Residual Neuromuscular Blockade Affects Postoperative Pulmonary Function

Kumar, Gopalaiah Venkatesh; Nair, Anita Pramod; Murthy, H.S. Niranjana; Jalaja, Koppa Ramegowda; Ramachandra, Karnate; Parameshwara, Gundappa

doi:10.1097/aln.0b013e3182715b80

Cited by 76 publications

(47 citation statements)

References 18 publications

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“…21 PORC has been shown to result in impaired pharyngeal function and upper airway obstruction, 22,23 as well as reduction in peak expiratory flow and FVC. 24 An increase in postoperative respiratory complications, including the need for re-intubation, has been seen in patients with PORC. 25 At a minimum, when neuromuscular blocking drugs are administered intra-operatively or in the ICU, the use of qualitative neuromuscular twitch monitoring should be utilized to assess the need for neuromuscular blockade reversal.…”

Section: Residual Neuromuscular Blockadementioning

confidence: 99%

Tracheal ExtubationDiscussion

Artime¹,

Hagberg²

2014

Respir Care

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Tracheal extubation in both the critical care and anesthesia setting is not only an important milestone for patient recovery, but also a procedure that carries a considerable risk of complication or failure. Mechanical ventilation is associated with significant complications that are time-dependent in nature, with a longer duration of intubation resulting in a higher incidence of complications, including ventilator-associated pneumonia, and increased mortality. Extubation failure and subsequent re-intubation are associated with an overall increase in the duration of mechanical ventilation, increased mortality, a greater need for tracheostomy, and higher medical costs. These risks demand that the process of extubation be managed by practitioners with a detailed understanding of the causes of extubation failure and the potential complications. A pre-established extubation plan with considerations made for the possible need for re-intubation is of the utmost importance.

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Section: Residual Neuromuscular Blockadementioning

confidence: 99%

Tracheal ExtubationDiscussion

Artime¹,

Hagberg²

2014

Respir Care

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“…Residual paralysis is defined as a train-of-four ratio \ 0.9. Data from Naguib et al, 2 Murphy et al, 4,15 Kumar et al, 10 Butterly et al, 16 Thilen et al 21 L'incidence de curarisation résiduelle dans les études cliniques portant sur les curares à action prolongée (long-acting) et les curares à action intermédiaire (intermediate-acting) en fonction de l'année de publication de l'étude. On définit la curarisation résiduelle comme un rapport quatrième/première réponse \ 0,9.…”

Section: Diaphragmunclassified

“…On définit la curarisation résiduelle comme un rapport quatrième/première réponse \ 0,9. Données tirées de Naguib et coll., 2 Murphy et coll., 4,15 Kumar et coll., 10 Butterly et coll., 16 Thilen et coll. 21 Residual paralysis 715 its normal value of 1.0, indices of upper airway function, such as genioglossus activity, 7 maintenance of a patent airway, 8,9 and ability to clench teeth, 8 are affected at TOFR values of 0.8-0.9.…”

Section: Diaphragmunclassified

“…Forced vital capacity was found to be decreased in all patients after surgery, but more so in those with residual paralysis. 10 Patients with residual paralysis are more at risk of hypoxia, airway obstruction, the need for a maneuver to maintain the airway, and generalized weakness. 3,11 Again, the problem is not the pump function of the lungs, but the fragility of the upper airway.…”

Section: Clinical Studiesmentioning

confidence: 99%

“…On a observé une capacité vitale forcée réduite chez tous les patients après la chirurgie, mais cette diminution était plus prononcée chez les patients souffrant de curarisation résiduelle. 10 Les patients touchés par une curarisation résiduelle courent davantage le risque de manifester de l'hypoxie, d'avoir une obstruction des voies aériennes, de nécessiter des manoeuvres pour garder des voies aériennes perméables, et de ressentir une faiblesse généralisée. 3,11 Comme mentionné plus haut, le problème ne réside pas dans la capacité des poumons à inspirer ou à expirer, mais bien dans la fragilité des voies aériennes supérieures.…”

Section: é Tudes Cliniquesunclassified

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Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Purpose Over the past three decades, many studies have shown a high proportion of patients in the recovery room with residual neuromuscular blockade after anesthesia. The purpose of this Continuing Professional Development module is to present the physiological consequences of residual paralysis, estimate the extent of the problem, and suggest solutions to prevent its occurrence. Principal findings Residual paralysis is defined as a train-of-four ratio (TOFR) \ 0.9 at the adductor pollicis. While tidal volume and, to a lesser extent, vital capacity are well preserved as the intensity of blockade increases, the probability of airway obstruction, impaired swallowing, and pulmonary aspiration increases markedly as TOFR decreases. In recent studies, incidences of residual paralysis from 4-57% have been reported, but surveys indicate that anesthesiologists estimate the incidence of the problem at 1% or less. The decision to administer neostigmine or sugammadex should be based on the degree of spontaneous recovery at the adductor pollicis muscle (thumb), not on recovery at the corrugator supercilii (eyebrow). The most important drawback of neostigmine is its inability to reverse profound blockade, which is a consequence of its ceiling effect. When spontaneous recovery reaches the point where TOFR [ 0.4 or four equal twitch responses are seen, reduced doses of neostigmine may be given. The dose of sugammadex required in a given situation depends on the intensity of blockade. Conclusion Careful monitoring and delaying the administration of neostigmine until four twitches are observed at the adductor pollicis can decrease the incidence of residual paralysis. The clinical and pharmacoeconomic effects of unrestricted sugammadex use are unknown at this time. ObjectivesAfter reading this module, the reader should be able to:1. Describe the physiological effects of residual neuromuscular blockade 2. Define and justify the current threshold used for residual paralysis 3. Interpret the information provided by qualitative and quantitative monitors 4. Decide the dose and timing of administration of neostigmine 5. Manage neuromuscular blockade and reversal during and after anesthesia.In 1979, Viby-Mogensen et al. 1 reported that 42% of patients receiving non-depolarizing neuromuscular blocking agents during anesthesia followed by neostigmine at the end of the procedure had neuromuscular weakness in the recovery room, as documented by a train-of-four ratio 123Can J Anesth/J Can Anesth (2013) 60:714-729 DOI 10.1007 (TOFR) \ 0.7. This first description of what was later termed residual paralysis, residual curarization, or postoperative residual curarization was followed by many other observations in many countries around the world and in different settings. The introduction of shorter-acting agents, such as vecuronium and atracurium and later rocuronium and cisatracurium, to replace the longer-acting agents available in 1979 led to a decrease in the incidence of residual paralysis. 2 Nevertheless, many lines of evidence now...

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