Qualitative monitoring is inadequate for reliably determining full recovery from neuromuscular block whatever the protocol used

Abstract

Editor—Thilen and colleagues1Thilen S.R. Ng I.C. Cain K.C. Treggiari M.M. Bhananker S.M. Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine.Br J Anaesth. 2018; 121: 367-377Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar continue to promulgate the use of qualitative neuromuscular monitoring perioperatively and recommend the use of a protocol to reduce the incidence of postoperative residual neuromuscular block after administration of a specific neuromuscular blocking drug (rocuronium) and reversal with neostigmine. Such methods of monitoring neuromuscular block without obtaining an estimate of the train-of-four ratio (TOFR) have long been considered inadequate in determining sufficient recovery to permit safe tracheal extubation. In 2000, Viby-Mogensen2Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia.Br J Anaesth. 2000; 84: 301-303Abstract Full Text PDF PubMed Scopus (107) Google Scholar strongly advocated the use of quantitative monitoring which provides a measurement of the TOFR perioperatively. Erikkson3Erikkson L.I. Evidence-based practice and neuromuscular monitoring: it's time for routine quantitative assessment.Anesthesiology. 2003; 98: 1037-1039Crossref PubMed Scopus (149) Google Scholar endorsed this recommendation based on accumulating evidence and advised that the TOFR should recover to greater than 0.9 before tracheal extubation was effected. It had already been noted that residual block was common in the recovery room,4Berg H. Roed J. Viby-Mogensen J. et al.Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.Acta Anaesthesiol Scand. 1997; 4: 1095-1103Crossref Scopus (541) Google Scholar but this complication remorselessly persists as quantitative neuromuscular monitoring is infrequently used. Hopefully, a recent consensus statement providing detailed guidelines on neuromuscular monitoring will improve this lack of good practice.5Naguib M. Brull S.J. Kopman A.F. et al.Consensus statement on perioperative use of neuromuscular monitoring.Anesth Analg. 2018; 127: 71-80Crossref PubMed Scopus (140) Google Scholar Despite Viby-Mogensen's2Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia.Br J Anaesth. 2000; 84: 301-303Abstract Full Text PDF PubMed Scopus (107) Google Scholar strong recommendations, there has been little improvement in the standards of neuromuscular monitoring practised by anaesthetists certainly in the UK this century.6Pandit J.J. Andrade J. Bogod D.G. et al.5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of findings and risk factors.Br J Anaesth. 2014; 113: 549-559Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar To recommend the use of a protocol in which the incidence of residual block remains as high as 35% in the treatment group fails lamentably to reach the highest achievable standards of anaesthetic practice.1Thilen S.R. Ng I.C. Cain K.C. Treggiari M.M. Bhananker S.M. Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine.Br J Anaesth. 2018; 121: 367-377Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Rather than continuing to encourage such protocols, surely more efforts should be made by all anaesthetists to ensure that their departments have quantitative neuromuscular monitoring equipment that can be readily utilised to reliably prevent residual curarisation in every patient? Only then can the incidence of residual neuromuscular block with all its potential complications be reduced to the required aim of zero after an operation. JMH was Editor-in-Chief of the British Journal of Anaesthesia from 1997 to 2005, and Chair of the BJA Board from 2006 to 2012.