Universal quantitative neuromuscular blockade monitoring at an academic medical center—A multimodal analysis of the potential impact on clinical outcomes and total cost of care

Abstract

BackgroundQuantitative train-of-four monitoring is not currently the standard of care when using neuromuscular blockade, although it has the potential to eliminate the complications of residual neuromuscular blockade. There are major costs associated with the complications of residual neuromuscular blockade as well as the purchase of quantitative train-of-four monitors. The aim of this study was to determine the cost effectiveness of universal quantitative train-of-four ratio monitoring as it pertains to purchase and use of quantitative train-of-four monitors in comparison with potential costs of managing possible complications of residual neuromuscular blockade such as reintubation and pneumonia. MethodsThis observational study was conducted by the anesthesiology service for an urban academic medical center. All patients included were undergoing general endotracheal anesthesia with the use of neuromuscular blocking agents who were extubated at the end of their procedure. Qualitative and quantitative train-of-four ratio monitoring prior to extubation were compared to estimate the local incidence of residual post-operative neuromuscular blockade. The hospital electronic medical record and financial database were used to estimate the number of patients at risk for post-operative pneumonia or re-intubation, as well as the marginal costs associated with these complications. The incidence of residual post-operative neuromuscular blockade at the time of extubation was determined. The variable costs of care for patients who did or did not suffer either pneumonia or re-intubation in the postoperative period was compared to the annual cost of universal quantitative train-of-four ratio monitoring. ResultsA sensitivity analysis demonstrated that universal quantitative train-of-four ratio monitoring would result in a net cost savings for a broad range of efficacy estimates with regard to the reduction of post-operative pulmonary complications. ConclusionsIntroduction of universal quantitative train-of-four ratio monitoring may be justified based solely on the potential institutional cost savings.