Recovery from neuromuscular blockade: a survey of practice*

Abstract

Summary At present in the UK there is no consensus regarding the parameters anaesthetists use to indicate adequacy of reversal from neuromuscular blockade. In an attempt to determine current practice, we carried out a survey covering 12 anaesthetic departments throughout the UK. Individuals were asked to give details regarding their usage of available monitors or, alternatively, to list those clinical parameters which they felt offered the best guidance as to the adequacy of recovery from neuromuscular blockade. There was no consensus among anaesthetists as to the most reliable clinical signs of recovery from neuromuscular blockade. There was an apparent lack of understanding of the limitations of some clinical signs used to determine recovery, as well as inappropriate application of others. In all departments where monitors (quantitative or qualitative) were available, there was limited knowledge regarding the current minimum recommended train‐of‐four ratio which should be observed prior to extubation. There is an apparent overall confusion among clinicians as to the best method to confirm recovery from neuromuscular blockade. This is probably due to the lack of a single reliable clinical test which can be applied in the immediate postoperative period. Insufficient reliance is placed upon the use of quantitative monitors. There is a lack of clarity in national anaesthetic guidelines with respect to monitoring of neuromuscular function. Current standards need to be re‐assessed in the light of recent improvements in nerve stimulators.

Vücut sıcaklığının orta-etkili kas gevşeticilerde rezidüel nöromüsküler blokaja etkisi

“…A wrong judgement of recovery based on clinical assessment and early transfer to recovery room may lead to respiratory failure due to weakness in respiratory muscles induced by an insufficient reversal of neuromuscular block. It is suggested that postoperative hypoxia is closely related with residual neuromuscular block (8), patients could raise their heads for 3 seconds, open their eyes, stick their tongues out even when their TOF values are 60% nevertheless their vital capacity remains low (9). Surveys show that clinicians rely on clinical assessment for detection of residual neuromuscular block (10).…”

Monitorización intraoperatoria del bloqueo neuromuscular y la presión arterial con un solo dispositivo (TOF-Cuff): estudio comparativo con la mecanomiografía y la presión arterial invasiva

“…En una encuesta realizada en Reino Unido se puso de manifiesto que sólo el 2.4% de los participantes monitorizaban siempre el BNM, y el 62% no lo hacía nunca 35 . El único método fiable para la monitorización de la función neuromuscular es la estimulación de un nervio periférico accesible y la medición de la respuesta evocada del músculo esquelético que inerva.…”

“…Además muchos tests (elevar la cabeza, apretar la mano) no son específicos de la musculatura respiratoria, y de su correcta realización no podemos inferir una adecuada función respiratoria. A pesar de ello, la mayoría de los anestesiólogos toman como referencia los signos clínicos y los test para descartar BNMR antes de extubar al paciente, y el test que se realiza con más frecuencia es el de mantener la cabeza erguida durante 5 segundos 35 , aunque pacientes recién operados 85 son capaces de elevar 5 segundos la cabeza con ratios del TOF < 0.5. Otros múltiples estudios han mostrado que con la presencia de diversos grados de parálisis residual los pacientes realizan correctamente los tests clínicos y que todos los tests presentan una baja sensibilidad (11-14%) para detectar valores del TOF-ratio < 0.9 2,86 , siendo la valoración de la fuerza del masetero (p.ej.…”

“…La monitorización objetiva y de forma rutinaria del BNM es la herramienta más útil para disminuir la incidencia de bloqueo residual y de sus complicaciones respiratorias asociadas, estando su utilización ampliamente recomendada 126,139 , aunque en la práctica clínica su uso dista mucho del mínimo exigido para una buena praxis médica. No todos los departamentos de Anestesia disponen de aparatos para la monitorización objetiva, y en aquellos que sí disponen existe una falta de concienciación de la importancia de su utilización durante el empleo de ABNM, o al menos la medición del TOF-ratio previo a la extubación, como medida mínima recomendada 35 .…”

Clinical Predictors of Duration of Action of Cisatracurium and Rocuronium Administered Long-Term

“…9,27 After calibration of the device, the ulnar nerve was stimulated supramaximally N euromuscular blocking drugs (NBDs) are commonly used in anesthesia and to treat critically ill patients in intensive care units (ICUs), 1,2 but few clinicians use neuromuscular transmission monitoring. [3][4][5] In the United Kingdom, 31% of critically ill children are likely to receive NBDs, but the depth of the blockade is routinely assessed in only 16% of patients. 2 Results of a recent survey 4 indicated that only 22% of Canadian ICUs use standardized protocols for NBD application and that 16% of all Canadian intensive care providers do not use neuromuscular transmission monitoring at all.…”