Raval Amit D, Uyei Jennifer, Karabis Andreas, Bash Lori D, Brull Sorin J
Merck & Co., Inc., Center for Observational and Real-World Evidence, 2000 Galloping Hill Rd., Kenilworth, NJ 07033, USA.
IQVIA, Inc. 135 Main Street, San Francisco, CA 94105, USA.
J Clin Anesth. 2020 Apr 15;64:109818. doi: 10.1016/j.jclinane.2020.109818.
Neuromuscular blocking agents (NMBAs) have revolutionized the field of anesthesiology as they facilitate airway management and ensure optimal surgical conditions. Despite their beneficial and ubiquitous use during surgery, delayed or partial recovery from NMBAs, referred to as residual neuromuscular block (rNMB), is a common clinical problem. While it is well accepted that the antagonist sugammadex, compared to neostigmine, can more rapidly reverse rocuronium-induced NMB regardless of depth of block, the occurrence of rNMB for routinely used combinations of NMBAs with sugammadex or neostigmine has not yet been quantified or evaluated systematically.
We conducted a systematic literature review and meta-analysis of randomized controlled trials (RCTs) to quantify and compare the incidence of rNMB [defined as train-of-four ratio (TOFR) <0.9] in patients with moderate and deep neuromuscular block. Methods recommended by Cochrane Collaboration and PRISMA group were followed.
A total of 35 RCTs were identified, of which 20 contributed to the meta-analysis. For moderate block, rNMB incidence at 2 min after sugammadex administration was 19.2% (95% CI 0.0-57.8; 122 patients) and declined to 2.8% (95% CI 0.0-16.7; 93 patients) at 6 min post administration. For timepoints 10 to 60 min after administration, rNMB incidence ranged between 0.05% to 2.8%. In contrast, rNMB incidence at 2 min after neostigmine administration was 100% (95% CI 89.9-100; 182 patients) and was 82% (95% CI 71.4-91.2; 93 patients) at 6 min post administration. For timepoints 10 to 60 min after administration, rNMB incidence ranged between 14 and 32%. For deep block, rNMB incidence following sugammadex was essentially reduced to 1% at 15 min after administration. Residual NMB incidence following neostigmine remained at or above 95% for the first 60 min after administration.
Overall, based on evidence from 20 RCTs, our results suggest that the combination of rocuronium or vecuronium plus sugammadex is more effective and more rapid in reversing NMB compared with combinations of rocuronium, vecuronium, cisatracurium, or pancuronium plus neostigmine.
神经肌肉阻滞剂（NMBAs）彻底改变了麻醉学领域，因为它们有助于气道管理并确保最佳手术条件。尽管它们在手术期间有广泛且有益的应用，但NMBAs延迟恢复或部分恢复，即残留神经肌肉阻滞（rNMB），是一个常见的临床问题。虽然人们普遍认为，与新斯的明相比，拮抗剂舒更葡糖无论阻滞深度如何，都能更迅速地逆转罗库溴铵诱导的神经肌肉阻滞，但常规使用的NMBAs与舒更葡糖或新斯的明联合使用时rNMB的发生率尚未得到系统的量化或评估。
我们对随机对照试验（RCTs）进行了系统的文献综述和荟萃分析，以量化和比较中度和深度神经肌肉阻滞患者中rNMB的发生率[定义为四个成串刺激比值（TOFR）<0.9]。遵循了Cochrane协作组和PRISMA小组推荐的方法。
共识别出35项RCTs，其中20项纳入了荟萃分析。对于中度阻滞，给予舒更葡糖后2分钟时rNMB发生率为19.2%（95%CI 0.0 - 57.8；122例患者），给药后6分钟时降至2.8%（95%CI 0.0 - 16.7；93例患者）。给药后10至60分钟各时间点，rNMB发生率在0.05%至2.8%之间。相比之下，给予新斯的明后2分钟时rNMB发生率为100%（95%CI 89.9 - 100；182例患者），给药后6分钟时为82%（95%CI 71.4 - 91.2；93例患者）。给药后10至60分钟各时间点，rNMB发生率在14%至32%之间。对于深度阻滞，给予舒更葡糖后15分钟时rNMB发生率基本降至1%。给予新斯的明后，最初60分钟内残留NMB发生率保持在95%及以上。
总体而言，基于20项RCTs的证据，我们的结果表明，与罗库溴铵、维库溴铵、顺式阿曲库铵或泮库溴铵加新斯的明的联合用药相比，罗库溴铵或维库溴铵加舒更葡糖的联合用药在逆转神经肌肉阻滞后更有效、更迅速。
