rocuronium and Obesity--Morbid

Topics: Adult; Body Mass Index; Dose-Response Relationship, Drug; Drug Dosage Calculations; Female; Humans; Ideal Body Weight; Male; Middle Aged; Models, Biological; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex; Vecuronium Bromide

This randomized, double-blind trial evaluated sugammadex-mediated recovery time from rocuronium- or vecuronium-induced moderate (M-) or deep (D-) neuromuscular block in morbidly obese adults dosed by actual (ABW) or ideal body weight (IBW).. ABW-based sugammadex dosing yields faster reversal without re-curarization, supporting ABW-based sugammadex dosing in the morbidly obese, irrespective of the depth of neuromuscular block or NMBA used.. Registered on November 17, 2017, at ClinicalTrials.gov under number NCT03346070 .

Topics: Anesthesia Recovery Period; Body Weight; Dose-Response Relationship, Drug; Double-Blind Method; Female; Humans; Ideal Body Weight; Male; Middle Aged; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex; Time Factors; Vecuronium Bromide

There is a controversy in the literature whether deep compared with moderate neuromuscular block (NMB) improves surgical conditions for laparoscopic surgery.. The primary outcome measure was to examine whether switching from moderate to deep NMB improves surgical conditions for laparoscopic surgery in the obese; secondary outcome measures were changes in intra-abdominal pressure, time required to perform the gastrojejunal anastomosis and peri-operative surgical complications.. A single-centre, randomised controlled study. Each patient was taken as their own control and examined twice: at the first evaluation (E1), all patients had a moderate NMB, thereafter patients were randomised to deep or moderate block and a second evaluation (E2) was performed within 10 min. Patients with excellent rating at E1 were excluded from E2, as their surgical condition could not be further improved.. University Hospital France.. Patients undergoing laparoscopic gastric bypass surgery under general anaesthesia were included. Main exclusion criteria were hypersensitivity to the drugs used and absence of written informed consent.. According to the group assignment, patients received bolus doses of rocuronium or 0.9% saline.. Surgical conditions were assessed with a 4-point rating scale. Intra-operative adverse events were assessed with the Kaafarani-classification and postoperative complications with the Clavien-Dindo classification.. Eighty-nine patients were initially included and data from 85 could be assessed at E1; surgical rating was excellent in 20, good in 35, acceptable in 18, poor in 12. After excluding those with an excellent rating, the remaining 65 patients were randomly assigned to deep or moderate block. At E2, an improvement of surgical conditions was observed in 29 out of 34 patients with deep block and in four out of 31 with moderate block; P < 0.0001. Poor surgical conditions were more frequently associated with surgical complications (61.5 versus 15.3%; P < 0.001).. Switching from moderate to deep block improves surgical conditions. Poor surgical conditions were associated with a higher incidence of surgical complications.. ClinicalTrials.gov identifier: NCT02118844.

Topics: Adult; Anesthesia, General; Double-Blind Method; Female; France; Gastric Bypass; Humans; Laparoscopy; Male; Middle Aged; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium

The majority of authors and the literature recommend sugammadex dose to be calculated according to RBW without taking fat content into consideration. Our aim was to compare the efficacy and safety of sugammadex at doses of 1.5, 2, and 4 mg/kg, calculated according to ideal body weight basis, for the reversal of moderate rocuronium-induced neuromuscular blockade in laparoscopic bariatric surgery.. One-hundred and eighty morbidly obese patients were randomly assigned into three groups according to sugammadex dose administrated (based on IBW after reaching T2 of TOF): Group I: patients were given 1.5 mg/kg. Group II: patients were given 2 mg/kg. Group III: patients were given 4 mg/kg. Both sugammadex and extubation times were recorded.. Sugammadex time was significantly longer in groups I and II versus III (P=0.000, 0.005 respectively). Difference between groups I and II was insignificant. The extubation time was insignificantly different in the three groups (P>0.05).. A dose of sugammadex of 1.5 mg/kg calculated according to IBW successfully reversed moderate rocuronium-induced NMB in laparoscopic bariatric surgeries.

Topics: Adolescent; Adult; Bariatric Surgery; Female; Humans; Ideal Body Weight; Laparoscopy; Male; Middle Aged; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex; Young Adult

In morbidly obese patients, the speed of reversal of neuromuscular blockade with sugammadex based on ideal body weight is still matter of debate. In this single-center, randomised, double-blinded study, neuromuscular blockade was monitored in 50 patients using acceleromyography at the adductor pollicis. At the end of surgery with deep rocuronium-induced neuromuscular blockade, patients randomly received sugammadex 4 mg.kg(-1) (high dose group), 2 mg.kg(-1) (middle dose group), or 1 mg.kg(-1) (low dose group) of ideal body weight. After administration of the first dose of sugammadex, the mean (SD) recovery time (censored at 600 s) from deep neuromuscular blockade was significantly shorter (p < 0.001) in the high-dose group (n = 14; 255 (63) s) vs the middle-dose group (n = 13; 429 (102) s), or low-dose group (n = 4; 581 (154) s). Success rate from neuromuscular blockade reversal defined by a train-of-four ≥ 0.9 within 10 min after sugammadex administration, were 93%, 77% and 22% for these high, middle and low-dose groups respectively (p < 0.05 vs low-dose group). In morbidly obese patients, 4 mg.kg(-1) of ideal body weight of sugammadex allows suitable reversal of deep rocuronium-induced neuromuscular blockade. Monitoring remains essential to detect residual curarisation or recurarisation.

Topics: Accelerometry; Adolescent; Adult; Aged; Androstanols; Dose-Response Relationship, Drug; Double-Blind Method; Electric Stimulation; Female; gamma-Cyclodextrins; Humans; Male; Middle Aged; Myography; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex; Young Adult

Complete and fast recovery of neuromuscular function is very important in morbidly obese patients because of the possible influence of postoperative residual curarization (PORC) on respiratory function in the postoperative period. Recent reports underline incidences of the residual influence of neuromuscular blocking agents.. Seventy morbidly obese (BMI >40 kg m(-2)) patients requiring general anaesthesia and receiving rocuronium for muscle relaxation were randomly assigned into two groups: at the end of the anaesthetic procedure, one group received sugammadex 2 mg kg(-1) of corrected body weight (Group SUG) and the other group received neostigmine 0.05 mg kg(-1) of CBW (Group NEO). At the end of surgery and when response reached a train-of-four (TOF) score of 2, patients received the study drugs. The neuromuscular function was recorded and time to achieve 90% of TOF (safe extubation) was measured. Patients were examined directly after arrival to the post-anaesthesia care unit (PACU) by a blinded investigator for the presence of PORC.. Thirty-five patients received sugammadex and 35 neostigmine. Mean dose of rocuronium was 87.9 vs 85.6 mg (P>0.05), mean time to 90% of TOF was 2.7 vs 9.6 min (P<0.05), and TOF at the PACU was 109.8% vs 85.5% (P<0.05) in Groups SUG and NEO, respectively.. Administration of sugammadex provides fast recovery of neuromuscular function and prevents PORC in the morbidly obese, however neostigmine does not.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Anthropometry; Bariatric Surgery; gamma-Cyclodextrins; Humans; Middle Aged; Monitoring, Physiologic; Neostigmine; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Prospective Studies; Rocuronium; Sugammadex; Young Adult

Topics: Adult; Androstanols; Bariatric Surgery; Female; Humans; Intubation, Intratracheal; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Prospective Studies; Rocuronium; Single-Blind Method; Time Factors; Young Adult

To date, the dosing of sugammadex is based on real body weight without taking fat content into account. We compared the reversal of profound rocuronium-induced neuromuscular blockade in morbidly obese patients using doses of sugammadex based on four different weight corrections. One hundred morbidly obese patients, scheduled for laparoscopic bariatric surgery under propofol-sufentanil anaesthesia, were randomly assigned four groups: ideal body weight; ideal body weight + 20%; ideal body weight + 40%; and real body weight. Patients received sugammadex 2 mg.kg(-1), when adductor pollicis monitoring showed two responses. The primary endpoint was full decurarisation. Secondary endpoints were the ability to get into bed independently on arrival to the post-anaesthetic care unit and clinical signs of residual paralysis. There was no residual paralysis in any patient. Morbidly obese patients can safely be decurarised from rocuronium-induced neuromuscular blockade T1-T2 with sugammadex dosed at 2 mg.kg(-1) ideal body weight + 40% (p < 0.0001).

Topics: Adult; Androstanols; Anesthesia Recovery Period; Bariatric Surgery; Body Weight; Dose-Response Relationship, Drug; Female; gamma-Cyclodextrins; Humans; Laparoscopy; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex; Young Adult

To compare tracheal intubation conditions in morbidly obese patients 60 seconds after administration of succinylcholine or rocuronium doses based on real weight or ideal weight.. We evaluated patients with a body mass index (BMI) of 40 kg x m(-2) or more but no other indications of difficult-intubation risk. Induction was performed under fentanyl and propofol at doses calculated based on real weight. Patients were assigned to 1 of 4 groups for tracheal intubation. Group 1 received 1 mg of succinylcholine per kilogram of ideal weight, group 2 received 1 mg of succinylcholine per kilogram of real weight, group 3 received 0.6 mg of rocuronium per kilogram of ideal weight, and group 4 received 0.6 mg of rocuronium per kilogram of real weight. Tracheal intubation was performed 60 seconds later and intubation conditions were recorded using a clinical scoring system.. Eighty patients with a mean BMI of 47.5 kg x m(-2) were enrolled. The difficult intubation rate was 3.75%. All patients were intubated. Laryngoscopy conditions and position and movement of vocal cords were similar in all 4 groups. Reaction to cuff inflation revealed intergroup differences; group 3 presented slight limb movements, diaphragm movement, and sustained cough for more than 10 seconds.. These results suggest that administration of succinylcholine calculated based on real weight or ideal weight and rocuronium based on real weight can provide clinically acceptable conditions for tracheal intubation in morbidly obese patients with no other difficult-intubation criteria.

Topics: Adult; Androstanols; Body Weight; Cough; Diaphragm; Dose-Response Relationship, Drug; Female; Humans; Hypoxia; Intraoperative Complications; Intubation, Intratracheal; Male; Middle Aged; Movement; Muscle Relaxation; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Respiratory Aspiration; Risk; Rocuronium; Succinylcholine; Vocal Cords

We investigated the pharmacodynamic effects of rocuronium on morbidly obese patients. Twelve morbidly obese female patients (body mass index >40 kg/m(2)) admitted for laparoscopic gastric banding were randomized into two groups. Group 1 (n = 6) received 0.6 mg/kg of rocuronium based on real body weight, whereas Group 2 (n = 6) received 0.6 mg/kg of rocuronium based on ideal body weight. In a control group of six normal-weight female patients admitted for laparoscopic surgery, rocuronium was dosed on the basis of their real body weight. Neuromuscular transmission was monitored by using acceleromyography of the adductor pollicis; anesthesia was induced and maintained with remifentanil and propofol. The onset time tended to be shorter in Group 1 and the control group compared with Group 2, but this did not achieve statistical significance. Duration of action to 25% of twitch tension was more than double in Group 1 (55 min) compared with the other two groups (22 and 25 min; P < 0.001). Duration of action was similar between Group 2 and control. Recovery index tended to be longer in Group 1, but without a significant difference. In conclusion, in morbidly obese patients, the duration of action of rocuronium is significantly prolonged when it is dosed according to real body weight. Therefore, the dosage should be assessed on the basis of ideal rather than on real body weight in clinical practice.

Topics: Adult; Aging; Androstanols; Anesthesia Recovery Period; Body Mass Index; Body Weight; Calibration; Female; Gastric Bypass; Humans; Laparoscopy; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sex Characteristics; Stomach

Topics: Adolescent; Adult; Aging; Androstanols; Anesthesia Recovery Period; Body Mass Index; Body Weight; Female; Humans; Infusions, Intravenous; Middle Aged; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Prospective Studies; Rocuronium

Deep neuromuscular block (NMB) and opioid-free anaesthesia (OFA) improve surgical workspace and reduce post-operative opioid consumption, but its impact on perioperative outcomes is unknown. This observational study compared complications and healthcare resource utilization after bariatric surgery, with or without continuous deep NMB or OFA.. We included all 9246 patients who underwent laparoscopic bariatric surgery at our institution from January 2009 to February 2017. Continuous clinical deep NMB was defined as receiving a continuous infusion of rocuronium with a dose of > 1 mg/kg IBW for each hour or sugammadex > 2 mg/kg total body weight at the time of reversal. We analysed the effect of continuous clinical deep NMB and OFA and covariates on 1 month post-operative complications using the Clavien-Dindo (CD) classification (grades II-V) and healthcare utilization (hospital length of stay [LOS], rates of reoperations within 1 week, high-dependency care unit admissions, and readmissions within 1 month). Covariates included experience of the attending anaesthesiologist, patient age, sex, body mass index, American Society of Anesthesiologists physical status score, obstructive sleep apnoea syndrome, diabetes, hypertension, surgery type, surgical team experience, and neostigmine use.. OFA, continuous deep NMB, surgical and anaesthesia team experience, younger age, and surgery type were associated with fewer complications. OFA was associated with lower healthcare resource utilization. Reduced LOS was also associated with younger age, surgical team experience, and surgery type, but not continuous deep NMB.. Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery.

Topics: Adult; Anesthesia, General; Bariatric Surgery; Female; Humans; Intraoperative Complications; Laparoscopy; Male; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Postoperative Complications; Regression Analysis; Retrospective Studies; Risk Factors; Rocuronium; Sugammadex

Topics: Androstanols; gamma-Cyclodextrins; Humans; Neuromuscular Blockade; Obesity, Morbid; Rocuronium; Sugammadex

An unanticipated difficult airway during induction of anesthesia can be a vexing problem. In the setting of can't intubate, can't ventilate (CICV), rapid recovery of spontaneous ventilation is a reasonable goal. The urgency of restoring ventilation is a function of how quickly a patient's hemoglobin oxygen saturation decreases versus how much time is required for the effects of induction drugs to dissipate, namely the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade. It has been suggested that prompt reversal of rocuronium-induced neuromuscular blockade with sugammadex will allow respiratory activity to recover before significant arterial desaturation. Using pharmacologic simulation, we compared the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade in normal, obese, and morbidly obese body sizes in this life-threatening CICV scenario. We hypothesized that although neuromuscular function could be rapidly restored with sugammadex, significant arterial desaturation will occur before the recovery from unresponsiveness and/or central ventilatory depression in obese and morbidly obese body sizes.. We used published models to simulate the duration of unresponsiveness and ventilatory depression using a common induction technique with predicted rates of oxygen desaturation in various size patients and explored to what degree rapid reversal of rocuronium-induced neuromuscular blockade with sugammadex might improve the return of spontaneous ventilation in CICV situations.. Our simulations showed that the duration of neuromuscular blockade was longer with 1.0 mg/kg succinylcholine than with 1.2 mg/kg rocuronium followed 3 minutes later by 16 mg/kg sugammadex (10.0 vs 4.5 minutes). Once rocuronium neuromuscular blockade was completely reversed with sugammadex, the duration of hemoglobin oxygen saturation >90%, loss of responsiveness, and intolerable ventilatory depression (a respiratory rate of ≤4 breaths/min) were dependent on the body habitus and duration of oxygen administration. There is a high probability of intolerable ventilatory depression that extends well beyond the time when oxygen saturation decreases <90%, especially in obese and morbidly obese patients. If ventilatory rescue is inadequate, oxygen desaturation will persist in the latter groups, despite full reversal of neuromuscular blockade. Depending on body habitus, the duration of intolerable ventilatory depression after sugammadex reversal may be as long as 15 minutes in 5% of individuals.. The clinical management of CICV should focus primarily on restoration of airway patency, oxygenation, and ventilation consistent with the American Society of Anesthesiologist's practice guidelines for management of the difficult airway. Pharmacologic intervention cannot be relied upon to rescue patients in a CICV crisis.

Topics: Adult; Androstanols; Anesthesia Recovery Period; Anesthesia, General; Biomarkers; Body Mass Index; Computer Simulation; gamma-Cyclodextrins; Humans; Intubation, Intratracheal; Lung; Male; Models, Theoretical; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Obesity; Obesity, Morbid; Oxyhemoglobins; Pulmonary Ventilation; Recovery of Function; Respiration, Artificial; Respiratory Center; Risk Factors; Rocuronium; Succinylcholine; Sugammadex; Time Factors

Topics: Androstanols; Anesthesia, General; Bariatric Surgery; Electric Impedance; Female; gamma-Cyclodextrins; Humans; Middle Aged; Monitoring, Intraoperative; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Respiratory Mechanics; Rocuronium; Sugammadex; Tomography

Topics: Androstanols; Anesthesia, General; Anesthetics; Drug Synergism; Female; gamma-Cyclodextrins; Humans; Hypertension; Magnesium Sulfate; Middle Aged; Myocardial Ischemia; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Sugammadex

Topics: Adult; Androstanols; Anesthesia, General; Female; gamma-Cyclodextrins; Humans; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Postoperative Period; Respiratory Insufficiency; Rocuronium; Sugammadex; Time Factors

Topics: Adult; Anaphylaxis; Androstanols; Anesthesia; Blood Pressure; Colostomy; Dose-Response Relationship, Drug; Epinephrine; Female; gamma-Cyclodextrins; Humans; Hypotension; Intraoperative Complications; Neuromuscular Nondepolarizing Agents; Obesity, Morbid; Rocuronium; Spinal Dysraphism; Sugammadex; Vasoconstrictor Agents