Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus

Errando-Oyonarte, Carlos Luis; Moreno-Sanz, Carlos; Vila-Caral, P.; Adana-Belbel, J.C. Ruiz de; Vázquez-Alonso, E.; Ramírez-Rodríguez, José Manuel; Veiga-Ruiz, G.; Guasch-Arévalo, E.; D'Ocón, Joaquín

doi:10.1016/j.redare.2016.12.001

Cited by 4 publications

(2 citation statements)

References 27 publications

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“…Moreover, there is considerable variability in reported doses between articles aiming for the same level of NMB. The 2017 AQUILES consensus study 5 assembled a large panel of anesthesiologists and surgeons to establish expert recommendations on the use of deep NMB in clinical practice. Expert opinion was nearly unanimous in the belief that deep NMB is highly suitable in abdominal surgery (94.1%), and more than 80% of the panelists agreed on the need for consensus protocols applicable to both surgeons and anesthesiologists.…”

Section: Perioperative Medicinementioning

confidence: 99%

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

Albers-Warlé,

Reijnders-Boerboom,

Bijkerk

et al. 2024

Anesthesiology

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Background The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a post tetanic count of 1-2) and how to implement it has not been reached. The ESAIC does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia. Methods Data from three trials investigating deep NMB during laparoscopic surgery with TIVA (n=424) was pooled to analyze the required rocuronium dose, when to start continuous infusion and how to adjust. The resulting algorithm was validated (n=32) and compared to the success rate in ongoing studies where the algorithm was not used (n=180). Results The mean rocuronium dose based on actual bodyweight for PTC 1-2 was 1.0 ± 0.27 mg.kg -1.h -1 in the trials where mean duration of surgery was ±2 hours (116 minutes). An induction dose of 0.6 mg.kg -1 lead to a PTC of 1-5 in a quarter of patients after a mean of 11 minutes. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a ±15-minute wait after PTC 0 for return of PTC to ≥1. Using the proposed algorithm, a mean 76% of all 5-minute measurements throughout surgery were on target PTC 1-2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0-20 patients (42% on target, P≤.001, Cohen’s d=1.4 [95% CI 0.9, 1.8]) to 81-100 patients (61% on target, P≤.05, Cohen’s d=0.7 [95% CI 0.1, 1.2]). Conclusions We propose a dosing algorithm for deep NMB with rocuronium in patients receiving TIVA.

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Section: Perioperative Medicinementioning

confidence: 99%

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

Albers-Warlé,

Reijnders-Boerboom,

Bijkerk

et al. 2024

Anesthesiology

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“…Epidemiological studies from the 1980s indicated that postoperative residual neuromuscular blockade occurs in approximately 40-60% of patients. Recent observational studies have found that the current frequency is up to 32%, but the use of clinical (qualitative) and quantitative observations can reduce this frequency to 18 and 27%, respectively [10][11][12]. Cardiac and thoracic surgery, morbidly obese populations (BMI more than 40 kg/m 2 ), end-stage renal failure, liver dysfunction, and neuromuscular disorders are factors that contribute to ahigher risk of inadequate reversal neuromuscular block, and pediatric and geriatric patients are also at higher risk [13,14].…”

Section: Introductionmentioning

confidence: 99%

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

Kosciuczuk,

Dardzinska,

Kasperczuk

et al. 2024

JCM

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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.

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Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study

et al. 2023

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Introduction NMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity. Objective To investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00). Methods We performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old. Results We included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB. Conclusions The rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.

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Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus

Cited by 4 publications

References 27 publications

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

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

Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study

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