A survey of current management of neuromuscular block in the United States and Europe

Exploring Differences in Intraoperative Medication Use Between African American and Non-Hispanic White Patients During General Anesthesia: Retrospective Observational Cohort Study

This study aimed to explore whether differences exist in anesthesia care providers' use of intraoperative medication between African American and non-Hispanic White patients in adult surgical patients who underwent noncardiothoracic nonobstetric surgeries with general anesthesia. A retrospective observational cohort study used electronic health records between January 1, 2018 and August 31, 2019 at a large academic health system in the southeastern United States. To evaluate the isolated impact of race on intraoperative medication use, inverse probability of treatment weighting using the propensity scores was used to balance the covariates between African American and non-Hispanic White patients. Regression analyses were then performed to evaluate the impact of race on the total dose of opioid analgesia administered, and the use of midazolam, sugammadex, antihypotensive drugs, and antihypertensive drugs. Of the 31,790 patients included in the sample, 58.9% were non-Hispanic Whites and 13.6% were African American patients. After adjusting for significant covariates, African American patients were more likely to receive midazolam premedication (p < .0001; adjusted odds ratio [aOR] = 1.17, 99.9% CI [1.06, 1.30]), and antihypertensive drugs (p = .0002; aOR = 1.15, 99.9% CI [1.02, 1.30]), and less likely to receive antihypotensive drugs (p < .0001; aOR = 0.85, 99.9% CI [0.76, 0.95]) than non-Hispanic White patients. However, we did not find significant differences in the total dose of opioid analgesia administered, or sugammadex. This study identified differences in intraoperative anesthesia care delivery between African American and non-Hispanic White patients; however, future research is needed to understand mechanisms that contribute to these differences and whether these differences are associated with patient outcomes.

Machine learning based analysis and detection of trend outliers for electromyographic neuromuscular monitoring

PURPOSE

Neuromuscular monitoring is frequently plagued by artefacts, which along with the frequent unawareness of the principles of this subtype of monitoring by many clinicians, tends to lead to a cynical attitute by clinicians towards these monitors. As such, the present study aims to derive a feature set and evaluate its discriminative performance for the purpose of Train-of-Four Ratio (TOF-R) outlier analysis during continuous intraoperative EMG-based neuromuscular monitoring.

METHODS

Patient data was sourced from two devices: (1) Datex-Ohmeda Electromyography (EMG) E-NMT: a dataset derived from a prospective observational trial including 136 patients (21,891 TOF-R observations), further subdivided in two based on the type of features included; and (2) TetraGraph: a clinical case repository dataset of 388 patients (97,838 TOF-R observations). The two datasets were combined to create a synthetic set, which included shared features across the two. This process led to the training of four distinct models.

RESULTS

The models showed an adequate bias/variance balance, suggesting no overfitting or underfitting. Models 1 and 2 consistently outperformed the others, with the former achieving an F1 score of 0.41 (0.31, 0.50) and an average precision score (95% CI) of 0.48 (0.35, 0.60). A random forest model analysis indicated that engineered TOF-R features were proportionally more influential in model performance than basic features.

CONCLUSIONS

Engineered TOF-R trend features and the resulting Cost-Sensitive Logistic Regression (CSLR) models provide useful insights and serve as a potential first step towards the automated removal of outliers for neuromuscular monitoring devices.

TRIAL REGISTRATION

NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.

Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method

Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.

The feasibility of the posterior tibial nerve-flexor hallucis brevis pathway applied in neuromuscular monitoring: a multicentric, controlled, and prospective clinical trial

This study aimed to investigate the clinical viability of utilizing the flexor hallucis brevis as an alternative site for neuromuscular monitoring compared to the conventional adductor pollicis. Patients were recruited from three medical centers. Cis-atracurium was administered, and two monitors were employed independently to assess neuromuscular blockade of the adductor pollicis and the ipsilateral flexor hallucis brevis, following a train of four (TOF) pattern until TOF ratios exceeded 0.9 or until the conclusion of surgery. Statistical analysis revealed significant differences in onset time, duration of no-twitch response, spontaneous recovery time, and total monitoring time between the two sites, with mean differences of -53.54 s, -2.49, 3.22, and 5.89 min, respectively (P < 0.001).The posterior tibial nerve-flexor hallucis brevis pathway presents a promising alternative for neuromuscular monitoring during anesthesia maintenance. Further investigation is warranted to explore its utility in anesthesia induction and recovery. Trial registration: The trial was registered at www.chictr.org.cn (20/11/2018, ChiCTR1800019651).

A compressomyograph train of four monitoring device

The monitoring of the neuromuscular blockade is critical for patient's safety during and after surgery. The monitoring of neuromuscular blockade often requires the use of Train of Four (TOF) technique. During a TOF test two electrodes are attached to the ulnar nerve, and a series of four electric pulses are applied. The electrical stimulation causes the thumb to twitch, and the amount of twitch varies depending on the amount of neuromuscular blockade in patient's system. Current medical devices used to assist anesthesiologists to perform TOF monitoring often require free hand movement and do not provide accurate or reliable results. The goal of this work is to design, prototype and test a new medical device that provides reliable TOF results when thumb movement is restricted. A medical device that uses a pressurized catheter balloon to detect the response thumb twitch of the TOF test is created. An analytical model, numerical study, and mechanical finger testing were employed to create an optimum design. The design is tested through a pilot human subjects study. No significant correlation is reported with subjects' properties, including hand size.

Macrocycles and Acyclic Cucurbit[n]urils as Pseudo[2]catenane Partners for Long-Acting Neuromuscular Blocks and Rapid Reversal In Vivo

Long-acting neuromuscular blocks followed by rapid reversal may provide prolonged surgeries with improved conditions by omitting repetitive or continuous administration of the neuromuscular blocking agent (NMBA), eliminating residual neuromuscular block and minimizing postoperative recovery, which, however, is not clinically available. Here, we demonstrate that imidazolium-based macrocycles (IMCs) and acyclic cucurbit[n]urils (ACBs) can form such partners by functioning as long-acting NMBAs and rapid reversal agents through a pseudo[2]catenation mechanism based on stable complexation with Ka values of over 109 M-1. In vivo experiments with rats reveal that, at the dose of 2- and 3-fold ED90, one IMC attains a duration of action corresponding to 158 or 442 min for human adults, covering most of prolonged surgeries. The block can be reversed by one ACB with recovery time significantly shorter than that achieved by sugammadex for reversing the block of rocuronium, the clinically most widely used intermediate-acting NMBA.

Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review

Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.

Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial

BACKGROUND

Objective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s STUDY OBJECTIVE: The present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements.

DESIGN

Observational trial.

SETTING

Tertiary Belgian hospital, from August 2020 up to September 2021.

PATIENTS AND INTERVENTIONS

Seventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria).

MAIN RESULTS

Published rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance.

CONCLUSIONS

Simulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics.

TRIAL REGISTRATION

NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.

Educating anaesthetists on neuromuscular monitoring: the challenges continue

The need to introduce guidelines on neuromuscular monitoring emphasising the use of quantitative techniques that record the train-of-four ratio is now recognised by an increasing number of national anaesthetic societies in the Western world. But the challenge of convincing individual anaesthetists to adopt and use this practice routinely remains. For >10 yr, it has been recognised that all staff in anaesthetic departments need to have regular training in modern neuromuscular monitoring techniques. We discuss a publication in this journal that describes the challenges of setting up multicentre training in Spain to expand the use of quantitative neuromuscular monitoring and their short-term results.

Efficacy and safety of sugammadex sodium in reversing rocuronium-induced neuromuscular blockade in children: An updated systematic review and meta-analysis

Objective

In response to the differences in pharmacodynamic and pharmacokinetic characteristics of neuromuscular blocking agents between children and adults and limited studies which existing meta-analyses included, this study will update the safety and efficacy of sugammadex (Sug) sodium in reversing rocuronium-induced neuromuscular blockade in children.

Methods

Five electronic databases were searched for clinical trials on the safety and efficacy of Sug sodium in reversing rocuronium-induced neuromuscular block in children. A random-effects model was used to calculate the standardized mean difference (SMD) for primary outcomes. The relative risk (RR) was calculated for secondary outcomes.

Results

As of 2022-11-03, 18 out of 236 studies included 724 children in the intervention group and 478 children in the control group for meta-analysis. The results showed that compared with the control group, the time required for Train-of-Four Ratio (TOFR) to return to 0.9 and the extubation time were shortened in both 2 mg/kg and 4 mg/kg of Sug sodium, with statistically significant differences (TOFR ≥0.9: 2 mg/kg: SMD = -2.90; 95%CI: -3.75, -2.04; 4 mg/kg: -3.31; -4.79, -1.84; extubation time: 2 mg/kg: -2.95; -4.04, -1.85; 4 mg/kg: -1.57; -1.90, -1.23). Compared with the control group, the total incidence of adverse effects in the Sug group was lower (RR = 0.44; 0.24,0.82).

Conclusions

This review and meta-analysis suggest that Sug sodium is more effective and safer in reversing rocuronium-induced neuromuscular blockade in children than traditional antagonistic regimens or placebos.

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

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.

Comparison of visual and electromyographic assessments with train-of-four stimulation of the ulnar nerve: a prospective cohort study

PURPOSE

The use of a peripheral nerve stimulator to assess the level of neuromuscular blockade tasks the anesthesia clinician with subjectively assessing the response to neurostimulation. In contrast, objective neuromuscular monitors provide quantitative information. The purpose of this study was to compare subjective evaluations from a peripheral nerve stimulator with objective measurements of neurostimulation responses from a quantitative monitor.

METHODS

Patients were enrolled preoperatively, and intraoperative neuromuscular blockade management was at the discretion of the anesthesiologist. Electromyography electrodes were placed over the dominant or nondominant arm in a randomized fashion. Following onset of nondepolarizing neuromuscular blockade, the ulnar nerve was stimulated, the response was measured with electromyography, and anesthesia clinicians, who were blinded to the objective measurements, subjectively (visually) evaluated the response to neurostimulation.

RESULTS

Fifty patients were enrolled and 666 neurostimulations were performed at 333 different time points. Anesthesia clinicians subjectively overestimated the response of the adductor pollicis muscle following neurostimulation of the ulnar nerve 155/333 (47%) of the time when compared with objective electromyographic measurements. When subjective evaluations and objective measurements differed to any degree, subjective evaluations were higher than objective measurements 155/166 (92%) of the time (95% CI, 87 to 95; P < 0.001), representing significant evidence that subjective evaluation overestimates the response to train-of-four stimulation.

CONCLUSIONS

Subjective observations of a "twitch" do not consistently correspond to objective measurements of neuromuscular blockade with electromyography. Subjective evaluation overestimates the response to neurostimulation and may be unreliable for determining the depth of block or confirming adequate recovery.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

OBJECTIVES

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.

INTERVENTIONS

An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.

MEASUREMENTS AND MAIN RESULTS

The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.

CONCLUSIONS

The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

Comparison of Relaxometry Between Ulnar Nerve and Posterior Tibial Nerve After Cisatracurium Administration Using Electromyography

BACKGROUND

Electromyography can be used for quantitative neuromuscular monitoring during general anesthesia, mostly using the stimulation train-of-four (TOF) pattern. Relaxometry measures the muscular response of the adductor pollicis muscle to electrical stimulation of the ulnar nerve, which is routinely used in clinical practices for monitoring the neuromuscular block. However, when it is not always possible to be used for all patients, the posterior tibial nerve is a suitable alternative.

OBJECTIVES

Using electromyography, we compared the neuromuscular block between the ulnar and the posterior tibial nerves.

METHODS

In this study, the participants were 110 patients who met inclusion criteria and submitted their written consent. Following the administration of cisatracurium intravenously, the patients had relaxometry performed simultaneously on the ulnar and the posterior tibial nerves using electromyography.

RESULTS

Eighty-seven patients were included in the final analysis. The onset time was 296 ± 99 s at the ulnar nerve and 346 ± 146 s at the tibial nerve, with a mean difference of -50 s and a standard deviation of 164 s. The 95% limits of agreement ranged from -372 s to 272 s. The relaxation time was 105 ± 26 min at the ulnar nerve and 87 ± 25 min at the tibial nerve, with a mean difference of 18 min and a standard deviation of 20 min.

CONCLUSIONS

Using electromyography, no statistically significant difference was noticed between the ulnar and the posterior tibial nerve during the neuromuscular block. The onset time and the relaxation time assessed with an electromyogram to compare the stimulation of the ulnar and posterior tibial nerves showed large limits of agreement.

Routine administration of neostigmine after recovery of spontaneous breathing versus neuromuscular monitor-guided administration of neostigmine in pediatric patients: a parallel, randomized, controlled study

BACKGROUND

Neostigmine used to reverse the muscle relaxants should be guided by neuromuscular monitoring, as the degree of spontaneous pre-reversal recovery is the key to success to reverse the neuromuscular block. But neuromuscular monitoring is not always available for some patients during anesthesia and, in consequence, we need to use other clinical judgment to guide the use of neostigmine to reverse the neuromuscular block. In this trial, we aimed to evaluate the incidence of residual neuromuscular blockade (rNMB) in pediatric patients with routine use of neostigmine after recovery of spontaneous breathing compared with the patients with the use of neostigmine guided by neuromuscular monitoring.

METHODS

A parallel, randomized, controlled noninferiority study was conducted. We enrolled aged 3 months to 12 years old patients who underwent inguinal hernia repair under general anesthesia. The enrolled patients were randomly divided into experimental and control groups. After surgery, children in the experimental group were given 0.02 mg/kg neostigmine after recovery of spontaneous breathing. Children in the control group were given 0.02 mg/kg neostigmine when the train-of-four (TOF) ratio was between 0.4 and 0.9. However, no neostigmine was administered if the TOF ratio was higher than 0.9. The primary outcome was the incidence of rNMB after extubation (TOF ratio < 0.9). Secondary outcomes included the incidence of neostigmine-induced muscle paralysis, end of surgery - extubation interval, end of surgery - exit OR interval, the length of stay in the PACU, the incidence of hypoxia in the PACU, the number of children who required assisted ventilation during the PACU stay, and neostigmine-related adverse events.

RESULTS

A total of 120 children were included in this study, with 60 in the experimental group and 60 in the control group. There was no significant difference in the incidence of rNMB after extubation between the groups (45/60 vs 44/60, RR 1.02 [95% CI, 0.83 to 1.26], p = 0.84). There was no neostigmine-induced muscle paralysis in either group. Adverse events were similar occurred in both groups. However, time from end of the surgery to leaving the operating room was earlier in the experimental group than in the control group (13.6 ± 5.2 vs 15.7 ± 5.6 min, MD -2.10 min [95% CI, -3.70 to -0.50], p = 0.04). The risk ratio of the incidence of TOF ratio < 0.3 for the experimental group was 31.12 (95%CI, 1.89 to 512.61) compared with the control group (12/60 vs 0/60, p = 0.00) in exploratory analysis.

CONCLUSIONS

Recovery of spontaneous breathing could be used as a substitute of neuromuscular monitoring to guide neostigmine use in pediatric patients following minor surgeries. However, care should be taken for the residual neuromuscular block.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IOR-17012890. Registered on 5 October 2017.

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

A survey on the availability, usage and perception of neuromuscular monitors in Europe

PURPOSE

Neuromuscular blocking agents (NMBAs) are routinely administered to patients in a multiplicity of anesthetic settings. Absence of postoperative residual neuromuscular block is widely considered an anesthetic patient safety mandate. Despite the increasing availability of a wider range of commercial quantitative neuromuscular monitors, the availability and use of neuromuscular monitoring devices is deemed to be suboptimal even in countries with above-average health system ratings. The present study aims to more precisely characterize the perceived availability, cost sensitivity and usability of neuromuscular monitoring devices within European anesthesia departments.

METHODS

A pre-registered internet-based survey assessing the availability, cost sensitivity and usability of neuromuscular monitoring devices was distributed as e-mail newsletter by the European Society of Anaesthesiology and Intensive Care (ESAIC) to all of its active full members. The survey was available online for a total of 120 days.

RESULTS

Having targeted a total of 7472 ESAIC members, the survey was completed by a total of 692 anesthesiologists (9.3%) distributed across 37 different European countries. Quantitative monitors were reported to be proportionally more available than qualitative ones (87.6% vs. 62.6%, respectively), as well as in greater monitor-per-operating room ratios. Most anesthesiologists (60.5%) expressed moderate confidence in quantitative monitors, with artifactual recordings and inaccurate measurements being the most frequently encountered issues (25.9%). The commercial pricing of quantitative devices was considered more representative of a device's true value, when compared to qualitative instruments (average cost of €4.500 and €1.000 per device, respectively).

CONCLUSION

The availability of quantitative NMM in European operating theaters has increased in comparison with that reported in previous decades, potentially indicating increasing monitoring rates. European anesthesiologists express moderate confidence in quantitative neuromuscular monitors, along with a sentiment of adequate pricing when compared to their qualitative counterparts. Trust in quantitative monitors is marked by caution and awareness for artifactual recordings, with a consequent expectation that developments focusing on accuracy, reliability and ergonomics of neuromuscular monitors be prioritized.

Sample size considerations for studies comparing intubating conditions using quantitative monitoring versus a fixed interval during onset of neuromuscular blockade

INTRODUCTION

Data in the literature are still scarce to establish any recommendations on the use of quantitative monitoring during tracheal intubation.

PATIENTS AND METHODS

In this monocentric study, non-morbidly obese adult female patients without risk factors for difficult tracheal intubation were prospectively included. After 0.5 mg.kg^-1 atracurium during propofol-sufentanil anaesthesia, intubation conditions were evaluated using the Copenhague and Cormack-Lehane classification at the complete twitch suppression at the TOF to the AP (monitor group) or after a fixed 3 min waiting time after atracurium injection (3-min group). We also examined sample size for future studies.

RESULTS

We included 102 (monitor group) and 97 (3-min group) adult non-obese female patients without different characteristics. Intubation conditions were acceptable in 96/102 (94%) in the monitor group vs. 84/97 (87%) in the 3-min group, p = 0.07. The presence of a Cormack and Lehane view of 1 was marginally better in the monitor group as compared to the 3-min group, p = 0.041. We propose two possibility of sample size based on a difference of observed events based on acceptable intubation conditions, n = 602, or on excellent intubation conditions, n = 550.

DISCUSSION

This observational study shows that the use of a neuromuscular TOF monitoring of the ulnar nerve as compared to a fixed 3-min waiting time after atracurium injection could improve laryngoscopic view and show a tendency to better intubation conditions without conclusive statistical significance. We suggest that researchers consider our recommendations in terms of the sample size to include in their future research, keeping in mind the limitations of our study.

Neuromuscular monitoring during general anaesthesia: a review of current national and international guidelines

Background

The extent to which neuromuscular monitoring is included in professional anaesthesia society guidelines is unclear. Our aim was to comprehensively review neuromuscular monitoring guidelines published by these societies.

Methods

National societies were identified using the World Federation of Societies of Anaesthesiologists' member list and further manual searches were undertaken to identify multinational societies and specialist medical colleges. A web search and secondary literature search were conducted to locate guidelines for monitoring during anaesthesia. The income of each nation or group of nations was determined using the World Bank classification.

Results

Forty guidelines were identified. Of 38 nations or classifiable groups of nations, 25 (66%) were high-income nations and 13 (34%) were middle-income nations. Neuromuscular monitoring was mentioned in 36 (90%) of the 40 guidelines. Availability of neuromuscular monitoring was mentioned in 17 (47%) guidelines (mandated in eight [47%] and recommended in nine [53%]). Use of neuromuscular monitoring was mentioned in 26 (72%) guidelines (mandated in three [12%] and recommended in 23 [88%]). Quantitative neuromuscular monitoring was specified in nine (25%) of the guidelines, with the type of monitoring unspecified in the remaining 27 (75%) of the 36 guidelines. Quantitative monitoring was only mandated in one guideline, and this was only when monitoring equipment was available.

Conclusions

We identified a gap in the availability of professional anaesthesia society neuromuscular monitoring guidelines, particularly in middle- and low-income nations. Recommendations about availability, use and type of monitoring varied among guidelines. An effort to improve the availability and consistency of guidelines is required.

Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine

Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.

Assessment of the New Acceleromyograph TOF 3D Compared with the Established TOF Watch SX: Bland-Altman Analysis of the Precision and Limits of Agreement between Both Devices-A Randomized Clinical Comparison

The new acceleromyograph TOF 3D was compared with the established TOF Watch SX in patients undergoing elective laparoscopic gynecological surgery. Neuromuscular transmission was assessed by simultaneous recording with both devices. Measurements were performed simultaneously at the left and the right M. adductor pollicis (Group A, 25 patients), or the M. corrugator supercilii (Group CS, 25 patients). The repeatability, time course, and limits of agreement (Bland-Altman) were compared. The primary endpoint was the 90% train-of-four recovery time (TOFR 0.9). Other endpoints included onset time of block, maximum T1 depression, time to 25% T1 recovery, the recovery time course of T1 response, and TOF ratio, respectively. In group CS, the repeatability coefficient of the TOF 3D was lower (4.66 (1.6)) than of the TOF Watch SX (6.02 (1.9); p = 0.026). In group A, the onset of the block was faster when measured by the TOF 3D (98.7 (30) s vs. 112.2 (36) s (mean (SD)); p = 0.032). In group A, time to recovery to a TOFR of 90% was measured earlier by the TOF 3D (bias −0.71 min, limits of agreement from −8.94 to +7.51 min). The TOF 3D provides adequate information with high precision and sensitivity. It is suitable even for measurement sites with small muscle contractions such as the M. corrugator supercilii.

Pro-Con Debate: Do We Need Quantitative Neuromuscular Monitoring in the Era of Sugammadex?

In this Pro-Con article, we debate the merits of using quantitative neuromuscular blockade monitoring. Consensus guidelines recommend their use to guide the administration of nondepolarizing neuromuscular blockade and reversal agents. A major impediment to this guideline is that until recently, reliable quantitative neuromuscular blockade monitors have not been widely available. Without them, anesthesia providers have been trained with and are adept at using a variety of qualitative neuromuscular blockade monitors otherwise known as peripheral nerve stimulators. Although perhaps less accurate, anesthesia providers find them reliable and easy to use. They have a long track record of using them with the perception that their use leads to effective neuromuscular blockade reversal and minimizes clinically significant adverse events from residual neuromuscular blockade. In the recent past, 2 disruptive developments have called upon anesthesia care providers to reconsider their practice in neuromuscular blockade administration, reversal, and monitoring. These include: (1) commercialization of more reliable quantitative neuromuscular monitors and (2) widespread use of sugammadex, a versatile reversal agent of neuromuscular blockade. Sugammadex appears to be so effective at rapidly and effectively reversing even the deepest of neuromuscular blockades, and it has left anesthesia providers wondering whether quantitative monitoring is indeed necessary or whether conventional, familiar, and less expensive qualitative monitoring will suffice? This Pro-Con debate will contrast anesthesia provider perceptions with evidence surrounding the use of quantitative neuromuscular blockade monitors to explore whether quantitative neuromuscular monitoring (NMM) is just another technology solution looking for a problem or a significant advance in NMM that will improve patient safety and outcomes.

Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative

BACKGROUND

Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis.

METHODS

The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes.

RESULTS

From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001).

CONCLUSIONS

In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

EDITOR’S PERSPECTIVE

Improving neuromuscular monitoring and reducing residual neuromuscular blockade via e-learning: A multicentre interrupted time-series study (INVERT study)

Background

Neuromuscular monitoring should be applied routinely to avoid residual neuromuscular block. However, anaesthetists often refrain from applying it, even when the equipment is available. We aimed to increase neuromuscular monitoring in six Danish anaesthesia departments via e‐learning.

Methods

Interrupted time series study, with baseline data from a previous study and prospective data collection after implementation of the module, which was available for 2 weeks from 21 November 2016. We included all patients receiving general anaesthesia with muscle relaxants until 30 April 2017. Main outcome was application of acceleromyography, grouped as succinylcholine only and non‐depolarising relaxants. Secondary outcomes were last recorded train‐of‐four ratio (non‐depolarising) relaxants and score on a ten‐question pre‐ and post‐course multiple‐choice test.

Results

The post‐intervention data consisted of 6525 cases (3099 (48%) succinylcholine only, 3426 (52%) non‐depolarising relaxants). Analysing all departments, we found a positive pre‐intervention trend in application of acceleromyography for both groups, of estimated 7.5% and 4.8% per year, respectively (p < .001). The monitoring rate increased significantly for succinylcholine in two departments post‐intervention (p = .045 and .010), and for non‐depolarising relaxants in one department (p = .041), but followed by a negative trend of −37.0% per year (p = .041). The rate was already close to 90% at the time of the intervention and the mean last recorded train‐of‐four ratio was 0.97 (SD 0.21), also without a significant change. The median score on the post‐course test increased from 7 (IQR 5–8) to 9 (IQR 8–10) (p < .001, Wilcoxon Signed‐Ranks Test).

Conclusion

We found no overall effect of the e‐learning module on application of neuromuscular monitoring, although the post‐course test indicated an effect on anaesthetists’ knowledge in this field.

Trial registration

Trial registration: Clinicaltrials.gov identifier: NCT02925143. https://clinicaltrials.gov/ct2/show/NCT02925143

Neuromuscular Blocking Agents and Monitoring in China: A Cross-Sectional Survey of Current Management

Background

Little is known about the recent use of neuromuscular blocking agents (NMBAs) and monitoring in China. This paper presents the results of a nationwide survey conducted to obtain information regarding the current management of NMBAs in China.

Methods

A questionnaire was sent to Chinese anesthesiologists inviting them to participate in the study. The questionnaire was available through the wenjuanxing website, and the link was sent to 1,488 anesthesiologists using the Wechat mini app.

Results

The web-based survey consisted of 28 questions, and data were collected using an online tool. Between May 19, 2021 and June 16, 2021, 637 responses were collected (response rate = 42.8%). Only 10.2% of anesthesiologists reported using neuromuscular function monitors, and 6.59% of respondents reported that they had the relevant monitors in the operating room.

Conclusion

Although PORC is a potential safety issue, the frequency of using reversal agents and monitors remains extremely low in China. Surveys such as this are important to understand the use and application customs of NMBAs in China.

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

Mobile Applications in Clinical and Perioperative Care for Anesthesia: Narrative Review

BACKGROUND

The increasing use of smartphones by providers and patients alike demonstrates that digital health utilizing mobile applications has the potential to transform perioperative care and education in anesthesia.

OBJECTIVE

This literature review describes the current scope of the use of mobile applications in anesthesiology.

METHODS

Literature was searched using PubMed, Scopus, and clinicaltrials.gov for articles published from January 1, 2010, through April 1, 2020. Only English language studies were included. Articles were included if they examined the use of a mobile health application in the setting of anesthesia or the perioperative (immediate preoperative, intraoperative, and postoperative) period. Studies were excluded if they explored video interventions or did not examine the feasibility or efficacy of the mobile app.

RESULTS

We included 29 articles, and three areas of clinical functionality were identified: patient-centered care (preoperative, intraoperative, and postoperative), systems-based improvement, and medical education. Several studies demonstrate the feasibility and reliability of mobile apps in these areas, but many are only tested for efficacy in simulated environments or with small patient samples.

CONCLUSIONS

Mobile health applications show promise in improving communication between anesthesiologists, improving workflow efficiency, enhancing medical education, and reducing hospital costs. However, there is a need for validation and improvement before full implementation by the provider, patients, and hospital systems. Future studies are needed to demonstrate meaningful health outcomes to create guidelines and recommendations specific to the application of mobile technology to health care.

Neuromuscular Blockade and Reversal Agent Practice Variability in the US Inpatient Surgical Settings

Introduction

The management of neuromuscular blockade (NMB) has evolved over time and remains a critical component of general anesthesia. However, NMB use varies by patient and procedural characteristics, clinical practices, protocols, and drug access. National utilization patterns are unknown. We describe changes in NMB and NMB reversal agent administration in surgical inpatients since the US introduction of sugammadex in December 2015.

Methods

In a retrospective observational study of inpatients involving NMB with rocuronium or vecuronium in the Premier Healthcare Database, we estimate associations between factors related to choice of (1) active NMB reversal versus spontaneous recovery and (2) sugammadex versus neostigmine as the reversal agent.

Results

Among 4.3 million adult inpatient encounters involving rocuronium or vecuronium, the most widely administered NMB agent was rocuronium alone (86%). Over time, gradual declines in both neostigmine use and spontaneous reversal were observed (64% and 36% in 2014 to 38% and 28%, respectively in the first half of 2019). Several factors were independently associated with use of active versus spontaneous NMB recovery including years since 2016, patient (age, race, comorbidities), and procedure (admission and surgery type) characteristics. Among those actively reversed, these and other factors were independently associated with choice of reversal agent administered, including size and teaching affiliation of hospital. While both impacted choices in treatment, the direction and magnitude of effect of patient comorbidities and procedure type varied in their impact on choice of mode (pharmacologic vs. spontaneous) and agent (neostigmine vs. sugammadex) of NMB reversal independent of other factors and each other. Sites which adopted sugammadex earlier were more likely to choose sugammadex over neostigmine compared with later adopters independent of other factors.

Conclusions

Among US adult inpatients administered NMBs, we observed complex relationships between patient, site, procedural characteristics, and NMB management choices as NMBA choice and active reversal options among inpatient cases changed over time.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01835-2.

Neuromuscular blocking agents, medications that temporarily paralyze muscles, are used frequently during surgical procedures to facilitate intubation and patient immobility. Over time, muscle function can return spontaneously or through pharmacological reversal agents. This study looked at how the use of reversal agents in inpatients undergoing surgical procedures changed after a new reversal agent, sugammadex, became available for use in the USA in December 2015.

Medical records of 4.3 million adult patients treated with neuromuscular blocking agents (rocuronium or vecuronium) in the USA were studied. In 2014 (before sugammadex was available), one-third of patients (36%) recovered spontaneously from a neuromuscular blocking agent and two-thirds (64%) were treated with the reversal agent neostigmine. The use of both neostigmine and spontaneous recovery reduced gradually after sugammadex became available, so that by the first half of 2019, 38% of patients were treated with neostigmine and 28% of patients recovered spontaneously.

Whether or not a patient was treated with a reversal agent and what type of agent was chosen were affected by the length of time since 2016, patient characteristics, the type of surgical procedure that was performed as well as local hospital characteristics and practice differences.

Neuromuscular Blockade Monitoring

Neuromuscular monitoring is essential for optimal management of neuromuscular blocking drugs. Postoperative residual neuromuscular blockade continues to occur with an unacceptably high incidence and is associated with adverse patient outcomes. Use of a peripheral nerve stimulator and subjective tactile or visual assessment is useful for intraoperative management of neuromuscular blockade, especially when the patient's hand is accessible. Quantitative monitoring is necessary for confirmation of adequate reversal and for identification of patients who have recovered spontaneously and therefore should not receive pharmacologic reversal agents. Guidelines, as well as more user-friendly monitoring equipment, have created momentum toward improving routine perioperative neuromuscular monitoring.

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

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.

Quantitative Neuromuscular Monitoring With Train-of-Four Ratio During Elective Surgery: A Prospective, Observational Study

OBJECTIVES

Postoperative residual neuromuscular block (PRNB) is a serious problem that can cause death after surgery. It was aimed to evaluate the adequacy of neuromuscular block (NMB) during endotracheal intubation and the adequacy of neuromuscular recovery during clinically extubation decision and follow-up with the train-of-four ratio (TOFR) using quantitative monitoring.

METHODS

This study has a prospective-observational single-blind study design. A total of 205 adult patients who underwent elective surgery, who had American Society of Anesthesiologists physical statuses I to III, and who were intubated with neuromuscular blocking agent under general anesthesia were included in the study. Train-of-four ratio measurements were provided single-blindly by another anesthesiologist outside the team. The TOFRs were measured at the time of intubation (TOFRind), before reversal agent administration (TOFRpre-rev) and after (TOFRpost-rev), at the time of extubation (TOFRext), and on admission to the postoperative care unit (TOFRPACU). If clinical signs of PRNB appeared, the recovery protocol was applied and then TOFRrec was measured. Postoperative respiratory complications were also evaluated for the first 24 hours after surgery.

RESULTS

Endotracheal intubation was performed in 41.5% of the patients (n = 85) without adequate NMB. In 48.8% (n = 100) of the patients, adequate recovery (TOFRext ˂0.9) was not available at the time of extubation. Adequate TOFRPACU rate was found to be significantly higher in those who did not receive additional neuromuscular blocking agent doses (P < 0.001). In the recovery protocol, low-dose sugammadex administered to patients with clinical signs of PRNB significantly increased the TOFRrec rate compared with neostigmine (P ˂ 0.001). The first 24 hours, postoperative respiratory complication rate was 5.4% (n = 11), and the most common hypoxemia was observed.

CONCLUSIONS

Approximately half of the patients are intubated without sufficient NMB and extubated without sufficient neuromuscular recovery. This suggests that routine use of quantitative neuromuscular monitoring is necessary for patient safety.

Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

BACKGROUND

The paucity of easy-to-use, reliable objective neuromuscular monitors is an obstacle to universal adoption of routine neuromuscular monitoring. Electromyography (EMG) has been proposed as the optimal neuromuscular monitoring technology since it addresses several acceleromyography limitations. This clinical study compared simultaneous neuromuscular responses recorded from induction of neuromuscular block until recovery using the acceleromyography-based TOF-Watch SX and EMG-based TetraGraph.

METHODS

Fifty consenting patients participated. The acceleromyography and EMG devices analyzed simultaneous contractions (acceleromyography) and muscle action potentials (EMG) from the adductor pollicis muscle by synchronization via fiber optic cable link. Bland-Altman analysis described the agreement between devices during distinct phases of neuromuscular block. The primary endpoint was agreement of acceleromyography- and EMG-derived normalized train-of-four ratios greater than or equal to 80%. Secondary endpoints were agreement in the recovery train-of-four ratio range less than 80% and agreement of baseline train-of-four ratios between the devices.

RESULTS

Acceleromyography showed normalized train-of-four ratio greater than or equal to 80% earlier than EMG. When acceleromyography showed train-of-four ratio greater than or equal to 80% (n = 2,929), the bias was 1.3 toward acceleromyography (limits of agreement, -14.0 to 16.6). When EMG showed train-of-four ratio greater than or equal to 80% (n = 2,284), the bias was -0.5 toward EMG (-14.7 to 13.6). In the acceleromyography range train-of-four ratio less than 80% (n = 2,802), the bias was 2.1 (-16.1 to 20.2), and in the EMG range train-of-four ratio less than 80% (n = 3,447), it was 2.6 (-14.4 to 19.6). Baseline train-of-four ratios were higher and more variable with acceleromyography than with EMG.

CONCLUSIONS

Bias was lower than in previous studies. Limits of agreement were wider than expected because acceleromyography readings varied more than EMG both at baseline and during recovery. The EMG-based monitor had higher precision and greater repeatability than acceleromyography. This difference between monitors was even greater when EMG data were compared to raw (nonnormalized) acceleromyography measurements. The EMG monitor is a better indicator of adequate recovery from neuromuscular block and readiness for safe tracheal extubation than the acceleromyography monitor.

EDITOR’S PERSPECTIVE

[Muscle Relaxant And Reversal Practices And Impact Of Reversal Modalities On Operating Room And Postoperative Room Duration - Results Of A Delphi Study]

OBJECTIVE

The objectives of this Delphi study are to describe muscle relaxant and reversal practices in France and to seek a consensus on the impact of the reversal method on the time spent in the OR and PACU.

METHOD

A two-round Delphi survey was conducted on a panel of French anesthetists involved in colectomies, hysterectomies or bariatric surgery. The questionnaire was designed in collaboration with a scientific committee and was intended to assess neuromuscular blockade reversal techniques and their impact on time spent in the OR and PACU. The first round gathered data on practices and the second round sought a consensus for the time aspect.

RESULTS

Overall, all participants (99%) monitored neuromuscular blockade, with a majority (82%) doing so continuously. Of the participants, 22% routinely used a reversal drug. The time saved in the OR or PACU with sugammadex varied between 1 and 43 minutes depending on the surgery and the neuromuscular blockade reversal method it was compared to.

CONCLUSION

Although SFAR recommendations (French Society of Anesthesia & Intensive Care Medicine) were generally well followed, the use of neuromuscular blockade reversal drugs was observed to be not fully integrated into regular practice, despite the fact that more than half of patients were reported to have residual neuromuscular blockade post-surgery and that sugammadex is known to reduce time spent in the OR and PACU compared to other neuromuscular blockade reversal methods.

Vigilance: the behavioral impact of quantitative monitoring on administration and antagonism of neuromuscular blocking agents

PURPOSE

The aim of this study was to determine whether use of acceleromyography (1) changes dosing of neuromuscular blocking agents (NMBAs), and (2) increases the time between neostigmine administration and extubation, when compared with subjective assessment of neuromuscular blockade.

METHODS

For this retrospective study, data were collected from patient electronic medical records. Patients were included if they had received an NMBA as part of a general anesthetic in 2013 and 2014. Data were analyzed by category of monitoring device: quantitative monitor (acceleromyograph [AMG]) or subjective device (peripheral nerve stimulator [PNS]). Outcomes measured were the total dose of NMBA administered and, the timing of the last dose of NMBA and anticholinesterase relative to tracheal extubation.

RESULTS

Results from multivariate models showed that use of acceleromyography was not associated with a change in the total dose of NMBA administered. In contrast, the number of times any monitor was used, as determined by the frequency with which the train-of-four count (TOFC) was recorded, correlated with the administration of greater amounts of rocuronium (P < 0.01) and vecuronium (P < 0.01). The use of acceleromyography did not prolong the time interval between neostigmine administration and tracheal extubation. The number of times any monitor was used during an anesthetic was associated with a decrease in this time interval. The interval decreased an average of 2.7 min each successive time the TOFC was recorded (P < 0.01).

CONCLUSIONS

The data presented provides insight about the behavioral engineering inherent to the practice of anesthesiology. Introduction of neuromuscular blockade assessment appeared to increase provider vigilance in dosing of NMBAs-regardless of assessment method. The frequency of intraoperative monitoring (quantitative or subjective) was associated with an increased total dose of NMBA administered and decreased time interval between the last dose of neostigmine and extubation.

Exploratory Outlier Detection for Acceleromyographic Neuromuscular Monitoring: Machine Learning Approach

Background

Perioperative quantitative monitoring of neuromuscular function in patients receiving neuromuscular blockers has become internationally recognized as an absolute and core necessity in modern anesthesia care. Because of their kinetic nature, artifactual recordings of acceleromyography-based neuromuscular monitoring devices are not unusual. These generate a great deal of cynicism among anesthesiologists, constituting an obstacle toward their widespread adoption. Through outlier analysis techniques, monitoring devices can learn to detect and flag signal abnormalities. Outlier analysis (or anomaly detection) refers to the problem of finding patterns in data that do not conform to expected behavior.

Objective

This study was motivated by the development of a smartphone app intended for neuromuscular monitoring based on combined accelerometric and angular hand movement data. During the paired comparison stage of this app against existing acceleromyography monitoring devices, it was noted that the results from both devices did not always concur. This study aims to engineer a set of features that enable the detection of outliers in the form of erroneous train-of-four (TOF) measurements from an acceleromyographic-based device. These features are tested for their potential in the detection of erroneous TOF measurements by developing an outlier detection algorithm.

Methods

A data set encompassing 533 high-sensitivity TOF measurements from 35 patients was created based on a multicentric open label trial of a purpose-built accelero- and gyroscopic-based neuromuscular monitoring app. A basic set of features was extracted based on raw data while a second set of features was purpose engineered based on TOF pattern characteristics. Two cost-sensitive logistic regression (CSLR) models were deployed to evaluate the performance of these features. The final output of the developed models was a binary classification, indicating if a TOF measurement was an outlier or not.

Results

A total of 7 basic features were extracted based on raw data, while another 8 features were engineered based on TOF pattern characteristics. The model training and testing were based on separate data sets: one with 319 measurements (18 outliers) and a second with 214 measurements (12 outliers). The F1 score (95% CI) was 0.86 (0.48-0.97) for the CSLR model with engineered features, significantly larger than the CSLR model with the basic features (0.29 [0.17-0.53]; P<.001).

Conclusions

The set of engineered features and their corresponding incorporation in an outlier detection algorithm have the potential to increase overall neuromuscular monitoring data consistency. Integrating outlier flagging algorithms within neuromuscular monitors could potentially reduce overall acceleromyography-based reliability issues.

Trial Registration

ClinicalTrials.gov NCT03605225; https://clinicaltrials.gov/ct2/show/NCT03605225

Ease of Application of Various Neuromuscular Devices for Routine Monitoring

BACKGROUND

Subjective evaluations to confirm recovery from neuromuscular blockade with a peripheral nerve stimulator (PNS) is inadequate. Quantitative monitors are the only reliable method to confirm adequate recovery of neuromuscular function. Unfortunately, many clinicians are unfamiliar with such devices and there is concern that the introduction of objective monitoring would be exceedingly laborious and could cause workflow delays. This study investigates how long it takes experienced nurse anesthetists to apply various neuromuscular devices as well as their perception regarding the ease of application.

METHODS

Twenty nurse anesthetists were consented and participated in an educational session that familiarized them with 3 devices: SunStim Plus PNS (SunMed, Grand Rapids, MI), the acceleromyography-based IntelliVue NMT device (Philips, Amsterdam, the Netherlands), and electromyography-based TetraGraph device (Senzime B.V., Uppsala, Sweden). Participants were timed while placing each monitor on patients in a real-world setting. For the quantitative devices (IntelliVue NMT and TetraGraph), participants were also timed when obtaining calibrated baseline train-of-four (TOF) ratios. Friedman test and pairwise Wilcoxon signed-rank tests were used to evaluate the difference in time to connect different devices. Participants were surveyed about how easy they found it to utilize these devices.

RESULTS

After adjusting for multiple comparison, time to connect was significantly less for PNS (median, 29; range, 16-58 seconds) compared to either the TetraGraph device (median, 62.8; range, 32-101 seconds; P < .001) or the IntelliVue NMT device (median, 46; range: 28-90 seconds; P < .001). The difference in time to connect between the TetraGraph device and the IntelliVue NMT device was not statistically significant (P = .053), but it took significantly less time to calibrate the TetraGraph device than the IntelliVue NMT device (median difference, -16; range, -88 to 49 seconds; P = .002). The participants found applying either the IntelliVue NMT device (P = .042) or the TetraGraph device (P = .048) more difficult than applying a PNS while finding it easier to calibrate the TetraGraph device versus the IntelliVue NMT device (P < .001).

CONCLUSIONS

It takes 19 seconds longer to apply a quantitative neuromuscular monitor (the IntelliVue NMT device) than a PNS. While this difference reached significance, this relatively minimal additional time represents an inappropriate barrier to the application of quantitative monitors. Regardless of which quantitative monitor was utilized, these nurse anesthetists found the application and utilization of such devices relatively straightforward.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures

ABSTRACT

Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US

INTRODUCTION

Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer's budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery.

METHODS

A 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared.

RESULTS

A total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of -$3,079,703 (-$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses.

CONCLUSIONS

The additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.

Spontaneous recovery of neuromuscular blockade is an independent risk factor for postoperative pulmonary complications after abdominal surgery: A secondary analysis

BACKGROUND

In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven.

OBJECTIVE

To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs).

DESIGN

The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data.

SETTING

Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016.

PATIENTS

Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases.

INTERVENTIONS

The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery.

MAIN OUTCOME MEASURES

The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed.

RESULTS

From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82).

CONCLUSION

Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02158923.

Comparison of the TetraGraph and TOFscan for monitoring recovery from neuromuscular blockade in the Post Anesthesia Care Unit

STUDY OBJECTIVE

Comparison of the TetraGraph (TG) and TOFscan (TS) for monitoring recovery from neuromuscular blockade in the Post Anesthesia Care Unit (PACU).

DESIGN

Randomized, multicenter trial.

SETTING

PACU in three tertiary care hospitals.

PATIENTS

120 patients (40 per site) receiving neuromuscular blockade during elective surgery.

INTERVENTIONS

Patients were enrolled preoperatively and intraoperative neuromuscular blockade management was at the discretion of the anesthesiologist. Upon arrival to the PACU, patients were randomized to have either TG or TS placed on their dominant hand. The alternate device (TS or TG) was placed on the non-dominant hand. Following simultaneous ulnar nerve stimulation on each arm, the response of the adductor pollicis was measured.

MEASUREMENTS

Train-of-four ratios (TOFRs) were obtained upon arrival to the PACU (t = 0), after 5 min (t = + 5) and after +10 min (t = + 10).

MAIN RESULTS

There was there was no significant difference in the mean TOFRs obtained with the TG and TS at t = 0 (0.97 ± 0.18 vs 0.94 ± 0.13, P = 0.06, respectively) and t = + 5 (0.96 ± 0.20 vs 0.95 ± 0.12, P = 0.29, respectively). At (t = + 10), there was a statistically significant difference in mean TOFRs obtained with the TG and TS, (0.99 ± 0.14 vs 0.94 ± 0.12, P < 0.001, respectively). The bias between devices at t = 0 was estimated to be 0.03 (95% CI, -0.29 to 0.35, P = 0.26); at t = + 5 min, it was estimated to be 0.02 (95% CI, -0.36 to 0.40, P = 0.54); and at t = +10 min, it was estimated to be 0.05 (95% CI, -0.25 to 0.36, P = 0.77).

CONCLUSIONS

TS and TG provide interchangeable quantitative measurements once the TOF ratio has returned to a value of 0.90 or greater in the PACU.

REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study

BACKGROUND

Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery.

METHODS

A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications.

RESULTS

A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs).

CONCLUSIONS

The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.