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

Abstract

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...

Timing of reversal with respect to three nerve stimulator end-points from cisatracurium-induced neuromuscular block

“…The median (IQR [range]) times from administration of the reversal agents to a TOF ratio of 0.9 in the TOF4, TOF-fade and DBS-fade groups was 11 (9-15.5 ) min, 8 (4-13.5 ) min and 7 (4-10 [2][3][4][5][6][7][8][9][10][11][12][13][14][15]) min, respectively. The reversal time to a TOF ratio of 0.7 and 0.8 was shorter in the TOF-fade and DBS-fade groups than in the TOF4 group (p = 0.001 and 0.0013, respectively) and the time to a TOF ratio of 0.9 was shorter in the DBS-fade group than in the TOF4 group (p = 0.046) (Fig.…”

Sugammadex versus two doses of neostigmine for reversal of rocuronium in gastric sleeve surgery

“…A TOF ratio >0.9 is attained in 2–3 min when appropriate doses are given. [4] In our study, we were using continuous NMT monitoring which displayed TOF ratio and PTC. NMT monitoring is essential to determine the proper dose of SUG.…”

Management of neuromuscular blockade in ambulatory patients

“…Moreover, in patients with a more intense residual block (train-of-four count 1-3), even a dose of 70 mcg/kg was not found to be effective in producing an adequate reversal (defined as a TOFR >0.9) 10 min after application in 75-100% of the included patients [36]. It has been suggested that in these patients, the agent may improve the early recovery but possibly delay the later one, which finally results in an unsatisfying efficacy [37]. Consequently, it has been recommended that neostigmine for reversal should be only administered if recovery progress has reached at least four responses following a train-of-four stimulation [38].…”