An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia

Díaz‐Cambronero, Óscar; Mazzinari, Guido; Errando, C.L.; Garutti, Ignacio; Gurumeta, Alfredo Abad; Serrano, Ana B.; Esteve, N.; Montañes, Maria Vila; Neto, Ary Serpa; Hollmann, Markus W.; Schultz, Marcus J.; Navarro, María; Pérez, María del Pino Heredia; Núñez, Victoria Carvajal; Linero, Inmaculada Benítez; Aparicio, María del Pilar García; Mata, Alba María Miguel González de la; Marín, Alejandro Martínez; Fernández, Luis Carlos Mora; Robles, Ana Ferrer; González, David Fabián; Gil, Marta Mariscal; Romero, Germán Gómez; Montero, Begoña Ayas; Estellés, María José Alberola; Jaén, Salomé Matoses; Ortolá, C. Ferrando; Vargas, Esther Romero; Jaramago, J. Martín; Mataix, Javier Barrio; Gonzalez, Estefanía Martínez; Sanus, Alma Casasempere; Vicent, María José Fas; Ortega, Juan Antonio; López, María Angeles Pallardó; Chornet, María Rosselló; Hernández, Alicia Sánchez; Belmonte, José Pedro García; Martín, Miguel Ángel Marcelino; Domínguez, Montserrat Noelia Rodríguez; Becerra-Bolaños, Ángel; Trujillo-Morales, Héctor; Palacín, Rebeca Pascual; Pacheco, María José Bartolomé; Pérez, Osvaldo; Rábago, J; Caral, Pere Vila; Cortes, Ana Isabel Fernández; Milán, Marta Caballero; García, Lourdes Pérez; Alsina, Carme Subirà; Grauwinkel, Cassandra Gimeno; González, José Manuel López; Gómez, Bárbara María Jiménez; Cadórniga, Alvaro Manuel Gasalla; González, Iván Areán; Campelo, María Ángeles Gil; Solores, Felix Lobato; Santiago, Ana Crespo; Ortíz, Alvaro Elicegui; García, Irma; Perote, Lara Castellanos; Murillo, Miguel; Rueda, Fernando Ramasco; Roca, A. Planas; Irujo, Javier Ariño; Elguezábal, Pedro de la Calle; Palacios, Raúl Villalba; Saavedra, Bárbara; Learte, Mar Establés; López, Sandra Gadín; González, Rosa; Melchor, Javier Ripollés; Hurtado, Eugenio Martínez; Abad‐Motos, Ane; López, María Uribarri; Martínez, Cristina Miguel

doi:10.1016/j.bja.2023.02.031

Cited by 8 publications

(3 citation statements)

References 35 publications

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“…Several initiatives addressed adherence to routine quantitative NMB monitoring in patients undergoing surgery with the use of NMB monitors. A recent publication by Díaz-Cambronero et al [12] described an effort to reduce residual paralysis in the postoperative period using an educational intervention across 34 centres in Spain. This study demonstrated that clinical practice behaviour changes were challenging; during their study, an educational aid regarding the use of quantitative NMT and reversal of NMB was used in multiple centres for six months.…”

Section: Discussionmentioning

confidence: 99%

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative

Perez,

Segura-Salgero,

Wąsowicz

et al. 2023

ait

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Residual neuromuscular blockade (NMB) following general anaesthesia is associated with a prolonged length of stay (LOS) in the post-anaesthesia care unit (PACU) [1], unscheduled critical care admission [2], hospital readmissions [3], and postoperative pulmonary complications [4,5]. Routine monitoring of NMB reversal with train-of-four-ratio (TOFR) ensuring a value > 0.9 prior to extubation may reduce the incidence of postoperative pulmonary complications [6]. Despite evidence and professional guidelines mandating quantitative neuromuscular monitoring [7], clinical practice relies on clinical judgment and subjective assessments to determine the appropriateness of extubation [8].

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Section: Discussionmentioning

confidence: 99%

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative

Perez,

Segura-Salgero,

Wąsowicz

et al. 2023

ait

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“…A recent multicenter trial investigating the impact of an education intervention program on reducing RNMB found no difference in the incidence of RNMB or use of a reversal agent in the pre-and post-education arms. The study did find a significant increase in the use of quantitative monitoring and a decrease in pulmonary complications [56]. Given the historical lack of effective, commercially available quantitative monitors, clinicians are not often familiar with such devices and the important differences detectable by a quantitative monitor compared to other methods of attempting to monitor residual NMB [34].…”

Section: Obstacles To Quantitative Monitoring Implementationmentioning

confidence: 93%

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

Blum,

Locke,

Nathan

et al. 2024

JCM

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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.

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“…It can be appealing to resort to a deep NMB, especially since the option of reverting it safely is available with sugammadex [68][69][70]. It should be noted that postoperative residual curarization (PORC) is a well-known clinical condition that has been associated with increased postoperative morbidity [71], and it can be observed even after sugammadex reversal [72]. Given the potential for significant differences in how patients respond and the potential drawbacks of a deep NMB, we recommend that low intra-abdominal pressure (IAP) should be supported with at least moderate NMB and the depth of NMB can be increased as needed.…”

Section: Individualizing Pressure and Volume Measures To Increase The...mentioning

confidence: 99%

Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review

Mazzinari,

Rovira,

Albers-Warlé

et al. 2024

JCM

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Laparoscopy offers numerous advantages over open procedures, minimizing trauma, reducing pain, accelerating recovery, and shortening hospital stays. Despite other technical advancements, pneumoperitoneum insufflation has received little attention, barely evolving since its inception. We explore the impact of pneumoperitoneum on patient outcomes and advocate for a minimally invasive approach that prioritizes peritoneal homeostasis. The nonlinear relationship between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV) is discussed, emphasizing IAP titration to balance physiological effects and surgical workspace. Maintaining IAP below 10 mmHg is generally recommended, but factors such as patient positioning and surgical complexity must be considered. The depth of neuromuscular blockade (NMB) is explored as another variable affecting laparoscopic conditions. While deep NMB appears favorable for surgical stillness, achieving a balance between IAP and NMB depth is crucial. Temperature and humidity management during pneumoperitoneum are crucial for patient safety and optical field quality. Despite the debate over the significance of temperature drop, humidification and the warming of insufflated gas offer benefits in peritoneal homeostasis and visual clarity. In conclusion, there is potential for a paradigm shift in pneumoperitoneum management, with dynamic IAP adjustments and careful control of insufflated gas temperature and humidity to preserve peritoneal homeostasis and improve patient outcomes in minimally invasive surgery.

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An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia

Cited by 8 publications

References 35 publications

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative

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

Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review

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