Forty years of neuromuscular monitoring and postoperative residual curarisation: a meta-analysis and evaluation of confidence in network meta-analysis

Abstract

Background: The reported incidence of postoperative residual curarisation (PORC) is still unacceptably high. The capacity of intraoperative neuromuscular monitoring (NMM) to reduce the incidence of PORC has yet to be established from pooled clinical studies. We conducted a meta-analysis of data from 1979 to 2019 to reanalyse this relationship. Methods: English language, peer-reviewed, and operation room adult anaesthesia setting articles published between 1979 and 2019 were searched for on PubMed, Cochrane Central Register of Controlled Trials, ISI-WoK, and Scopus. The primary outcome was PORC incidence as defined by an at-or post-extubation train-of-four ratio (TOFR) of lower than 0.7, 0.9, or 1.0. Additional collected variables included the duration of action of neuromuscular blocking agents (NMBAs) used, sugammadex or neostigmine use, and the technique of anaesthesia maintenance. Results: Fifty-three studies (109 study arms, 12 664 patients) were included. The pooled PORC incidence associated with the use of intermediate duration NMBAs and quantitative NMM was 0.115 (95% confidence interval [CI], 0.057e0.188). This was significantly lower than the PORC rate for both qualitative NMM (0.306; 95% CI, 0.09e0.411) and no NMM (0.331; 95% CI, 0.234e0.435). Anaesthesia type did not significantly affect PORC incidence. Sugammadex use was associated with lower PORC rates. The GRADE global level of evidence was very low and the refined assessment of the network metaanalysis by means of a confidence in network meta-analysis raised concerns on within-and across-study bias. Conclusions: Quantitative NMM outperforms both subjective and no NMM monitoring in reducing PORC as defined by a TOFR of <0.9.

Enhanced recovery: joining the dots

“…Whilst other intraoperative areas are topical such as total intravenous anaesthesia (TIVA), deep neuromuscular blockade (DNB) and opioid-free anaesthesia (OFA) have produced some encouraging results, the use of TIVA (to reduce long term cancer recurrence), DNB (to allow reduction in intraabdominal pressures during minimally invasive surgery) and OFA (to reduce postoperative nausea and vomiting) have yet to find a clear, evidence based established place. An area of practice that requires renewed attention is ensuring that neuromuscular blockade is adequately reversed at the end of surgery, as the incidence is of postoperative residual curarisation (PORC) and the associated sequalae is still high, although it is reduced by the use of quantitative neuromuscular monitoring [35]. The focus for perioperative physicians will direct attention to other areas such as patient blood management, prehabilitation, perioperative opioid management to early recognition and management of postoperative organ dysfunction and perioperative opioid stewardship to minimize the risks of opioid-related harm.…”

Advanced Bioelectrical Signal Processing Methods: Past, Present, and Future Approach—Part III: Other Biosignals

“…Therefore, the EMG is usually performed simultaneously with the so-called nerve conduction studies (NCSs), which enable measurement of the nerves conductivity. The needle-based EMG and the NCSs are tested in case the patient suffers from neuromuscular disorder symptoms, such as limb pain or weakness, muscle paralysis, or spasms [21][22][23]. Moreover, the examination is also beneficial in diagnosing the nerve compression or injury (e.g., carpal tunnel syndrome or sciatica), and other neuromuscular disorders, such as amyotrophic lateral sclerosis (ALS), myasthenia gravis, and muscular dystrophy [22].…”

Lidocaine combined with magnesium sulfate preserved hemodynamic stability during general anesthesia without prolonging neuromuscular blockade: a randomized, double-blind, controlled trial

“…Drugs such as lidocaine and magnesium sulfate are frequently used in combination with neuromuscular blocking agents (NMBAs) [6], the latter of which may contribute to residual neuromuscular blockade (NMB). It is a well-known [7] and ongoing problem [8] that NMBAs have the inherent risk of residual paralysis [9], even when used alone [10]. Furthermore, residual paralysis is most likely associated with postoperative pulmonary complications, which has also been well known for many years [11] but has still not been resolved [12].…”