scholarly journals Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

2019 ◽  
Author(s):  
Gonzalo Domenech ◽  
Matias Kampel ◽  
Maria Eugenia Garcia Guzzo ◽  
Delfina Sanchez Novas ◽  
Sergio Terrasa ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Multivariable Analysis ◽  
Perioperative Period ◽  
University Hospital ◽  
Exclusion Criterion ◽  
Adductor Pollicis Muscle ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents ◽  
Elective Surgical Procedures ◽  
Observational Cohort

Abstract Background: Complete avoidance of residual neuromuscular blockade (RNMB) during the postoperative period has not yet been achieved in current anesthesia practice. Evidently, compliance with NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. To our knowledge, no publications have reported the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. Methods: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit (PACU). Scheduled recovery in the intensive care unit was the only exclusion criterion. Results: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P < 0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. Conclusions: The results of the present study suggest that intra-operative quantitative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

scholarly journals Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

2019 ◽  
Author(s):  
Gonzalo Domenech ◽  
Matias Kampel ◽  
Maria Eugenia Garcia Guzzo ◽  
Delfina Sanchez Novas ◽  
Sergio Terrasa ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Multivariable Analysis ◽  
Perioperative Period ◽  
University Hospital ◽  
Exclusion Criterion ◽  
Adductor Pollicis Muscle ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents ◽  
Elective Surgical Procedures ◽  
Observational Cohort

Abstract Background: Current neuromuscular blockade (NMB) management techniques cannot completely prevent residual NMB (RNMB) during the postoperative period. Evidently, compliance with NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. To our knowledge, no publications have reported the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. Methods: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit (PACU). Scheduled recovery in the intensive care unit was the only exclusion criterion. Results: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P < 0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. Conclusions: The results of the present study suggest that intra-operative quantitative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

scholarly journals Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

2019 ◽  
Author(s):  
Gonzalo Domenech ◽  
Matias Kampel ◽  
Maria Eugenia Garcia Guzzo ◽  
Delfina Sanchez Novas ◽  
Sergio Terrasa ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Multivariable Analysis ◽  
Perioperative Period ◽  
University Hospital ◽  
Exclusion Criterion ◽  
Adductor Pollicis Muscle ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents ◽  
Elective Surgical Procedures ◽  
Train Of Four

Abstract Background: Current neuromuscular blockade (NMB) management techniques cannot completely prevent residual NMB (RNMB) during the postoperative period. Evidently, compliance to NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. We have not found publications that report the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. Methods: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit. Scheduled recovery in the intensive care unit was the only exclusion criterion. The primary outcome was the presence of RNMB, defined as a train-of-four ratio of <0.9. The secondary outcomes were the associations between RNMB and potentially related variables. Results: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P<0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. Conclusions: The results of the present study suggest that quantitative intra-operative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

scholarly journals Repeat Administration of Reversal Agents in Patients Receiving Neostigmine or Sugammadex: A Retrospective Observational Study

2020 ◽  
Author(s):  
Laura Gilbertson ◽  
Francis Wolf ◽  
Grant C. Lynde
Keyword(s):  
Neuromuscular Blockade ◽  
Repeated Administration ◽  
Not Given ◽  
Reversal Agent ◽  
Progressive Decline ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents ◽  
Rescue Dose ◽  
Repeat Administration ◽  
Effective Use

Abstract Background: Antagonism of neuromuscular blockade (NMB) induced by rocuronium and vecuronium can be achieved with either neostigmine or sugammadex. Compared to sugammadex, antagonism with neostigmine is more likely to result in incomplete reversal, i.e. residual neuromuscular blockade (rNMB). The administration of additional doses of a reversal agent following an initial reversal dose may be a marker for suspected rNMB. We studied the frequency and temporal patterns of repeat (rescue) administration of reversal agents in patients who received an initial dose of neostigmine vs. sugammadex. Methods: We analyzed retrospective data from electronic anesthesia records to identify surgical patients who received rescue dose reversal, defined as two or more doses of reversal agent, following administration of non-depolarizing NMB and extubation in the operating room. We assessed rates of rescue reversal over time following the introduction of sugammadex and compared rescue rates for patients receiving neostigmine vs sugammadex. Results: A total of 24,027 cases using cisatracurium, rocuronium, and vecuronium were analyzed. Following the addition of sugammadex to formulary in 2016, reversal with neostigmine decreased from 79% to 5.3% (p <0.001) and the use of rescue reversal after neostigmine increased from 6.0% to 18% (p<0.001). In contrast, rescue reversal after sugammadex was 2.5%, with no change over the study period (p=0.059). The percentage of patients who were not given any reversal agent following non-depolarizing NMB decreased from 20% to 13% (p<0.001). As neostigmine usage progressively decreased after introduction of sugammadex, there was a corresponding increase in rescue reversal dosing when initial reversal was attempted with neostigmine. Conclusions: Repeated administration of a reversal agent was 7 times more likely to occur in patients initially reversed with neostigmine compared to sugammadex. This finding likely reflects increased rates of observed weakness in patients reversed with neostigmine. The correlation between decreasing neostigmine use and increasing rescue reversal after neostigmine may indicate a progressive decline in the effective use of neostigmine (as knowledge and experience waned), and/or decreasing confidence in its efficacy.

Neuromuscular Blockers and Reversal Agents

2019 ◽  
Author(s):  
Kristen Flight ◽  
Jennifer J Yang ◽  
Lindsay M Urben ◽  
Michael J Schontz
Keyword(s):  
Neuromuscular Blockade ◽  
Neuromuscular Transmission ◽  
Muscle Relaxation ◽  
Neuromuscular Blocking ◽  
Neuromuscular Monitoring ◽  
Clinical Effects ◽  
Duration Of Action ◽  
Residual Neuromuscular Blockade ◽  
Neuromuscular Blocking Drugs ◽  
Reversal Agents

Neuromuscular blocking drugs, which include depolarizing and nondepolarizing drugs, are used to facilitate intubation and provide skeletal muscle relaxation during surgery and in the intensive care unit. The agents differ in their mechanism, duration of action, side-effect profile, and metabolism. Succinylcholine is the only depolarizing agent in clinic use and is typically used for emergent control of the airway, rapid sequence intubations, and short surgical procedures. The risk of hyperkalemia in certain clinical conditions and risk of malignant hyperthermia in susceptible individuals limit the use of succinylcholine in specific patient populations. Nondepolarizing agents vary in their duration of action, but all provide muscle relaxation for a longer duration than succinylcholine. Clinical effects of neuromuscular blocking drugs can be assessed with neuromuscular monitoring, although there is significant variability among providers in the regular use of neuromuscular monitoring. Reversal agents are used to restore neuromuscular transmission, as residual neuromuscular blockade after extubation has been associated with multiple adverse events, including hypoxemia, atelectasis, and aspiration. Sugammadex is an encapsulating agent capable of immediately reversing the effects of rocuronium-induced neuromuscular blockade that will likely impact the way many providers administer rocuronium and may decrease the future use of succinylcholine. This review contains 4 figures, 6 tables, and 41 references. Keywords: hyperkalemia, neuromuscular monitoring, neuromuscular transmission, nondepolarizing neuromuscular blocking agents, residual neuromuscular blockade, reversal agents, succinylcholine sugammadex, sugammadex

Predictive Study of Pharmacological Reversal for Residual Neuromuscular Blockade, Early and Late Postoperative Pulmonary Complications: A Prospective, Observational, Cohort Study

2021 ◽  
Author(s):  
Cristian Aragón-Benedí ◽  
Ana Pascual-Bellosta ◽  
Sonia Ortega-Lucea ◽  
Sara Visiedo-Sanchez ◽  
Javier Martinez-Ubieto
Keyword(s):  
Cohort Study ◽  
Neuromuscular Blockade ◽  
Demographic Data ◽  
Pulmonary Complications ◽  
Neuromuscular Monitoring ◽  
Observational Cohort Study ◽  
Prospective Observational Cohort Study ◽  
Postoperative Pulmonary Complications ◽  
Residual Neuromuscular Blockade ◽  
Observational Cohort

Abstract Background The primary objective was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal, comparing neostigmine and sugammadex. The secondary objective was to present a prognostic model to predict the probability of having residual neuromuscular blockade depending on patient's comorbidities and intraoperative neuromuscular blocking agents management. Methods Single-center, prospective, observational, cohort study including patients undergoing surgical procedures with general anaesthesia divided into four groups: cisatracurium, cisatracurium with neostigmine antagonism, rocuronium, and rocuronium with sugammadex antagonism. A binomial generalized linear model was used to predict the residual neuromuscular blockade analyzing patients demographic data, comorbidities, intraoperative neuromuscular monitoring and pharmacological reversal for each patient group. Results A total of 714 patients were analyzed. According to our model, none of the studied comorbidities were a predisposing factor for an increase in residual neuromuscular blockade. However, the use of rocuronium, pharmacological reversal with sugammadex, and, particularly, neuromuscular monitoring during surgery markedly decreased the probability. When using rocuronium, avoidance of neuromuscular monitoring and pharmacological reversal led to an incidence of residual neuromuscular blockade of 41.27%; conversely, the use of neuromuscular monitoring and pharmacological reversal with sugammadex decreased the probability to 2.17%. Conclusions In our study, intraoperative neuromuscular monitoring and pharmacological reversal with sugammadex, unlike neostigmine, were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early postoperative pulmonary complications in PACU (upper airway obstruction and desaturation) and late postoperative pulmonary complications (pneumonia or atelectasis) within 30 days.

Residual Neuromuscular Blockade in the Critical Care Setting

2018 ◽  
Vol 29 (1) ◽  
pp. 15-24 ◽  
Author(s):  
Nicole Stawicki ◽  
Patty Gessner
Keyword(s):  
Neuromuscular Blockade ◽  
Acute Care ◽  
Care Setting ◽  
Recovery Process ◽  
Neuromuscular Blocking ◽  
Advanced Practice ◽  
Acute Care Setting ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents

Residual neuromuscular blockade is a widespread challenge for providers in the acute care setting that, if left unrecognized or untreated, places patients at higher risk for morbidity and mortality. The condition is estimated to occur in 26% to 88% of patients undergoing general anesthesia. The role of the advanced practice nurse in the acute care setting is to facilitate a safe recovery process by identifying early signs of deterioration and supporting the patient until full muscular strength has returned. This article discusses the prevalence of residual neuromuscular blockade and associated complications and patient risk factors. A review is included of the current uses for neuromuscular blockade, pathophysiology of the neuromuscular junction, pharmacologic characteristics of neuromuscular blocking agents (including drug-drug interactions), monitoring modalities, and effectiveness of reversal agents. Treatment recommendations pertinent to residual neuromuscular blockade are outlined.

scholarly journals AB0619 PROGNOSTIC FACTORS OF PATIENTS WITH ANTI-MDA5 ANTIBODY-POSITIVE DERMATOMYOSITIS COMPLICATED WITH INTERSTITIAL PNEUMONIA -A JAPANESE SINGLE CENTER STUDY-

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1605.1-1605
Author(s):  
A. Umeda ◽  
M. Sawada ◽  
N. Watanabe ◽  
M. Suzuki ◽  
T. Naganawa ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Interstitial Pneumonia ◽  
Serum Ferritin ◽  
Protective Factor ◽  
Detection System ◽  
Ferritin Level ◽  
Multivariable Analysis ◽  
University Hospital ◽  
Rank Test ◽  
Roc Curve Analysis

Background:Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is frequently associated with rapidly progressive interstitial pneumonia (RPIP), whose prognosis is assumed to be poor[1]. Although outcome of DM-RPIP has been reported to be improved by early immunosuppressive therapy, we still experience the cases with severe outcome. Only several reports mentioned the prognostic factors and they have not been fully elucidated.Objectives:To identify the predictors of prognosis in patients with anti-MDA5 Ab-positive DM associated with interstitial pneumonia (DM-IP).Methods:Anti-MDA5 Ab-positive DM-IP patients admitted to Fujita Health University Hospital between January 2010 and October 2019 were consecutively included and stratified into 2 groups, the survived and the deceased groups. DM was diagnosed according to the criteria proposed by Bohan and Peter[2]. Clinically amyopathic DM was diagnosed according to the criteria proposed by Sontheimer [3]. Diagnosis of IP was based on findings of high resolution CT scan (HRCT). The definition of RPIP was rapid exacerbation of hypoxemia or HRCT findings in a period of days to one month after the onset. Clinical features and prognosis of the patients were collected retrospectively and compared between groups. Candidates of predictors are extracted by the univariable analysis using Fisher’s exact test for dichotic parameters and Wilcoxon signed-rank test for continuous parameters and multivariable analysis using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was examined to obtain the cut-off level. Survival was examined using Kaplan-Meier method and Log-rank test.Results:Twenty-one patients were involved. Eight were deceased and 13 were survived. The deceased group had a higher ratio of male (75% versus 25%, p= 0.018). All deceased cases were with RPIP and 67 % in the survived cases. Levels of serum ferritin (4490 versus 646 ng/mL, p = 0.0026), CRP (2.1 versus 0.9 mg/dL, p = 0.0490), CK (1150 versus 290 U/L, p = 0.017), AST (194 versus 108 U/L, p = 0.025) and LDH (674 versus 368 U/L, p = 0.011) were higher in the deceased group. Interestingly, skin ulcers were tended to be more frequent (12.5% versus 87.5%, p= 0.0587), and anti-SS-A antibody was also more frequently detected (14.3% versus 85.7%, p=0.0072) in the survived group. Using ROC analysis cut-off values were 963 ng/mL for serum ferritin level (sensitivity 100%, specificity 83%), 0.7 mg/dL for CRP (sensitivity 75%, specificity 69%), 308 U/L for CK (sensitivity 88%, specificity 77%), 62 U/L for ALT (sensitivity 100%, specificity 62%), and 454 U/L for LDH (sensitivity 88%, specificity 77%). Patients were divided into two groups based on these cut-offs or based on dichotic parameters and survival was examined between 2 groups. Except CRP and anti-SS-A antibody, survival was significantly worse in parameter-positive or higher groups. Interestingly, anti-SS-A antibody-positive group had better outcome compared with those without.Conclusion:In our analysis, novel candidates such as serum CK, AST, and LDH levels were newly extracted and parameters previously reported was also included and those were also associated with the clinical outcome. In addition, anti-SS-A antibody was identified as a novel protective factor associated with a good outcome.References:[1]Nakashima R, Hosono Y, Mimori T. Clinical significance and new detection system of autoantibodies in myositis with interstitial lung disease. Lupus 2016;25:925-33.[2]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Eng J Med 1975;292:344-7.[3]Sontheimer RD. Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin 2000;20:387-408.Disclosure of Interests:None declared

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