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.

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.

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

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.

Post-operative residual neuromuscular blockade after the administration of a single intubating dose of intermediate-acting non-depolarising neuromuscular blocking agent in adult elective surgical procedures

2020 ◽  
Vol 64 ◽  
pp. 142-146
Author(s):  
Rita Mae J. Gollaba ◽  
Derick Erl P. Sumalapao ◽  
Mary Ellen M. Chiong-Perez
Keyword(s):  
Neuromuscular Blockade ◽  
Surgical Procedures ◽  
Short Interval ◽  
Blocking Agent ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agent ◽  
Reversal Agent ◽  
Post Anaesthesia Care Unit ◽  
Residual Neuromuscular Blockade ◽  
Anaesthesia Care

Objectives: Post-operative residual neuromuscular blockade may result in life-threatening conditions if not properly managed making it a common and significant concern among anaesthesiologists. Among adult elective surgeries requiring single intubating dose of intermediate-acting non-depolarising neuromuscular blocking agent, the study determined the incidence and risk factors associated with post-operative residual neuromuscular blockade during early post-operative period. Materials and Methods: A prospective, open-labelled, non-randomised observational study conducted in an operating room and post-anaesthesia care unit. A total of 175 ASA-PS Class I and II patients admitted in the surgical wards scheduled for elective surgical operation and were administered of a single intubating dose of intravenous intermediate-acting non-depolarising neuromuscular blocking drug. The train-of-four (TOF) method of peripheral nerve stimulation detects the presence of post-operative residual neuromuscular blockade. Results: A significant post-operative residual paralysis was identified in specific age groups (26–35, 46–55 and 56–65), in surgical procedures in the orthopaedic service, and among patients who were given a reversal agent. Residual neuromuscular blockade is still present even if the interval between the last dose of muscle relaxant and the measurement of TOF ratio at the post-anaesthesia care unit was long, however, less than that observed in short interval surgeries. Conclusion: Clinical importance of residual neuromuscular blockade is still evident up to the present time and the present study recommends routine monitoring of neuromuscular blockade and pharmacologic antagonism in the reversal of non-depolarising neuromuscular blocking drugs.

scholarly journals The Effect of Preload on Electromyographic Train-Of-Four Ratio at the First Dorsal Interosseous Muscle during Spontaneous Recovery from Neuromuscular Blockade

2018 ◽  
Vol 46 (6) ◽  
pp. 614-619
Author(s):  
A. Bansal ◽  
P. A. Stewart ◽  
S. Phillips ◽  
S. Liang ◽  
X. Wang
Keyword(s):  
Neuromuscular Blockade ◽  
Spontaneous Recovery ◽  
Repeated Measurements ◽  
First Dorsal Interosseous ◽  
Reversal Agent ◽  
Residual Neuromuscular Blockade ◽  
Train Of Four ◽  
First Dorsal Interosseous Muscle ◽  
Induction Of Anaesthesia ◽  
Dorsal Interosseous Muscle

Accurate and reliable quantitative neuromuscular function monitoring is desirable for the optimal management of neuromuscular blockade, selection of the most appropriate reversal agent and dosage, and assessing the completeness of reversal to exclude residual neuromuscular blockade. Applying preload to the thumb may affect the precision of electromyography. This study compared the precision and agreement of electromyography with and without preload during recovery from non-depolarising neuromuscular blockade. After induction of anaesthesia and before neuromuscular blockade, the supramaximal current required at the first dorsal interosseous muscle with and without preload was determined. During recovery, train-of-four ratios were recorded using electromyography every 20 seconds. Alternating pairs of measurements (with and without preload) were obtained until spontaneous recovery was achieved. The preload device applied a resting tension of 75–150 g to the thumb. Bland–Altman analysis for repeated measurements was used to assess precision and agreement of electromyography responses with and without muscle preload. Two hundred and seventy-five sets of repeated measurements were collected from 35 participants. The repeatability coefficient for train-of-four ratios recorded by electromyography with a preload was 0.030 (95% confidence intervals, CI, 0.028 to 0.031) versus 0.068 (95% CI 0.064 to 0.072) without. Train-of-four ratios with preload demonstrated a bias of +0.038 (95% CI 0.037 to 0.042) compared to electromyography without, with 95% limits of agreement of 0.035–0.111. Preload significantly improved the precision of electromyographic train-of-four ratios, with 95% of consecutive measurements differing by less than 3%. Furthermore, electromyography with preload demonstrated a positive bias of 0.04 compared with electromyography alone, the clinical significance of which requires further research.

A survey of current management of neuromuscular block and reversal in Australia and New Zealand

2021 ◽  
pp. 0310057X2199549
Author(s):  
Benjamin L Olesnicky ◽  
Andrew Lindberg ◽  
Frank B Marroquin-Harris ◽  
Kerrie Ren
Keyword(s):  
New Zealand ◽  
Neuromuscular Blockade ◽  
Response Rate ◽  
Neuromuscular Block ◽  
Reversal Agent ◽  
Web Based ◽  
Reversal Agents ◽  
Zealand College ◽  
Clinically Significant ◽  
Contemporary Practice

In recent years there has been a significant investment in education on the management of neuromuscular blockade and increased availability of sugammadex in anaesthetic practice. This survey aimed to examine contemporary practice of Australian and New Zealand anaesthetists in managing neuromuscular blockade and its reversal. A web-based, voluntary survey was distributed to a cohort of 1000 Fellows of the Australian and New Zealand College of Anaesthetists. We received 229 completed responses (survey response rate of 23%). Seventy-one percent (95% confidence interval (CI) 64% to 76%) of the survey respondents thought that 5% or fewer of the patients in their hospital display clinically significant postoperative paralysis. Only 35% (95% CI 18% to 29%) thought that quantitative neuromuscular twitch monitors should be used to monitor neuromuscular block, and the dose and time given for reversal agents was often inconsistent with published recommendations. Sugammadex was the preferred reversal agent for 78% (95% CI 72% to 83%) of survey respondents, but they indicated that cost remains a significant barrier to its widespread uptake. Despite the low response rate, this survey identified that some reported practices in Australia and New Zealand deviate from guidelines and current recommendations in the management of neuromuscular blockade. If the respondents are representative of the broader anaesthetic community, there appears be a greater preference for sugammadex over neostigmine for reversal of neuromuscular blockade.

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 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.

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