Abstract Background Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents’ administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. Methods One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients’ dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg−1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. Results Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. Conclusions The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. Clinical trial number and registry URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999. agents crucial practice TrainOfFour Train Of Four (TOFC electromyographybased electromyography (TetraGraph acceleromyographybased TOFscan. . (TOFscan) enrolled dominant/nondominant dominantnondominant dominant/non dominant non 05 5 mgkg1 mgkg mg kg 1 mg.kg− rocuronium 2 trainoffour train four Median (Median 102 02 1.0 0.88, 088 88 [0.88 1.20 vs 100 00 0.64, 064 64 [0.64 1.01, 101 1.01 , 01 1.01] respectively 0.001. 0001 0.001 001 0.001) 16 40, 40 [40 900 12 60, 60 [60 300 NCT05120999 NCT https//clinicaltrials.gov/ct2/show/NCT05120999. httpsclinicaltrialsgovct2showNCT05120999 httpsclinicaltrialsgovctshowNCT https //clinicaltrials.gov/ct2/show/NCT05120999. clinicaltrials gov ct2 show ct https://clinicaltrials.gov/ct2/show/NCT05120999 (TOFscan nondominant dominantnon mg.kg 10 1. 0.88 08 8 [0.8 1.2 0.64 06 6 [0.6 000 0.00 4 [4 90 [6 30 NCT0512099 https//clinicaltrials.gov/ct2/show/NCT05120999 httpsclinicaltrialsgovct showNCT httpsclinicaltrialsgovct2showNCT0512099 clinicaltrialsgovct2showNCT05120999 clinicaltrialsgovctshowNCT //clinicaltrials.gov/ct2/show/NCT05120999 https://clinicaltrials.gov/ct2/show/NCT0512099 0.8 [0. 0.6 0.0 [ 9 3 NCT051209 https//clinicaltrials.gov/ct2/show/NCT0512099 httpsclinicaltrialsgovct2showNCT051209 clinicaltrialsgovct clinicaltrialsgovct2showNCT0512099 //clinicaltrials.gov/ct2/show/NCT0512099 https://clinicaltrials.gov/ct2/show/NCT051209 [0 NCT05120 https//clinicaltrials.gov/ct2/show/NCT051209 httpsclinicaltrialsgovct2showNCT05120 clinicaltrialsgovct2showNCT051209 //clinicaltrials.gov/ct2/show/NCT051209 https://clinicaltrials.gov/ct2/show/NCT05120 NCT0512 https//clinicaltrials.gov/ct2/show/NCT05120 httpsclinicaltrialsgovct2showNCT0512 clinicaltrialsgovct2showNCT05120 //clinicaltrials.gov/ct2/show/NCT05120 https://clinicaltrials.gov/ct2/show/NCT0512 NCT051 https//clinicaltrials.gov/ct2/show/NCT0512 httpsclinicaltrialsgovct2showNCT051 clinicaltrialsgovct2showNCT0512 //clinicaltrials.gov/ct2/show/NCT0512 https://clinicaltrials.gov/ct2/show/NCT051 NCT05 https//clinicaltrials.gov/ct2/show/NCT051 httpsclinicaltrialsgovct2showNCT05 clinicaltrialsgovct2showNCT051 //clinicaltrials.gov/ct2/show/NCT051 https://clinicaltrials.gov/ct2/show/NCT05 NCT0 https//clinicaltrials.gov/ct2/show/NCT05 httpsclinicaltrialsgovct2showNCT0 clinicaltrialsgovct2showNCT05 //clinicaltrials.gov/ct2/show/NCT05 https://clinicaltrials.gov/ct2/show/NCT0 https//clinicaltrials.gov/ct2/show/NCT0 httpsclinicaltrialsgovct2showNCT clinicaltrialsgovct2showNCT0 //clinicaltrials.gov/ct2/show/NCT0 https://clinicaltrials.gov/ct2/show/NCT https//clinicaltrials.gov/ct2/show/NCT clinicaltrialsgovct2showNCT //clinicaltrials.gov/ct2/show/NCT

Abstract The CLIC system in the Dräger Apollo anesthesia workstation allows a successful pre-use machine checkout without the presence of a carbon dioxide absorbent canister. It also allows the canister to be changed without interrupting controlled ventilation. However, this canister can be easily installed improperly with the CLIC adapter. We report a case in which a patient could not be ventilated by mask after the induction of general anesthesia, resulting in oxygen desaturation before successful ventilation was achieved with a bag valve mask. This case illustrates the importance of a leak test after components of the breathing circuit are changed.

Resumo Descrevemos um caso incomum de insuficiência hepática hiperaguda após a anestesia geral em uma paciente que recebeu um transplante simultâneo de rim-pâncreas. Apesar de uma avaliação agressiva das causas estruturais, imunológicas, virais e toxicológicas, uma causa definitiva não pôde ser identificada. A paciente precisou de um transplante de fígado que resultou em prolongamento da internação hospitalar. Discutimos as potenciais causas da insuficiência hepática fulminante e o manejo da anestesia no período perioperatório de seu subsequente transplante de fígado.

Abstract We describe an unusual case of hyperacute hepatic failure following general anesthesia in a patient receiving a simultaneous kidney-pancreas transplant. Despite an aggressive evaluation of structural, immunological, viral, and toxicological causes, a definitive cause could not be elucidated. The patient required a liver transplant and suffered a protracted hospital course. We discuss the potential causes of fulminant hepatic failure and the perioperative anesthesia management of her subsequent liver transplantation.