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pearl
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There exists a wide range of inter-patient variability for modern, intermediate-duration muscle relaxants.
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003 May 1;98(5):1042-8.
  Daniel Jolley
pearl
1
Post-operative residual paralysis is common.
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003 May 1;98(5):1042-8.
  Daniel Jolley
summary
1
Debaene et al. investigated residual paralysis in the PACU after a single intubating dose of intermediate NMBD in the absence of reversal.
They identified PORC (Post-Operative Residual Curarization = TOFR <0.9) in 45% of patients, with 'time since NMBD' ranging from 30 to 400 minutes.
In a subgroup of patients 2 hours after a single NMBD dose there was still a 37% incidence of PORC.
Additionally there was very wide inter-patient variability, with PORC persisting more than 6 hours in three patients, and several patients with TOFR of only 0.2 after 2 hours.
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003 May 1;98(5):1042-8.
  Daniel Jolley
pearl
1
Addition of rocuronium for intubation improves intubating conditions compared with propofol and remifentanil alone.
Mencke T, Jacobs RM, Machmueller S et al. Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial. BMC Anesthesiol. 2014 Jan 1; 14: 39.
  Daniel Jolley
summary
1
In 83 patients researchers compared intubation with propofol 1.5 mg/kg, remifentanil 0.30 μg/kg/min & sevoflurane 1.0 MAC to intubation with the same propofol & remifentanil dose, along with rocuronium 0.45 mg/kg.
Acceptable intubating conditions were 18% more frequent in the muscle relaxant group than in those receiving propofol/remi/sevo.
Incidence of laryngeal injury, hoarseness and sore throat was similar between the two groups - which is different to the result from an earlier, larger study of intubation without relaxant: Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort.
Mencke T, Jacobs RM, Machmueller S et al. Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial. BMC Anesthesiol. 2014 Jan 1; 14: 39.
  Daniel Jolley
pearl
1
Intubation using propofol and remifentanil without muscle relaxant is associated with a greater incidence of poor intubating conditions.
Schlaich N, Mertzlufft F, Soltész S et al. Remifentanil and propofol without muscle relaxants or with different doses of rocuronium for tracheal intubation in outpatient anaesthesia. Acta Anaesthesiol Scand. 2000 Jul 1;44(6):720-6.
  Daniel Jolley
summary
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Schlaich et al. compared intubation using only propofol and remifentanil with the addition of rocuronium at various doses (0.3, 0.45, 0.6 mg/kg) in four groups of 30 patients. Intubating conditions were poor in 40% of those not receiving rocuronium, versus almost universally good conditions (89 of 90) when rocuronium was used.
Schlaich N, Mertzlufft F, Soltész S et al. Remifentanil and propofol without muscle relaxants or with different doses of rocuronium for tracheal intubation in outpatient anaesthesia. Acta Anaesthesiol Scand. 2000 Jul 1;44(6):720-6.
  Daniel Jolley
pearl
1
Intubation without muscle relaxant is associated with greater incidence of sore throat, hoarseness, hypotension, bradycardia and intubation difficulty.
Combes X, Andriamifidy L, Dufresne E et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007 Aug 1;99(2):276-81.
  Daniel Jolley
summary
0
Researchers compared induction with propofol (2.5 mg/kg), alfentanil (15 µg/kg) and rocuronium (0.6 mg/kg) to using propofol (2.5 mg/kg) and alfentanil (40 µg/kg) alone. Patients who did not receive muscle relaxants experienced more sore throat and hoarseness, more hypotension and bradycardia and a 10 times greater incidence of intubation difficulty.
Combes X, Andriamifidy L, Dufresne E et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007 Aug 1;99(2):276-81.
  Daniel Jolley
summary
1
This paper is full of many important pearls, and should be read in full.
Regarding common practices in the conduct of BIS-guided anaesthesia:
It has been suggested that a BIS range of 60–75 is suitable for ‘the end of surgery’, but our results show that if neuromuscular block is used, this range is consistent with full awareness.
...and on the use of the Signal Quality Index:
Given that the major cause of patient-related artifact is movement, it is not surprising that the SQI will increase towards 100 when NMBDs are administered, as we found. Unfortunately, the high SQI will indicate that the BIS is at its most reliable exactly when it is performing most poorly in the aware but paralysed patient.
Schuller PJ, Newell S, Strickland PA et al. Response of bispectral index to neuromuscular block in awake volunteers†. Br J Anaesth. 2015 Jul 1;115 Suppl 1:i95-i103.
  Daniel Jolley