The use of sugammadex and quantitative neuromuscular monitoring to facilitate fast-track liver transplantation: an observational study

Fast-track anesthesia protocols for liver transplantation are becoming more common as institutions strive to innovate and advance perioperative care. However, patients with end-stage liver disease present unique challenges to medication management due to altered pharmacokinetics and pharmacodynamics. The current study was designed to investigate the role of sugammadex administration guided by quantitative neuromuscular monitoring and its impact on postoperative outcomes in patients undergoing fast-track anesthesia protocols for liver transplantation. Consenting patients undergoing liver transplantation were enrolled in this observational, descriptive study. Prior to induction of general anesthesia, an electromyographic neuromuscular device (TetraGraph, Senzime AB, Uppsala, Sweden) was placed to monitor the adductor pollicis muscle. Anesthetic management was at the discretion of the attending anesthesiologist and included the use of rocuronium to establish and maintain neuromuscular block. At the conclusion of the operation, sugammadex was administered to restore neuromuscular function based on electromyographic measurements recorded every 20 s until tracheal extubation. Neuromuscular function was measured upon arrival to the recovery room, then 5 min and 10 min after arrival. Postoperative outcomes (pulmonary complications, delirium) were extracted from the medical records. Forty-five patients were enrolled and 30 completed the study. Seven patients had not fully recovered neuromuscular function at the time of tracheal extubation, and two patients had residual neuromuscular block upon arrival to the recovery room. After 10 min in the recovery room, one of these patients had recovered neuromuscular function (train-of-four ratio, TOFR > 0.90), while the other patient required additional sugammadex. Two patients required admission to the intensive care unit; no patients experienced postoperative pulmonary complications or delirium during the first 30 postoperative days. While the use of sugammadex did not eliminate the incidence of residual neuromuscular block, it is a feasible option when guided by quantitative monitoring to facilitate fast-track anesthesia for liver transplantation and avoid admission to the intensive care unit.