Postoperative Residual Paralysis Research Articles

Decurarization After Thoracic Anesthesia using sugammadex compared to neostigmine (DATA trial): a multicenter randomized double-blinded controlled trial

BackgroundThoracic surgery is a high-risk surgery especially for the risk of postoperative pulmonary complications. Postoperative residual paralysis has been shown to be a risk factor for pulmonary complications. Nevertheless, there are few data in the literature concerning the use of neuromuscular blocking agent antagonists in patients undergoing lung surgery.MethodsSeventy patients were randomized in three Italian centers to receive sugammadex or neostigmine at the end of thoracic surgery according to the depth of the residual neuromuscular block. The primary outcome was the time from reversal administration to a train-of-four ratio (TOFR) of 0.9. Secondary outcomes were the time to TOFR of 1.0, to extubation, to postanesthesia unit (PACU) discharge, postoperative complications until 30 days after surgery, and length of hospital stay.ResultsMedian time to recovery to a TOFR of 0.9 was significantly shorter in the sugammadex group compared to the neostigmine one (88 vs. 278 s — P < 0.001). The percentage of patients who recovered to a TOFR of 0.9 within 5 min from reversal administration was 94.4% and 58.8% in the sugammadex and neostigmine groups, respectively (P < 0.001). The time to extubation, but not the PACU stay time, was significantly shorter in the sugammadex group. No differences were found between the study groups as regards postoperative complications and length of hospital stay. The superiority of sugammadex in shortening the recovery time was confirmed for both deep/moderate and shallow/minimal neuromuscular block.ConclusionsAmong patients undergoing thoracic surgery, sugammadex ensures a faster recovery from the neuromuscular block and earlier extubation compared to neostigmine.

THE IMPORTANCE OF SUGAMMADEX AT POSTOPERATIVE RESIDUAL NEUROMUSCULAR BLOCK

Introduction: postoperative residual neuromuscular blockade is the postoperative muscle paralysis caused by incomplete or null antagonism of neuromuscular blocking agents. Post-surgical residual paralysis (PORP) has a high incidence and may cause adverse effects, increasing postoperative morbidity and mortality. The gold standard for complete reversal of neuromuscular blockade is a T4/T1 ratio of 0.9. Small degrees of paralysis are associated with an increased risk of postoperative pulmonary complications. Recent research indicates that residual neuromuscular blockade is a significant risk factor for patient safety. Objective: to detail the current information related to postoperative residual paralysis, in addition to explaining the use and characteristics of sugammadex in its reversal. Methodology: a total of 45 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 35 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: postoperative residual neuromuscular block, postoperative muscle weakness, sugammadex, anticholinesterase inhibitors. Results: Neuromuscular block occurs due to muscle fragility in the postoperative period due to antagonism, which produces a decrease in the musculature of the upper and lower airways. When this phase is properly managed, extubation delays are reduced, and postoperative pulmonary complications are reduced. Sugammadex is a relaxant that decreases the possibility of persistent neuromuscular paralysis; as neuromuscular blockade increases, contraction decreases. Therefore, when this drug is used, the risk of adverse effects, mostly respiratory, is avoided. This drug inactivates rocuronium, and the adverse effects it presents (although very infrequent) are dysgeusia, cough, grimacing or increased secretion through the endotracheal tube. Conclusions: sugammadex is suggested to be used before neostigmine, although it should be used in patients with high risk of postoperative complications, such as patients over 80 years of age or with post cardiothoracic surgery. However, sugammadex reverses neuromuscular blockade more rapidly, with a decrease in the frequency of residual neuromuscular blockade and postoperative pulmonary complications such as pneumonias. A point to consider is that sugammadex is more expensive and is usually accompanied by higher presentations of adverse effects. KEY WORDS: sugammadex, paralysis, residual, postoperative, antagonism, neuromuscular.

804: SUGAMMADEX (BRIDION) MEDICATION USE EVALUATION IN A 591-BED TEACHING HOSPITAL

Introduction: Sugammadex is a modified gamma cyclodextrin encapsulating agent that reverses the action of neuromuscular blocking agents [NMBA] rocuronium and vecuronium. It is one of our institutional’ s high cost medications. As compared to neostigmine, sugammadex has lower incidence of bradycardia, post-operative nausea vomiting, and postoperative residual paralysis. The purpose of this review is to evaluate guideline reinforcement, safety & cost-effectiveness of sugammadex. Methods: This is a retrospective chart review study. IRB approval is not required by NYU-LI as this is a quality improvement project. Inclusion criteria includes patients ≥ 18 years of age received sugammadex or neostigmine in the months of July 2021 and September 2021 at NYU Langone Health Hospital Long Island. Exclusion criteria includes patients on pediatric service or receiving neostigmine for purposes other than reversal of NMBA. Results: Total of 316 patient charts were reviewed. The most common surgery service to utilize sugammadex was gastroenterology. The median dose of sugammadex was 200mg. The guideline reinforcement resulted in the following: ​reduction of non-adherent dosing from 30% to 20%, which is equivalent to $20,000 reduction in cost from Fiscal Quarter 4 2021 (June, July, & August) to Fiscal Quarter 1 2022 (September, October, November). No differences were observed in time to clinical outcomes including NMBA reversal in operating room or PACU exit, and extubation; time under anesthesia, and OR/PACU times between sugammadex and neostigmine patients. Train of Four (TOF) documentation only occurred in 41% of the patient cases. Conclusions: Education is needed to reinforce sugammadex prescribing guideline. Train of four documentation is lacking in most cases.

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review.

High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.

Post-operative residual neuromuscular blockade after the administration of a single intubating dose of intermediate-acting non-depolarising neuromuscular blocking agent in adult elective surgical procedures

Objectives: Post-operative residual neuromuscular blockade may result in life-threatening conditions if not properly managed making it a common and significant concern among anaesthesiologists. Among adult elective surgeries requiring single intubating dose of intermediate-acting non-depolarising neuromuscular blocking agent, the study determined the incidence and risk factors associated with post-operative residual neuromuscular blockade during early post-operative period. Materials and Methods: A prospective, open-labelled, non-randomised observational study conducted in an operating room and post-anaesthesia care unit. A total of 175 ASA-PS Class I and II patients admitted in the surgical wards scheduled for elective surgical operation and were administered of a single intubating dose of intravenous intermediate-acting non-depolarising neuromuscular blocking drug. The train-of-four (TOF) method of peripheral nerve stimulation detects the presence of post-operative residual neuromuscular blockade. Results: A significant post-operative residual paralysis was identified in specific age groups (26–35, 46–55 and 56–65), in surgical procedures in the orthopaedic service, and among patients who were given a reversal agent. Residual neuromuscular blockade is still present even if the interval between the last dose of muscle relaxant and the measurement of TOF ratio at the post-anaesthesia care unit was long, however, less than that observed in short interval surgeries. Conclusion: Clinical importance of residual neuromuscular blockade is still evident up to the present time and the present study recommends routine monitoring of neuromuscular blockade and pharmacologic antagonism in the reversal of non-depolarising neuromuscular blocking drugs.

Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks

BackgroundNeuromuscular blocking agents (NMBAs) with a non-depolarising mechanism of action carry the risk of postoperative residual paralysis and are associated with postoperative pulmonary complications (POPC). Owing to the shorter duration of action, the depolarising NMBA succinylcholine may be associated with less postoperative residual paralysis, and hence fewer POPC. We tested the association of succinylcholine administration during anaesthesia and POPC. MethodsIn a retrospective cohort study of registry data from two large US academic medical centres, 244 850 adult noncardiac surgical patients undergoing general anaesthesia were included. The primary outcome was POPC, defined as post-extubation haemoglobin oxygen de-saturation to <90%, or re-intubation requiring intensive care unit admission within 7 days after surgery. The association between succinylcholine and POPC and its dose-dependency were tested in a hierarchical fashion using a multivariable logistic regression model. ResultsA total of 13 206 patients (5.4%) experienced POPC. Use of succinylcholine was associated with increased risk of POPC (adjusted odds ratio [ORAdj]=1.11; 95% confidence interval [CI], 1.06–1.16; P<0.001; adjusted risk=5.18%; 95% CI, 5.06–5.30 without and 5.69%; 95% CI, 5.53–5.85 with succinylcholine), with a dose-dependent relationship (ORAdj=1.08; 95% CI, 1.05–1.11 per mg kg−1; P<0.001). In patients receiving non-depolarising NMBAs, succinylcholine further increased the risk of POPC (ORAdj=1.08; 95% CI, 1.03–1.14; P=0.001). The association between succinylcholine and POPC was modified (P=0.03 for interaction) by the duration of surgery with higher odds of POPC in patients undergoing surgeries of <2 vs ≥2 h (ORAdj=1.24; 95% CI, 1.15–1.33 and 1.05; 95% CI, 1.00–1.10, respectively). ConclusionsIn contrast to our prediction, succinylcholine administration was associated with an increased risk of POPC. This association was dose-dependent and magnified in surgeries of shorter duration.

Do clinical signs of recovery from neuromuscular blockade compare reliably with objective parameters of train-of-four and double burst stimulation: An observational single-center study

Background: Recovery from neuromuscular blockade is commonly assessed by clinical signs. There exists wide disparity in what is recommended to monitor neuromuscular blockade and routine clinical practice by anesthesiologists. The objective signs of train-of-four (TOF) ratio of >0.9 and double burst stimulation (DBS) ratio of 1.0 indicate adequate neuromuscular function. This study was planned at a tertiary care hospital to evaluate the ongoing practice of assessing neuromuscular recovery employing clinical signs and comparing with simultaneous TOF and DBS values. Design: A cross-sectional analytical study. Methodology: A total of 100 consecutive patients undergoing surgical procedures lasting more than 1-h duration under general anesthesia with intermediate acting muscle relaxant were enrolled and data of 60 patients analyzed. After extubation, an independent observer recorded simultaneous TOF and DBS ratio using acceleromyography as the clinical signs of neuromuscular recovery (eye opening, tongue protrusion, head lift, sustained bite, hand grip strength, and ability to cough) were attained. Statistical Analysis: Statistical analysis was done utilizing SPSS version 20 (SPSS Inc., Chicago IL, USA) software. Continuous variables are expressed as mean (standard deviation) and Pearson's correlation coefficient was applied to study the correlation between the clinical parameters and quantitative measures of neuromuscular recovery. Results: There was a significant association between ability to retain tongue depressor (sustained bite), absent double vision and ability to cough effectively and TOF and DBS ratios (P 0.9 or DBS ratio of 1.0. Conclusion: Clinical signs of recovery fail to reliably predict postoperative residual paralysis compared to objective neuromuscular monitoring.

Neostigmine-based reversal of intermediate acting neuromuscular blocking agents to prevent postoperative residual paralysis: A systematic review.

Neostigmine is widely used to antagonise residual paralysis. Over the last decades, the benchmark of acceptable neuromuscular recovery has increased progressively to a train-of-four (TOF) ratio of at least 0.9. Raising this benchmark may impact on the efficacy of neostigmine. The systematic review evaluates the efficacy of neostigmine to antagonise neuromuscular block to attain a TOF ratio of at least 0.9. We performed a systematic search of the literature from January 1992 to December 2015. PubMed, EMBASE and the Cochrane Controlled Clinical Trials database were searched for randomised controlled human studies. Search was performed without language restrictions, using the following free text terms: 'neostigmine', 'sugammadex', 'edrophonium' or 'pyridostigmine' AND 'neuromuscular block', 'reversal' or 'reverse'. Studies were accepted for inclusion if they used quantitative neuromuscular monitoring and neostigmine as the reversal agent. Selected trials were checked by two of the authors for data integrity. Trials relevant for inclusion had to report the number of patients included, the type of anaesthetic maintenance, the type of neuromuscular blocking agent used, the reversal agent and dose used, the depth of neuromuscular block when neostigmine was administered and the reversal time (time from injection of neostigmine until a TOF ratio ≥0.9 was attained). 19 trials were eligible for quantitative analysis. In patients with deep residual block [T1 (first twitch height) <10%] 70 μg kg neostigmine was used (five trials, 118 patients), and the mean reversal time was 17.1 min (95% confidence interval (CI) [12.4 to 21.8]). In patients with moderate residual block (T1 10% to <25%) the mean neostigmine dose was 56 μg kg (seven trials, 342 patients), and the mean reversal time was 11.3 min (95% CI [9.2 to 13.4]). In patients with a shallow residual block (T1 ≥ 25%) the mean neostigmine dose was 40 μg kg (13 trials, 535 patients), and the mean reversal time was 8.0 min (95% CI [6.8 to 9.2]). Based on the findings of this systematic review, we recommend that the administration of neostigmine be delayed until an advanced degree of prereversal recovery has occurred (i.e. a T1 >25% of baseline), or that a recovery time longer than 15 min be accepted.

Risk factors for postoperative residual paralysis in patients undergoing general anesthesia

Objective To determine the risk factors for postoperative residual paralysis in patients undergoing general anesthesia and establish the warning score system initially. Methods A total of 369 patients who underwent general anesthesia and developed residual paralysis after returning to the recovery room and 740 patients who did not developed residual paralysis were enrolled in the study.Logistic regression was used to analyze the factors of which P values were less than 0.05 to identify the independent risk factors for postoperative residual paralysis.The warning score system was established initially according to the odds ratios of each risk factor, and the area under receiver operating characteristic curve was used to evaluate the predicting ability of the system. Results Logistic regression analysis showed that the consumption of cisatracurium more than 0.4 mg·kg-1·h-1, time from the last administration of muscle relaxants to the end of operation less than 60 min and volume of intraoperative fluid infused more than 20 ml/kg were independent risk factors for postoperative residual paralysis in patients undergoing general anesthesia.The warning score system of residual paralysis was established initially, and the area under receiver operating characteristic curve was 0.82.The best cut-off value of predicting residual paralysis was 1.5 (sensitivity 63.5%, specificity 82.7%, Youden index 0.462), and thus the risk stratification criteria were determined initially with score less than or equal to 1 predicting low risk, and score more than or equal to 2 predicting high risk. Conclusion The consumption of cisatracurium more than 0.4 mg·kg-1·h-1, time from the last administration of muscle relaxants to the end of operation less than 60 min and volume of intraoperative fluid infused more than 20 ml/kg are independent risk factors for postoperative residual paralysis in patients undergoing general anesthesia; the initially established warning score system produces higher accuracy in predicting postoperative residual paralysis. Key words: Anesthesia, general; Muscle relaxation; Risk factors

Train-of-four guard-controlled sugammadex reversal in patients with multiple sclerosis.

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating autoimmune disease of the central nervous system. It is known that the disease, which is manifested by a wide variety of symptoms, may exacerbate after anesthesia and show different responses to muscle relaxants in the normal population. It is planned to measure train-of-four (TOF) values of MS patients to be operated under general anesthesia before sugammadex application. With the approval of the local ethics committee of the University of Health Sciences Bagcilar Training and Research Hospital and with written consents of participants, we anesthetized ten patients (from April 2014 to March 2017) with MS and ten American Society of Anesthesiologists I-III patients without MS. Neuromuscular conduction was assessed by the acceleromyometric method using a TOF-Guard apparatus (Organon, Holland). The patients were extubated after recovery of TOF higher than 0.9. The primary efficacy variable was the time from the start of administration of sugammadex to recovery of the TOF ratio to 0.9. The demographic characteristics of both groups, the type and duration of surgery and anesthesia applied, and the temperature of the operation room were similar. Similar characteristics of both groups were of concern for postoperative residual paralysis, and therefore we did not notice any difference between time to TOF> 90/s for both groups. Sugammadex and TOF patients will increase patient safety in general anesthesia practice.

The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta-analysis and trial sequential analysis.

We compared the efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. Our outcomes were: recovery time from second twitch to train-of-four ratio >0.9; recovery time from post-tetanic count 1-5 to train-of-four ratio >0.9; and risk of composite adverse and serious adverse events. We searched for randomised clinical trials irrespective of publication status and date, blinding status, outcomes reported or language. We included 41 studies with 4206 participants. Time to reversal of neuromuscular blockade from second twitch to a train-of-four ratio >0.9 was 2.0min with sugammadex 2mg.kg-1 and 12.9min with neostigmine 0.05mg.kg-1 , with a mean difference (MD) (95%CI)) of 10.2 (8.5-12.0) (I2 =84%, 10 studies, n=835, Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate quality). Time to reversal of neuromuscular blockade from a post-tetanic count of 1-5 to a train-of-four ratio >0.9 was 2.9min with sugammadex 4mg.kg-1 and 48.8min with neostigmine 0.07mg.kg-1 , with a MD (95%CI) of 45.8 (39.4-52.2) (I2 =0%, 2 studies, n=114, GRADE: low quality). There were significantly fewer composite adverse events in the sugammadex group compared with neostigmine, with a risk ratio (95%CI) of 0.60 (0.49-0.74) (I2 =40%, 28 studies, n=2298, number needed to treat (NNT): 8, GRADE: moderate quality). Specifically, the risk of bradycardia (RR (95%CI) 0.16 (0.07-0.34), n=1218, NNT: 14, GRADE: moderate quality), postoperative nausea and vomiting (RR (95%CI) 0.52 (0.28-0.97), n=389, NNT: 16, GRADE: low quality) and overall signs of postoperative residual paralysis (RR (95%CI) 0.40 (0.28-0.57), n=1474, NNT: 13, GRADE: moderate quality) were all reduced. There was no significant difference regarding the risk of serious adverse events (RR 0.54, 95%CI 0.13-2.25, I2 =0%, n=959, GRADE: low quality). Sugammadex reverses neuromuscular blockade more rapidly than neostigmine and is associated with fewer adverse events.

Comment on the article “Postoperative residual paralysis in patients aged over 65 years old at the Post-Anesthesia Care Unit”

Comment on the article “Postoperative residual paralysis in patients aged over 65 years old at the Post-Anesthesia Care Unit”

Impact of reversal strategies on the incidence of postoperative residual paralysis after rocuronium relaxation without neuromuscular monitoring: A partially randomised placebo controlled trial.

Electronic neuromuscular monitoring is not widely used to determine either the reversal requirements for neuromuscular block before extubation of the trachea, or to determine if there is any subsequent postoperative residual neuromuscular block (PORNB). To investigate the incidence of PORNB using acceleromyography after spontaneous recovery of rocuronium-induced block and to compare this with the administration of sugammadex, neostigmine or a placebo. Partially randomised, partially randomised, placebo-controlled, double-blind, four-group parallel-arm study. Single-centre study performed between October 2013 and December 2015 in a university hospital. Of the 134 eligible patients, 128 gave their consent and 125 of these completed the study. Patients received general anaesthesia with propofol, sevoflurane, fentanyl and rocuronium. Neuromuscular transmission was measured by acceleromyography (TOF-Watch-SX; Organon Teknika B.V., Boxtel, the Netherlands) but the anaesthetist was blind to the results. If the anaesthetist deemed pharmacological reversal to be necessary before extubation of the trachea then patients were assigned randomly to receive either sugammadex (2.0 mg kg), neostigmine (0.05 mg kg) or a placebo. In the postanaesthesia care unit, an independent anaesthetist, unaware of the treatment given, assessed the neuromuscular function using acceleromyography. The incidence of a normalised train-of-four ratio less than 0.9 on arrival in the recovery room. In total, 125 patients were recruited. Neuromuscular block was allowed to recover spontaneously in 50 patients, whereas the remainder received either sugammadex (27), neostigmine (26) or placebo (22). The number of cases with PORNB were one (3.7%), four (15%), 13 (26%) and 10 (45%) after sugammadex, neostigmine, spontaneous recovery and placebo, respectively. Sugammadex and neostigmine were more effective than placebo [odds ratio (OR): 0.05, 95% confidence interval (CI): 0.005 to 0.403, P = 0.005; OR: 0.22, 95% CI: 0.056 to 0.85, P = 0.028, respectively]. Sugammadex performed better than spontaneous recovery (OR: 0.11, 95% CI: 0.014 to 0.89, P = 0.039) unlike neostigmine (OR: 0.52, 95% CI: 0.15 to 1.79, P = 0.297). Yet, antagonism (pooled data) was more effective than spontaneous recovery (OR: 0.3, 95% CI: 0.1 to 0.9, P = 0.03). Although pharmacological reversal based on clinical signs was superior to spontaneous recovery it did not prevent PORNB, irrespective of the reversal agent. The study is registered under EUDRACT number 2013-001965-17.

Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults.

Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults.

Is neuromuscular blocker needed in children undergoing inguinal herniorrhaphy?: A prospective, randomized, and controlled trial.

Background:Intraoperative neuromuscular blocker is widely used, but is known to be associated with postoperative residual paralysis, which is known to be associated with increased risk of pulmonary complications. Hence, its use should be individualized and restricted to procedures where it is mandatory. We examined whether not using a neuromuscular blocker affects the surgical conditions in children undergoing inguinal herniorrhaphy.Methods:Anesthesia was induced and maintained with sevoflurane in 60% nitrous oxide, and the airway was maintained using an I-gel. In total, 66 children aged 1 to 6 years were randomized to receive rocuronium (rocuronium group, n = 33) or saline (control group, n = 33); 61 children of them finished the study. A single surgeon who performed the operation rated the surgical condition of each patient on a 4-point scale (1 = poor, 2 = acceptable, 3 = good, and 4 = excellent). Intraoperative patient movement, recovery time, emergence agitation, and postoperative pain scores were evaluated.Results:One patient in control group and no patient in rocuronium group showed intraoperative movement. When noninferiority test was done for intraoperative patient movement, with the noninferiority margin of 20%, the difference of absolute risk was 3.3% (95% confidence interval −8.0% to 16.7%) and saline group was noninferior to rocuronium group. All of the patients showed good to excellent surgical conditions, and no difference was found between the 2 groups. The recovery time was shorter in the control group than in the rocuronium group (4.5 ± 1.8 vs 5.6 ± 2.2 minutes, respectively; P = .028).Conclusion:In children aged 1 to 6 years undergoing inguinal herniorhaphy under sevoflurane anesthesia using an I-gel, not using neuromuscular blocker showed similar intraoperative condition and shortened recovery time compared with using neuromouscular blocker.

Incidence of postoperative residual paralysis in a nigerian teaching hospital.

Postoperative residual paralysis (PORP) is a known risk factor after general anesthesia (GA) for critical respiratory events and increased postoperative morbidity. PORP is defined as a train-of-four ratio (TOFR) of <0.9 using acceleromyography (AMG). TOFR <0.9 has been associated with increased risk of aspiration, obstruction of the upper airway and an impaired hypoxic ventilatory response. The aim of this study was to determine the incidence of PORP, associated factors related with its occurrence and critical respiratory events in the postanesthesia recovery room (PAR) at our institution. Forty-one adult patients were scheduled for elective surgeries requiring GA with the use of at least 1 dose of a nondepolarizing neuromuscular blocking drug (NMBD). An independent anesthetist quantitatively measured TOFR of recruited patients postoperatively in the recovery room using the TOF-watch SX acceleromyograph (Organon Teknika) 5 min after arrival. The incidence of PORP was 75.6% (n = 31), with severe PORP (TOFR <0.7) seen in 41.5% (n = 17) of patients. Median time to full recovery in the PAR was 33 min (range 5-164 min). There was no statistical difference in the incidence of PORP related to the choice of NMBD (P = 0.186) or duration of surgery (P = 0.175). No respiratory complications or events were observed in patients with residual blockade. The incidence of PORP is quite high and undetected in our environment. Quantitative monitoring for residual paralysis is advocated as part of routine monitoring with the use of NMBDs for improved patient safety.

Relajación residual postoperatoria en la unidad de cuidados postanestésicos de un hospital universitario: estudio de corte transversal

IntroductionPostoperative residual paralysis has been related with postoperative complications. ObjectiveTo determine the prevalence of postoperative residual paralysis in a university hospital and its association with perioperative conditions. MethodsA prospective registry of 102 patients in a period of 4 months was designed to include ASA I-II patients who intraoperatively received nondepolarizing neuromuscular blockers. Abductor pollicis response to a train-of-four stimuli based on accelleromyography and thenar eminence temperature (TOF-Watch SX®. Organon, Ireland) was measured immediately upon arrival to the postanesthetic care unit and 30seconds after. Uni-bivariate analysis were planned to determine possible associations with residual paralysis, defined as two repeated values of T4/T1 ratio <0.90 in response to train-of-four stimuli. ResultsPostoperative residual paralysis was detected in 42.2% of the subjects. Pancuronium was associated with a high risk for train-of-four response<0.9 at the arrive to postoperative care unit (RR:2.56 [IC95% 1.99-3.30]; p=0.034). A significant difference in thenar temperature (°C) was found in subjects with train-of-four<0.9 when compared to those who reach adecuate neuromuscular function (29.9±1.6 vs. 31.1±2.2; respectively. p=.003). However we were unable to demonstrate a direct atribution of findings in train-of-four response to temperature (R2 determination coefficient=0.08%). ConclusionA high prevalence of postoperative residual paralysis persists in university hospitals despite a reduced use of long lasting neuromuscular blockers. Strategies to assure neuromuscular monitoring practice and access to therapeutic alternatives in this setting must be considered. Intraoperative neuromuscular blockers using algorithms and continued education in this field must be priorities of Anesthesia services.

Postoperative residual paralysis in patients aged over 65 years old at the Post-Anesthesia Care Unit

IntroductionFew studies have been made on the incidence of residual paralysis from non-depolarizing relaxants in people over 65 years old; however, estimating the number of cases and treatment thereof are both important. ObjectiveTo study the incidence of residual paralysis with non-depolarizing relaxants in patients over 65 years of age and discuss treatment. MethodologyAnalytical observational study based on a cohort design. ResultsThe pre-extubation residual paralysis was estimated at 23.2% and at 9.2% at patient admission to the Recovery Suite. Pharmacological reversal showed 89.4% and 100% success rates with Neostigmine and Sugammadex respectively, with similar times at T4/T1>0.9. ConclusionsThe incidence of pre-extubation residual paralysis was lower than the figure published worldwide. Pharmacological reversal therapies were typically highly effective.

Comparison of the TOF-Scan™ acceleromyograph to TOF-Watch SX™: Influence of calibration

IntroductionQuantitative neuromuscular monitoring is now widely recommended during anesthesia using neuromuscular blocking agents to prevent postoperative residual paralysis and its related complications. We compared the TOF-Watch SX™ accelerometer requiring initial calibration to the TOF-Scan™, a new accelerometer with a preset stimulation intensity of 50mA not necessitating calibration. Study designThis pilot, prospective, observational study included adults undergoing general anesthesia with endotracheal intubation and muscle relaxation, having both arms free during surgery. Accelerometers were set up randomly on each arm. Anesthesia was started with remifentanil and propofol before an intubation dose of atracurium or rocuronium. Train of four stimulation was performed every 15s. Differences between measures were tested using Student's t-test and agreement assessed by Bland and Altman analysis. ResultsThirty-two patients were included. During onset, a mean bias of −26seconds with a limit of agreement from −172 to +119seconds was observed between TOF-Watch SX™ and TOF-Scan™ to obtain 0 response to TOF. During recovery, TOF-Scan™ showed a significantly later recovery from 1 response to T4/T1>10%, but a bias of 0minute and limits of agreement from −4 to +4minutes for T4/T1>90% (NS). ConclusionThese results suggest a poor agreement between the calibrated TOF-Watch SX™ and the fix intensity TOF-Scan™ for onset and early recovery of relaxation (i.e. deep neuromuscular blockade) but a good agreement for recovery to TOF 90%. Data are not interchangeable between the devices, but both can be useful to detect residual paralysis.

Relajación residual en la unidad de cuidado posanestésico

El uso de relajantes neuromusculares en la práctica clínica es cada día más frecuente e indispensable en el acto anestésico y la unidad de cuidado intensivo. Aunque los bloqueantes neuromusculares tanto aminoesteroideos como benzilisoquinolinas de última generación tienen efectos adversos mínimos, la relajación residual es una complicación de incidencia considerable asociada con un incremento en la morbilidad y mortalidad. Debido a esto planteamos la importancia de conocer los diferentes métodos de monitoria del bloqueo neuromuscular con su interpretación, haciendo énfasis en la monitoria con el tren de cuatro (TOF), la razón entre la primera y la cuarta respuesta T4/T1 (TOF RATIO) y estrategias de prevención de la relajación residual. Abreviaturas: TOF, tren de cuatro; PORC, parálisis residual posoperatoria; RNMND, relajantes neuromusculares no despolarizantes; UCPA, unidad de cuidado posoperatorio.