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The use of quantitative neuromuscular monitoring during induction of anesthesia to establish a baseline neuromuscular response and ensure paralysis of the vocal cords during laryngoscopy and tracheal intubation has yet to become standard practice. The current study compared intubating conditions based on quantitative measurements (train-of-four count) with intubating conditions based on the time since rocuronium administration. Consenting adult patients undergoing general anesthesia requiring neuromuscular block were randomized into 2 groups. Following placement of a quantitative electromyographic neuromuscular monitor, general anesthesia was induced with propofol 1–1.5 mg/kg followed by rocuronium 0.6 mg/kg. In one group, intubation commenced 2 min after rocuronium administration (Time Group). In the other, intubation commenced when the first train-of-four (TOF) count was ≤1 (Count Group). Video laryngoscopy was used in both groups and the intubating conditions were noted. A Wilcoxon rank sum test or Fisher's exact test was used to compare intubating conditions between the 2 groups. Spearman's rank correlation test was used to describe the relationship between intubation conditions and the ratio of the amplitude of the first twitch of the TOF sequence, T1, to the control T1 amplitude (T1/Tc). There were 84 patients in the Count Group and 83 in the Time Group. More patients had ideal intubating conditions (relaxed jaw, abducted vocal cords, and no response to tracheal intubation) in the Count Group (61/84, 73 %) than the Time Group (47/83, 57 %, P = 0.036). The mean composite intubating score was better (lower) in the Count Group than in the Time Group (3.5 vs. 3.9, respectively, P = 0.016). The T1/Tc at intubation correlated with the composite intubating conditions score (Spearman's ρ = 0.34, P < 0.001). Intubating conditions were better when the timing of intubation was guided by quantitative neuromuscular monitoring to ensure a TOF count ≤1 versus waiting a fixed time interval of 2 min following administration of rocuronium. [Display omitted] •Quantitative neuromuscular monitoring is recommended to confirm adequate recovery.•The role of monitoring at induction of anesthesia is not well-described.•Monitoring predicted better conditions than waiting 2 min after rocuronium.

To determine the effect of tetanic stimulation on the time to achieve stabilization of the T1 height, by acceleromyography train-of-four (TOF) ratio monitoring, in patients aged 60 to 80 years. Randomized, prospective, single-blind, controlled trial in patients aged 60 to 80 years undergoing elective surgery under general anesthesia in two university hospitals in Brazil between December 2019 and March 2022. This trial was performed in accordance with the principles of the Helsinki Declaration and the guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II. Participants were randomly allocated by computer-generated numbers to receive tetanic stimulation (intervention group, n  =  25) or not receive tetanic stimulation (control group, n  =  25) to achieve T1 height stabilization on TOF ratio monitoring. The primary endpoint was to evaluate the effect of tetanic stimulation on the time to achieve stabilization of the T1 height. We also evaluated the effect on the onset time of rocuronium and time to recover from neuromuscular blockade with a single dose of rocuronium 0.6 mg.kg-1 with spontaneous recovery. There was no statistically significant difference between the groups in the time to T1 height stabilization (intervention: 4.3 [2.0-8.0] min; control: 5.8 [2.0-10.5] min; p  =  0.202), onset time of the neuromuscular blocking agent (intervention: 1.9 [±0.7] min; control: 2.2 [±1.0] min; p  =  0.219), or neuromuscular blockade recovery times to normalized TOF values of 0.7 (intervention: 106.1 [±37.2] min; control: 91.7 [±27.5] min; p  =  0.295), 0.8 (intervention: 114.3 [±40.1] min; control: 97.8 [±28.9] min; p  =  0.225), 0.9 (intervention: 126.5 [±44.0] min; control: 106.9 [±30.6] min; p  =  0.153), and 1.0 (intervention: 138.3 [±43.4] min; control: 123.8 [±43.5] min; p  =  0.425). The results of this study suggest that the recommendation to use tetanic stimulation to shorten the time to T1 height stabilization in neuromuscular monitoring did not alter the stabilization time of the T1 twitch or the pharmacodynamics of neuromuscular blockade with rocuronium in patients aged 60 to 80 years.

Background Both under-dosing and over-dosing of sugammadex for reversing neuromuscular block pose risks to patients, yet the optimal dosage for different degrees of neuromuscular block remains undefined. This study compared titration with single bolus of sugammadex recommended by manufacturer to determine the optimal dose for achieving a train-of-four ratio (TOFR) of 0.9 or greater while minimizing residual paralysis. Methods Patients were randomly assigned to titrated group or manufacturer-recommended group. In titrated group, sugammadex was given in 50-mg increments every 5 min until a TOFR of 0.9 or greater was reached. In recommended group, a single dose (2 mg/kg or 4 mg/kg) was given based on train-of-four count (TOFC). Neuromuscular block was monitored continuously, and residual paralysis was assessed in the post-anesthesia care unit (PACU). Results Of 210 enrolled patients, 205 were evaluated. The median dose of sugammadex for reversing different depths of neuromuscular block induced by rocuronium was ascertained via the titration method in this study. Titrated group required significantly less sugammadex to achieve a TOFR of at least 0.9 compared to recommended group ( P  < 0.001). Residual paralysis incidence was similar between groups (5.4% in titrated group vs. 4.9% in recommended group; P  = 0.564). Although recovery time was longer in titrated group, extubation time and length of stay in the PACU were comparable. Conclusions Titrated sugammadex administration significantly reduces required dosage without increasing residual paralysis risk. Continuous neuromuscular monitoring postoperatively is strongly recommended due to individual variability in dosage needs. Trial registration The study was registered in the Chinese Clinical Trial Registry on March 4, 2024(ChiCTR2400081540).

To evaluate the influence of reversal of neuromuscular blockade with sugammadex or neostigmine on postoperative quality of recovery following a single bolus dose of rocuronium after pars plana vitrectomy (PPV) under general anesthesia. Prospective, double-blind, randomized controlled trial. This study was conducted in a University Teaching Hospital from February to July 2017. A total of 84 patients with an American Society of Anesthesiologists physical status of I or II who were scheduled to undergo PPV under general anesthesia. The patients were randomly assigned to the neostigmine (Group N, n = 44) or sugammadex (Group S, n = 40) groups; 3 ml of study drug was prepared for the patients. For patients in Group N, a solution of neostigmine methylsulfate (1 mg) and glycopyrrolate (0.2 mg) was prepared, while a solution of sugammadex sodium (2 mg/kg) and normal saline was prepared for patients in Group S. The primary endpoint was the effect of sugammadex, compared with neostigmine, on the recovery rate in the physiological domain in patients who underwent PPV with general anesthesia. The quality of recovery was assessed using the Postoperative Quality Recovery Scale at 15 min and 40 min after surgery, and on postoperative day 1. The recovery rate in the physiological domain was higher in Group S at 15 min after surgery (P = 0.020). Though there were no significant differences in the overall cognitive recovery domain, patients in Group S could recall more numbers in reverse order. However, there were no significant differences between the groups in the other domains of the scale. The use of sugammadex may increase the quality of physiological recovery at early postoperative periods, compared with that of neostigmine, following a single bolus dose of rocuronium in patients undergoing PPV with general anesthesia. Trial Registration: Registered at ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03108989). Registration number: NCT03108989. •Reversal of neuromuscular blockade was performed with sugammadex and neostigmine.•Recovery quality after pars plana vitrectomy under general anesthesia was assessed.•The recovery rate in physiological domain was higher for sugammadex.•Sugammadex may improve the quality of early postoperative physiological recovery.

Background Endotracheal intubation may be performed using deep anesthesia, neuromuscular blocks, or the topical application of anesthetics on the vocal cords. The null hypothesis in this study was that there is no difference in hoarseness one hour after extubation between patients receiving neuromuscular blocks versus lidocaine sprayed on the glottis for endotracheal intubation. Methods A randomized, controlled, double-blinded study was conducted. A total of 114 patients were included. Group I (n = 58) received rocuronium 0.6 mg/kg. Group II (n = 56) received lidocaine spray 4 ml (20 mg/ml) on the vocal cords. The primary outcome measure was hoarseness one hour after extubation. Secondary outcomes were hoarseness at 24 and 48 h after extubation, sore throat at 1, 24, and 48 h after extubation, and intubation and extubation conditions. Results There was no statistically significant difference between groups in hoarseness one hour after extubation. At 24 h, Group I had significantly more reported hoarseness (27.6%) and observed hoarseness (1.7%) than Group II (12.5% reported) (p = 0.03). Group II had a significantly sorer throat (21.4%) than Group I (1.7%) (p < 0.001) at one hour. Beyond this, there were no differences between groups. Conclusion Even though some differences were observed in hoarseness and sore throat 24 h after extubation, there were few differences between topical lidocaine spray and the use of neuromuscular blocks before intubation for patient-reported and observed outcomes. Consequently, clinicians should choose an approach based on considerations other than those included in this study, such as the need for muscle relaxation or minimizing the number of laryngoscopies. The study was prospectively registered at Clinicaltrials.gov NCT05614609

Background The European Society of Anaesthesiology and Intensive Care recommends the use of neuromuscular blocking drugs for tracheal intubation, but the monitoring is difficult, because the parameters are mostly relative values (e.g. Train-of-four ratio), which show no or only weak correlations to the vocal cord aperture. We investigated the predictive effect of the quantitative single twitch (0.3 ms duration supramaximal stimulus, frequency 0.1 Hz) to estimate vocal cord aperture (primary endpoint). Secondarily, we focused on rocuronium dose-related differences between single twitch amplitude and maximum vocal cord aperture. Methods Thirty-six adult patients undergoing elective surgery with tracheal intubation using rocuronium were included. Patients received remifentanil and propofol for induction of anaesthesia before the neuromuscular block baseline was measured electromyographically using the single twitch stimulation pattern of the ulnar nerve from the abductor digiti minimi muscle. A video-laryngoscope was inserted to document baseline conditions before the patient received either 0.3 or 0.9 mg/kg IBW rocuronium. The vocal cord area was continuously videorecorded for four minutes, before the trachea was intubated. Results Thirty-five patients completed the study; 18 received 0.3 and 17 received 0.9 mg/kg IBW rocuronium. Data showed a strong correlation between single twitch amplitude and vocal cord aperture (bootstrapped Pearson’s coefficients, median ± IQR: -0.58 ± 0.22 in rocuronium 0.3 and -0.74 ± 0.18 in rocuronium 0.9 mg/kg IBW; p  < 0.001), meaning that the single twitch amplitude may be a reliable predictor of vocal cord opening. The higher rocuronium dose caused a stronger correlation, lower inter-patient variability, and a steeper single twitch decrease, but the effect on the maximum vocal cord aperture was comparable to that in the 0.3 mg/kg IBW rocuronium group. Conclusions The quantitative, electromyographic single twitch stimulation pattern can dose-independent predict vocal cord opening after rocuronium administration. Trial registration The study was registered at the German Clinical Trials Register on the 10th of July 2020 (DRKS00021433) prior to enrolment of the patients.

To evaluate the effect of neuromuscular blockade (NMB) upon the abdominal space during pneumoperitoneum establishment in laparoscopic surgery, comparing moderate NMB and deep NMB. Prospective, randomized, crossover clinical trial. Operating room. Seventy-six American Society of Anesthesiologists 1 to 2 patients scheduled for elective laparoscopic surgery. Two independent evaluations were performed at the establishment of pneumoperitoneum for a preset intraabdominal pressures (IAPs) of 8 and 12 mm Hg, both during moderate NMB (train-of-four count, 1-3) and deep NMB (posttetanic count, <5). Rocuronium was used to induce NMB, and sugammadex was used for reversal. We evaluated (i) the volume of CO2 introduced in 41 patients and (ii) the skin-sacral promontory distance in 35 patients, at pneumoperitoneum establishment. Compared to moderate NMB, deep NMB increased, in a significant manner, both the intraabdominal volume of CO2 insufflated (mean [SD], 2.24 [1.10] vs 2.81 [1.13] L at 8 mm Hg IAP, P<.001, and 3.52 [1.31] vs 4.09 [1.31] L at 12 mm Hg IAP, P<.001) and the skin-sacral promontory distance (11.78 [1.52] vs 12.16 [1.51] cm at 8 mm Hg IAP, P=.002, and 13.34 [1.87] vs 13.80 [1.81] cm at 12 mm Hg IAP, P<.001). Increase in intraabdominal volume after inducing deep NMB was observed in 88% and 81.7% of patients at 8 and 12 mm Hg pneumoperitoneum, with a volume increase of mean of 36.8% (95% confidence interval [CI], 22.8-50.8) and 25% (95% CI, 13.7-36.4), respectively (P=.003). Increase in distance was observed in 61% and 82% of patients at 8 and 12 mm Hg pneumoperitoneum, with a mean distance increase of 3.3% (95% CI, 1.3-5.4) and 3.6% (95% CI, 1.9-5.2), respectively (P=.840). Deep NMB, in comparison to moderate NMB, increased in a significant manner the abdominal space at pneumoperitoneum establishment. However, the effective increase in the abdominal cavity dimensions could be low, the increase showed a great interindividual variability, and it was not observed in every patient. Clinical significance of this increase on surgical conditions is yet to be demonstrated. •Effect of moderate vs deep neuromuscular blockade on laparoscopic space was assessed.•Abdominal space was increased in a significant manner with deep neuromuscular block.•Effective increase in the abdominal cavity dimensions could be low.•A great interindividual variability was observed in the response.•Clinical significance of this increase on surgical conditions is as yet uncertain.

The aim of this study is to compare the effects of neuromuscular blockade (NMB) on phase lag entropy (PLE) and the bispectral index (BIS). We recorded the BIS, electromyograph (EMG) activity on a BIS monitor (EMG_BIS), PLE, and EMG activity on a PLE monitor (EMG_PLE) in 40 patients receiving general anesthesia. During the awake state, we analyzed the changes in parameters before and 2 min after the eyes were closed. During sedation, we compared the changes in the parameters before and at 4 min after injecting rocuronium (group R) or normal saline (group C) between the two groups. During anesthesia, we compared the changes in parameters before and at 4 min after injecting sugammadex (group B) or normal saline (group D) between the two groups. During the awake state, the BIS, EMG_BIS, and EMG_PLE, but not PLE, decreased significantly with closed eyes. An effect of EMG on the BIS was evident, but not on PLE. During sedation, the BIS decreased with the decrease in EMG_BIS regardless of NMB caused by rocuronium, but NMB decreased PLE, although the degree of the decrease in EMG_PLE after NMB was similar to that after placebo. To determine the effect of NMB on electroencephalograms (EEGs) in groups R and C, we plotted the power spectra before and at 4 min after injecting rocuronium or normal saline. Changes in slow and delta frequency bands were observed at 4 min after injecting rocuronium relative to before injecting rocuronium. There was no effect of EMG on either the BIS or PLE during anesthesia. In conclusion, the effect of electromyograph activity and/or neuromuscular blockade on BIS or PLE depends on the level of consciousness.

Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed. Monocentric randomised controlled trial. Operating room. We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia. Patients were randomised into two groups to achieve either moderate (1–3 train of four response) or deep (1–2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups. The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption. Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228–472) μg.h−1 in the deep NMB group compared to 494 (392–618) μg.h−1 in the moderate NMB group (P < 0.001). Lowest L-SRS was 5 (4–5) in the deep NMB group versus 3 (2–5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different. This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions. The study was registered at ClinicalTrials.gov under NCT03910998. •Deep neuromuscular block NMB reduces NOL-guided remifentanil administration by 30 % during laparoscopic colorectal surgery.•Deep neuromuscular block improves surgical satisfaction and reduces intra-abdominal pressure during laparoscopic surgery.•Postoperative outcomes including postoperative pain scores and opioids' consumption were similar between groups.

Peribulbar anesthesia is mainly used for cataract surgery. Many studies had used atracurium and rocuronium as an additive to the local anesthetic (LA) drugs in eye surgery. The aim of this study is to evaluate the efficacy of adding atracurium versus rocuronium to a local anesthetic mixture, in providing an early onset of orbital akinesia and corneal anesthesia during cataract surgery. Ninety-three patients met the inclusion criteria and gave a written informed consent to participate. Patients were randomly allocated in three study groups (31 patients in each group). Group I received either 3 mL of a lidocaine2%(mixed by hyaluronidase 50 IU/ml) and 3 ml bupivacaine mixture, plus 0.5 mL rocuronium (5 mg) total volume 6.5 ml. Group II 3 mL of a lidocaine2%(mixed by hyaluronidase 50 IU/ml) and 3 ml bupivacaine mixture plus 0.5 mL (5 mg) atracurium total volume 6.5 ml. Group III or3 mL of a lidocaine2%(mixed by hyaluronidase 50 IU/ml) and − 3 ml bupivacaine mixture, plus 0.5 mL saline total volume 6.5 ml. The onset time of orbital akinesia was significantly lower in the rocuronium group and the atracurium group compared to the control group. Akinesia score was (0.90 ± 0.30) and (0.19 ± 0.40) in rocuronium group at 4 min and 6 min respectively which result in highly significant difference than atracurium and control groups. The use of rocuronium and atracurium will result in rapid orbital akinesia and rapid orbicularis muscle akinesia.