Residual neuromuscular block is common at the time of extubation, occurring in up to two thirds of patients in the absence of quantitative neuromuscular monitoring.

pearl

• Leif Saager, Eric M Maiese, Lori D Bash, Tricia A Meyer, Harold Minkowitz, Scott Groudine, Beverly K Philip, Pedro Tanaka, Tong Joo Gan, Yiliam Rodriguez-Blanco, Roy Soto, and Olaf Heisel.
• Cleveland Clinic, Department of Outcomes Research, Anesthesiology Institute, 9500 Euclid Ave. P77, Cleveland, OH 44195, United States. Electronic address: Lsaager@med.umich.edu.
• J Clin Anesth. 2019 Aug 1; 55: 33-41.

Study ObjectiveTo determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care.DesignBlinded multicenter cohort study.SettingOperating and recovery rooms of ten community and academic U.S. hospitals.PatientsTwo-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013.InterventionsTOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation.Main ResultsMost of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB.ConclusionsAssessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.Copyright © 2018 Elsevier Inc. All rights reserved.

39 keywords...

hide…