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pearl
1
Recovery of train of four ratio to > 0.9 signifies adequate recovery of muscle function after neuromuscular blockade.
Baumüller E, Schaller SJ, Chiquito Y et al. Postoperative impairment of motor function at train-of-four ratio ≥0.9 cannot be improved by sugammadex (1 mg kg-1). Br J Anaesth. 2015 May 1; 114 (5): 785-93.
  Daniel Jolley
pearl
1
Reversal with sugammadex may reduce the incidence of post-operative residual paralysis and consequent morbidity.
Ledowski T, Hillyard S, O'Dea B et al. Introduction of sugammadex as standard reversal agent: Impact on the incidence of residual neuromuscular blockade and postoperative patient outcome. Indian J Anaesth. 2013 Jan 1;57(1):46-51.
  Daniel Jolley
pearl
1
Although DBS is more sensitive than TOFC, manual assessment of DBS fade can only detect residual paralysis at TOF ratio < 0.7.
Ueda N, Muteki T, Tsuda H et al. Is the diagnosis of significant residual neuromuscular blockade improved by using double-burst nerve stimulation? Eur J Anaesthesiol. 1991 May 1;8(3):213-8.
  Daniel Jolley
comment
1
Interestingly, they found the risk of respiratory complications to be greater in those having shorter procedures (< 2 hours) presumably because of the shorter time between relaxant and extubation.
Grosse-Sundrup M, Henneman JP, Sandberg WS et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012 Jan 1;345:e6329.
  Daniel Jolley
comment
0
This is a very significant and large study, and should give us pause to ponder the consequences of invasive airway management and surgery requiring muscle relaxation. It is also important to note that qualitative neuromuscular monitoring (as opposed to quantitative) appears to offer no risk reduction, consistent with other research in this area.
Nonetheless, the retrospective nature of this study means these relationships should not necessarily be viewed as causal. This is not a study of an intervention per se, but the association between certain perioperative characteristics that may be unavoidable (e.g. using muscle relaxants).
An important paper for any concerned anaesthetist or anesthesiologist to read in full.
Grosse-Sundrup M, Henneman JP, Sandberg WS et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012 Jan 1;345:e6329.
  Daniel Jolley
pearl
1
Post-operative residual paralysis is associated with a greater incidence of desaturation in the post-anaesthesia care unit.
Sauer M, Stahn A, Soltesz S et al. The influence of residual neuromuscular block on the incidence of critical respiratory events. A randomised, prospective, placebo-controlled trial. Eur J Anaesthesiol. 2011 Dec 1; 28 (12): 842-8.
  Daniel Jolley
pearl
1
Partial paralysis with TOFR < 0.9 causes pharyngeal dysfunction and misdirected swallowing, increasing the risk of aspiration.
Sundman E, Witt H, Olsson R et al. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology. 2000 Apr 1;92(4):977-84.
  Daniel Jolley
pearl
1
Quantitative neuromuscular monitoring reduces the incidence of post-operative residual paralysis, desaturation and airway obstruction.
Murphy GS, Szokol JW, Marymont JH et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008 Sep 1;109(3):389-98.
  Daniel Jolley
pearl
1
Intrathecal magnesium extends analgesic duration of spinal opioids.
Pascual-Ramírez J, Gil-Trujillo S, Alcantarilla C. Intrathecal magnesium as analgesic adjuvant for spinal anesthesia: a meta-analysis of randomized trials. Minerva Anestesiol. 2013 Jun 1;79(6):667-78.
  Daniel Jolley
pearl
1
Residual post-operative paralysis is as common in children as in adults after receiving neuromuscular blocking drugs.
Ledowski T, O'Dea B, Meyerkort L et al. Postoperative Residual Neuromuscular Paralysis at an Australian Tertiary Children's Hospital. Anesthesiol Res Pract. 2015 Jan 1;2015:410248.
  Daniel Jolley