The Influence of Introducing Unrestricted Access to Sugammadex and Quantitative Neuromuscular Monitors on the Incidence of Residual Neuromuscular Block at a Tertiary Teaching Hospital. An Audit of ‘Real-Life’

Abstract

The influence of introducing unrestricted access to sugammadex and quantitative neuromuscular monitors on the incidence of residual neuromuscular block at a tertiary teaching hospital. An audit of 'real-life'.Residual neuromuscular block (RNMB) is a common phenomenon and has been identified as a significant risk factor for adverse postoperative patient outcome. The outcome of a recent randomised, controlled trial suggests that monitor-guided, sugammadex-based reversal of neuromuscular blocking agents (NMBA) may be able to completely eliminate the risk of RNMB 1 .However, it is unclear whether such results could be achieved in a 'real-life' clinical setting. Prior to the availability of quantitative neuromuscular transmission monitors and the unrestricted availability of sugammadex ( 2011), the incidence of RNMB at the Royal Perth Hospital after timing, neostigmine or sugammadex-based reversal was 53%, 59% and 8%, respectively 2 . As a result, Royal Perth Hospital introduced quantitative neuromuscular monitors for each anaesthesia workstation as well as unhindered access to sugammadex. To investigate the effects of these changes four years on (2015), we conducted an audit including all patients receiving NMBA over a two-week period. Ethics approval was obtained from the Royal Perth Hospital Ethics Committee for Human Research (RPH HREC A-15.002). RNMB was assessed by an independent researcher using a quantitative neuromuscular transmission monitor (train of four [TOF] supramaximal stimulation of the ulnar nerve) (NMT monitor, GE Healthcare, Helsinki, Finland) once the anaesthetist had declared the patient 'fit for extubation'. Choice of NMBA, monitoring and reversal were left to the anaesthetist.Data from 140 cases were analysed. Sugammadex, neostigmine or no reversal were used in 80.7%, 2.1% and 17.2%, respectively. Monitoring was used in 79%. The overall incidence of RNMB was 15%. However, failure (versus compliance) to monitor the effects of reversal resulted in 19% (versus 4%, P=0.02) severe RNMB (TOF ratio <0.7) and 33% (versus 13%, P=0.02) of overall RNMB (TOF ratio <0.9).From 2011 to 2015 the use of neuromuscular transmission monitoring increased from 62% to 78%, and the use of sugammadex from 39% to 81%. Using the same audit format utilised in 2011 2 , it appears likely that the observed changes in clinical practice contributed to the significantly reduced risk of RNMB found in 2015. However, the results also underline the crucial role of neuromuscular transmission monitoring. Without this, even the unrestricted use of sugammadex appears to be unable to completely abolish the risk of RNMB. Thus, more emphasis and continuous staff education about the dangers of RNMB as well the benefits Correspondence of neuromuscular transmission monitoring and adequate reversal appear to be required.

Preparing for the unexpected: special considerations and complications after sugammadex administration

“…Therefore, quantitative intraoperative neuromuscular monitoring is strongly recommended to prevent postoperative residual paralysis [ 3 , 39 – 41 ]. Without such objective monitoring, even the unrestricted use of sugammadex cannot completely eliminate the risk of residual paralysis [ 42 ]. Consequently, the purpose of neuromuscular monitoring is dual: on the one hand, the most effective dose should be administered in order to exclude residual paralysis.…”

A multicenter survey on the use of neuromuscular blockade in Greece. Does the real-world clinical practice indicate the necessity of guidelines?

“…Furthermore, since the response was anonymous, completion bias cannot be excluded. Although we included questions addressing limitations reported in other studies[678910] in order to develop a more complete questionnaire, a validation of the instrument was not performed prior to administration.…”

“…Multiple surveys conducted worldwide indicate that neuromuscular blocking drugs and their antagonists are commonly administered without adequate rationalization and monitoring, leading to variable incidence of RNMB. Studies from the United States, Europe,[6] Australia and New Zealand,[78] Italy,[910] Denmark,[11] Morocco,[12] and Brazil[13] suggest that currently, only a small percentage of anesthesiologists monitor neuromuscular function in their clinical practice, even in special patient groups. In addition, the absence of internationally accepted clinical guidelines regarding neuromuscular blockade remains a major problem.…”

Clinical Practice Guideline for the Management of Neuromuscular Blockade: What Are the Recommendations in the USA and Other Countries?

“…Nevertheless, objective NMM has been shown to decrease the incidence of RNMB and postoperative respiratory complications [35,36]. In addition, it has been reported that an institutional leader who is dedicated to a comprehensive education and implementation plan of objective monitoring can dramatically decrease the number of RNMB and critical respiratory events [42][43][44][45][46].…”