Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal

Optimizing neuromuscular block monitoring and reversal: A large-scale quality improvement initiative in a diverse healthcare setting

BACKGROUND

Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.

METHODS

An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.

RESULTS

The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.

CONCLUSION

This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.

Reversal of neuromuscular block with neostigmine and sugammadex: a retrospective cohort study in two centers using different types of neuromuscular monitoring

This bicentric retrospective cohort study evaluates reversal of muscle relaxation in real life achieved either by neostigmine or sugammadex in two hospitals using different types of neuromuscular monitoring (acceleromyography and kinemyography). The research question concerns compliance with recommendations. Patients who underwent an abdominal surgery under general anesthesia in the period from January 2017 through December 2020 with a neuromuscular block with rocuronium were included in the study. Data were extracted from the Centricity anesthesia information management system. In total, 2242 patients were assessed: 459 in center 1 (61 having received neostigmine and 398 sugammadex) and 1783 in center 2 (531 and 1252, respectively). Patients' characteristics differed between centers, with more high-risk patients in center 1. The mean train-of-four (TOF) ratio after supramaximal current determination (supramaximal threshold) was higher in center 1 (p < 0.001). Most patients received neostigmine while the TOF ratio was < 40% (68.6% in center 1 and 62.4% in center 2), while extubation was performed while the TOF ratio was > 90% in 61.0% in center 1 and in 32.1% in center 2 (p < 0.001). Patients received sugammadex irrespective of the number of responses to TOF before reversal, and extubation was performed while the TOF ratio was > 90% in 85.0% in center 1 and in 53.6% in center 2 (p < 0.001). No side effect was encountered. Despite guidelines for the TOF ratio before extubation, recommendations were not adequately respected and more vigilance is mandatory. The TOF test before use gave values that were 100% far apart with an underestimation with acceleromyography and an overestimation using kinemyography.

Success rate of acceleromyographic neuromuscular monitoring based on the depth of anesthesia at the time of sugammadex antagonism: a randomized controlled trial

OBJECTIVE

We aimed to compare the success of non-normalized acceleromyographic neuromuscular monitoring and recovery profiles based on the depth of anesthesia at the time of sugammadex administration.

METHODS

Patients undergoing general anesthesia were prospectively and randomly allocated to two groups. In the BIS60 group, sugammadex was administered when there was a bispectral index (BIS) <60 and anesthesia was maintained until a train-of-four ratio ≥1.0 was obtained, whereas in the BIS70 group, anesthesia was stopped at the completion of surgery, sugammadex was administered when the BIS was >70, and the recovery of neuromuscular function was monitored. The recovery profile and the incidence of emergence agitation of the two groups were compared.

RESULTS

The success rate of neuromuscular monitoring was significantly higher for the BIS60 group than for the BIS70 group (100% vs. 37.5%, respectively). The time taken for recovery for the two groups was comparable. The incidence of emergence agitation was significantly lower in the BIS60 group than in the BIS70 group (23.3% vs. 56.3%, respectively).

CONCLUSION

After the administration of sugammadex, the maintenance of anesthesia until the full recovery of neuromuscular function increases the success rate of neuromuscular monitoring without delaying recovery and reduces the risk of emergence agitation.Clinical trial registration: CRIS registration number KCT0007899 (https://cris.nih.go.kr/).