title: Reversal of rocuronium-induced neuromuscular blockade by sugammadex allows for optimization of neural monitoring of the recurrent laryngeal nerve.
abstract: OBJECTIVE
  The use of neuromuscular blocking agent may effect intraoperative neuromonitoring (IONM) during thyroid surgery. An enhanced neuromuscular-blockade (NMB) recovery protocol was investigated in a porcine model and subsequently clinically applied during human thyroid neural monitoring surgery.
  
  
  METHODS
  Prospective animal and retrospective clinical study.
  
  
  METHODS
  In the animal experiment, 12 piglets were injected with rocuronium 0.6 mg/kg and randomly allocated to receive normal saline, sugammadex 2 mg/kg, or sugammadex 4 mg/kg to compare the recovery of laryngeal electromyography (EMG). In a subsequent clinical application study, 50 patients who underwent thyroidectomy with IONM followed an enhanced NMB recovery protocol-rocuronium 0.6 mg/kg at anesthesia induction and sugammadex 2 mg/kg at the operation start. The train-of-four (TOF) ratio was used for continuous quantitative monitoring of neuromuscular transmission.
  
  
  RESULTS
  In our porcine model, it took 49 ± 15, 13.2 ± 5.6, and 4.2 ± 1.5 minutes for the 80% recovery of laryngeal EMG after injection of saline, sugammadex 2 mg/kg, and sugammadex 4 mg/kg, respectively. In subsequent clinical human application, the TOF ratio recovered from 0 to >0.9 within 5 minutes after administration of sugammadex 2 mg/kg at the operation start. All patients had positive and high EMG amplitude at the early stage of the operation, and intubation was without difficulty in 96% of patients.
  
  
  CONCLUSIONS
  Both porcine modeling and clinical human application demonstrated that sugammadex 2 mg/kg allows effective and rapid restoration of neuromuscular function suppressed by rocuronium. Implementation of this enhanced NMB recovery protocol assures optimal conditions for tracheal intubation as well as IONM in thyroid surgery.
  
  
  METHODS
  NA.
authors.affiliation: Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Anesthesiology , Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: I-Cheng
authors.initials: IC
authors.lastname: Lu
authors.affiliation: Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Otolaryngology-Head and Neck Surgery , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Che-Wei
authors.initials: CW
authors.lastname: Wu
authors.affiliation: Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Pi-Ying
authors.initials: PY
authors.lastname: Chang
authors.affiliation: Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Hsiu-Ya
authors.initials: HY
authors.lastname: Chen
authors.affiliation: Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Kuang-Yi
authors.initials: KY
authors.lastname: Tseng
authors.affiliation: Division of Thyroid and Parathyroid Surgery, Department of Laryngology and Otology , Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.|Massachusetts Eye and Ear Infirmary, and the Division of Surgical Oncology, Department of Surgery , Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Randolph
authors.affiliation: Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Anesthesiology , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Kuang-I
authors.initials: KI
authors.lastname: Cheng
authors.affiliation: Graduate Institute of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Faculty of Medicine , College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Otolaryngology-Head and Neck Surgery , Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Feng-Yu
authors.initials: FY
authors.lastname: Chiang
mesh_terms: D000328:Adult; D000368:Aged; D000732:Androstanols / Q000008:administration & dosage*; D000818:Animals; D004576:Electromyography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D019148:Neuromuscular Blockade / Q000379:methods*; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage*; D012009:Recurrent Laryngeal Nerve; D000077123:Rocuronium; D000077122:Sugammadex; D013552:Swine; D013965:Thyroidectomy; D047408:gamma-Cyclodextrins / Q000008:administration & dosage*
chemical_list: D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D000077123:Rocuronium
keywords: Intraoperative neuromonitoring; anesthesia; neuromuscular blocking agent; recurrent laryngeal nerve; sugammadex; thyroid surgery