Incidence Of Residual Neuromuscular Blockade Research Articles

Sugamadex na reversão da anafilaxia induzida por rocurônio em paciente pediátrico: relato de caso e revisão de literatura

INTRODUCTION: Among neuromuscular blockers (NMB), rocuronium is the most notably cited as a cause of anaphylactic reaction. Rocuronium-induced anaphylaxis is a serious and potentially fatal complication, requiring immediate and effective management. The advent of the specific antagonist, sugammadex, has widely spread its use because it reduces the incidence of residual neuromuscular blockade and is indicated in the protocol for the treatment and reversal of refractory anaphylaxis. This study reports an episode of anaphylaxis induced by rocuronium and successfully reversed after administration of sugammadex. CASE REPORT: A 6-year-old child, weighing 30 kg, scheduled for video-assisted thoracoscopy under general anesthesia presented with tachycardia, severe hypotension, and diffuse skin rash after induction of general anesthesia and administration of rocuronium. All therapeutic measures were immediately taken for the treatment of a severe allergic reaction, however there was no clinical improvement, and the patient progressed to sinus bradycardia. At this point, cardiopulmonary resuscitation maneuvers were initiated, and adrenaline was administered, but without satisfactory clinical response. In this context, the possibility of the causative agent being rocuronium was raised. Sugammadex was administered 16mg/kg, and the patient immediately returned to sinus rhythm and later presented a favorable clinical evolution and no sequelae. DISCUSSION: Sugammadex is a molecule that encapsulates rocuronium and removes it from both plasma and neuromuscular junction, and then excretes it inertly in the urine. Some authors suggest that sugammadex removes rocuronium molecules from the circulation, whether free or IgE-bound. This mechanism is extremely important, especially in grade III and IV anaphylactic reactions, which can lead to death. In view of the scarcity of publications, this report showed the role of sugammadex in the reversal of rocuronium-induced anaphylaxis, refractory to conventional treatment.

Demographic Profile and Incidence of Residual Neuromuscular Blockade with the Use of Rocuronium and Sugammadex in Oncological Patients in the Post-Anesthetic Recovery Room

Demographic Profile and Incidence of Residual Neuromuscular Blockade with the Use of Rocuronium and Sugammadex in Oncological Patients in the Post-Anesthetic Recovery Room

Effect of coadministration of 10 mg/kg calcium chloride and neostigmine on extubation time: A randomized controlled trial

Introduction and objectivesSome studies investigating the effect of calcium on neostigmine-induced recovery of neuromuscular blockade have shown that this combination promotes neuromuscular recovery, but does not significantly affect the incidence of postoperative residual curarization and time to extubation. This study aimed to evaluate the effects of 10 mg/kg calcium chloride co-administered with neostigmine on early recovery and time to extubation. Patients and methodsThis prospective, randomized, double-blinded, placebo-controlled study included 88 ASA I–II patients aged between 18 and 65 years who were scheduled for elective surgery lasting at least 1 h under general anaesthesia in which 10 mg/kg of calcium chloride or the same volume of normal saline was co-administered with 5 μg/kg of neostigmine at the end of surgery. Time to extubation (time from neostigmine administration to extubation), time from neostigmine administration to TOF ratio (TOFr) 0.9 (neuromuscular recovery), and the incidence of residual neuromuscular blockade (RNMB) and other adverse effects were recorded. ResultsMedian (Q1, Q3) extubation time was significantly shorter in the calcium group vs. the placebo group (6.5 min [5.52–7.43] vs. 9.78 min [8.35–11]), P < .001. Median neuromuscular recovery time in the calcium group was 5 min vs. 7.1 min in the placebo group, P < .001. Patients in the calcium group had significantly higher TOFr and lower incidence of RNMB at 5 and 10 min vs. the placebo group, and no significant side effects. ConclusionCalcium chloride at a dose of 10 mg/kg co-administered with neostigmine promotes early neuromuscular recovery and reduces time to extubation by about 32%.

Routine administration of neostigmine after recovery of spontaneous breathing versus neuromuscular monitor-guided administration of neostigmine in pediatric patients: a parallel, randomized, controlled study

BackgroundNeostigmine used to reverse the muscle relaxants should be guided by neuromuscular monitoring, as the degree of spontaneous pre-reversal recovery is the key to success to reverse the neuromuscular block. But neuromuscular monitoring is not always available for some patients during anesthesia and, in consequence, we need to use other clinical judgment to guide the use of neostigmine to reverse the neuromuscular block. In this trial, we aimed to evaluate the incidence of residual neuromuscular blockade (rNMB) in pediatric patients with routine use of neostigmine after recovery of spontaneous breathing compared with the patients with the use of neostigmine guided by neuromuscular monitoring.MethodsA parallel, randomized, controlled noninferiority study was conducted. We enrolled aged 3 months to 12 years old patients who underwent inguinal hernia repair under general anesthesia. The enrolled patients were randomly divided into experimental and control groups. After surgery, children in the experimental group were given 0.02 mg/kg neostigmine after recovery of spontaneous breathing. Children in the control group were given 0.02 mg/kg neostigmine when the train-of-four (TOF) ratio was between 0.4 and 0.9. However, no neostigmine was administered if the TOF ratio was higher than 0.9. The primary outcome was the incidence of rNMB after extubation (TOF ratio < 0.9). Secondary outcomes included the incidence of neostigmine-induced muscle paralysis, end of surgery – extubation interval, end of surgery – exit OR interval, the length of stay in the PACU, the incidence of hypoxia in the PACU, the number of children who required assisted ventilation during the PACU stay, and neostigmine-related adverse events.ResultsA total of 120 children were included in this study, with 60 in the experimental group and 60 in the control group. There was no significant difference in the incidence of rNMB after extubation between the groups (45/60 vs 44/60, RR 1.02 [95% CI, 0.83 to 1.26], p = 0.84). There was no neostigmine-induced muscle paralysis in either group. Adverse events were similar occurred in both groups. However, time from end of the surgery to leaving the operating room was earlier in the experimental group than in the control group (13.6 ± 5.2 vs 15.7 ± 5.6 min, MD −2.10 min [95% CI, −3.70 to −0.50], p = 0.04). The risk ratio of the incidence of TOF ratio < 0.3 for the experimental group was 31.12 (95%CI, 1.89 to 512.61) compared with the control group (12/60 vs 0/60, p = 0.00) in exploratory analysis.ConclusionsRecovery of spontaneous breathing could be used as a substitute of neuromuscular monitoring to guide neostigmine use in pediatric patients following minor surgeries. However, care should be taken for the residual neuromuscular block.Trial registrationChinese Clinical Trial Registry ChiCTR-IOR-17012890. Registered on 5 October 2017

Predictive study of pharmacological reversal for residual neuromuscular blockade and postoperative pulmonary complications: a prospective, observational, cohort study

In recent years, some studies have generated controversy since they conclude that intraoperatively pharmacological reversal of neuromuscular blockade does not contribute to the reduction of postoperative residual neuromuscular blockade or pulmonary complications. Therefore, the main objective of this study was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal. The secondary aim was to present a prognostic model to predict the probability of having postoperative residual neuromuscular blockade depending on a patient's comorbidities and intraoperative neuromuscular blocking agents management. A single-center, prospective, observational cohort study including patients undergoing surgical procedures with general anesthesia was designed. A total of 714 patients were analyzed. Patients were divided into four groups: cisatracurium with spontaneous reversal, cisatracurium with neostigmine antagonism, rocuronium with spontaneous reversal, and rocuronium with sugammadex antagonism. According to our binomial generalized linear model, none of the studied comorbidities was a predisposing factor for an increase in the residual neuromuscular blockade. However, in our study, pharmacological reversal of rocuronium with sugammadex and, particularly, neuromuscular monitoring during surgery were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early and late postoperative pulmonary complications.

Residual neuromuscular blockade in the ICU: a prospective observational study and national survey.

Residual neuromuscular blockade is associated with significant morbidity. It has been widely studied in anaesthesia; however, the incidence of residual neuromuscular blockade in patients managed in the ICU is unknown. We conducted a prospective observational study in a tertiary ICU to determine the incidence of residual neuromuscular blockade using quantitative accelerographic monitoring. We tested for residual neuromuscular blockade (defined as a train-of-four ratio < 0.9) before cessation of sedation in anticipation of tracheal extubation. We also surveyed 16 other ICUs in New Zealand to determine their use of neuromuscular monitoring. A total of 191 patients were included in the final analysis. The incidence (95%CI) of residual neuromuscular blockade was 43% (36-50%), with a similar incidence observed in non-postoperative and postoperative patients. There was a lower risk of residual neuromuscular blockade with atracurium than rocuronium (risk ratio (95%CI) of 0.39 (0.12-0.78)) and a higher risk with pancuronium than rocuronium (1.59 (1.06-2.49)). Our survey shows that, in New Zealand ICUs, monitoring of neuromuscular function is rarely carried out before tracheal extubation. When neuromuscular monitoring is undertaken, it is based on individual clinician suspicion and performed using qualitative measurements. No ICU reported using a quantitative monitor or a clinical guideline. The results demonstrate a high incidence of residual neuromuscular blockade in our ICU patients and identify the type of neuromuscular blocking drug as a possible risk factor. Monitoring neuromuscular function before tracheal extubation is not currently the standard of care in New Zealand ICUs. These data suggest that residual neuromuscular blockade may be an under-recognised problem in ICU practice.

This Month in Anesthesiology

This Month in Anesthesiology

The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

BackgroundInadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The pilot study aims to understand the baseline incidence of residual neuromuscular blockade (RNMB) and postoperative critical respiratory events (CREs), which are described in a modified Murphy’s criteria in the PACU.MethodThis is a prospective cohort study from January to March 2017 from a tertiary hospital in Saudi Arabia with thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) who were enrolled in the study. The Mann-Whitney U tests, chi-square tests and independent-samples T tests were used. The train-of-four (TOF) ratios were measured upon arrival in the PACU by using acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data and the occurrence of postoperative CREs in the PACU were recorded.ResultsTwenty-six (86.7%) patients out of thirty in the study have received rocuronium as NMBDs whilst neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p = 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p = 0.046) and in patients with a shorter duration of surgery (p = 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (p = 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (p = 0.047).ConclusionThis research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, routine quantitative neuromuscular monitoring is recommended to reduce the incidence of RNMB.

Residual neuromuscular blockade and late neuromuscular blockade at the post-anesthetic recovery unit: prospective cohort study

Introduction and objectivesThe use of neuromuscular blockers during surgery represented a landmark for anesthesiology. However, their use can prompt residual Neuromuscular Blockade (RNMB) and objective monitoring of neuromuscular function is crucial to warrant the recovery of muscle strength. The present study aimed to estimate the incidence of RNMB and late Neuromuscular Blockade (LNMB) at the Post-Anesthetic Recovery Unit (PACU). MethodThe study included 85 patients, 43 of which received cisatracurium and 42 of which, rocuronium. The depth of the Neuromuscular Blockade (NMB) was assessed by Train Of Four (TOF). NMB reversal was performed with the administration of neostigmine and atropine.RNMB was defined when a patient presented TOF below 90% at the PACU. ResultsRNMB at the PACU was diagnosed in 39.5% and 40.5% of the patients receiving cisatracurium and rocuronium, respectively (p = 1.0). LNMB at the PACU was found in 32.6% and 16.7% of the patients receiving cisatracurium and rocuronium, respectively (p = 0.131). ConclusionsThe incidence ofRNMB remains significant despite the use of intermediate-acting neuromuscular blockers and reversal agents. There was no statistically significant difference in the incidence of RNMB or LNMB in patients receiving cisatracurium or rocuronium. The use of objective NMB monitoring is effective for the diagnosis of RNMB, as well as for treatment management.

Appropriate Use of Neuromuscular Blocking Agents and Reversal Drugs to Enhance Recovery Following Cardiac Surgery

To provide a brief review of the use of neuromuscular blocking agents (NMBA) in cardiac surgery, including strategies for reversal and the effects of residual blockade. While ample evidence exists in non-cardiac surgery demonstrating the potential harms of residual neuromuscular blockade (NMB), little is known about the effect on cardiac surgery patients. Few studies have examined whether residual effects are present following cardiac surgery and whether residual NMB has an impact on postoperative outcomes. In non-cardiac surgery, the incidence of residual NMB after surgery is high and associated with pulmonary complications. Anesthesiologists frequently underestimate the incidence of residual NMB in non-cardiac surgery. Objective measurement of the degree of neuromuscular recovery with acceleromyography may be challenging to apply and the monitors are not universally available. Therefore, reversal agents may be underutilized or yield incomplete reversal. As clinicians aim to decrease extubation times following cardiac surgery, the potential implication of residual NMB on perioperative outcomes increases. Research into the incidence and effect of residual NMB on outcomes following cardiac surgery is needed.

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

ObjectivesNeuromuscular 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 methodsWe 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. ResultsA 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. ConclusionsOverall, 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.

Incidence and Risk Factors for Postoperative Residual Neuromuscular Blockade

To define the incidence of residual neuromuscular blockade (rNMB) and identify patients at risk. Incidence of rNMB continues to be high, and risk factors are complex and difficult to predict. Sequelae of rNMB, however, are significant. Despite literature describing the significance of rNMB on patient safety, the incidence continues to be high, and risk factors are difficult to predict. Patient, anesthetic, and surgical risk factors all contribute, and an understanding of the unique risks for each individual patient is required to properly prevent rNMB.

Postoperative residual neuromuscular blockade after reversal based on a qualitative peripheral nerve stimulator response: A randomised controlled trial.

Incomplete recovery of neuromuscular blockade is a common postoperative adverse event in the postanaesthesia care unit. We examined and compared the incidence of residual neuromuscular blockade when the recommended dose of neostigmine or sugammadex was administered according to a qualitative nerve stimulator response. A randomised controlled trial. A tertiary care hospital in South Korea from September 2017 to November 2017. Eighty patients aged between 18 and 69 years were included in this study. All were patients scheduled to undergo elective laparoscopic cholecystectomy and who had an American Society of Anaesthesiologists physical status of one or two were eligible. Patients were allocated randomly to receive neostigmine or sugammadex at the end of surgery. The doses of the reversal agents were based on the response to peripheral nerve stimulation, which was discontinued after administration of the reversal agent. The primary outcome was the incidence of postoperative residual neuromuscular blockade. The secondary outcomes were the incidences of symptoms or signs of residual neuromuscular blockade such as hypoxaemia, inability to maintain head-lift for 5 s and diplopia. The incidence of residual neuromuscular blockade on arrival in the recovery room was 44.4% in the neostigmine group and 0% in the sugammadex group (P < 0.0001, relative risk = 1.80, 95% confidence interval 1.36 to 2.41). The incidences of adverse events in the recovery room were low and comparable between the groups. The incidence of residual neuromuscular blockade on arrival in the recovery room was significantly higher in the neostigmine group than that in the sugammadex group. However, the incidence of adverse events was similar in the neostigmine and sugammadex groups. ClinicalTrials.gov identifier: NCT03292965.

Incidence of residual neuromuscular blockade in children below 3 years after a single bolus of cisatracurium 0.1mg/kg: A quality assurance study.

The aim of this quality assurance study was to determine the proportion of patients with residual block (train-of-four (TOF) ratio <0.9) upon conclusion of surgery after a bolus of cisatracurium 0.1mg/kg. It was considered good quality if less than 10% of the study population had residual block upon conclusion of surgery. A total of 40 patients ≤3years of age scheduled for cleft lip and palate repair were consecutively enrolled. They received general anaesthesia with either sevoflurane and fentanyl (n=20) or propofol and remifentanil (n=20). TOF stimulation using acceleromyography was applied on the tibial nerve. Cisatracurium 0.1mg/kg was administered to facilitate tracheal intubation. Three patients (8%; 95% CI: 1.7-21) had a TOF ratio <0.9 at conclusion of surgery, all three receiving sevoflurane. In the sevoflurane group, this corresponded to 16% (95% CI: 3.3-40) of the patients. Mean duration of action of cisatracurium 0.1mg/kg was 119minutes (SD 40) with sevoflurane and 73minutes (SD 29) during total intravenous anaesthesia (P<.001). Onset time of cisatracurium 0.1mg/kg was 166seconds (SD 37) with sevoflurane and 199seconds (SD 60) during total intravenous anaesthesia. We found that 8% of the children had residual neuromuscular blockade (TOF ratio <0.9) after administration of a single bolus of cisatracurium 0.1mg/kg but we cannot exclude that the true proportion is around 20%.

Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

BackgroundComplete avoidance of residual neuromuscular blockade (RNMB) during the postoperative period has not yet been achieved in current anesthesia practice. Evidently, compliance with NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. To our knowledge, no publications have reported the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables.MethodsThis retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit (PACU). Scheduled recovery in the intensive care unit was the only exclusion criterion.ResultsRNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P < 0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively.ConclusionsThe results of the present study suggest that intra-operative quantitative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

Preliminary Indications for the Use of Sugammadex After Its Addition to a Formulary at a Tertiary Care Children's Hospital.

Neuromuscular blocking agents (NMBAs) are administered to facilitate endotracheal intubation and provide skeletal muscle relaxation in surgical procedures. Sugammadex (Bridion) recently received approval by the United States Food and Drug Administration for reversal of rocuronium and vecuronium-induced neuromuscular blockade thereby providing an alternative to acetylcholinesterase inhibitors such as neostigmine. This quality improvement analysis sought to investigate the clinical reasons and common clinical perceptions for choosing sugammadex over neostigmine to reverse NMBAs. One hundred cases were reviewed where sugammadex was used for neuromuscular blockade reversal in the operating room. Cases were identified from electronic medical record reports. Anesthesia providers responsible for administering sugammadex were interviewed to obtain rationales for sugammadex use in the perioperative setting. Responses were reviewed to identify distinct reasons for using sugammadex. Two independent raters ranked the reasons according to prevalence. The study was exempt from Institutional Review Board approval as a quality improvement (QI) project. Forty-two anesthesia providers (15 Certified Registered Nurse Anesthetists, 5 anesthesiology trainees, and 22 attending anesthesiologists) were interviewed to identify reasons why sugammadex was administered intraoperatively in 100 surgical cases (69/31 male/female patients, age 9.4 ± 6.5 years). The author identified the top 19 common reasons respondents chose to use sugammadex for each case, and independent raters reviewed the response summaries for those 19 primary reasons sugammadex was used. The most common reasons for choosing sugammadex were: 1) beneficial pharmacokinetics of the agent; 2) sugammadex's perceived superior efficacy over neostigmine; and 3) concerns regarding adverse effects of neostigmine and/or the anticholinergic agent. Sugammadex has recently been introduced for clinical use to reverse NMBAs at our institution. Primary reasons and perceptions for its use over neostigmine included a limited adverse effect profile, a greater sense of control and predictability of patients' response, and a limited incidence of residual neuromuscular blockade.

Improving Neuromuscular Monitoring and Reducing Residual Neuromuscular Blockade With E-Learning: Protocol for the Multicenter Interrupted Time Series INVERT Study.

BackgroundMuscle relaxants facilitate endotracheal intubation under general anesthesia and improve surgical conditions. Residual neuromuscular blockade occurs when the patient is still partially paralyzed when awakened after surgery. The condition is associated with subjective discomfort and an increased risk of respiratory complications. Use of an objective neuromuscular monitoring device may prevent residual block. Despite this, many anesthetists refrain from using the device. Efforts to increase the use of objective monitoring are time consuming and require the presence of expert personnel. A neuromuscular monitoring e-learning module might support consistent use of neuromuscular monitoring devices.ObjectiveThe aim of the study is to assess the effect of a neuromuscular monitoring e-learning module on anesthesia staff’s use of objective neuromuscular monitoring and the incidence of residual neuromuscular blockade in surgical patients at 6 Danish teaching hospitals.MethodsIn this interrupted time series study, we are collecting data repeatedly, in consecutive 3-week periods, before and after the intervention, and we will analyze the effect using segmented regression analysis. Anesthesia departments in the Zealand Region of Denmark are included, and data from all patients receiving a muscle relaxant are collected from the anesthesia information management system MetaVision. We will assess the effect of the module on all levels of potential effect: staff’s knowledge and skills, patient care practice, and patient outcomes. The primary outcome is use of neuromuscular monitoring in patients according to the type of muscle relaxant received. Secondary outcomes include last recorded train-of-four value, administration of reversal agents, and time to discharge from the postanesthesia care unit as well as a multiple-choice test to assess knowledge. The e-learning module was developed based on a needs assessment process, including focus group interviews, surveys, and expert opinions.ResultsThe e-learning module was implemented in 6 anesthesia departments on 21 November 2016. Currently, we are collecting postintervention data. The final dataset will include data from more than 10,000 anesthesia procedures. We expect to publish the results in late 2017 or early 2018.ConclusionsWith a dataset consisting of thousands of general anesthesia procedures, the INVERT study will assess whether an e-learning module can increase anesthetists’ use of neuromuscular monitoring.Trial RegistrationClinicaltrials.gov NCT02925143; https://clinicaltrials.gov/ct2/show/NCT02925143 (Archived by WebCite® at http://www.webcitation.org/6s50iTV2x)

Cisatracurium- and rocuronium-associated residual neuromuscular dysfunction under intraoperative neuromuscular monitoring and postoperative neostigmine reversal: a single-blind randomized trial

BackgroundPostoperative residual neuromuscular blockade (RNMB) is a common complication in the postanesthesia care unit (PACU), but also one of the most controversial issues. Many studies and trials demonstrated that some methods and techniques can reduce the incidence and the extent of the phenomenon. Study ObjectiveTo determine the incidence of RNMB in the PACU at standardized times after extubation with the implementation of a protocol of careful neuromuscular blockade management. DesignRandomized, single-blinded controlled clinical trial. SettingOperating room and PACU. PatientsA total of 120 patients of either sex with American Society of Anesthesiologists grades 1, 2, and 3, aged 18 to 80 years were scheduled to undergo elective abdominal surgical procedures lasting for at least 60 minutes. InterventionsPatients were randomized to receive either cisatracurium (n=60) or rocuronium (n=60) at the time of intubation and during surgery. Every patient received quantitative neuromuscular monitoring during general anesthesia. On completion of surgery, patients were given neostigmine 0.05 mg kg−1. Patients were extubated at a train-of-four (TOF) ratio≥0.9. MeasurementsTOF measurements were performed 15, 30, and 60 minutes after extubation. Tolerability of neuromuscular monitoring was evaluated with a scale from 1 to 10 (with 1 meaning no discomfort at all and 10 meaning maximal discomfort or pain). ResultsSix, 11, and 14 patients (5.0%, 9.2%, and 11.7%) exhibited a TOF ratio <0.9 at 15, 30, and 60 minutes after extubation, respectively. No statistically significant difference in the postoperative RNMB between cisatracurium and rocuronium was found. The median tolerability score for neuromuscular monitoring was 3. ConclusionCareful conduction, monitoring, and subsequent reversal of neuromuscular block may allow for obtaining considerably low incidence of residual neuromuscular block. However, our trial shows that some mid- and long-term cases of TOF ratios <0.9 can still occur, possibly jeopardizing the patients' postoperative recovery.

The Effect of Quantitative Neuromuscular Monitoring on the Incidence of Residual Neuromuscular Blockade and Clinical Outcomes

Neuromuscular blocking agents (NMBAs) are useful perioperative medications. Despite this utility, their administration is associated with increased morbidity due to residual neuromuscular blockade. Clinical testing prior to tracheal extubation is subjective, dependent on the patient’s cooperation, and not predictive of adequate respiratory function to prevent the occurrence of postoperative critical respiratory events. The use of peripheral nerve stimulators may improve detection of residual weakness; however, this technique does not reliably detect residual paralysis, as it requires the subjective (and imperfect) assessment of fade in response to train-of-four (TOF) stimulation. Quantitative neuromuscular monitoring can be accomplished through a variety of modalities and remains as the most effective and reproducible method of detecting residual paralysis after NMBA administration. In this review, we will discuss the various techniques that are used clinically to assess depth of block and adequacy of reversal, with a focus on quantitative (objective) neuromuscular monitoring.

The RECITE Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade.

Postoperative residual neuromuscular blockade (NMB), defined as a train-of-four (TOF) ratio of <0.9, is an established risk factor for critical postoperative respiratory events and increased morbidity. At present, little is known about the occurrence of residual NMB in Canada. The RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study was a prospective observational study at 8 hospitals in Canada investigating the incidence and severity of residual NMB. Adult patients undergoing open or laparoscopic abdominal surgery expected to last <4 hours, ASA physical status I-III, and scheduled for general anesthesia with at least 1 dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of neuromuscular relaxation were enrolled in the study. Neuromuscular function was assessed using acceleromyography with the TOF-Watch SX. All reported TOF ratios were normalized to the baseline values. The attending anesthesiologist and all other observers were blinded to the TOF ratio (T4/T1) results. The primary and secondary objectives were to determine the incidence and severity of residual NMB (TOF ratio <0.9) just before tracheal extubation and at arrival at the postanesthesia care unit (PACU). Three hundred and two participants were enrolled. Data were available for 241 patients at tracheal extubation and for 207 patients at PACU arrival. Rocuronium was the NMB agent used in 99% of cases. Neostigmine was used for reversal of NMB in 73.9% and 72.0% of patients with TE and PACU data, respectively. The incidence of residual NMB was 63.5% (95% confidence interval, 57.4%-69.6%) at tracheal extubation and 56.5% (95% confidence interval, 49.8%-63.3%) at arrival at the PACU. In an exploratory analysis, no statistically significant differences were observed in the incidence of residual NMB according to gender, age, body mass index, ASA physical status, type of surgery, or comorbidities (all P > 0.13). Residual paralysis is common at tracheal extubation and PACU arrival, despite qualitative neuromuscular monitoring and the use of neostigmine. More effective detection and management of NMB is needed to reduce the risks associated with residual NMB.