Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit

Lin, Xu; Yong, Christine Yoke Kuen; Mok, May Un Sam; Poopalalingam, Ruban; Wong, Patrick

doi:10.11622/smedj.2019118

Cited by 9 publications

(15 citation statements)

References 36 publications

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“…However, a study in a teaching hospital in Singapore found that the majority of anaesthetists (98.7%) did not routinely use PNS monitoring, and that PNS monitoring was only used in 17.9% of patients. 4 The prevalence of PRNB detected in the post anaesthetic care unit was 33.4%. Factors associated with this include a lack of knowledge and education on neuromuscular monitoring.…”

Section: Dear Editormentioning

confidence: 92%

“…Factors associated with this include a lack of knowledge and education on neuromuscular monitoring. 4 The study's survey questionnaire revealed an underestimation of PRNB and incorrect answers by up to 69% of respondents, including those for the definition of PRNB, and the timing and use of reversal agents. 4 Our recommendations aim to promote appropriate use of neuromuscular blockade and its monitoring, and so improve the safety of anaesthesia care in Singapore.…”

Section: Dear Editormentioning

confidence: 95%

“…4 The study's survey questionnaire revealed an underestimation of PRNB and incorrect answers by up to 69% of respondents, including those for the definition of PRNB, and the timing and use of reversal agents. 4 Our recommendations aim to promote appropriate use of neuromuscular blockade and its monitoring, and so improve the safety of anaesthesia care in Singapore. Our recommendations are best practices in the opinion of our members and are not mandatory.…”

Section: Dear Editormentioning

confidence: 95%

See 2 more Smart Citations

Recommendations for standards of neuromuscular monitoring during anaesthesia

Wong

Seet

Kumar

et al. 2021

Ann Acad Med Singap

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Section: Dear Editormentioning

confidence: 92%

Section: Dear Editormentioning

confidence: 95%

Section: Dear Editormentioning

confidence: 95%

See 1 more Smart Citation

Recommendations for standards of neuromuscular monitoring during anaesthesia

Wong

Seet

Kumar

et al. 2021

Ann Acad Med Singap

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“…5 However, although it has been over 20 years since experts first recommended routine use of quantitative monitoring, 6 many anesthesiologists do not routinely use quantitative monitoring, which provides real-time TOFR measurements. [7][8][9][10][11] Sugammadex is a highly efficacious agent for reversal of rocuronium-and vecuronium-induced neuromuscular blockade; most hospitals currently have sugammadex on their formularies, but some clinicians are restricted from its routine use due to concerns for higher cost. [10][11][12][13] There is no broad consensus on the role for sugammadex, whether it should be used routinely or only selectively.…”

Section: Glossarymentioning

confidence: 99%

Evaluation of a Protocol for the Management of Maintenance and Reversal of Rocuronium Block Using Neostigmine or Sugammadex

Thilen

Liang

Kruse

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Postoperative residual neuromuscular blockade (PRNB) is defined as an adductor pollicis train-of-four ratio (TOFR) <0.9. It is a common postoperative complication when nondepolarizing muscle relaxants are either not reversed or reversed with neostigmine. PRNB has been reported in 25% to 58% of patients who receive intermediate-acting nondepolarizing muscle relaxants, and it is associated with increased morbidity and decreased patient satisfaction. We conducted a prospective descriptive cohort study during the implementation of a practice guideline that included the selective use of sugammadex or neostigmine. The primary study aim of this pragmatic study was to estimate the incidence of PRNB at arrival to the postanesthesia care unit (PACU) when the practice guideline is followed. METHODS: We enrolled patients undergoing orthopedic or abdominal surgery requiring neuromuscular blockade. Rocuronium administration was guided by surgical requirements and based on ideal body weight, with dose reductions for women and/or age >55 years. Only qualitative monitoring was available to the anesthesia providers, and selection of sugammadex or neostigmine was guided by tactile assessments of the response to train-of-four (TOF) stimulation by a peripheral nerve stimulator. Neostigmine was administered if no fade was detected in the TOF response at the thumb. Deeper blocks were reversed with sugammadex. The prespecified primary and secondary end points were the incidence of PRNB at arrival to the PACU, defined as a normalized TOFR (nTOFR) < 0.9, and severe PRNB, defined as nTOFR <0.7 on arrival to the PACU. Anesthesia providers were blinded to all quantitative measurements made by research staff. RESULTS: Analysis included 163 patients, and 145 underwent orthopedic and 18 abdominal surgeries. Of the 163 patients, 92 (56%) were reversed with neostigmine and 71 (44%) with sugammadex. The overall incidence of PRNB at PACU arrival was 5 of 163 or 3% (95% confidence interval [CI], 1-7). The incidence of severe PRNB in PACU was 1% (95% CI, 0-4). Three of the 5 subjects with PRNB had TOFR <0.4 at time of reversal but were given neostigmine since anesthesia providers detected no fade by qualitative assessment. CONCLUSIONS: The use of a protocol that specifies rocuronium dosing and selective use of sugammadex versus neostigmine based on qualitative assessment of TOF count and fade allowed us to achieve an incidence of PRNB of 3% (95% CI, 1-7) at PACU arrival. Quantitative monitoring may be needed to further reduce this incidence. (Anesth Analg 2023;136:1143-53) KEY POINTS• Question: Can selective use of sugammadex or neostigmine based on the qualitative assessment of train-of-four (TOF) count and fade reduce the incidence of postoperative residual neuromuscular blockade (PRNB) at arrival to the postanesthesia care unit (PACU)? • Findings: The incidence of residual PRNB was 3% (95% confidence interval [CI], 1-7).• Meaning: Quantitative neuromuscular monitoring may be needed to further reduce the incidence of PRNB when sugam...

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“…Many places still perform procedures without monitoring. 6,7 It is a basic safety feature that should be regarded as essential as oxygen saturation or heart rate measurement. and emotional intelligence' 1 and for acknowledging the importance of occupational wellbeing of anaesthesiologists.…”

mentioning

confidence: 99%