Leif Saager1, Eric M Maiese2, Lori D Bash2, Tricia A Meyer3, Harold Minkowitz4, Scott Groudine5, Beverly K Philip6, Pedro Tanaka7, Tong Joo Gan8, Yiliam Rodriguez-Blanco9, Roy Soto10, Olaf Heisel11. 1. Cleveland Clinic, Department of Outcomes Research, Anesthesiology Institute, 9500 Euclid Ave. P77, Cleveland, OH 44195, United States. Electronic address: Lsaager@med.umich.edu. 2. Merck & Co., Inc., Center for Observational and Real World Evidence, 2000 Galloping Hill Rd., Kenilworth, NJ 07033, United States. 3. Baylor Scott & White Healthcare, Department of Anesthesiology, 2401 S. 31st St., Temple, TX 76508, United States. 4. Memorial Hermann Memorial City Medical Center, Department of Anesthesiology, 921 Gessner Rd., Houston, TX 77024, United States. 5. Albany Medical Center, Department of Anesthesiology, 43 New Scotland Ave., Albany, NY 12208, United States. 6. Brigham and Women's Hospital, Department of Anesthesiology, 75 Francis St, Boston, MA 02115, United States. 7. Stanford University, Department of Anesthesia, 300 Pasteur Dr., Stanford, CA 94305, United States. 8. Duke University, Department of Anesthesiology, DUMC 3094, Durham, NC 27710, United States. 9. University of Miami, School of Medicine, Department of Anesthesiology, 1600 NW 10th Ave., Miami, FL 33136, United States. 10. William Beaumont Hospital - Royal Oak, Department of Anesthesiology, 3601 W 13 Mile Rd., Royal Oak, MI 48073, United States. 11. Syreon Corporation, Department of Clinical Sciences, 260-1401 West 8th Ave., Vancouver, British Columbia V6H 1C9, Canada.
Abstract
STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. DESIGN: Blinded multicenter cohort study. SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals. PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. MAIN RESULTS: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.
STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. DESIGN: Blinded multicenter cohort study. SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals. PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. MAIN RESULTS: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.
Authors: Sachin Kheterpal; Michelle T Vaughn; Timur Z Dubovoy; Nirav J Shah; Lori D Bash; Douglas A Colquhoun; Amy M Shanks; Michael R Mathis; Roy G Soto; Amit Bardia; Karsten Bartels; Patrick J McCormick; Robert B Schonberger; Leif Saager Journal: Anesthesiology Date: 2020-06 Impact factor: 7.892
Authors: Timur Z Dubovoy; Leif Saager; Nirav J Shah; Douglas A Colquhoun; Michael R Mathis; Steven Kapeles; Graciela Mentz; Sachin Kheterpal; Michelle T Vaughn Journal: Anesth Analg Date: 2020-11 Impact factor: 6.627
Authors: J Martinez-Ubieto; C Aragón-Benedí; J de Pedro; L Cea-Calvo; A Morell; Y Jiang; S Cedillo; P Ramírez-Boix; A M Pascual-Bellosta Journal: BMC Anesthesiol Date: 2021-02-16 Impact factor: 2.217