Residual Paralysis after Emergence from Anesthesia

Plaud, Benoît; Debaene, B.; Donati, François; Marty, J.

doi:10.1097/aln.0b013e3181cded07

Cited by 194 publications

(144 citation statements)

References 44 publications

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“…This is also the level of neuromuscular blockade at which reversal with acetylcholinesterase inhibitors is possible. 1 After sugammadex 2 mgÁkg -1 iv, the median time to obtain a TOF ratio (TOFR) C 0.9 was reported as 1.4(0.9-5.4) min and 2.1(1.6-64.2) min for rocuronium 2 and vecuronium, 3 respectively. After neostigmine 50 lgÁkg -1 iv, this delay was reported as 18.5(3.7-106.9) min and 21.9(2.9-76.2) min for rocuronium 2 and vecuronium, 3 respectively.…”

Section: Résumémentioning

confidence: 99%

Recurarization after sugammadex reversal in an obese patient

Corre

Nejmeddine

Fatahine

et al. 2011

Can J Anesth/J Can Anesth

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Purpose We report a case that involved immediate postoperative respiratory failure necessitating tracheal intubation, which was possibly related to recurarization after sugammadex reversal. Clinical findings A 54-yr-old woman weighing 115-kg was scheduled for laparoscopic repair of abdominal dehiscence under general anesthesia. Muscle relaxation was induced and maintained with rocuronium (170 mg iv total dose). At the end of the 170-min procedure, two twitches were visualized after supramaximal train-of-four (TOF) stimulation at the adductor pollicis muscle, and the patient's central core temperature was 35.6°C. Sugammadex 200 mg iv (1.74 mgÁkg -1 ) was administered. With the patient fully awake, a TOF ratio 0.9 was obtained five minutes later. The tracheal tube was then removed, and the patient was transferred to the postanesthesia care unit. Ten minutes later, the patient presented respiratory failure necessitating tracheal intubation and sedation with propofol. One TOF response only was visualized at the adductor pollicis muscle. Another dose of sugammadex 200 mg iv was administered. Forty-five minutes later, the patient was fully awake and her trachea was extubated after repeated measures of the TOF ratio (C 0.9) at the adductor pollicis muscle. The patient fully recovered without sequelae, further complication, or prolonged hospital stay. Conclusion Shortly after tracheal extubation, an obese patient experienced respiratory failure necessitating tracheal intubation and an additional dose of sugammadex. This occurred despite initial reversal of neuromuscular blockade with an appropriate dose of sugammadex 2 mgÁkg -1 iv given at two responses to TOF stimulation. RésuméObjectif Nous de´crivons un cas de de´tresse respiratoire survenu en postope´ratoire imme´diat ne´cessitant l'intubation de la trache´e, possiblement lie´a`une recurarisation apre`s une de´curarisation pharmacologique avec du sugammadex. É léments cliniques Une femme de 54 ans, pesant 115 kg, e´tait programme´e pour le traitement chirurgical d'une e´ventration de la paroi abdominale par laparoscopie sous anesthe´sie ge´ne´rale. La curarisation e´tait induite et entretenue par du rocuronium (dose totale 170 mg iv). A`la fin de l'intervention, durant 170 min, deux re´ponses e´taient visualise´es apre`s une stimulation supra-maximale par un train-de-quatre (Td4) a`l'adducteur du pouce, et la tempe´rature centrale e´tait de 35,6°C. Une dose de 200 mg iv de sugammadex (1,74 mgÁkg -1 ) a e´te´administre´e pour la de´curarisation pharmacologique. Un rapport de Td4 a`0,9 al 'adducteur du pouce e´tait obtenu cinq minutes plus tard permettant le retrait de la sonde d'intubation et le transfert en salle de re´veil, la patiente re´pondant aux ordres simples. Dix minutes plus tard, elle pre´sentait une de´tresse respiratoire ne´cessitant l'intubation de la trache´e et une se´dation au propofol. Une seule re´ponse e´tait visualise´e au Td4 a`l'adducteur du pouce. Une dose supple´mentaire de 200 mg iv de sugammadex a e´te´administre´e. Quarante-cinq

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Section: Résumémentioning

confidence: 99%

Recurarization after sugammadex reversal in an obese patient

Corre

Nejmeddine

Fatahine

et al. 2011

Can J Anesth/J Can Anesth

Self Cite

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“…Anticholinesterase agents enhance spontaneous recovery; as a result, they are more effective against intermediate-acting than long-acting agents because the former have a more rapid spontaneous recovery. This explains why residual paralysis is more frequent with long-acting agents 3,19 and why there has been a decrease in the reported incidence of TOFR \ 0.9 since the late 1970s as long-acting agents were replaced progressively with intermediate-acting agents (Fig. 1).…”

Section: Role Of Neuromuscular Blocking Agentmentioning

confidence: 99%

“…To reach a TOFR of 0.9 within 10-15 min, it is now recommended to wait until four twitches are seen, with or without fade. 3 When deep blockade is present (zero to three twitches present), there are no advantages in giving neostigmine early, even in large doses ([ 50 lgÁkg -1 ). When neostigmine is given early, studies have shown that the time from neostigmine administration to full recovery is no shorter than the time until four twitches reappear spontaneously plus the time from administering neostigmine at four twitches to full recovery (Fig.…”

Section: Ceiling Effectmentioning

confidence: 99%

“…2 Nevertheless, many lines of evidence now suggest that the TOFR threshold of 0.7 for the presence of residual paralysis was too low and that neuromuscular recovery cannot be considered complete unless the TOFR is [ 0.9. 3,4 The introduction of this new threshold means that residual paralysis is more prevalent, thus annihilating the improvement resulting from the use of intermediate-duration neuromuscular blocking agents. Recent studies show a prevalence of residual paralysis in the 20-50% range ( Fig.…”

Section: Objectivesmentioning

confidence: 99%

“…10 Patients with residual paralysis are more at risk of hypoxia, airway obstruction, the need for a maneuver to maintain the airway, and generalized weakness. 3,11 Again, the problem is not the pump function of the lungs, but the fragility of the upper airway. …”

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Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Purpose Over the past three decades, many studies have shown a high proportion of patients in the recovery room with residual neuromuscular blockade after anesthesia. The purpose of this Continuing Professional Development module is to present the physiological consequences of residual paralysis, estimate the extent of the problem, and suggest solutions to prevent its occurrence. Principal findings Residual paralysis is defined as a train-of-four ratio (TOFR) \ 0.9 at the adductor pollicis. While tidal volume and, to a lesser extent, vital capacity are well preserved as the intensity of blockade increases, the probability of airway obstruction, impaired swallowing, and pulmonary aspiration increases markedly as TOFR decreases. In recent studies, incidences of residual paralysis from 4-57% have been reported, but surveys indicate that anesthesiologists estimate the incidence of the problem at 1% or less. The decision to administer neostigmine or sugammadex should be based on the degree of spontaneous recovery at the adductor pollicis muscle (thumb), not on recovery at the corrugator supercilii (eyebrow). The most important drawback of neostigmine is its inability to reverse profound blockade, which is a consequence of its ceiling effect. When spontaneous recovery reaches the point where TOFR [ 0.4 or four equal twitch responses are seen, reduced doses of neostigmine may be given. The dose of sugammadex required in a given situation depends on the intensity of blockade. Conclusion Careful monitoring and delaying the administration of neostigmine until four twitches are observed at the adductor pollicis can decrease the incidence of residual paralysis. The clinical and pharmacoeconomic effects of unrestricted sugammadex use are unknown at this time. ObjectivesAfter reading this module, the reader should be able to:1. Describe the physiological effects of residual neuromuscular blockade 2. Define and justify the current threshold used for residual paralysis 3. Interpret the information provided by qualitative and quantitative monitors 4. Decide the dose and timing of administration of neostigmine 5. Manage neuromuscular blockade and reversal during and after anesthesia.In 1979, Viby-Mogensen et al. 1 reported that 42% of patients receiving non-depolarizing neuromuscular blocking agents during anesthesia followed by neostigmine at the end of the procedure had neuromuscular weakness in the recovery room, as documented by a train-of-four ratio 123Can J Anesth/J Can Anesth (2013) 60:714-729 DOI 10.1007 (TOFR) \ 0.7. This first description of what was later termed residual paralysis, residual curarization, or postoperative residual curarization was followed by many other observations in many countries around the world and in different settings. The introduction of shorter-acting agents, such as vecuronium and atracurium and later rocuronium and cisatracurium, to replace the longer-acting agents available in 1979 led to a decrease in the incidence of residual paralysis. 2 Nevertheless, many lines of evidence now...

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Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults

Hristovska

Duch

Allingstrup

et al. 2017

Cochrane Database of Systematic Reviews

194

267

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Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium-induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality).

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Residual Paralysis after Emergence from Anesthesia

Cited by 194 publications

References 44 publications

Recurarization after sugammadex reversal in an obese patient

Recurarization after sugammadex reversal in an obese patient

Residual paralysis: a real problem or did we invent a new disease?

Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults

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