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Journal of Clinical Anesthesia Apr 2020Neuromuscular blocking agents (NMBAs) have revolutionized the field of anesthesiology as they facilitate airway management and ensure optimal surgical conditions....
Incidence of residual neuromuscular blockade and use of neuromuscular blocking agents with or without antagonists: A systematic review and meta-analysis of randomized controlled trials.
OBJECTIVES
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.
REVIEW METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
PubMed: 32304958
DOI: 10.1016/j.jclinane.2020.109818 -
The Cochrane Database of Systematic... Apr 2005Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or intraventricular hemorrhage, and are exposed to more severe barotrauma, which consequently could impair their clinical outcome. Neuromuscular paralysis, which eliminates spontaneous breathing efforts of the infant, has potential advantages in this respect. However, a number of complications have been reported with muscle relaxation in infants, so that concerns exist regarding the safety of prolonged neuromuscular paralysis in newborn infants.
OBJECTIVES
To determine whether routine neuromuscular paralysis of newborn infants receiving mechanical ventilation compared with no routine paralysis results in clinically important benefits or harms.
SEARCH STRATEGY
The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), MEDLINE (from 1966 to April 2004) and EMBASE (from 1988 to April 2004) were searched. References of review articles were hand searched. Language restriction was not imposed.
SELECTION CRITERIA
All trials using random or quasi-random patient allocation, in which the routine use of neuromuscular blocking agents during mechanical ventilation was compared to no paralysis or selective paralysis in newborn infants. Methodological quality was assessed blindly and independently by the two authors.
DATA COLLECTION AND ANALYSIS
Data were abstracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with independent evaluation of trial quality, and abstraction and synthesis of data by both authors. Treatment effect was analysed using relative risk, risk difference and weighted mean difference.
MAIN RESULTS
Ten possibly eligible trials were identified, of which six were included in the review. All the included trials studied preterm infants ventilated for respiratory distress syndrome, and used pancuronium as the neuromuscular blocking agent. In the analysis of the results of all trials, no significant difference was found in mortality, air leak or chronic lung disease, but there was a significant reduction in intraventricular hemorrhage and a trend towards less severe intraventricular hemorrhages. In the subgroup analysis of trials studying a selected population of ventilated infants with evidence of asynchronous respiratory efforts, a significant reduction in intraventricular hemorrhage (any grade and severe IVH) was found, and a trend towards less air leak. In the subgroup analysis of trials studying an unselected population of ventilated infants, no significant differences were found for any of the outcomes.
AUTHORS' CONCLUSIONS
For ventilated preterm infants with evidence of asynchronous respiratory efforts, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular hemorrhage and possibly on air leak. Uncertainty remains, however, regarding the long term pulmonary and neurologic effects, and regarding the safety of prolonged use of pancuronium in ventilated newborn infants. There is no evidence from randomized trials on the effects of neuromuscular blocking agents other than pancuronium. The routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended based on current evidence.
Topics: Cerebral Hemorrhage; Humans; Infant, Newborn; Infant, Premature; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Outcome Assessment, Health Care; Pancuronium; Pneumothorax; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome, Newborn
PubMed: 15846639
DOI: 10.1002/14651858.CD002773.pub2 -
The Cochrane Database of Systematic... 2000Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or... (Review)
Review
BACKGROUND
Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or intraventricular hemorrhage, and are exposed to more severe barotrauma, which consequently could impair their clinical outcome. Neuromuscular paralysis, which eliminates spontaneous breathing efforts of the infant, has potential advantages in this respect. However, a number of complications have been reported with muscle relaxation in infants, so that concerns exist regarding the safety of prolonged neuromuscular paralysis in newborn infants.
OBJECTIVES
To determine whether routine neuromuscular paralysis of newborn infants receiving mechanical ventilation compared with no routine paralysis results in clinically important benefits or harms.
SEARCH STRATEGY
MEDLINE (from 1966 to May 2000) and EMBASE (from 1988 to May 2000) were searched, as well as The Cochrane Controlled Trials Register (issue 2, 2000). References of review articles were hand searched. Language restriction was not imposed.
SELECTION CRITERIA
All trials using random or quasi-random patient allocation, in which the routine use of neuromuscular blocking agents during mechanical ventilation was compared to no paralysis or selective paralysis in newborn infants. Methodological quality was assessed blindly and independently by the two authors.
DATA COLLECTION AND ANALYSIS
Data were abstracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with independent evaluation of trial quality, and abstraction and synthesis of data by both authors. Treatment effect was analysed using relative risk, risk difference and weighted mean difference.
MAIN RESULTS
Ten possibly eligible trials were identified, of which five were included in the review. All the included trials studied preterm infants ventilated for respiratory distress syndrome, and used pancuronium as the neuromuscular blocking agent. In the analysis of the results of all trials, no difference was found in mortality, air leak or chronic lung disease, but there was a significant reduction in intraventricular hemorrhage and a trend towards less severe intraventricular hemorrhages. In the subgroup analysis of trials studying a selected population of ventilated infants with evidence of asynchronous respiratory efforts, a significant reduction in intraventricular hemorrhage (any grade and severe IVH) was found, and a trend towards less air leak. In the subgroup analysis of trials studying an unselected population of ventilated infants, no differences were found for any of the outcomes.
REVIEWER'S CONCLUSIONS
For ventilated preterm infants with evidence of asynchronous respiratory efforts, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular hemorrhage and possibly on air leak. Uncertainty remains, however, regarding the long term pulmonary and neurologic effects, and regarding the safety of prolonged use of pancuronium in ventilated newborn infants. There is no evidence from randomized trials on the effects of neuromuscular blocking agents other than pancuronium. Therefore, the routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended based on current evidence.
Topics: Cerebral Hemorrhage; Humans; Infant, Newborn; Infant, Premature; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Outcome Assessment, Health Care; Pancuronium; Pneumothorax; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome, Newborn
PubMed: 11034760
DOI: 10.1002/14651858.CD002773 -
The Cochrane Database of Systematic... Oct 2009Sugammadex is the first selective relaxant binding agent that has been studied for reversal of neuromuscular blockade induced by rocuronium and other steroidal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Sugammadex is the first selective relaxant binding agent that has been studied for reversal of neuromuscular blockade induced by rocuronium and other steroidal non-depolarizing neuromuscular blocking agents (NMBAs).
OBJECTIVES
To assess the efficacy and safety of sugammadex in reversing neuromuscular blockade induced by steroidal non-depolarizing NMBAs and in preventing postoperative residual neuromuscular blockade.
SEARCH STRATEGY
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), and EMBASE (1980 to August 2008). In addition, we handsearched reference lists of relevant articles and meeting abstracts. Furthermore, we contacted the medication's manufacturer for more information.
SELECTION CRITERIA
All randomized controlled trials (RCTs) on adult patients (>/= 18 years old) in which sugammadex was compared with placebo or other medications, or in which different doses of sugammadex were compared with each other. We excluded non-randomized trials and studies on healthy volunteers.
DATA COLLECTION AND ANALYSIS
We independently performed determination of trial inclusion, quality assessment, and data extraction. We applied standard meta-analytic techniques.
MAIN RESULTS
We included18 RCTs (n = 1321 patients). Seven trials were published as full-text papers, and 11 trials only as meeting abstracts. All the included trials had adequate methods of randomization and allocation concealment. The results suggest that, compared with placebo or neostigmine, sugammadex can more rapidly reverse rocuronium-induced neuromuscular blockade regardless of the depth of the block. We identified 2, 4, and 16 mg/kg of sugammadex for reversal of rocuronium-induced neuromuscular blockade at T(2) reappearance , 1 to 2 post-tetanic counts, and 3 to 5 minutes after rocuronium, respectively. The number of trials are very limited regarding vecuronium and pancuronium. Serious adverse events occurred in < 1% of all patients who received the medication. There was no significant difference between sugammadex and placebo in terms of the prevalence of drug-related adverse events (RR 1.20, 95% CI 0.61 to 2.37; P = 0.59, I(2) = 0%, 5 RCTs). Also, no significant difference was found between sugammadex and neostigmine for adverse events (RR 0.98, 95% CI 0.48 to1.98; P = 0.95, I(2) = 43%, 3 RCTs).
AUTHORS' CONCLUSIONS
Sugammadex was shown to be effective in reversing rocuronium-induced neuromuscular blockade. This review has found no evidence of a difference in the instance of unwanted effects between sugammadex, placebo or neostigmine. These results need to be confirmed by future trials on larger patient populations and with more focus on patient-related outcomes.
Topics: Adult; Androstanols; Cholinesterase Inhibitors; Humans; Neostigmine; Neuromuscular Blockade; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Pancuronium; Randomized Controlled Trials as Topic; Rocuronium; Sugammadex; Vecuronium Bromide; gamma-Cyclodextrins
PubMed: 19821409
DOI: 10.1002/14651858.CD007362.pub2 -
Canadian Journal of Anaesthesia =... Jan 2002To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and... (Review)
Review
PURPOSE
To review the use of adjuncts to intravenous regional anesthesia (IVRA) for surgical procedures in terms of their intraoperative effects (efficacy of block and tourniquet pain) and postoperative analgesia.
SOURCE
A systematic search (Medline, Embase, reference lists) for randomized, controlled and double-blinded studies using adjuncts to IVRA for surgical procedures was conducted. Data were collected on intraoperative effects (onset/offset and quality of block and tourniquet pain), postoperative effects (pain intensity and analgesic consumption) and side effects recorded. Statistical significance as indicated in the original report and likely clinical relevance were taken into account to arrive at a judgment of overall benefit.
PRINCIPAL FINDINGS
Twenty-nine studies met all inclusion criteria. Data on 1,217 study subjects are included. Adjuncts used were opioids (fentanyl, meperidine, morphine, sufentanil), tramadol, non-steroidal anti-inflammatory drugs (NSAIDs; ketorolac, tenoxicam, acetyl-salicylate), clonidine, muscle relaxants (atracurium, pancuronium, mivacurium), alkalinization with sodium bicarbonate, potassium and temperature. There is good evidence to recommend NSAIDs in general and ketorolac in particular, for improving postoperative analgesia. Clonidine 1 microg/kg also appears to improve postoperative analgesia and prolong tourniquet tolerance. Opioids are poor by this route; only meperidine 30 mg or more has substantial postoperative benefit but at the expense of postdeflation nausea, vomiting and dizziness. Muscle relaxants improve intraoperative motor block and aid fracture reduction.
CONCLUSION
Using NSAIDs or clonidine as adjuncts to IVRA improves postoperative analgesia and muscle relaxant improves motor block.
Topics: Adjuvants, Anesthesia; Anesthesia, Conduction; Anesthesia, Intravenous; Humans; Randomized Controlled Trials as Topic
PubMed: 11782326
DOI: 10.1007/BF03020416 -
The Cochrane Database of Systematic... Sep 2012Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic (low red blood cell count), which may require treatment during the pregnancy by blood transfusion while the baby remains within the uterus (called an intrauterine blood transfusion).
OBJECTIVES
To compare, using the best available evidence, the benefits and harms of different techniques of intrauterine fetal blood transfusion for women with red-cell alloimmunisation.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 June 2012).
SELECTION CRITERIA
We considered randomised controlled trials comparing different techniques of intrauterine fetal blood transfusion (either alone or in combination with another technique) for inclusion.
DATA COLLECTION AND ANALYSIS
Two authors evaluated trials under consideration for appropriateness for inclusion and methodological quality, without consideration of their results according to the prestated eligibility criteria. We planned to use a fixed-effect meta-analysis for combining study data if we judged the trials to be sufficiently similar. We planned to investigate statistical heterogeneity using the I² statistic; if this indicated a high degree of statistical heterogeneity, we planned to use a random-effects model.
MAIN RESULTS
Our search strategy identified four reports of three studies for consideration, of which two met the inclusion criteria, involving 44 women. We identified a single trial comparing the use of intrauterine fetal blood transfusion and intravenous immunoglobulin versus intrauterine fetal blood transfusion alone, and a single trial comparing the use of atracurium and pancuronium. There were no statistically significant differences identified for any of the reported outcomes.
AUTHORS' CONCLUSIONS
There is little available high quality information from randomised controlled trials to inform the optimal procedural technique when performing fetal intrauterine fetal blood transfusions for women with an anaemic fetus due to red cell alloimmunisation. Further research evaluating the benefits and harms associated with different techniques is required.
Topics: Atracurium; Blood Transfusion, Intrauterine; Erythrocyte Transfusion; Female; Humans; Immunoglobulins, Intravenous; Neuromuscular Depolarizing Agents; Pancuronium; Pregnancy; Randomized Controlled Trials as Topic; Rh Isoimmunization; Treatment Outcome
PubMed: 22972102
DOI: 10.1002/14651858.CD007096.pub3 -
The Cochrane Database of Systematic... Jun 2010Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Red-cell alloimmunisation can occur when there are incompatibilities between a woman's blood type and that of her unborn baby. This can cause the baby to become anaemic (low red blood cell count), which may require treatment during the pregnancy by blood transfusion while the baby remains within the uterus (called an intrauterine blood transfusion).
OBJECTIVES
To compare, using the best available evidence, the benefits and harms of different techniques of intrauterine fetal blood transfusion for women with red-cell alloimmunisation.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010).
SELECTION CRITERIA
We considered randomised controlled trials comparing different techniques of intrauterine fetal blood transfusion (either alone or in combination with another technique) for inclusion.
DATA COLLECTION AND ANALYSIS
Two authors evaluated trials under consideration for appropriateness for inclusion and methodological quality, without consideration of their results according to the prestated eligibility criteria. We planned to use a fixed-effect meta-analysis for combining study data if we judged the trials to be sufficiently similar. We planned to investigate statistical heterogeneity using the I(2) statistic; if this indicated a high degree of statistical heterogeneity, we planned to use a random-effects model.
MAIN RESULTS
Our search strategy identified four reports of three studies for consideration, of which two met the inclusion criteria, involving 44 women. We identified a single trial comparing the use of intrauterine fetal blood transfusion and intravenous immunoglobulin versus intrauterine fetal blood transfusion alone, and a single trial comparing the use of atracurium and pancuronium. There were no statistically significant differences identified for any of the reported outcomes.
AUTHORS' CONCLUSIONS
There is little available high quality information from randomised controlled trials to inform the optimal procedural technique when performing fetal intrauterine fetal blood transfusions for women with an anaemic fetus due to red cell alloimmunisation. Further research evaluating the benefits and harms associated with different techniques is required.
Topics: Blood Transfusion, Intrauterine; Erythrocyte Transfusion; Female; Humans; Immunoglobulins, Intravenous; Pregnancy; Randomized Controlled Trials as Topic; Rh Isoimmunization; Treatment Outcome
PubMed: 20556774
DOI: 10.1002/14651858.CD007096.pub2 -
European Journal of Anaesthesiology May 2024Extravascular injection of neuromuscular blocking drugs (NMBDs) can cause a neuromuscular block because of systemic absorption. Currently, there are no guidelines...
Extravascular injection of neuromuscular blocking drugs (NMBDs) can cause a neuromuscular block because of systemic absorption. Currently, there are no guidelines available on managing extravasation of NMBDs. This article reviews the available literature on extravasation of NMBDs. Medline and Embase databases were searched for studies concerning the paravenous or subcutaneous injection of NMBDs. Nine articles were included consisting of seven case reports, one case series and one clinical trial. Rocuronium was used as primary NMBD in nine cases, vecuronium in two cases and pancuronium in one case. Although there exists significant heterogeneity between the reported information in the included studies, the majority of the case reports describe a slower onset, with a median delay of 20 min and prolonged duration of the neuromuscular block. Nine patients had a residual neuromuscular block at the end of the surgery. Postoperative monitoring in the recovery room was prolonged (median time 4 h). Most studies suggest that the delay in NMBD onset and recovery is caused by the formation of a subcutaneous depot, from which the NMBD is slowly absorbed into the systemic circulation. According to the current literature, extravasation of NMBDs results in an unpredictable neuromuscular block. Strategies to prevent potentially harmful side effects, such as frequent train-of-four (TOF) monitoring, the use of NMBD reversal agents and prolonged length of stay in the postanaesthesia care unit (PACU), should be considered. This article suggests a clinical pathway that can be used after extravascular injection of NMBDs.
Topics: Humans; Neuromuscular Blockade; Rocuronium; Vecuronium Bromide; Delayed Emergence from Anesthesia; Monitoring, Intraoperative
PubMed: 38410855
DOI: 10.1097/EJA.0000000000001967 -
European Journal of Anaesthesiology Jul 2019Nondepolarising muscle relaxants (NDMRs) provide optimal conditions for tracheal intubation and improve surgical conditions. Several clinical conditions, diseases and...
BACKGROUND
Nondepolarising muscle relaxants (NDMRs) provide optimal conditions for tracheal intubation and improve surgical conditions. Several clinical conditions, diseases and pharmacological interactions have been suggested to cause resistance towards NDMRs that may translate into difficult intubation or inadequate operating conditions during surgery.
OBJECTIVE
The aim of this study was to evaluate the current evidence of patient groups with resistance towards NDMRs. A prolonged onset time was defined as a difference that exceeded 25% compared with controls.
DESIGN
A systematic review of randomised controlled trials and cohort studies.
DATA SOURCES
A comprehensive search was performed in 2016 in PubMed and EMBASE.
ELIGIBILITY CRITERIA
Patients with conditions or diseases, or patients taking medication, which lead to resistance towards current NDMRs (rocuronium, vecuronium, cisatracurium, atracurium, mivacurium and pancuronium). Included outcomes were onset time defined as the time between administration of NDMR to maximal (90, 95 or 100%) depression of baseline twitch height of the first twitch in a train-of-four.
RESULTS
Twenty-five studies were included. Strong evidence supports a prolonged onset time of rocuronium in patients with thermal injury and Duchenne muscular dystrophy. Moderate evidence supports a prolonged onset time of NDMRs during hypothermia and in patients with infection, oculopharyngeal muscular dystrophy, liver cirrhosis treated with ulinastatin, when remifentanil is administered prior to administration of an NDMR, in fasting patients being rehydrated intravenously prior to administration of NDMR, in children with end-stage renal failure and in patients with atrial or ventricular septal defects.
CONCLUSION
A prolonged onset time should be suspected in patients with thermal injury and Duchenne's muscular dystrophy. Further, evidence supports a prolonged onset time in patients with infection, oculopharyngeal muscular dystrophy, congenital heart defects, kidney failure, liver cirrhosis treated with ulinastatin along with remifentanil or intravenous fluids administered prior to NDMR.
Topics: Drug Resistance; Humans; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Randomized Controlled Trials as Topic; Risk Factors; Time Factors
PubMed: 30950905
DOI: 10.1097/EJA.0000000000000991 -
British Journal of Anaesthesia Mar 1999We have estimated the effect of omitting antagonism of neuromuscular block on postoperative nausea and vomiting. A systematic search (MEDLINE, EMBASE, Biological... (Meta-Analysis)
Meta-Analysis
We have estimated the effect of omitting antagonism of neuromuscular block on postoperative nausea and vomiting. A systematic search (MEDLINE, EMBASE, Biological Abstracts, Cochrane library, reference lists and hand searching; no language restriction, up to March 1998) was performed for relevant randomized controlled trials. In eight studies (1134 patients), antagonism with neostigmine or edrophonium was compared with spontaneous recovery after general anesthesia with pancuronium, vecuronium, mivacurium or tubocurarine. On combining neostigmine data, there was no evidence of an antiemetic effect when it was omitted. However, the highest incidence of emesis with neostigmine 1.5 mg was lower than the lowest incidence of emesis with 2.5 mg. Numbers-needed-to-treat to prevent emesis by omitting neostigmine compared with using it were consistently negative with 1.5 mg, and consistently positive (3-6) with 2.5 mg. There was a lack of evidence for edrophonium. In two studies, three patients with spontaneous recovery after mivacurium or vecuronium needed rescue anticholinesterase drugs because of clinically relevant muscle weakness (number-needed-to-harm, 30). Omitting neostigmine may have a clinically relevant antiemetic effect when high doses are used. Omitting antagonism, however, introduces a non-negligent risk of residual paralysis even with short-acting neuromuscular blocking agents.
Topics: Cholinesterase Inhibitors; Humans; Muscle Weakness; Neostigmine; Neuromuscular Blocking Agents; Postoperative Complications; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic; Risk Assessment
PubMed: 10434820
DOI: 10.1093/bja/82.3.379