Neuromuscular Depth and Surgical Conditions

In an era where deep neuromuscular blockade is out of fashion, along with residual paralysis concerns, this study shows that in patients undergoing elective laparoscopic colorectal surgery, deep neuromuscular blockade was associated with better surgical conditions than moderate blockade, as measured by a reduction in the incidence of intra-abdominal pressure alarms (as well as surgical rating). The moderate group was reversed with Neostigmine and the deep group with Sugammadex 4mg/kg. The availability of Sugammadex certainly makes this a more feasible practice.



Perioperative Peripheral Nerve Injury After General Anesthesia

A review article discusses the incidence, mechanisms, diagnosis and prevention of peripheral nerve injuries during general anesthesia. It is an area still in evolution, as it is found that anesthesia care is appropriate in 90% of cases. Concepts such as ischemia, inflammation, “double crush”, mechanical factors are discussed as well as evoked potential monitoring like SSEP, nerve conduction studies and EMG.


Intubation in OR vs ICU

A Spanish study compares OR vs ICU intubation by direct laryngoscopy. Everything was somewhat worse in  the ICU: worse view, lower first attempt success, higher rate of difficult intubation and use of airway adjuncts,  and higher complication rate. They suggest that patient and environmental factors may be of more importance than the operator (even previously known easy intubations were more difficult in ICU). Despite all that, their success rate was better than other studies, which they attribute to high use of neuromuscular blocking agents, an increasingly recommended practice. Videolaryngoscopy has met with better success in many but not all studies.

At the least, greater preparation, optimized positioning and airway equipment,  and trained assistance should be available for non-OR intubation




Further NAP6 Allergy & Anesthesia Insights

Teicoplanin over 16 tines culprit antibiotic in allergic reaction – twice other antibiotics. It seems to be a UK thing in terms of practice.

Test doses don’t serve any real purpose.

Since most anaphylaxis occurs within 5-10 mins a suggestion is to administer before anesthesia induction.

B-Blockers and ACEIs as well as older sicker patients and those with coronary artery disease have more hypotension and do worse.

Obese patients figured highly in mortality cases.

Hypotension is the presenting sign in half. Most severe cases may not show skin rash. Bronchospasm more an initial feature of Succinylcholine, which is also responsible for twice the anaphylaxis rate of non-depolarizing agents. Rocuronium leads the latter pack, followed by Atracurium and Mivacurium. No cases with Vecuronium or Cisatracurium.

There is a potential and debated relationship between Rocuronium allergy and Pholcodine, an opioid cough suppressant especially used in Australia which could sensitize subjects.

Chlorhexidine identified as responsible agent in 9%, often presenting with hypotension that is delayed and missed as diagnosis.

Fluid and epinephrine are the go to treatments not steroids and antihistamines which only play a corollary role. Sugammadex is not at this point an evidence based treatment for Rocuronium allergy. CPR was not started in many cases when it should have been.

Patent Blue dye (used in sentinel node locating in breast surgery) also a significant allergy culprit.

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Sugammadex vs. Neostigmine

The rapid and complete reversal of neuromuscular block with Sugammadex is undisputed. Other benefits that might justify its cost have been postulated. The current study did not find any difference in nausea and vomiting compared to Neostigmine/Glycopyrrolate. Diplopia, dry mouth and 2 hour sedation scores were improved but no outcome differences apparent at 24 hours. In the real world, rescue Sugammadex after a misjudged attempt at reversal would seem to save a whole lot of trouble!   link


Don’t forget to advise female patients taking birth control of the interaction when Sugammadex was used.

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As an aside, as always neuromuscular block must be monitored to determine an adequate dose of Sugammadex. And what if reintubation is needed? Succinylcholine still works normally, and Rocuronium can be used but in the first few hours after Sugammadex it may need double the dose;  alternatively Cisatracurium is unaffected (and unreversible by Sugammadex). We are also seeing some reports of allergic reactions to Sugammadex or the complex it forms, so no it’s not a recommended treatment for Rocuronium allergic reaction.