What Rules of Thumb Do Clinicians Use to Decide Whether to Antagonize Nondepolarizing Neuromuscular Blocking Drugs?

Videira, Rogério Luiz da Rocha; Vieira, Joaquim Edson

doi:10.1213/ane.0b013e31822c986e

Cited by 32 publications

(17 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Patients without reversal received a lower dose of NMBDs and underwent surgeries with longer durations than patients who received neostigmine; this was to be expected because the NMBD was not only administered at a lower dose but also had more time to be eliminated. This result is in line with the findings by Videira et al in which the clinical decision in their institution to antagonise NMBDs seemed mainly based on the pharmacological forecast 14 . Only 38% of the patients not reversed received neuromuscular monitoring prior to tracheal extubation.…”

Section: Discussionsupporting

confidence: 92%

A Prospective, Observational Study Comparing Postoperative Residual Curarisation and Early Adverse Respiratory Events in Patients Reversed with Neostigmine or Sugammadex or after Apparent Spontaneous Recovery

Cammu

Smet

Jongh

et al. 2012

Anaesth Intensive Care

View full text Add to dashboard Cite

Six years ago, a study performed in our department reported that the incidence of postoperative residual curarisation (PORC) was 39%. The reassessment of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice is relevant now that sugammadex has become available. The incidence of PORC, defined by a train-of-four (TOF) <90%, was evaluated at post-anaesthesia care unit (PACU) arrival in patients whose neuromuscular block had been reversed with neostigmine or sugammadex and those in whom reversal was felt unnecessary (adequate spontaneous recovery). During the PACU stay we recorded the oxygen saturation (SpO 2) at arrival, episodes of SpO 2 <90%, airway manoeuvres and/or stimulation required to maintain SpO 2 >90%, and the need for re-intubation. In total, 624 patients were studied. Fifteen percent (66/441) of the patients who were not reversed, 15% (21/139) of those who were reversed with neostigmine and 2% (1/44) of those who received sugammadex exhibited PORC (P=0.06). No patient required reintubation in the PACU. The absence of neuromuscular monitoring and pharmacological reversal before extubation were not associated with PORC. A TOF <90% at PACU arrival was not associated with SpO 2 <90% during the PACU stay. Body mass index was the only independent predictor of SpO 2 <90% during the stay in the PACU. These findings indicate that in recent years, the incidence of PORC, defined by a TOF <90%, has dramatically decreased in our institution. The differences in PORC were not statistically significant between patients who received sugammadex for reversal and patients with spontaneous recovery or neostigmine reversal.

show abstract

Section: Discussionsupporting

confidence: 92%

A Prospective, Observational Study Comparing Postoperative Residual Curarisation and Early Adverse Respiratory Events in Patients Reversed with Neostigmine or Sugammadex or after Apparent Spontaneous Recovery

Cammu

Smet

Jongh

et al. 2012

Anaesth Intensive Care

View full text Add to dashboard Cite

show abstract

“…[4,9,21] However, decision on reversal of NMB is still based on clinical judgement, notably in settings where neuromuscular monitoring is not widely available or routinely used. [35] Previous studies have shown that anesthesiologists usually elect NMB reversal based on the moment and dose of the last NMB administration and qualitative judgement of the adequacy of the breathing pattern. [35] We believe this was also most likely the case in our institution, even though it was not the objective of this study to determine the decision-making process.…”

Section: Discussionmentioning

confidence: 99%

Use of neuromuscular blockers and neostigmine for general anesthesia and its association with neuraxial blockade

Santos

Braga²,

Junqueira³

et al. 2017

Medicine

View full text Add to dashboard Cite

This research aimed to assess the use of neuromuscular blockers (NMB) and its reversal, associated or not with neuraxial blockade, after general anesthesia.This retrospective study analyzed 1295 patients that underwent surgery with general anesthesia at Prof. Dr. José Aristodemo Pinotti Hospital in 2013. The study included patients aged >1 year, with complete, readable medical charts and anesthetic records.Rocuronium (ROC) was the most used NMB (96.7%), with an initial dose of 0.60 (0.52–0.74) mg/kg and total dose of 0.38 (0.27–0.53) mg/kg/h. In 24.3% of the cases, neuraxial blockade was associated with a significantly longer anesthesia (P < .001) than in cases without neuraxial block, regardless of technique (total intravenous (TIV) vs intravenous and inhalational (IV+IN)). In 71.9% of the cases, a single dose of NMB was used. Patients under TIV general anesthesia associated with neuraxial blockade had a lower total dose of ROC (mg/kg/h) in comparison with TIV GA alone (0.30 (0.23–0.39) and 0.42 (0.30–0.56) mg/kg/h, respectively, P < .001). The same was observed for patients under IV+IN GA (0.32 (0.23–0.41) and 0.43 (0.31–0.56) mg/kg/h, respectively, P < .001). The duration of anesthesia was longer according to increasing number of additional NMB doses (P < .001). Dose of neostigmine was 2.00 (2.00–2.00) mg or 29.41 (25.31–33.89) μg/kg. The interval between neostigmine and extubation was >30 minutes in 10.9% of cases.The most widely used NMB was ROC. Neuroaxial blockade (spinal or epidural) was significantly associated with reduced total dose of ROC (mg/kg/h) during general anesthesia, even in the absence of neuromuscular monitoring and regardless of general anesthetic technique chosen. In most cases, neostigmine was used to reverse neuromuscular block. The prolonged interval between neostigmine and extubation (>30 minutes) was neither associated with total doses of ROC or neostigmine, nor with the time of NMB administration. This study corroborates the important role of quantitative neuromuscular monitors and demonstrates that neuraxial blockade is associated with reduced total ROC dose. Further studies are needed to evaluate the possible role of neuraxial blockade in reducing the incidence of postoperative residual curarization.

show abstract

“…Many clinicians also rely on the duration from the latest atracurium dose to decide if reversal is warranted, and are less likely to reverse patients if the duration is greater than 60 minutes [22]. The typical duration of action of atracurium is 20-35 minutes, with a time to recovery of approximately 60-70 minutes [23].…”

Section: Clinical Trial Number: Nct02673853mentioning

confidence: 99%

Postoperative Residual Neuromuscular Blockade (rNMB) Following Low-Dose (<2×ED95) Atracurium in Patients Receiving Laryngeal Mask Airway - An Audit Study

Yh¹,

Koh²,

Ayuningtyas³

et al. 2018

Med Saf Glob Health

View full text Add to dashboard Cite

Background Post-operative residual neuromuscular blockade (rNMB) is defined as the incomplete recovery of muscle function following intraoperative administration of neuromuscular blockers, evidenced by a train-of-four (ToF) ratio of <0.9 [1], and is associated with various pulmonary and general postoperative complications [2,3], as well as increased risk of 30 day readmission [4]. The prevalence of rNMB varies from 5% to 88% [5-7], and is exacerbated by inappropriate omission of pharmacological reversal [8]. Koh et al. demonstrated the role of low dose atracurium (0.05 mg/kg or 0.1 mg/kg) in improving conditions for LMA insertion [9]. A recent study evaluating risk factors for difficult ventilation with LMA in a major tertiary care hospital in SouthEast Asia also showed that 19% of the patients who had LMA also received neuromuscular blockers [10]. Despite this high prevalence, few studies have evaluated the effects of low dose neuromuscular blockers, and the prevalence of postoperative residual paralysis in such situations is not known [11-14]. In the Koh et al. study cohort, there were rapid spontaneous respiration returned after giving low dose atracurium, and patients were able to achieve good tidal volumes spontaneously. This may result in the anesthesiologists' clinical decision not to reverse patients who were given the low dose atracurium. This study aims to audit the practice of the major tertiary hospital by establishing the prevalence of rNMB in patients undergoing general anesthesia with LMA following a low dose of atracurium (<2xED 95 , or <0.46 mg/kg). Our secondary aim looks at the use of neostigmine in preventing rNMB and if there is a dose-dependent relationship, as well as post-operative complications associated with rNMB.

show abstract

What Rules of Thumb Do Clinicians Use to Decide Whether to Antagonize Nondepolarizing Neuromuscular Blocking Drugs?

Cited by 32 publications

References 25 publications

A Prospective, Observational Study Comparing Postoperative Residual Curarisation and Early Adverse Respiratory Events in Patients Reversed with Neostigmine or Sugammadex or after Apparent Spontaneous Recovery

A Prospective, Observational Study Comparing Postoperative Residual Curarisation and Early Adverse Respiratory Events in Patients Reversed with Neostigmine or Sugammadex or after Apparent Spontaneous Recovery

Use of neuromuscular blockers and neostigmine for general anesthesia and its association with neuraxial blockade

Postoperative Residual Neuromuscular Blockade (rNMB) Following Low-Dose (<2×ED95) Atracurium in Patients Receiving Laryngeal Mask Airway - An Audit Study

Contact Info

Product

Resources

About