Masui. The Japanese journal of anesthesiology
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In patients receiving a neuromuscular blocking agent, quantitative monitoring of neuromuscular function is essential. For this purpose, neuromuscular monitoring devices which provide train-of-four ratio values are necessary In the absence of a quantitative monitoring device, neuromuscular function may be evaluated with the use of a nerve stimulator. Muscle responses can be monitored either using the mechanomyography, electromyography, acceleromyography, or phonomyography. ⋯ Also, results from one monitoring method cannot be extrapolated to other methods. Anesthesiologists should be aware of these differences. In this article, the basics of neuromuscular monitoring are summarized.
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Neuromuscular blocking agents are used to facilitate tracheal intubation and surgical procedure in ambulatory anesthesia. However, the ideal neuromuscular blocking agents for ambulatory anesthesia are not yet available. The only depolarizing neuromuscular blocking agent, suxamethonium, is still widely used by its rapid onset and short duration of action producing excellent intubating conditions, in spite of its numerous adverse effects. ⋯ The use of neostigmine for reversal and the measurement of the TOF ratio during recovery are recommended after intermediate-acting neuromuscular blocking agents. Some studies have shown that tracheal intubation without neuromuscular agents may be associated with postoperative hoarseness and vocal cord injuries. Sugammadex will resolve many issues in using nondepolarizing neuromuscular agents in ambulatory anesthesia.
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In the intensive care unit (ICU), neuromuscular blocking agent (NMBA) is occasionally used with sedatives and/or analgesics, for the management of mechanically-ventilated critically ill patients. For its application in ICU, close attention should be paid on the side effects unlikely seen during operation because the basal conditions of ICU patients are more serious and its infusion period is likely to be long. There have been reports of the prolonged weakness after the long term use of NMBA. ⋯ Strategy should be focused on its prevention. For example, routine monitoring with peripheral nerve stimulation and titration to the minimum dose of requirement, are relevant and effective. The application of NMBA in ICU is reviewed and rocuronium recently placed on market is within the scope of this article.
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Curare was clinically used in a patient with acute appendicitis by Griffith and Johnson in January 1942. From the day on, the development of new muscle relaxants went on in the world. ⋯ At present, pancuronium, vecuronium and rocuronium are routinely used in the world. In the future, we expect development of new muscle relaxants with rapid onset, intermediate duration of action, rapid recovery and without side effects.
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We report two cases of elderly patients who underwent ultrasound-guided combined femoral nerve and lateral femoral cutaneous nerve blocks for osteosynthesis of femur neck fracture. In both cases, neuraxial anesthesia was contraindicated due to coagulopathy, and severe restrictive ventilatory disorder was observed. The femoral nerve and lateral femoral cutaneous nerve blocks were performed with 20ml of 0.375% ropivacaine under ultrasonographic visualization using a high frequency linear probe. ⋯ Supplemental local infiltration of anesthetics and intravenous low-dose sedative drugs were administered during surgery. The perioperative course was uneventful in both cases. This combined block technique could be a choice for osteosynthesis of femur neck fracture especially in high-risk patients.