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summary
1
This very large cohort study demonstrated an association between use of intermediate-duration NMBD and risk of postoperative desaturation and reintubation requiring ICU admission, and a similar association with these outcomes and neostigmine reversal.
Qualitative neuromuscular monitoring did not reduce this risk.
Study population was all patients at Massachusetts General Hospital undergoing general anaesthesia including a muscle relaxant over a 4 year period, and who were extubated at the end of the procedure.
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
summary
1
Observation of pharyngeal function in 14 awake volunteers demonstrated pharyngeal dysfunction and increased aspiration risk at TOF ratios < 0.90.
“Partial neuromuscular paralysis caused by atracurium is associated with a four- to fivefold increase in the incidence of misdirected swallowing. … The majority of misdirected swallows resulted in penetration of bolus to the larynx.”
(Sundman in a 2000 follow-up study: The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium.)
Eriksson LI, Sundman E, Olsson R et al. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology. 1997 Nov 1;87(5):1035-43.
  Daniel Jolley
summary
0
Murphy et al. showed in this randomised, non-blinded trial that patients monitored with quantitative acceleromyography before extubation experienced less PORC, less desaturation below 90% (0% versus 21%) and less airway obstruction (0% versus 11%) during transport to the PACU.
Once in the PACU these patients also experienced less frequent, shorter duration and less severe hypoxic events.
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
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
summary
1
This small (N=64) post-operative audit of children receiving muscle relaxants in an Australian tertiary paediatric hospital identified a 28% incidence of post-operative residual paralysis, measured immediately before extubation.
Worryingly, the incidence of residual paralysis was even higher in the subgroup reversed with neostigmine (38%), which the authors attribute to anaesthetists not waiting long enough after administration.
Severe residual paralysis (TOFR < 0.7) was observed in 7% of cases.
Only 23% of anaesthetists used intra-operative neuromuscular monitoring.
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
comment
0
This is a great review to start with, providing a good overview of many of the myths regarding the use of neuromuscular blocking drugs that are still widely believed and practised by the global anaesthesia community.
All five of Fink & Hollman's 'myths' still hold today after reviewing the latest research in these areas.
Fink H Hollmann MW. Myths and facts in neuromuscular pharmacology. New developments in reversing neuromuscular blockade. Minerva Anestesiol. 2012 Apr 1;78(4):473-82.
  Daniel Jolley