the metablog

Posts written by Daniel Jolley.
Daniel Jolley

About the author

Daniel Jolley is an anesthesiologist, founder and CEO of metajournal, providing personalized medical research recommendations to fellow doctors.

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If sugammadex is the answer what is the question?

Sugammadex (Bridion®) is a remarkable drug. It also has a cool name. The anaesthesia community has moved very quickly to embrace the potential of this first and only 'selective relaxant binding agent' (SRBA), despite it's considerable cost.

"Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s." - Miller RD 1

Novel pharmacology and a cool name are however insufficient reasons alone to alter our practice. There is a certain lack of clarity in the community and literature as to where sugammadex fits into anaesthesia practice and to what extent it should alter how we currently manage muscle relaxation and reversal. There has also been very limited discussion of the unintended consequences of a shift to rocuronium-sugammadex based techniques over other neuromuscular drugs.

There is no doubt that sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular that from rocuronium.  The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex‘s onset is 10 times faster than neostigmine and three times faster than edrophonium.2

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  1. Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology? Anesth Analg. 2007 Mar;104(3):477-8. 

  2. Sacan O, White PF, Tufanogullari B, Klein K. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg. 2007 Mar;104(3):569-74. 

Neuromuscular myths: We need to do better

The rise of sugammadex has lead me down a path looking into wider aspects of my own neuromuscular blocking drug (NMBD) use. The evidence for NMBD use, monitoring and reversal is interesting, both for how consistently the same messages have been repeated over the past three decades – and for how little we have improved our practice in spite of mounting evidence demanding that we should.1

I need to do better and you probably also need to do better with how we manage NMBDs.

What is PORC?

Post-operative residual curarisation (PORC) or residual paralysis, refers to persisting neuromuscular blockade in a patient after extubation. It is considered present when the Train-of-four (TOF) ratio is less than 0.9, usually measured in recovery or the post anesthesia care unit (PACU).

The historical comparison of studies investigating PORC is difficult because for many years a TOF ratio of 0.7 was considered the cutoff value for PORC. Volunteers given d-tubocurarine had normal vital capacity and inspiratory force when the TOFR recovered above 0.7. Then in the mid-1990s a TOF ratio of 0.8 was used in studies investigating PORC.

Now in the 21st century a TOFR 0.9 is considered the cut-off for defining PORC. A TOFR 0.9 has been chosen because consequences of residual paralysis, such as pharyngeal dysfunction and impairment of respiratory function have been shown below this TOF ratio.

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  1. Case in point: Donati F. Neuromuscular monitoring: what evidence do we need to be convinced? Anesth Analg. 2010 Jul;111(1):6-8. (pubmed

Wow! A great response from our beta users!

A big thank you to all those members of metajournal who signed up for our special beta pricing – I am humbled by your support!

Metajournal has been in open beta for only a few weeks, yet the number of articles we have indexed and the number of doctors using metajournal continues to grow.

While metajournal's supernatural-ability to suggest interesting articles is the core of the service, I have many new features currently being worked on – and even more on the drawing board. I am most excited to soon be adding the ability to add notes to articles: summaries, pearls and comments to share with the rest of the metajournal community.

Our special beta pricing will only continue for another couple of weeks, so sign up now for a paid account to save $50 on your first year subscription – and so keep up to date!

On Anaesthesia and Simplicity

It is easy to lose sight of the core of the practice of anaesthesia. As a profession we are easily seduced and distracted by the new and exciting; quickly forgetting that satisfyingly favourable outcomes for our patients occur not because of the advances in the technology and pharmacology of anaesthesia, but rather are owed to our training and performance as anaesthetists and anaesthesiologists managing that complex system.

Our ability to understand the complex model of patient, surgeon, drugs and scalpel; to resist distraction by the blinkenlights of whatever new device has been dragged in by the friendly equipment rep; the exciting kinetics of the latest drug; or the new ventilator modes on the anaesthetic machine - our ability to conceptually simplify these things and achieve good outcomes is at the core of what we do.

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Metajournal now in open beta!

Exciting news for metajournal this week — we're in open beta! This means that now anyone can sign up for a metajournal account and stay up to date with the latest, most personally relevant evidence in anesthesia, critical care and emergency medicine.

To thank all our early access users already using metajournal, we have both new pricing – and for a limited time a further $50 off the first year of your metajournal subscription.

Start your subscription today.

The quality of metajournal's article recommendations have continued to improve, and get spookily prescient once you are following a critical number of topics. To get (very!) good results follow at least 30 topics. For clairvoyant-quality evidence suggestions aim for 50-100 topics and be delightfully surprised!

Thank you!

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