Neostigmine Reversal And Neuromuscular Recovery

April 11, 2017 updated by: Glenn S. Murphy, MD, NorthShore University HealthSystem
Patients undergoing surgery often receive paralytic agents (or neuromuscular blocking agents (NMBAs)) to facilitate the procedure. At the end of surgery, the effects NMBAs are reversed with a drug called neostigmine. The use of neostigmine significantly reduces the risk that a patient will be left with muscle weakness in the recovery room. Many anesthesiologists routinely use neostigmine because postoperative muscle weakness may lead to adverse events after surgery. Other anesthesiologists do not routinely administer neostigmine in the operating room because of concerns about potential side effects. Surprisingly, some investigators have reported that neostigmine-induced muscle weakness may occur if the drug is given when the effects of the NMBAs have completely worn off. In contrast, other investigators have not observed this side effect when neostigmine was given at the end of surgery. The aim of this study is to determine whether neostigmine use is associated with muscle weakness when it is given at the time of nearly complete recovery from NMBAs. Muscle strength will be measured using a sensitive monitor (TOF-Watch-SX) and through an examination of the patient for evidence of muscle weakness. Patients will also be evaluated how they recover from anesthesia and surgery.

Study Overview

Status

Status

Indicates the current recruitment status or the expanded access status.
Completed

Conditions

Conditions

The disease, disorder, syndrome, illness, or injury that is being studied. On ClinicalTrials.gov, conditions may also include other health-related issues, such as lifespan, quality of life, and health risks.

Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.

Detailed Description

120 patients will be enrolled in this randomized clinical trial. Patients will be assigned, via a computer-generated randomized table, to either a neostigmine group or a no neostigmine group. Patients in the neostigmine group will receive neostigmine 40 µg/kg at the end of the surgical procedure when TOF ratios have recovered to 0.9 or greater. Patients in the no neostigmine group will be administered saline (control) at the time of neuromuscular recovery. Patients with TOF ratios < 0.9 will be excluded from either study cohort. These subjects will be administered neostigmine 50 µg/kg at the conclusion of surgery. The same postoperative data (see below) will be recorded in this group as will be collected in the two study cohorts in order to determine the characteristics of patients not achieving spontaneous recovery.

Anesthetic care will be standardized in both study groups. Patients will be induced with propofol 1-2 mg/kg, fentanyl 100 µg/kg, and rocuronium as the NMBA (1 X ed 95 dose). No further rocuronium will be administered unless requested by the surgeon. Clinicians will be instructed to manage neuromuscular blockade so that full recovery of muscle strength is present at the end of the surgical procedure.

Neuromuscular blockade in the operating room will be quantified with the TOF-Watch-SX, an FDA-approved quantitative monitoring device. After induction of anesthesia, baseline data will be collected. A 5-second 50 Hz tetanic stimulation will be applied to reduce the time required to achieve baseline signal stabilization. After signal stability is achieved, the TOF-Watch will be calibrated and then a baseline TOF value recorded. Rocuronium will then be administered and the oral endotracheal tube placed 2-4 minutes later. Neuromuscular blockade will be managed to allow spontaneous recovery of neuromuscular function to occur, with the goal of reaching a TOF ratio of ≥ 0.9 at the end of the surgical procedure. At the time when neostigmine is typically administered, one of two syringes will be attached to the intravenous line, and the clear solution (neostigmine or saline) given. These syringes will be prepared prior to the end of surgery. For patients in the in the neostigmine group, 40 µg/kg of neostigmine (with an appropriate dose of glycopyrrolate) will be drawn up into the syringe and labeled accordingly. For patients in the no neostigmine group, an equal volume of saline will be drawn into a syringe, and a neostigmine label applied to the syringe. Both the neostigmine and saline solutions are clear and indistinguishable (to be prepared by pharmacy). Thereafter, all data collection will be obtained by research assistants blinded to group assignment.

Immediately prior to neostigmine or saline administration, TOF ratios will be recorded, and then the syringe attached to the intravenous line and the solution injected. Train-of-four ratios will then be recorded every 12 seconds until the time of tracheal extubation.

During transport from the operating room to the PACU, a research assistant will observe oxygen saturation levels, and the lowest value recorded. Oxygenation by pulse oximeter will also be monitored and recorded for the first 30 minutes of the PACU admission (every 1 minute via the PACU monitoring system). The need for addition oxygen therapy at any time following extubation will be noted. During this same time period (from extubation until 30 minutes after the PACU arrival) patients will be carefully observed for any evidence of airway obstruction or need for maneuvers to maintain a patent airway. This data will be recorded by the research assistant and the PACU nursing staff. In addition, 15 minutes after the PACU admission, subjects will be examined for 11 signs and 16 symptoms of muscle weakness. This examination will be performed by the blinded research assistant. The times required to achieve discharge criteria and actual PACU discharge will be recorded.

Study Type

Study Type

Describes the nature of a clinical study. Study types include interventional studies (also called clinical trials), observational studies (including patient registries), and expanded access.
Interventional

Enrollment (Actual)

Enrollment

The number of participants in a clinical study. The "anticipated" enrollment is the target number of participants that the researchers need for the study.
120

Phase

Phase

The stage of a clinical trial studying a drug or biological product, based on definitions developed by the U.S. Food and Drug Administration (FDA). The phase is based on the study's objective, the number of participants, and other characteristics. There are five phases: Early Phase 1 (formerly listed as Phase 0), Phase 1, Phase 2, Phase 3, and Phase 4. Not Applicable is used to describe trials without FDA-defined phases, including trials of devices or behavioral interventions.
  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Illinois
      • Evanston, Illinois, United States, 60201
        • Northshore University Healthsystem

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Eligibility Criteria

The key requirements that people who want to participate in a clinical study must meet or the characteristics they must have. Eligibility criteria consist of both inclusion criteria (which are required for a person to participate in the study) and exclusion criteria (which prevent a person from participating). Types of eligibility criteria include whether a study accepts healthy volunteers, has age or age group requirements, or is limited by sex.

Ages Eligible for Study

18 years to 80 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Ages of 18-80
  • Patients undergoing general anesthesia requiring endotracheal intubation
  • Procedures that do not require maintenance of neuromuscular blockade for completion of the surgical procedure

Exclusion Criteria:

  • Presence of renal failure (creatinine > 2.0 mg/dL)
  • Neuromuscular disease impacting upper airway musculature or neuromuscular monitoring
  • Lack of access to either upper extremity for monitoring
  • Procedure duration less than 30 minutes
  • Requirement for postoperative intubation
  • Patients not achieving a TOF ratio of ≥ 0.9 at the end of surgery will be excluded from either study cohort.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Diagnostic
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Quadruple

Arms and Interventions

Participant Group / Arm

Participant Group / Arm

A group or subgroup of participants in a clinical trial that receives a specific intervention/treatment, or no intervention, according to the trial's protocol.
Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.
Experimental: Neostigmine Group
Neostigmine will be administered at the conclusion of the surgical procedure
Drug: Neostigmine Group
Neostigmine will be used to reverse neuromuscular block at the conclusion of the surgical procedure. The effect on muscle strength will be determined using the TOF-Watch-SX and clinical examination
Placebo Comparator: No Neostigmine group
Saline will be administered at the conclusion of the surgical procedure
Other: No Neostigmine group
Saline will be administered to patients at the end of the surgical procedure when neuromuscular function has recovered
Other Names:
  • Placebo Comparator

What is the study measuring?

Primary Outcome Measures

Primary Outcome Measures

In a clinical study's protocol, the planned outcome measure that is the most important for evaluating the effect of an intervention/treatment. Most clinical studies have one primary outcome measure, but some have more than one.
Outcome Measure
Measure Description
Time Frame
Change in train-of-four (TOF) ratio
Time Frame: 30 minutes after the end of the surgical procedure
The effect of neostigmine or placebo (saline) on TOF ratios, when given at full neuromuscular recovery, will be assessed
30 minutes after the end of the surgical procedure

Secondary Outcome Measures

Secondary Outcome Measures

In a clinical study's protocol, a planned outcome measure that is not as important as the primary outcome measure for evaluating the effect of an intervention but is still of interest. Most clinical studies have more than one secondary outcome measure.
Outcome Measure
Measure Description
Time Frame
airway obstruction-presence or absence (yes or no)
Time Frame: 30 minutes after the end of the surgical procedure
Any episodes of airway obstruction will be recorded
30 minutes after the end of the surgical procedure
hypoxemic events (oxygen saturation by pulse oximeter (SpO2) < 94%)
Time Frame: 30 minutes after the end of the surgical procedure
Any hypoxemic events will be recorded
30 minutes after the end of the surgical procedure

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sponsor

The organization or person who initiates the study and who has authority and control over the study.
NorthShore University HealthSystem

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

Study Start

The actual date on which the first participant was enrolled in a clinical study. The "anticipated" study start date is the date that the researchers think will be the study start date.
April 1, 2015

Primary Completion (Actual)

Primary Completion

The date on which the last participant in a clinical study was examined or received an intervention to collect final data for the primary outcome measure. Whether the clinical study ended according to the protocol or was terminated does not affect this date. For clinical studies with more than one primary outcome measure with different completion dates, this term refers to the date on which data collection is completed for all the primary outcome measures. The "anticipated" primary completion date is the date that the researchers think will be the primary completion date for the study.
December 1, 2016

Study Completion (Actual)

Study Completion

The date on which the last participant in a clinical study was examined or received an intervention/treatment to collect final data for the primary outcome measures, secondary outcome measures, and adverse events (that is, the last participant's last visit). The "anticipated" study completion date is the date that the researchers think will be the study completion date.
April 1, 2017

Study Registration Dates

First Submitted

First Submitted

The date on which the study sponsor or investigator first submitted a study record to ClinicalTrials.gov. There is typically a delay of a few days between the first submitted date and the record's availability on ClinicalTrials.gov (the first posted date).
April 24, 2015

First Submitted That Met QC Criteria

First Submitted That Met QC Criteria

The date on which the study sponsor or investigator first submits a study record that is consistent with National Library of Medicine (NLM) quality control (QC) review criteria. The sponsor or investigator may need to revise and submit a study record one or more times before NLM's QC review criteria are met. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
April 29, 2015

First Posted (Estimate)

First Posted

The date on which the study record was first available on ClinicalTrials.gov after National Library of Medicine (NLM) quality control (QC) review has concluded. There is typically a delay of a few days between the date the study sponsor or investigator submitted the study record and the first posted date.
May 5, 2015

Study Record Updates

Last Update Posted (Actual)

Last Update Posted

The most recent date on which changes to a study record were made available on ClinicalTrials.gov. There may be a delay between when the changes were submitted to ClinicalTrials.gov by the study's sponsor or investigator (the last update submitted date) and the last update posted date.
April 12, 2017

Last Update Submitted That Met QC Criteria

Last Update Submitted That Met QC Criteria

The most recent date on which the study sponsor or investigator submitted changes to a study record that are consistent with National Library of Medicine (NLM) quality control (QC) review criteria. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
April 11, 2017

Last Verified

Last Verified

The most recent date on which the study sponsor or investigator confirmed the information about a clinical study on ClinicalTrials.gov as accurate and current. If a study with a recruitment status of recruiting; not yet recruiting; or active, not recruiting has not been confirmed within the past 2 years, the study's recruitment status is shown as unknown.
April 1, 2017

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

Other Study ID Numbers

Identifiers or ID numbers other than the NCT number that are assigned to a clinical study by the study's sponsor, funders, or others. These numbers may include unique identifiers from other trial registries and National Institutes of Health grant numbers.
  • EH15-089

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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