation information (L1-V1-R1-R2-V2-L2) were compared between endotracheal tube (ET) and TC methods. In the 15 cancer patients (30 nerves), TC-IONM provided significant higher electromyography (EMG) amplitude (p < 0.001), signal stability (lower V1/V2 signal correlation, r = 0.955 vs. r = 0.484, p = 0.004), signal quality (higher ratio of V1 or V2 amplitude <500µV, 0.0% vs. 43.8%, p = 0.005) and lower R1-R2p change (7.1% vs. 37.5%, p = 0.049) compared to ET-IONM. In the 18 benign patients (28 nerves), TC-IONM provided significantly higher EMG amplitude (p < 0.001), signal stability (r = 0.945 vs. r = 0.746, p = 0.0324) and non-significant higher signal quality and R1-R2p change. This report is the first to discuss the use of TC-IONM in pediatric thyroid surgery. In contrast with ET-IONM, TC-IONM had superior amplitude, stability and quality of EMG signals, which greatly facilitates the meticulous recurrent laryngeal nerve dissection in pediatric thyroidectomies. The TC-IONM method can be considered a feasible, effective and preferable method of monitored thyroidectomy in pediatric thyroid cancer.

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Neuromuscular blockade management for intraoperative neural monitoring

Cited by 19 publications

References 55 publications

Investigation of potential neuropharmacological activity of neostigmine‐glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Investigation of potential neuropharmacological activity of neostigmine‐glycopyrrolate for intraoperative neural monitoring in thyroid surgery

Dosage effect of cisatracurium on intubation and intraoperative neuromonitoring during thyroidectomy: a randomized controlled trial

Laryngeal Neural Monitoring during Pediatric Thyroid Cancer Surgery—Is Transcartilage Recording a Preferable Method?

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