Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery?

Abstract

Neuromuscular blocking agents are used to facilitate tracheal intubation in patients undergoing ambulatory surgery. The use of high-dose neuromuscular blocking agents to achieve muscle paralysis throughout the case carries an increased risk of residual post-operative neuromuscular blockade, which is associated with increased respiratory morbidity. Visually monitoring the train-of-four (TOF) fade is not sensitive enough to detect a TOF fade between 0.4 and 0.9. A ratio <0.9 indicates inadequate recovery. Quantitative neuromuscular transmission monitoring (e.g., acceleromyography) should be used to exclude residual neuromuscular blockade at the end of the case. Residual neuromuscular blockade needs to be reversed with neostigmine, but it’s use must be guided by TOF monitoring results since deep block cannot be reversed, and neostigmine administration after complete recovery of the TOF-ratio can induce muscle weakness. The development and use of new selectively binding reversal agents (sugammadex and calabadion) warrants reevaluation of this area of clinical practice.

Residual Neuromuscular Blockade in the Critical Care Setting

“…The upper airway is compromised by even small amounts of paralytic medications because negative inspiratory pressure required at the beginning of the breathing cycle is weakened or absent and the airway loses its ability to remain open. 5 The usual synchronization of the proximal and distal pharyngeal muscles, the upper esophageal sphincter, and the tongue becomes disjointed, resulting in an amplified threat of gastric content aspiration. 5 Skeletal muscle paralysis of the diaphragm and accessory muscles will hinder breathing further until full muscular tone returns.…”

“…5 The usual synchronization of the proximal and distal pharyngeal muscles, the upper esophageal sphincter, and the tongue becomes disjointed, resulting in an amplified threat of gastric content aspiration. 5 Skeletal muscle paralysis of the diaphragm and accessory muscles will hinder breathing further until full muscular tone returns. 5 During RNMB, ventilatory drive is halted, causing a decrease in inspiratory volume and flow and retention of carbon dioxide.…”

“…5 Skeletal muscle paralysis of the diaphragm and accessory muscles will hinder breathing further until full muscular tone returns. 5 During RNMB, ventilatory drive is halted, causing a decrease in inspiratory volume and flow and retention of carbon dioxide. Carotid arch chemoreceptorswhich usually would respond to the resulting hypoxemia, hypercapnia, and acidosis-may be blunted after exposure to neuromuscular blockade, suppressing this essential compensatory mechanism.…”

“…Carotid arch chemoreceptorswhich usually would respond to the resulting hypoxemia, hypercapnia, and acidosis-may be blunted after exposure to neuromuscular blockade, suppressing this essential compensatory mechanism. 5 …”

Observational study on patterns of neuromuscular blockade reversal

“…In their response to a survey, 82 % of European and 65 % of American practitioners have reported that they did not routinely administer a reversal agent following use of non-depolarizing NMB drugs [ 8 ]. Current experts’ opinions suggest that NMB monitoring should guide administration of NMB agents [ 1 , 4 ] as well as NMB reversal agents [ 10 , 11 ]. However, a wide gap continues to exist between experts’ recommendations and current clinical practice of monitoring and NMB antagonism [ 9 , 12 ].…”