REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study

Abstract

BACKGROUND: Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery. METHODS: A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo 2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications. RESULTS: A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs). CONCLUSIONS: The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.

The optimal effect-site concentration of remifentanil and propofol for keeping proper anesthesia and promoting early recovery during patient state index-guided anesthesia.

“…However, our study showed, compared with other two groups, the patients in middle concentration group experienced the shortest extubation and PACU stay time. According to the preceding report, awakening time from anesthesia relies on various elements, involving age, sex, BMI, operation time, drugs administration [26,27] and metabolism of muscle relaxants [28,29]. In this study, these factors make little difference.…”

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review

“…Patrocínio et al retrospectively analyzed data of 6,224 patients who were monitored quantitatively for postoperative respiratory complications (defined as need for invasive mechanical ventilation within 7 days or postextubation desaturation). 53 The investigators observed that a low train-of-four ratio (less than 0.9) was associated with postoperative pulmonary complications (adjusted odds ratio, 1.43 [95% CI, 1.11 to 1.85]; P = 0.006). In a randomized trial enrolling 691 patients, those who received pancuronium and had residual block in the PACU had a 3.5-fold higher risk of a postoperative pulmonary complication (defined as a pneumonic infiltrate or atelectasis on a chest radiograph).…”

“…The authors concluded that quantitative monitoring to ensure a train-of-four ratio less than 0.90 was superior to Residual Neuromuscular Block Prediction Score as a predictor of postoperative respiratory complications and recommended that "clinicians use quantitative neuromuscular monitoring in patients at risk for residual neuromuscular blockade." 53 Todd et al reported on the implementation of an electromyographic quantitative monitoring system at an academic medical center after a review of an adverse events database that revealed that two to four reintubations occurred in the PACU per year that were likely related to residual neuromuscular block. 59 The investigators conducted five sampling surveys, involving 409 patients, over a 2-yr period after the electromyographic system was installed in all operating rooms.…”

Risk Scores to Improve Quality and Realize Health Economic Gains in Perioperative Care

“…In this month’s edition of Anesthesia & Analgesia , Patrocinio et al 1 present a single-center retrospective cohort study evaluating the REsidual neuromuscular block Prediction Score (REPS) and its association with a primary composite outcome of postoperative respiratory complications. The study spans from 2005 to 2018 and includes an impressive 101,510 patients.…”

“…The authors conclude that REPS is a useful screening tool to identify patients that would likely benefit most from quantitative neuromuscular monitoring to reduce risk of residual neuromuscular blockade and subsequent postoperative respiratory complications. 1…”