Effect of quantitative versus qualitative neuromuscular blockade monitoring on rocuronium consumption in patients undergoing abdominal and gynecological surgery: a retrospective cohort study

Abstract

The level of neuromuscular blockade can be assessed by subjective (qualitative) and objective (quantitative) methods. This study aims to compare the dosage of the neuromuscular blocking agents (NMBA) rocuronium and the need for reversion by sugammadex between those methods. A retrospective, observational analysis was conducted. In the tactile qualitative-neuromuscular monitoring-group (tactile NMM) (n = 244), muscle contractions were assessed tactilely. In the quantitative neuromuscular monitoring-group (n = 295), contractions were accessed using an acceleromyograph. Primary endpoints were dosage of rocuronium per minute operation-time (milligram per kilogram bodyweight per minute (mg/kgBW/min)), count of repeated rocuronium administrations and use of sugammadex. Secondary endpoints were: NMM use before repeated NMBA application or extubation, time to extubation, post-operative oxygen demand. A total of n = 539 patients were included. n = 244 patients were examined with tactile NMM and 295 patients by quantitative NMM. Quantitative NMM use resulted in significantly lower rocuronium dosing (tactile NMM: 0.01 (± 0.007) mg/kgBW/min vs. quantitative NMM: 0.008 (± 0.006) mg/kgBW/min (p < 0.001)). In quantitative NMM use fewer repetitions of rocuronium application were necessary (tactile NMM: 83% (n = 202) vs. quantitative NMM: 71% (n = 208) p = 0.007). Overall, 24% (n = 58) in the tactile NMM-group, and 20% (n = 60) in the quantitative NMM-group received sugammadex ((p = 0.3), OR: 1.21 (0.81–1.82)). Significantly fewer patients in the quantitative NMM-group required oxygen-supply postoperative (quantitative NMM: 43% (n = 120)) vs. tactile NMM: 57% (n = 128)) (p = 0.002). The use of quantitative assessment of NMBA results in a lower overall dosage and requires fewer repetitions of rocuronium application. Therefore, quantitative monitoring systems should be used to monitor NMBA intraoperatively to reduce NMBA dosing, while achieving continuous neuromuscular blockade.

Residual Neuromuscular Blockade and Postoperative Pulmonary Complications in the Post-anesthesia Care Unit: A Prospective Observational Study

“…RNMB, as indicated by the persistence of low TOF ratios, has been associated with various adverse events in the literature, including postoperative respiratory complications. Similar studies [8][9][10][11][12][13][14] in the past emphasize the clinical importance of RNMB detection, as its presence has been linked to factors such as age, type of neuromuscular agents used, and the choice of reversal agents. Esteves et al's study [8] highlights the importance of RNMB detection with a 5.5% incidence rate upon PACU arrival, suggesting that even a modest incidence warrants clinical attention.…”

Intraoperative Monitoring of Neuromuscular Blockade

“…Monitoring of neuromuscular blockade using a simple nerve stimulator is more precise than the simple clinical assessment [ 25 ] which uses pharmacological data; nevertheless, simple monitoring does not allow an estimation of the exact state of neuromuscular paralysis, especially when it is located in intermediate values; visual and tactile estimation are not as accurate, and evaluation remains usually in a lower range compared to quantified instrumental monitoring. Blum et al [ 26 ] recently compared qualitative monitoring (tactile) versus quantitative monitoring (accelerography) in abdominal and gynecological surgery and found quantitative monitoring permitted the use of a lower quantity of muscle relaxants which putatively might decrease the incidence of residual neuromuscular blockade. It should be remembered that simple qualitative monitoring using a nerve stimulator does not yet prevent adverse respiratory effects [ 27 ] or decrease the dose of relaxant given [ 28 ] but remains preferable compared to the total absence of monitoring [ 29 ].…”

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

“…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].…”

“…Recent observational studies have found that the current frequency is up to 32%, but the use of clinical (qualitative) and quantitative observations can reduce this frequency to 18 and 27%, respectively [10][11][12]. Cardiac and thoracic surgery, morbidly obese populations (BMI more than 40 kg/m 2 ), end-stage renal failure, liver dysfunction, and neuromuscular disorders are factors that contribute to ahigher risk of inadequate reversal neuromuscular block, and pediatric and geriatric patients are also at higher risk [13,14].…”