Ann Surg Treat Res.  2019 Dec;97(6):282-290. 10.4174/astr.2019.97.6.282.

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial

• Gunes ME
• Dural AC
• Akarsu C
• Guzey D
• Sahbaz NA
• Tulubas EK
• Bulut S
• Donmez T

• KMID: 2464783
• DOI: http://doi.org/10.4174/astr.2019.97.6.282

Abstract

PURPOSE
The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery.
METHODS
The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission.
RESULTS
In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups.
CONCLUSION
Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Keyword

Neuromuscular blockade; Recurrent laryngeal nerve; Sugammadex; Thyroidectomy

MeSH Terms

Anesthesia
Clinical Study
Electromyography
Humans
Intubation
Neuromuscular Blockade
Neuromuscular Blocking Agents
Paralysis
Peripheral Nerves
Prospective Studies
Recurrent Laryngeal Nerve
Thyroid Gland*
Thyroidectomy
Neuromuscular Blocking Agents

Figure

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  Fig. 1 Flowchart diagram of the study. RLN, recurrent laryngeal nerve.

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  Fig. 2 The electromyography (EMG) values of the vagus nerve. Group A, control group; group B, sugammadex group.

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  Fig. 3 Train-of-four (TOF) values of group B. Group B, sugammadex group.

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  Fig. 4 Train-of-four (TOF) values of group A. Group A, control group.

Reference

1. Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope. 2002; 112:124–133.

2. Dionigi G, Dionigi R. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation: to the editor. World J Surg. 2010; 34:2794–2795.

3. Dralle H, Sekulla C, Lorenz K, Brauckhoff M, Machens A. German IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008; 32:1358–1366.

4. Kim SJ, Lee KE, Oh BM, Oh EM, Bae DS, Choi JY, et al. Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during robotic thyroid surgery: a preliminary prospective study. Ann Surg Treat Res. 2015; 89:233–239.

5. Barczynski M, Konturek A, Cichon S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009; 96:240–246.

6. Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery--a meta-analysis. J Formos Med Assoc. 2013; 112:463–472.

7. Angelos P. Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues. Surg Clin North Am. 2009; 89:1157–1169.

8. Randolph GW, Kamani D. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve during thyroid and parathyroid surgery: experience with 1,381 nerves at risk. Laryngoscope. 2017; 127:280–286.

9. Shindo M, Chheda NN. Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg. 2007; 133:481–485.

10. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010; 34:223–229.

11. Lee C, Jahr JS, Candiotti KA, Warriner B, Zornow MH, Naguib M. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology. 2009; 110:1020–1025.

12. Marusch F, Hussock J, Haring G, Hachenberg T, Gastinger I. Influence of muscle relaxation on neuromonitoring of the recurrent laryngeal nerve during thyroid surgery. Br J Anaesth. 2005; 94:596–600.

13. Wu CW, Wang MH, Chen CC, Chen HC, Chen HY, Yu JY, et al. Loss of signal in recurrent nerve neuromonitoring: causes and management. Gland Surg. 2015; 4:19–26.

14. Lu IC, Wu CW, Chang PY, Chen HY, Tseng KY, Randolph GW, et al. Reversal of rocuronium-induced neuromuscular blockade by sugammadex allows for optimization of neural monitoring of the recurrent laryngeal nerve. Laryngoscope. 2016; 126:1014–1019.

15. Kopman AF, Zank LM, Ng J, Neuman GG. Antagonism of cisatracurium and rocuronium block at a tactile train-of-four count of 2: should quantitative assessment of neuromuscular function be mandatory? Anesth Analg. 2004; 98:102–106.

16. Pavoni V, Gianesello L, Martinelli C, Horton A, Nella A, Gori G, et al. Recovery of laryngeal nerve function with sugammadex after rocuronium-induced profound neuromuscular block. J Clin Anesth. 2016; 33:14–19.

17. Kovac AL. Sugammadex: the first selective binding reversal agent for neuromuscular block. J Clin Anesth. 2009; 21:444–453.

18. Duvaldestin P, Kuizenga K, Saldien V, Claudius C, Servin F, Klein J, et al. A randomized, dose-response study of sugammadex given for the reversal of deep rocuronium- or vecuronium-induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg. 2010; 110:74–82.

19. Barczynski M, Randolph GW, Cernea CR, Dralle H, Dionigi G, Alesina PF, et al. External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement. Laryngoscope. 2013; 123 Suppl 4:S1–S14.

20. Dralle H, Lorenz K. Intraoperative neuromonitoring of thyroid gland operations: Surgical standards and aspects of expert assessment. Chirurg. 2010; 81:612–619.

21. Gonzalez-Sanchez C, Franch-Arcas G, Gomez-Alonso A. Morbidity following thyroid surgery: does surgeon volume matter? Langenbecks Arch Surg. 2013; 398:419–422.

22. Randolph GW, Dralle H. International Intraoperative Monitoring Study Group. Abdullah H, Barczynski M, Bellantone R, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011; 121 Suppl 1:S1–S16.

23. Dionigi G, Kim HY, Wu CW, Lavazza M, Ferrari C, Leotta A, et al. Vagus nerve stimulation for standardized monitoring: technical notes for conventional and endoscopic thyroidectomy. Surg Technol Int. 2013; 23:95–103.

24. Wu CW, Dionigi G, Chen HC, Chen HY, Lee KW, Lu IC, et al. Vagal nerve stimulation without dissecting the carotid sheath during intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery. Head Neck. 2013; 35:1443–1447.

25. Chiang FY, Lu IC, Tsai CJ, Hsiao PJ, Lee KW, Wu CW. Detecting and identifying nonrecurrent laryngeal nerve with the application of intraoperative neuromonitoring during thyroid and parathyroid operation. Am J Otolaryngol. 2012; 33:1–5.

26. Yamamoto S, Yamamoto Y, Kitajima O, Maeda T, Suzuki T. Reversal of neuromuscular block with sugammadex: a comparison of the corrugator supercilii and adductor pollicis muscles in a randomized dose-response study. Acta Anaesthesiol Scand. 2015; 59:892–901.

27. Empis de Vendin O, Schmartz D, Brunaud L, Fuchs-Buder T. Recurrent laryngeal nerve monitoring and rocuronium: a selective sugammadex reversal protocol. World J Surg. 2017; 41:2298–2303.

28. Lu IC, Chu KS, Tsai CJ, Wu CW, Kuo WR, Chen HY, et al. Optimal depth of NIM EMG endotracheal tube for intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroidectomy. World J Surg. 2008; 32:1935–1939.

29. Suy K, Morias K, Cammu G, Hans P, van Duijnhoven WG, Heeringa M, et al. Effective reversal of moderate rocuronium-or vecuronium-induced neuromuscular block with sugammadex, a selective relaxant binding agent. Anesthesiology. 2007; 106:283–288.

30. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014; 188:152–161.