Half dose sugammadex combined with neostigmine is non-inferior to full dose sugammadex for reversal of rocuronium-induced deep neuromuscular blockade: a cost-saving strategy

Abstract Background Sugammadex reverses the effect of rocuronium more rapidly and effectively than neostigmine, at all levels of neuromuscular blockade (NMB). However, its cost is prohibitive. The combination of half dose sugammadex with neostigmine would be non-inferior to full dose sugammadex for the reversal of deep NMB. This approach would reduce the cost of sugammadex while preserving its efficacy. Methods Patients were randomly allocated to receive sugammadex 4 mg/kg (Group S) or sugammadex 2 mg/kg with neostigmine 50 μg/kg and glycopyrrolate 10 μg/kg (Group NS) for reversal of rocuronium deep NMB. The primary outcome was the percentage of patients who recovered to 90% Train of Four (TOF) ratio within 5 min. The non-inferiority margin was set at 10%. Results Twenty eight patients were enrolled in each group. The number of patients who reached 90% TOF ratio within 5 min was 27 out of 28 (96%) in group S versus 25 out of 28 (89%) in group NS by intention-to-treat (difference: 7%, 95% CI of the difference: −9% to 24%). The number of patients who reached 90% TOF ratio within 5 min was 26 out of 26 (100%) in group S versus 23 out of 25 (92%) in group NS by per-protocol (difference: 8%, 95% CI of the difference: −6% to 25%). Conclusions Sugammadex 2 mg/kg with neostigmine 50 μg/kg was at worst 9% and 6% less effective than sugammadex 4 mg/kg by intention-to-treat and by per-protocol analysis respectively. Hence, the combination is non-inferior to the recommended dose of sugammadex. Trial registration Clinicaltrials.gov NCT 02375217 , registered on February 11, 201

International Clinical Guidelines at the American University of Beirut, Physical Therapy Department: Strategy of Implementation and Evaluation

Purpose. The purpose of the study is (1) to describe the selection process of an international clinical guideline (CGL) for patients with low back pain (LBP) for adoption and implementation at the Physical Therapy Department at the American University of Beirut Medical Center (AUBMC), and (2) to evaluate the physiotherapists’ compliance. Method. International guidelines were identified through a literature search and compared according to the AGREE instrument for selection. Quality indicators were selected. Physiotherapists were educated about guidelines’ benefits and the content of the adopted guidelines during interactive sessions; patients’ files were optimized and audited in order to evaluate compliance. Results. Out of six guidelines for LBP, we selected that of the Royal Dutch Association of Physiotherapy. Full adherence of physiotherapists to the educational sessions was noted. A total of 72 patient files were available. However, only 23 out of 72 files (32%) were complete to test the therapists’ adherence to the new assessment forms using 13 quality indicators. A high level of compliance with a mean score of 90% was recorded for the diagnostic process indicators, and a low level for the mean score of therapeutic process indicators (42%) except the indicator for the advice to stay active (100%). The mean score for the outcome of care was very low (13%). Conclusions. Dutch guidelines for low back pain were selected for adoption and implementation. A relatively high level of adherence to guidelines recommendations was noticed in the diagnostic process and a low level in the therapeutic process

End-Tidal CO

This prospective study included 32 patients undergoing cardiopulmonary bypass (CPB) for elective coronary artery bypass grafting correlates the respiratory end-tidal CO2 (ETCO2) during partial separation from CPB with cardiac output (CO) following weaning from CPB. After induction of general anesthesia, a pulmonary artery catheter was inserted for measurement of cardiac output by thermodilution. Patients were monitored using a 5-lead ECG, pulse oximeter, invasive blood pressure monitoring, rectal temperature probe, and end-tidal capnography. At the end of surgery, patients were weaned from CPB in a stepwise fashion. Respiratory ETCO2 and in-line venous oximetry were continuously monitored during weaning. The ETCO2 was recorded at quarter pump flow and after complete weaning from CPB. Following weaning from CPB, CO was measured by thermodilution. The CO values were correlated with the ETCO2 during partial bypass and following weaning from bypass. Regression analysis of ETCO2 at quarter-flow and post-bypass CO showed significant correlation (r = 0.57, p 30 mm Hg during partial CPB will always predict an adequate CO following weaning from CPB. An ETCO2 <30 mm Hg may denote either a low or a normal cardiac output and hence other predictive parameters such as SvO2 must be added

The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia

Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses. In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued. Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 +/- 0.011 microg x kg(-1) x min(-1)) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates. Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube

Excellent intubating conditions with remifentanil-propofol and either low-dose rocuronium or succinylcholine

The shortest time to tracheal intubation, the best intubating conditions, and the shortest duration of muscle paralysis are achieved with succinylcholine. During a lidocaine-remifentanil-propofol induction of anesthesia, we compared intubating conditions 90 s after administering low-dose rocuronium (0.3 mg center dot A kg(-1)) with intubating conditions 60 s after administering succinylcholine 1.5 mg center dot A kg(-1). The randomized double-blind study included 184 healthy adult patients scheduled for elective surgery. Anesthesia was induced in all patients with lidocaine 1.5 mg center dot A kg(-1), remifentanil 2 mu g center dot A kg(-1), and propofol 2 mg center dot A kg(-1) administered over 30 s. In one group, rocuronium 0.3 mg center dot A kg(-1) was administered before the induction sequence, and in the other group, succinylcholine 1.5 mg center dot A kg(-1) was administered after the induction sequence. Laryngoscopy was attempted 90 s after rocuronium administration and 60 s after succinylcholine administration. Intubating conditions were assessed as excellent, good, or poor on the basis of ease of laryngoscopy, position of the vocal cords, and reaction to insertion of the tracheal tube and cuff inflation. There were 92 patients per group. In the rocuronium group, intubating conditions were excellent in 83 patients (90%), good in 8 (9%), and poor in 1 (1%), not significantly different from the intubating conditions in the succinylcholine group, which were excellent in 88 patients (96%), good in 3 (3%), and poor in 1 (1%) (P = 0.3). During a lidocaine-remifentanil-propofol induction of anesthesia, rocuronium 0.3 mg center dot A kg(-1) administered before the induction sequence provides intubating conditions comparable to those achieved with succinylcholine 1.5 mg center dot A kg(-1) administered after the induction sequence

A Randomized Trial Comparing Colloid Preload to Coload During Spinal Anesthesia for Elective Cesarean Delivery

BACKGROUND: Hypotension after spinal anesthesia for cesarean delivery is common. Previous studies have demonstrated that a crystalloid fluid "coload" (rapid administration of a fluid bolus starting at the time of intrathecal injection) is superior to the conventional crystalloid preload (fluid administered before the intrathecal injection) for preventing hypotension. Colloid preload provides a sustained increase in central blood volume. We hypothesized that, in contrast to crystalloid, a colloid preload may be more effective than colloid coload for reducing the incidence of spinal anesthesia-induced hypotension. METHODS: In this double-blind study, 178 patients were randomly assigned to receive a preload of 500 mL of hydroxyethyl starch over a period of 15-20 min before initiation of spinal anesthesia (n = 90) or an identical fluid bolus of hydroxyethyl starch starting at the time of identification of cerebrospinal fluid (n = 88). Vasopressors (ephedrine or phenylephrine) were administered if systolic arterial blood pressure decreased less than 80% of the baseline pressure and <100 mm Hg, or with smaller decreases in blood pressure if accompanied by nausea, vomiting, or dizziness. The primary outcome was the incidence of hypotension (defined as the administration of at least one dose of vasopressor). RESULTS: There was no significant difference between the groups in the incidence of hypotension (68% in preload group and 75% in coload group, 95% confidence interval of difference -6%-20%; P = 0.28), doses of ephedrine and phenylephrine, and number of vasopressor unit doses. The incidence of severe hypotension (systolic blood pressure <80 mm Hg) was 16% in the preload group and 22% in the coload group (P = 0.30). There were no differences in the incidence of nausea and/or vomiting, or neonatal outcome between the groups. CONCLUSION: There was no difference in the incidence of hypotension in women who received colloid administration before the initiation of spinal anesthesia compared with at the time of initiation of anesthesia. Both modalities are inefficient as single interventions to prevent hypotension. (Anesth Analg 2009;109:1219-24