Pro-Con Debate: Do We Need Quantitative Neuromuscular Monitoring in the Era of Sugammadex?

Abstract

In this Pro-Con article, we debate the merits of using quantitative neuromuscular blockade monitoring. Consensus guidelines recommend their use to guide the administration of nondepolarizing neuromuscular blockade and reversal agents. A major impediment to this guideline is that until recently, reliable quantitative neuromuscular blockade monitors have not been widely available. Without them, anesthesia providers have been trained with and are adept at using a variety of qualitative neuromuscular blockade monitors otherwise known as peripheral nerve stimulators. Although perhaps less accurate, anesthesia providers find them reliable and easy to use. They have a long track record of using them with the perception that their use leads to effective neuromuscular blockade reversal and minimizes clinically significant adverse events from residual neuromuscular blockade. In the recent past, 2 disruptive developments have called upon anesthesia care providers to reconsider their practice in neuromuscular blockade administration, reversal, and monitoring. These include: (1) commercialization of more reliable quantitative neuromuscular monitors and (2) widespread use of sugammadex, a versatile reversal agent of neuromuscular blockade. Sugammadex appears to be so effective at rapidly and effectively reversing even the deepest of neuromuscular blockades, and it has left anesthesia providers wondering whether quantitative monitoring is indeed necessary or whether conventional, familiar, and less expensive qualitative monitoring will suffice? This Pro-Con debate will contrast anesthesia provider perceptions with evidence surrounding the use of quantitative neuromuscular blockade monitors to explore whether quantitative neuromuscular monitoring (NMM) is just another technology solution looking for a problem or a significant advance in NMM that will improve patient safety and outcomes.

Simple grip strength device for assessing the degree of recovery from residual neuromuscular blockade after general anaesthesia: An observational study

“…The 2018 Expert Consensus states that objective neuromuscular monitoring must be performed whenever non-depolarizing neuromuscular blocking agents are used, and that quantitative monitoring is used to guide the use of non-depolarizing muscle relaxants intraoperatively and to reduce the incidence of residual neuromuscular blockade [4,5]. The 2021 British Anaesthesia Society guidelines suggest that the use of continuous head elevation, eye opening on exhalation and tongue depressor tests to assess residual neuromuscular blockade is inadequate and that these modalities are only 30%-50% sensitive with a positive predictive value of less than 50% [21][22][23].…”

“…However, studies have shown that only 17% of anesthesiologists choose to use objective monitoring. However, studies have shown that only 17% of anesthesiologists choose to use objective monitoring, while the majority of anesthesiologists choose to use subjective judgement [4,5]. Though objective monitoring can reduce the incidence of postoperative residual neuromuscular blockade from 62% to 4%, objective monitoring is di cult to use in clinical practice [6].…”

Why a guideline on peri-operative management of neuromuscular blockade? Why now?

“…With such a strategy, a compliance greater than 90% can be achieved in documenting the minimally acceptable degree of neuromuscular recovery (TOF ratio >90) before tracheal extubation. 11 Despite a still ongoing (and poorly defended) argument against the routine use of quantitative monitors, 12 there is irrefutable evidence that quantitative monitoring must become routine. 5 For other currently accepted routine monitoring modalities such as pulse oximetry and end-tidal CO 2 monitors there is no evidence that they affect patients' outcomes.…”

Quantitative Neuromuscular Monitoring: “Love All, Trust a Few, Do Wrong to None”

“…I n this issue of Anesthesia & Analgesia, Blobner et al 1 present an erudite debate about the value of quantitative neuromuscular monitoring in a modern clinical practice that includes the selective relaxant binding agent, sugammadex. The article provides an interesting and educational debate, clearly designed to expose the reasons behind clinicians' decisions to use quantitative neuromuscular monitors (Pro section) or to avoid their use (Con).…”

“…Belief that routine administration of sugammadex supplants the need for monitoring. In the "con" section of the debate, 1 the authors stated that monitoring is not needed in the era of sugammadex, since its reversal is "fast and effective." However, sugammadex is 3× more selective for rocuronium than for vecuronium.…”