A Prospective, Observational Study Comparing Postoperative Residual Curarisation and Early Adverse Respiratory Events in Patients Reversed with Neostigmine or Sugammadex or after Apparent Spontaneous Recovery

Abstract

Six years ago, a study performed in our department reported that the incidence of postoperative residual curarisation (PORC) was 39%. The reassessment of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice is relevant now that sugammadex has become available. The incidence of PORC, defined by a train-of-four (TOF) <90%, was evaluated at post-anaesthesia care unit (PACU) arrival in patients whose neuromuscular block had been reversed with neostigmine or sugammadex and those in whom reversal was felt unnecessary (adequate spontaneous recovery). During the PACU stay we recorded the oxygen saturation (SpO 2) at arrival, episodes of SpO 2 <90%, airway manoeuvres and/or stimulation required to maintain SpO 2 >90%, and the need for re-intubation. In total, 624 patients were studied. Fifteen percent (66/441) of the patients who were not reversed, 15% (21/139) of those who were reversed with neostigmine and 2% (1/44) of those who received sugammadex exhibited PORC (P=0.06). No patient required reintubation in the PACU. The absence of neuromuscular monitoring and pharmacological reversal before extubation were not associated with PORC. A TOF <90% at PACU arrival was not associated with SpO 2 <90% during the PACU stay. Body mass index was the only independent predictor of SpO 2 <90% during the stay in the PACU. These findings indicate that in recent years, the incidence of PORC, defined by a TOF <90%, has dramatically decreased in our institution. The differences in PORC were not statistically significant between patients who received sugammadex for reversal and patients with spontaneous recovery or neostigmine reversal.

Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

“…In contrast, 33 out of 76 (43%) patients given neostigmine did. Cammu and colleagues 60 reported similar findings in 2012. In a study of 624 patients, 15% of those who received no reversal agent developed residual block (TOFR <0.9) as did 15% of those who received neostigmine.…”

A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade

“…Neuromuscular blockade is monitored in less than a third of paralysed patients , due to unavailable or broken monitors and ignorance of the adverse effects of residual neuromuscular blockade . Neuromuscular blockade can persist after giving sugammadex, particularly if inadequate doses are given and its effects are not monitored .…”

The Association Between Residual Neuromuscular Blockade (Rnmb) and Critical Respiratory Events: A Prospective Cohort Study

“…According to the World Health Organisation (2016), subjects with BMI equal to or greater than 30 kg/m 2 are considered obese. Obesity has physiological effects on the respiratory system's compliance and lung volumes and that BMI was signi cantly associated with severe hypoxemia (SpO2 < 90%) during the PACU stay (P=0.01) (Hodgson et al 2015;Cammu et al (2012).…”

“…According to Murphy et al (2008a), between 33% and 64% of patients have evidence of incomplete neuromuscular recovery or RNMB during their stay in the PACU, despite the use of techniques proven to limit the degree of RNMB, such as reversal drugs. The incidence of RNMB ranges between 26% and 88%, based on the type of NMBDs, reversal drugs, or neuromuscular monitoring used (Cammu et al 2012;Fortier et al 2015). The RNMB can be reliably detected through the use of neuromuscular monitoring such as Train-of-Four (TOF) monitoring, which is according to Murphy et al (2011) is considered one of the most commonly used approaches in clinical practice.…”

“…Accordingly, The RNMB might place patients at an increased risk of critical respiratory events (CREs) in the PACU. Evidence from observational studies suggests that TOF ratios when it is less than 0.90 are usually associated with the incidence of CREs that include inadequate recovery of pulmonary function, upper airway obstruction, impaired pharyngeal re exes, decreased muscle coordination, impaired hypoxic ventilatory response and increased risk of aspiration (Cammu et al 2012;Herbstreit et al 2009;Murphy et al 2008a).…”