Neuromuscular Monitoring: Does the use of acceleromyography in comparison to the unaided clinical assessment result in lower occurrences of postoperative residual neuromuscular blockade in patients admitted to the post anesthesia care unit?
AbstractThe occurrence of postoperative residual neuromuscular blockade continues to affect a considerable percentage of patients admitted to the post anesthesia care unit (PACU). Recent evidence suggest 17-36% of patients that arrive to the PACU present with objective manifestation of incomplete neuromuscular blockade reversal as determined by train-of-four ratios less than 0.90.1(p389) Patients presenting to the PACU with a train of four (TOF) ratio < 0.90 are considered to have residual neuromuscular blockade and are at an increased risk for experiencing adverse respiratory events such as reduced upper airway volumes, airway obstruction, hypoxemia events, and postoperative pulmonary complications.2 Research supports the proponents of quantitative acceleromyography for monitoring neuromuscular blockade and recovery. Qualitative neuromuscular monitoring includes peripheral nerve stimulator and clinical sign assessment such as the 5-second head-lift test, tongue blade stability between the incisors to a quantitative approach (ex. acceleromyography). However, this change in practice is accompanied by hesitancy and uncertainty from practitioners across the nations who underestimate the occurrence of postoperative residual neuromuscular blockade and its effects. The rationale to switch from the qualitative assessments for a more quantitative approach using an accelerometer needs review. The purpose of this report is to determine if objective acceleromyography in comparison to subjective peripheral twitch monitors and clinical assessment are more effective in decreasing the occurrence of post-operative residual neuromuscular blockade.
2. Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis at the time of tracheal extubation. Anesth Analg. 2005; 115:1840-45.
3. Naguib M. Kopman AF. Ensor JE. Neuromuscular monitoring and postoperative residual curarization: a meta-analysis. Brit J Anaesth. 2007; 98 (3): 302–16. doi:10.1093/bja/ael386.
4. Murphy GS, Szokol JW, Avram MJ et al. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesth Analg. 2013; 117(1): 133-41.
5. Murphy GS, Szokol JW, Avram MJ et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesth. 2011; 115(5): 946-54.
6. Capron F, Alla F, Hottier C, Meistelman C, & Fuchs-Buder T. Can acceleromyography detect low levels of residual paralysis? a probability approach to detect a mechanomyographic train-of-four ratio of 0.9. Anesth. 2004; 100(5): 1119-24. PMID: 15114208.
7. Esteves S, Martins M, Barros F et al. Incidence of postoperative residual neuromuscular blockade in the postanaesthesia care unit: an observational multicentre study in Portugal. Eur J Anaesthesiol. 2013; 30(5): 243-9. doi: 10.1097/EJA.0b013e32835dccd7.
8. Grayling M. Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesth. 2007; 62: 806–809. doi:10.1111/j.1365-2044.2007.05101.
9. Murphy GS. Brull SJ. Residual neuromuscular block: lessons unlearned. part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg.2010;111:120-8.
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