A multicenter survey on the use of neuromuscular blockade in Greece. Does the real-world clinical practice indicate the necessity of guidelines?

Abstract

Background and Aims: The aim of this study was to investigate the current status of clinical practice regarding neuromuscular blocking drugs and their antagonists in Greece. Material and Methods: This is a multicenter survey, including a questionnaire based on previous studies, which was translated and modified by a Task Force of the Hellenic Society of Anaesthesiology. It was completed on a web-based database after invitation via e-mail and was left online for a period of 2 months. Results: A total of 1,100 questionnaires were sent, with a response rate of 7.9%. 13.7% stated that they do not use neuromuscular monitoring. Rocuronium was most commonly used for intubation [“often” stated by 19 (21.8%) and “very often” by 62 (71.2%)], followed by cis-atracurium, atracurium, and succinylcholine. Neostigmine and sugammadex were both used, with reversal not always administered by 23 (26.4%). Both agents were mostly used at fixed doses and not calculated based on TOF monitoring or body weight. Sugammadex was preferred in special patient groups and in operations of short duration. Reversal was most often administered based on clinical signs of neuromuscular recovery rather than objective monitoring. A significant percentage of respondents used an inadequate TOF ratio for extubation [37 (43.2%) used a TOF ratio <90%]. The reported incidence of observed residual neuromuscular blockade (RNMB) was 44.8%. Conclusion: Great variability was observed in Greek clinical practice regarding the use of neuromuscular blockade, which indicates serious issues that must be addressed. The needs for educating anesthesia providers and developing official guidelines are obvious in order to improve patient outcomes.

Practice Guidelines for Monitoring Neuromuscular Blockade—Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method

“…Other publications have found that 75% of Danish anesthesiologists reported technical problems when using these devices, accounting for 25% of anesthesia equipment [29]. Batistaki et al reported that 60% of respondents stated that the devices for monitoring the degree of skeletal muscle relaxation should be minimal in the anesthesia workstation [30]. Cyclically implemented recommendations in Great Britain have resulted in a significant increase in the frequency of monitoring the degree of relaxation, from 9 to 31%, and a reduction in the number of respondents who did not routinely use this method, from 62 to 8.9% [13,[31][32][33][34].…”

Intraoperative Monitoring of Neuromuscular Blockade

“…However, equipment alone is not enough; repeated educational efforts as part of a quality assurance program are mandatory [ 60 ]. Education of clinicians and other anesthesia providers on outcomes of untreated residual neuromuscular blockade [ 61 ], monitoring with indicators such as the use of neuromuscular monitoring whenever neuromuscular blockers are used, documenting and using the results to motivate anesthesia providers to pursue the trend, and elaborating clear protocols in the use of different antagonists would help to decrease the incidence of complications.…”

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US

“…The present study assumes national rates of procedures using NMB and market shares of NMBAs and reversal agents, based on unpublished data and surveys, due to a lack of published information. NMB and NMB reversal practice may vary by patient, procedure, and provider, with significant variability within the US and across countries, as evidenced by the lack of international guidelines [73][74][75][76]. Hence, the findings need to be interpreted with care for smaller geographical regions, potential temporal change in these estimates, and varying local practice [74].…”