Relationship between Normalized Adductor Pollicis Train-of-four Ratio and Manifestations of Residual Neuromuscular Block

Heier, Tom; Caldwell, James E.; Feiner, John; Liu, Luke; Ward, Theresa A.; Wright, P. M. C.

doi:10.1097/aln.ob013e3181ebddca

Cited by 40 publications

(44 citation statements)

References 41 publications

(44 reference statements)

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“…The ability to swallow is also interfered with when only modest degrees of neuromuscular block are present, at TOFR values of 0.6-0.9. 8,9 Vital capacity decreases less markedly, being close to normal at TOFR values of 0.5-0.6, 8 and tidal volume remains normal even at TOF ratio values of 0.4. 8 Worth mentioning, hand grip and head lift are usually normal at TOF ratios of 0.6-0.7, so they are poor clinical tests of neuromuscular blockade.…”

Section: Diaphragmmentioning

confidence: 90%

“…6 Tidal volume is preserved even when hand grip is markedly depressed. 7,8 Nevertheless, normal respiratory function depends on more than adequate diaphragm recovery. After a general anesthetic, patients must regain the ability to cough and swallow in order to avoid aspiration.…”

Section: Diaphragmmentioning

confidence: 99%

Section: Diaphragmmentioning

confidence: 99%

“…Données tirées de Naguib et coll., 2 Murphy et coll., 4,15 Kumar et coll., 10 Butterly et coll., 16 Thilen et coll. 21 Residual paralysis 715 its normal value of 1.0, indices of upper airway function, such as genioglossus activity, 7 maintenance of a patent airway, 8,9 and ability to clench teeth, 8 are affected at TOFR values of 0.8-0.9. The ability to swallow is also interfered with when only modest degrees of neuromuscular block are present, at TOFR values of 0.6-0.9.…”

Section: Diaphragmmentioning

confidence: 99%

“…Also, normal breathing involves early activation of upper airway muscles, such as those of the tongue, to maintain airway patency during inspiration and counteract the tendency of the structures higher than the larynx to collapse in response to negative intrathoracic pressures. 7,8 Upper airwayIt is customary to express the different behaviour of the various muscle groups as a function of train-of-four (TOF) recovery at the adductor pollicis because the hand is convenient and usually available for monitoring purposes. Ability to clench teeth is usually lost at levels of 0.8-0.9 8 so it is a more sensitive test of neuromuscular function.…”

mentioning

confidence: 99%

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Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Purpose Over the past three decades, many studies have shown a high proportion of patients in the recovery room with residual neuromuscular blockade after anesthesia. The purpose of this Continuing Professional Development module is to present the physiological consequences of residual paralysis, estimate the extent of the problem, and suggest solutions to prevent its occurrence. Principal findings Residual paralysis is defined as a train-of-four ratio (TOFR) \ 0.9 at the adductor pollicis. While tidal volume and, to a lesser extent, vital capacity are well preserved as the intensity of blockade increases, the probability of airway obstruction, impaired swallowing, and pulmonary aspiration increases markedly as TOFR decreases. In recent studies, incidences of residual paralysis from 4-57% have been reported, but surveys indicate that anesthesiologists estimate the incidence of the problem at 1% or less. The decision to administer neostigmine or sugammadex should be based on the degree of spontaneous recovery at the adductor pollicis muscle (thumb), not on recovery at the corrugator supercilii (eyebrow). The most important drawback of neostigmine is its inability to reverse profound blockade, which is a consequence of its ceiling effect. When spontaneous recovery reaches the point where TOFR [ 0.4 or four equal twitch responses are seen, reduced doses of neostigmine may be given. The dose of sugammadex required in a given situation depends on the intensity of blockade. Conclusion Careful monitoring and delaying the administration of neostigmine until four twitches are observed at the adductor pollicis can decrease the incidence of residual paralysis. The clinical and pharmacoeconomic effects of unrestricted sugammadex use are unknown at this time. ObjectivesAfter reading this module, the reader should be able to:1. Describe the physiological effects of residual neuromuscular blockade 2. Define and justify the current threshold used for residual paralysis 3. Interpret the information provided by qualitative and quantitative monitors 4. Decide the dose and timing of administration of neostigmine 5. Manage neuromuscular blockade and reversal during and after anesthesia.In 1979, Viby-Mogensen et al. 1 reported that 42% of patients receiving non-depolarizing neuromuscular blocking agents during anesthesia followed by neostigmine at the end of the procedure had neuromuscular weakness in the recovery room, as documented by a train-of-four ratio 123Can J Anesth/J Can Anesth (2013) 60:714-729 DOI 10.1007 (TOFR) \ 0.7. This first description of what was later termed residual paralysis, residual curarization, or postoperative residual curarization was followed by many other observations in many countries around the world and in different settings. The introduction of shorter-acting agents, such as vecuronium and atracurium and later rocuronium and cisatracurium, to replace the longer-acting agents available in 1979 led to a decrease in the incidence of residual paralysis. 2 Nevertheless, many lines of evidence now...

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Section: Diaphragmmentioning

confidence: 90%

Section: Diaphragmmentioning

confidence: 99%

Section: Diaphragmmentioning

confidence: 99%

Section: Diaphragmmentioning

confidence: 99%

mentioning

confidence: 99%

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Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Reversal of experimental paralysis in a human by intranasal neostigmine aerosol suggests a novel approach to the early treatment of neurotoxic envenomation

Lewin

Bickler

Heier

et al. 2013

Clinical Case Reports

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Key Clinical MessageNeurotoxic snake envenomation can result in respiratory failure and death. Early treatment is considered important to survival. Inexpensive, heat-stable, needle-free, antiparalytics could facilitate early treatment of snakebite and save lives, but none have been developed. An experiment using aerosolized neostigmine to reverse paralysis suggests how early interventions could be developed.

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Is Postoperative Residual Neuromuscular Block Associated with Adverse Clinical Outcomes? What Is the Evidence?

Kopman

Brull

2013

Curr Anesthesiol Rep

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Relationship between Normalized Adductor Pollicis Train-of-four Ratio and Manifestations of Residual Neuromuscular Block

Cited by 40 publications

References 41 publications

Residual paralysis: a real problem or did we invent a new disease?

Residual paralysis: a real problem or did we invent a new disease?

Reversal of experimental paralysis in a human by intranasal neostigmine aerosol suggests a novel approach to the early treatment of neurotoxic envenomation

Is Postoperative Residual Neuromuscular Block Associated with Adverse Clinical Outcomes? What Is the Evidence?

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