Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision.

The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808).

Protamine titration to optimize heparin antagonization after cardiopulmonary bypass.

Objectives: To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB).

Design: A prospective, observational trial.

Setting: Single-center, non-university teaching hospital.

Residual Neuromuscular Blockade and Postoperative Pulmonary Complications: What Does the Recent Evidence Demonstrate?

Purpose Of Review: The purpose of this review is to assess how residual neuromuscular block impacts postoperative pulmonary complications and whether we can modify the risk by improving certain aspects in daily clinical care.

Recent Findings: Postoperative respiratory impairment may be due to various causes, such as age, surgery type, comorbidity, smoking, preoperative anemia, and general anesthesia. However, increasing evidence suggests that residual neuromuscular block is an important risk factor for postoperative pulmonary complications and may affect the outcome.

Sugammadex: Appropriate Use in the Context of Budgetary Constraints.

Purpose Of Review: The purpose of this review is to assess how sugammadex impacts postoperative residual curarization using appropriate doses based on neuromuscular transmission monitoring and whether the advantages of sugammadex versus neostigmine outweigh its higher cost.

Recent Findings: An accurate assessment of neuromuscular blockade with monitoring is necessary before selecting neostigmine versus sugammadex for reversal at the end of surgery to overcome incomplete neuromuscular recovery. The main advantages of sugammadex over neostigmine are its predictability and its ability to extend the range of blockade reversal.

[Functional respiratory imaging after neostigmine- or sugammadex-enhanced recovery from neuromuscular blockade in the anesthetised rat: a randomised controlled pilot study].

Objectives: Reductions in diaphragm activity are associated with the postoperative development of atelectasis. Neostigmine reversal is also associated with increased atelectasis. We assessed the effects of neostigmine, sugammadex, and spontaneous reversal on regional lung ventilation and airway flow.

Diaphragmatic and intercostal electromyographic activity during neostigmine, sugammadex and neostigmine-sugammadex-enhanced recovery after neuromuscular blockade: A randomised controlled volunteer study.

Background: Electromyographic activity of the diaphragm (EMGdi) during weaning from mechanical ventilation is increased after sugammadex compared with neostigmine.

Objective: To determine the effect of neostigmine on EMGdi and surface EMG (sEMG) of the intercostal muscles during antagonism of rocuronium block with neostigmine, sugammadex and neostigmine followed by sugammadex.

Design: Randomised, controlled, double-blind study.

Neuromuscular blockade: what was, is and will be.

Non-depolarizing neuromuscular blocking agents (NMBAs) produce neuromuscular blockade by competing with acetylcholine at the neuromuscular junction, whereas depolarizing NMBAs open receptor channels in a manner similar to that of acetylcholine. Problems with NMBAs include malignant hyperthermia caused by succinylcholine, anaphylaxis with the highest incidence for succinylcholine and rocuronium, and residual neuromuscular blockade. To reverse these blocks, anticholinesterases can act indirectly by increasing the amount of acetylcholine in the neuromuscular junction; sugammadex is the only selective relaxant binding agent (SRBA) in clinical use.

Electromyographic activity of the diaphragm during neostigmine or sugammadex-enhanced recovery after neuromuscular blockade with rocuronium: a randomised controlled study in healthy volunteers.

Background: The use of neuromuscular blocking agents has been associated with severe postoperative respiratory morbidity. Complications can be attributed to inadequate reversal, and reversal agents may themselves have adverse effects.

Objective: To compare the electromyographic activity of the diaphragm (EMGdi) during recovery from neuromuscular blockade using neostigmine and sugammadex.

Effect of sugammadex on QT/QTc interval prolongation when combined with QTc-prolonging sevoflurane or propofol anaesthesia.

Background: We evaluated the potential for QT/corrected QT (QTc) interval prolongation after sugammadex given with propofol or sevoflurane anaesthesia.

Methods: This was a two-factorial, randomized, parallel-group study in 132 healthy subjects. Anaesthesia was maintained with sevoflurane or propofol.

Management of tight intraoperative glycemic control during off-pump coronary artery bypass surgery in diabetic and nondiabetic patients.

Objectives: To optimize intra- and postoperative insulin management in cardiac surgical patients.

Design: A prospective, randomized, open-label, single-center study.

Setting: A large nonuniversity hospital.

Perioperative blood glucose management in patients undergoing tumor hepatectomy.

Study Objective: To determine whether our institutional insulin management (modified Atlanta) protocol is efficient and safe in controlling blood glucose levels in the perioperative period in surgical patients undergoing tumor hepatectomy.

Design: Retrospective study.

Setting: Large community hospital.

Tight perioperative glucose control is associated with a reduction in renal impairment and renal failure in non-diabetic cardiac surgical patients.

Introduction: Acute renal failure after cardiac surgery increases in-hospital mortality. We evaluated the effect of intra- and postoperative tight control of blood glucose levels on renal function after cardiac surgery based on the Risk, Injury, Failure, Loss, and End-stage kidney failure (RIFLE) criteria, and on the need for acute postoperative dialysis.

Methods: We retrospectively analyzed two groups of consecutive patients undergoing cardiac surgery with cardiopulmonary bypass between August 2004 and June 2006.

Dynamic tight glycemic control during and after cardiac surgery is effective, feasible, and safe.

Background: Tight blood glucose control reduces mortality and morbidity in critically ill patients, but intraoperative glucose control during cardiac surgery is often difficult, and risks hypoglycemia. In this study, we evaluated the safety and efficacy of a nurse-driven insulin protocol (the Aalst Glycemia Insulin Protocol) for achieving a target glucose level of 80-110 mg/dL during cardiac surgery and in the intensive care unit (ICU).

Methods: We included 483 nondiabetics and 168 diabetics scheduled for cardiac surgery with cardiopulmonary bypass.

Endoscopic cardiac tumor resection.

Background: The purpose of this study is to report our 9 years' experience with endoscopic cardiac tumor resection using the port access approach.

Methods: From March 1997 to December 2005, 27 patients (mean age, 56.2 +/- 16.

Muscle relaxation does not influence venous oxygen saturation during cardiopulmonary bypass.

Study Objective: To examine whether the omission of neuromuscular blocking drugs during cardiopulmonary bypass (CPB) is associated with increased anesthetic requirements, higher frequency of intraoperative movements, and lower venous oxygen saturation (SvO(2)).

Design: Prospective, randomized study.

Setting: Large community hospital.

Preinduction glycemia and body mass index are important predictors of perioperative insulin management in patients undergoing cardiac surgery.

Study Objective: To investigate whether preinduction glucose is an important predictor for perioperative insulin management in patients undergoing cardiac surgery.

Design: Prospective cohort study.

Setting: Large community hospital.

Effective reversal of moderate rocuronium- or vecuronium-induced neuromuscular block with sugammadex, a selective relaxant binding agent.

Background: Sugammadex rapidly reverses rocuronium-induced neuromuscular block. This study explored the dose-response relation of sugammadex given as a reversal agent at reappearance of the second muscle twitch after rocuronium- and vecuronium-induced block. A secondary objective was to investigate the safety of single doses of sugammadex.

Modified maze during endoscopic mitral valve surgery: the OLV Clinic experience.

Background: The use of radiofrequency ablation to perform the mini-maze procedure (pulmonary veins isolation) has been reported with good results. The aim of this study was to evaluate our practice with the association of the mini-maze procedure, done with the use of the Cardioblade pen, and minimally invasive mitral valve surgery.

Methods: From January 1999 to November 2004, 103 patients underwent a minimally invasive mitral valve surgery with a concomitant pulmonary veins isolation (modified maze procedure) done with unipolar radiofrequency.

Postoperative residual paralysis in outpatients versus inpatients.

Postoperative residual paralysis is an important complication of the use of neuromuscular blocking drugs. In this prospective study, the incidence of residual paralysis detected as a train-of-four response <90% was less frequent in surgical outpatients (38%) than inpatients (47%) (P = 0.001).

Intraoperative severity assessment of coronary artery stenosis in patients at risk: the role of transesophageal echocardiography.

A 71-yr-old male was scheduled for infrarenal abdominal aortic aneurysm repair. Although he had only minor clinical predictors for increased perioperative cardiovascular risk with >4 estimated metabolic equivalents for activities, intraoperative transesophageal echocardiography revealed an abnormal maximal-to-prestenotic blood flow velocity ratio in the left main coronary artery. Postoperatively, a severe distal left main coronary artery stenosis was confirmed with coronary angiography.

Criteria for immediate postoperative extubation in adult recipients following living-related liver transplantation with total intravenous anesthesia.

Study Objective: To evaluate whether our criteria for immediate postoperative extubation predicts successful extubation in living-related liver transplantation of the right lobe, and to test the effects of our standardized anesthetic technique on the success of immediate postoperative extubation.

Design: Open-label, descriptive study.

Setting: University hospital.