• Humans
• Male
• Neuromuscular Blockade/methods
• Female
• Retrospective Studies
• Cross-Sectional Studies
• Middle Aged
• Aged
• Renal Insufficiency/physiopathology
• Rocuronium/administration & dosage
• Sugammadex/administration & dosage
• Neuromuscular Nondepolarizing Agents
• Neostigmine/administration & dosage
• Neuromuscular Blocking Agents
• Glomerular Filtration Rate
• Atracurium/analogs & derivatives
• Registries
• Adult

• K08 HL159327 NHLBI NIH HHS

The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.

• Dialysis
• Sedation
• Critical care
• Anaesthesia
• Intensive care
• Pharmacology
• Renal impairment

• coronary artery bypass grafting (CABG)
• fast-track extubation (FTE)
• neuromuscular blockade (NMB) reversal
• sugammadex
• train-of-four (TOF)

• Not applicable William Carey University

• Aged
• Female
• Humans
• Male
• Middle Aged
• Cohort Studies
• Inpatients
• Neuromuscular Blocking Agents
• Renal Insufficiency
• Retrospective Studies
• Surgical Procedures, Operative

• K08 HL159327 NHLBI NIH HHS

• NSCLC
• chemotherapy
• epidural anesthesia
• general anesthesia
• histological
• hospital stay
• hydromorphone
• midazolam
• phenylephrine
• post-anesthesia care unit
• radiotherapy
• remifentanil
• rocuronium bromide

• Child-Pugh grades
• diaphragm ultrasonography
• neuromuscular monitoring
• postoperative residual curarization
• rocuronium
• sugammadex

• Wu Jieping Medical Foundation

• anesthesia
• neuromuscular blocking agent
• perioperative care
• quantitative monitoring
• residual neuromuscular block

• anesthesia
• anesthetic management
• body mass index
• obesity
• surgery

Rocuronium, a nondepolarizing muscle relaxant, is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery. Sugammadex, the selective reversal agent of rocuronium, fully reverses the neuromuscular blockade (NMB) at the end of surgery. Most reports show that sugammadex rapidly achieves a ratio of train-of-four (TOF), a quantitative method of neuromuscular monitoring, of 0.9 which ensures adequate recovery for safe extubation. However, very rare patients with neuromuscular diseases may respond poorly to sugammadex.

A 69-year-old female presented with abdominal fullness and nausea, and was diagnosed with gastroparesis. She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium (0.7 mg/kg). At the end of surgery, sugammadex 3.6 mg/kg was administered when TOF showed 2 counts. Afterward, the TOF ratio recovered to 0.65 in 30 min. She was awake but could not fully open her eyelids. The tidal volume during spontaneous breathing was low. After additional doses of sugammadex (up to 7.3 mg/kg) in the following 3 h, the TOF ratio was 0.9, and the endotracheal tube was smoothly removed. After excluding possible mechanisms underlying the prolonged recovery course, we speculated our patient may have had an undiagnosed neuromuscular disease, hinted by her involuntary movement of the tongue and mouth. Furthermore, her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.

In our case, both prolonged rocuronium-induced NMB and poor response to sugammadex were noted. To optimize the dose of rocuronium, perioperative TOF combined with other neuromuscular monitoring is suggested.

• Sugammadex
• Train-of-four
• Rocuronium
• Neuromuscular blockade
• General anesthesia
• Case report

The aim is to investigate and compare the anesthesia effect of cisatracurium besylate and mivacurium chloride otolaryngology surgery.

108 patients who underwent ENT surgery under general anesthesia in our hospital from November 2021 to March 2022 were recruited for retrospective analysis, in which patients in the experimental group A were anesthetized with cisatracurium besylate and patients in the experimental group B were anesthetized with mivacurium, and the anesthetic effects and recovery of the two groups were compared and analyzed.

There was no significant difference in mean arterial pressure, heart rate, and pulse oximetry levels between the two groups at the six time points of admission, anesthesia induction, intubation, end of operation, recovery of consciousness, and extubation (all P > 0.05). The train of four stimulation values at end of operation, recovery of consciousness, and extubation were significantly higher than those of the experimental group A (all P > 0.05). The recovery time of self-consciousness, extubation time, and eye-opening time of the experimental group B were significantly shorter than those of the experimental group A, and the occurrence of agitation was significantly less than that of the experimental group A (all P > 0.05). The total incidence of adverse conditions in the experimental group B was significantly lower than that in the experimental group A (P > 0.05).

Compared with cisatracurium besylate in otolaryngology surgery, mivacurium chloride anesthesia offers a promising route with respect to less impact on hemodynamics, faster postoperative recovery, absence of the accumulation of neuromuscular blockade, less adverse reactions, and higher safety.

Neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is administered, but surveys have demonstrated inconsistent monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine neuromuscular monitoring and consistent reversal practice.

Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture. Interviews were conducted at five Danish and one US hospital. Data were analysed using template analysis.

Danish anaesthetists used objective neuromuscular monitoring when administering a non‐depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective neuromuscular monitoring, objective neuromuscular monitoring was generally not available and most had not used it. Danish anaesthetists used neuromuscular monitoring to assess readiness for extubation, whereas US residents used subjective neuromuscular monitoring, clinical tests like 5‐second head lift and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and monitoring use. Barriers to consistent and correct neuromuscular monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of neuromuscular blocking agents and residual block, lack of standards and guidelines and departmental culture.

Using qualitative methods, we found that though Danish anaesthetists generally apply objective neuromuscular monitoring routinely and residents at the US institution often apply subjective neuromuscular monitoring, barriers to consistent and correct use still exist.

• focus group interview
• neuromuscular blocking agent
• neuromuscular monitoring
• qualitative methods

Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use.

It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.

• Critical care
• Intensive care unit
• Neuromuscular blockade
• Neuromuscular blocking agents
• Neuromuscular monitoring
• Pharmacologic antagonism

• Liver transplantation
• Neostigmine
• Recovery time
• Reversal
• Rocuronium

• Anesthesia Recovery Period
• Cholinesterase Inhibitors/pharmacology
• Female
• Humans
• Infusions, Intravenous
• Liver Transplantation
• Male
• Middle Aged
• Neostigmine/pharmacology
• Neuromuscular Nondepolarizing Agents/administration & dosage
• Rocuronium/administration & dosage
• Sugammadex/pharmacology

• Anesthesia
• Perioperative
• Renal failure
• Renal replacement therapy

• anaesthesia
• ophthalmology
• small animals
• surgery

• Anesthesia management
• Goal directed therapy
• Resuscitation
• Sepsis
• Septic shock

• Anesthesiologists
• Blood Transfusion
• Fluid Therapy
• Hemodynamics/physiology
• Humans
• Neuromuscular Blocking Agents/therapeutic use
• Perioperative Care
• Physician's Role
• Sepsis/complications
• Sepsis/therapy
• Shock, Septic/complications
• Shock, Septic/therapy
• Vasoconstrictor Agents/therapeutic use

Pediatric acute liver failure is a rapidly progressive, life-threatening, and devastating illness in children without preexisting liver disease. Due to the rarity and heterogeneity of this syndrome, there is a significant lack of data to guide evaluation and management of this disease. Most of our practice is extrapolated from adult literature and guidelines. This leads to significant controversies in medical management of acute liver failure in children. With advances in critical care, there has been a tremendous improvement in outcomes with decreased morbidity and mortality; however, there is a dire need for more research in this field. This chapter discusses challenges as well as controversies in diagnostic evaluation and management of this rare but potentially fatal disease. Latest developments in supportive care of liver failure, including advances in the area of liver support systems, are also discussed.

• acute liver failure
• pediatric
• multi-organ system failure
• hepatic encephalopathy
• liver support systems
• liver transplantation

• Acute liver failure
• Coagulopathy
• Hepatic encephalopathy
• Liver transplantation
• Multi-organ system failure
• Pediatric

Neuromuscular blockade plays an important role in the safe management of patient airways, surgical field improvement, and respiratory care. Rapid-sequence induction of anesthesia is indispensable to emergency surgery and obstetric anesthesia, and its purpose is to obtain a stable airway, adequate depth of anesthesia, and appropriate respiration within a short period of time without causing irritation or damage to the patient. There has been a continued search for new neuromuscular blocking drugs (NMBDs) with a rapid onset of action. Factors that affect the onset time include the potency of the NMBDs, the rate of NMBDs reaching the effect site, the onset time by dose control, metabolism and elimination of NMBDs, buffered diffusion to the effect site, nicotinic acetylcholine receptor subunit affinity, drugs that affect acetylcholine (ACh) production and release at the neuromuscular junction, drugs that inhibit plasma cholinesterase, presynaptic receptors responsible for ACh release at the neuromuscular junction, anesthetics or drugs that affect muscle contractility, site and methods for monitoring neuromuscular function, individual variability, and coexisting disease. NMBDs with rapid onset without major adverse events are expected in the next few years, and the development of lower potency NMBDs will continue. Anesthesiologists should be aware of the use of NMBDs in the management of anesthesia. The choice of NMBD and determination of the appropriate dosage to modulate neuromuscular blockade characteristics such as onset time and duration of neuromuscular blockade should be considered along with factors that affect the effects of the NMBDs. In this review, we discuss the factors that affect the onset time of NMBDs.

• Acetylcholine receptor
• Anesthesia
• Drug interactions
• Neuromuscular junction
• Neuromuscular monitoring
• Non-depolarizing neuromuscular blocking agents
• Onset time
• Pharmacodynamics
• Pharmacokinetics

• duchenne muscular dystrophy
• neuromuscular blocking agents
• pediatrics
• sugammadex

• Androstanols/antagonists & inhibitors
• Anesthesia, General
• Child
• Humans
• Male
• Muscular Dystrophy, Duchenne
• Neuromuscular Blockade/methods
• Neuromuscular Nondepolarizing Agents/antagonists & inhibitors
• Rocuronium
• Sugammadex
• gamma-Cyclodextrins/pharmacology

The aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen for neuromuscular block (NMB) management.

We conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium–sugammadex) and as rescue therapy after neostigmine reversal (rocuronium–neostigmine–sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen was carried out. To such purpose, two periods were compared: 2011–2012, without sugammadex available; 2013–2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective.

The introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P<0.001) and were discharged to the surgical ward (P<0.001) more rapidly than controls. The cost-saving of sugammadex as first-choice reversal drug has been estimated to be €2.9/case. Patients receiving sugammadex as rescue therapy after neostigmine reversal (3.2%) showed no difference in time to discharge to the surgical ward (P=0.44) compared to controls. No unplanned intensive care unit (ICU) admissions with rocuronium–neostigmine–sugammadex strategy were observed. The potential economic benefit in avoiding postoperative residual curarization (PORC)-related ICU admission in the 2013–2014 period was estimated at an average value of €13,548 (€9,316–€23,845).

Sugammadex eliminated PORC and associated morbidities. In our center, sugammadex reduced the costs of NMB management and promoted rapid turnover of patients in operating rooms, with total cost-effectiveness that counteracts the disadvantages of its high cost.

• cost-benefit analysis
• neuromuscular blockade
• neuromuscular blocking agents
• postoperative residual curarization
• rocuronium
• sugammadex

Sugammadex is a reversal agent with well known advantages but it’s effects on haemostasis and bleeding have been a topic of interest. Septoplasty is a common surgical procedure with postoperative respiratory complications and bleeding. The aim of this study is to investigate the effects of sugammadex on postoperative coagulation parameters and bleeding after septoplasty procedure.

In this randomized controlled study, fifty patients were grouped into two groups; neostigmine (Group N) vs. sugammadex (Group S). For the evaluation of PT, aPTT and INR, blood samples were taken for at the postoperative 120^th minutes and alteration of these values with respect to preoperative values were documented. Postoperative bleeding was measured by evaluating the amount of blood absorbed on the nasal tip dressing during 3 hours postoperatively.

Postoperative bleeding amount was significantly higher in the Group S compared to Group N (p=0.013). No significant difference was observed between two groups according to coagulation parameters (PT; p=0.953, aPTT; p=0.734, INR; p=0.612).

Sugammadex was associated with higher amount of postoperative bleeding than neostigmine in septoplasty patients. In surgical procedures having high risk of bleeding the safety of sugammadex need to be verified.

• digestive system surgical procedures: hepatic
• gamma-Cyclodextrins: sugammadex
• liver diseases
• neuromuscular blockade
• neuromuscular nondepolarizing agents: rocuronium

• Androstanols/adverse effects
• Androstanols/antagonists & inhibitors
• Androstanols/blood
• Anesthesia Recovery Period
• Chelating Agents/administration & dosage
• Chelating Agents/pharmacology
• Chelating Agents/therapeutic use
• Clinical Trials as Topic/statistics & numerical data
• Drug Approval
• Europe
• Humans
• Neuromuscular Blockade/adverse effects
• Neuromuscular Junction/drug effects
• Neuromuscular Nondepolarizing Agents/adverse effects
• Neuromuscular Nondepolarizing Agents/antagonists & inhibitors
• Neuromuscular Nondepolarizing Agents/blood
• Postoperative Complications/chemically induced
• Postoperative Complications/drug therapy
• Receptors, Cholinergic/drug effects
• Rocuronium
• Sensation Disorders/chemically induced
• Sugammadex
• Vecuronium Bromide/adverse effects
• Vecuronium Bromide/antagonists & inhibitors
• Vecuronium Bromide/blood
• Vomiting/chemically induced
• gamma-Cyclodextrins/administration & dosage
• gamma-Cyclodextrins/adverse effects
• gamma-Cyclodextrins/pharmacology
• gamma-Cyclodextrins/therapeutic use