Thyroid Surgery, IONM and Sugammadex Sodium Relationships: Benefits in Sugammadex Sodium Use for IONM

Abstract

Background. It is important to protect recurrent laryngeal nerve (RLN) during thyroid surgery. Thus, intraoperative neuromonitoring (IONM) has got popularity. But, the half life of neuromuscular blocking agents used has a reverse correlation with reliability and effectiveness of IONM. This study aimed to research the effect of Sugammadex Sodium, a specific nemuromuscular blocking agent antagonist, on nerve conduction and IONM.Materials and methods. Twenty patients who underwent thyroidectomy under IONM followed an enhanced NMB recovery protocol-rocuronium 0.6 mg/kg at anesthesia induction and sugammadex 2 mg/kg at the beginning of operation. To prevent laryngeal nerve injury during the surgical procedures, all patients underwent intraoperative monitoring. At the same time, the measurement of TOF-Watch acceleromyograph of the adductor pollicis muscle response to ulnar nerve stimulation was performed; recovery was defined as a train-of-four (TOF) ratio ≥ 0.9. Age, sex, recurrent laryngeal nerve transmission speeds prior to and after operation, BMI, duration of surgery, the change in nerve transmission after drug administration and complications were analyzed.Results. The mean age and the mean BMI were 47.6±11.82 years and 28.74±3.20, respectively. The mean operation duration was 52.65±5.51 minutes. There was no difference in either right or left RLN monitoring values before and after surgery. Following the drug injection, the TOF guard measurements on the 1 st , 2 nd , 3 rd and 4 th minutes were 23.5±4.90; 69.5±6.86; 88±4.1 and 135.9±10.62, respectively.Conclusion. Neuromuscular blocking antagonist use and monitoring nerve transmission speed with TOFguard can provide a safer resection.

Administration of neostigmine after tracheal intubation shortens time to successful intraoperative neuromonitoring during thyroid surgery: a randomized controlled trial

“…Therefore, we used rocuronium as an NMBA with a reversal agent when IONM was planned. Previous studies have reported sugammadex after rocuronium use is useful for IONM 13 , 17 , 18 . While some studies suggest a dose of 2 mg/kg sugammadex for reversal of neuromuscular blockade prior to IONM 13 , 17 , one study comparing 1 mg/kg and 2 mg/kg sugammadex showed that a dose of 1 mg/kg sugammadex induced fewer intraoperative bucking events than a 2 mg/kg dose, while still providing comparable IONM quality 5 .…”

“…Previous studies have reported sugammadex after rocuronium use is useful for IONM 13 , 17 , 18 . While some studies suggest a dose of 2 mg/kg sugammadex for reversal of neuromuscular blockade prior to IONM 13 , 17 , one study comparing 1 mg/kg and 2 mg/kg sugammadex showed that a dose of 1 mg/kg sugammadex induced fewer intraoperative bucking events than a 2 mg/kg dose, while still providing comparable IONM quality 5 . This demonstrates that the goal of administering NMBAs is not complete recovery from neuromuscular blockade, but just enough reversal so that IONM is possible while still providing good anesthetic and surgical conditions.…”

“…The optimal time to administer reversal agents is also unknown. Many studies have reported the administration of reversal agents directly before IONM 13 , 17 , 18 , 22 . One study noted that when sugammadex was administered directly after tracheal intubation, up to 35% of patients experienced intraoperative bucking events, more than 60% of which occurred during skin incision and flap dissection 5 .…”

A Surgeon-Centered Neuromuscular Block Protocol Improving Intraoperative Neuromonitoring Outcome of Thyroid Surgery

“…Sugammadex has gained increasing popularity in IONM during thyroid surgery. The reported dose of sugammadex that was effective for IONM ranged from 0.5 to 2.0 mg/kg ( 28 , 29 , 31 , 32 , 41 , 42 ). There is a wide variation between patients in the spontaneous recovery time from rocuronium-induced NMB group.…”