A retrospective observational study of neuromuscular monitoring practice in 30,430 cases from six Danish hospitals

Abstract

Summary Timely application of objective neuromuscular monitoring can avoid residual neuromuscular blockade. We assessed the frequency of objective neuromuscular monitoring with acceleromyography and the last recorded train‐of‐four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving neuromuscular blocking agents, divided into non‐depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a neuromuscular blocking drug. Non‐depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non‐depolarising neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non‐depolarising drugs and from 3% to 79% for succinylcholine alone. The median ( IQR [range]) of the last recorded train‐of‐four ratio before tracheal extubation was 0.97 (0.90–1.06 [0.01–2.20]) when non‐depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95% CI 2.33–2.70) p < 0.001] and non‐depolarising drugs [2.57 (95% CI 2.32–2.84) p < 0.001] as compared with cases where no neuromuscular blockade drug was used. In conclusion, acceleromyography was almost always used in cases where non‐depolarising neuromuscular blocking drugs were used, but a train‐of‐four ratio of 0.9 was not always achieved. Monitoring was used in less than 30% of cases where succinylcholine was the sole drug used.

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

“…Acceleromyography data were recorded automatically when the TOF stimulation was initiated, while anaesthetics and other medicines were recorded manually by the anaesthetist by pressing a software button. Baseline data before implementation of the intervention was obtained from a descriptive study using the same database 5 …”

“…However, anaesthetists do not apply neuromuscular monitoring consistently 2‐4 . Especially, when administering succinylcholine as the sole neuromuscular blocking agent (NBMA), monitoring is often omitted, 5,6 although this may have serious consequences for the patients 7 . In 2014, following a year‐long quality improvement project, an increase in objective neuromuscular monitoring rate of approximately 95% was reported in one institution 8 .…”

Quantitative Monitoring Practice Change: Comment

“…We strongly support the implementation of quantitative twitch monitoring to guide neuromuscular blocker administration and to ensure that patients have recovered adequately before extubation, and we applaud the efforts of Weigel et al . 1 and others 2 to do so. Weigel et al .…”

Validity and Tolerability of Awake Calibration of an Accelerometer Neuromuscular Monitor

“…Acceleromyography is the most commonly used quantitative neuromuscular monitoring method. 1 Current guidelines recommend calibration of acceleromyographic devices for scientific purposes by setting monitor gain and defining supramaximal current. 2,3 Calibration is rarely performed in clinical practice.…”