Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Anesthesiology
Published in: BMC Anesthesiology 1/2017

Open Access 01-12-2017 | Research article

Development of an algorithm using clinical tests to avoid post-operative residual neuromuscular block

Authors: Christoph Unterbuchner, Manfred Blobner, Friedrich Pühringer, Matthias Janda, Sebastian Bischoff, Berthold Bein, Annette Schmidt, Kurt Ulm, Viktor Pithamitsis, Heidrun Fink

Published in: BMC Anesthesiology | Issue 1/2017

Login to get access

Abstract

Background

Quantitative neuromuscular monitoring is the gold standard to detect postoperative residual curarization (PORC). Many anesthesiologists, however, use insensitive, qualitative neuromuscular monitoring or unreliable, clinical tests. Goal of this multicentre, prospective, double-blinded, assessor controlled study was to develop an algorithm of muscle function tests to identify PORC.

Methods

After extubation a blinded anesthetist performed eight clinical tests in 165 patients. Test results were correlated to calibrated electromyography train-of-four (TOF) ratio and to a postoperatively applied uncalibrated acceleromyography. A classification and regression tree (CART) was calculated developing the algorithm to identify PORC. This was validated against uncalibrated acceleromyography and tactile judgement of TOF fading in separate 100 patients.

Results

After eliminating three tests with poor correlation, a model with four tests (r = 0.844) and uncalibrated acceleromyography (r = 0.873) were correlated to electromyographical TOF-values without losing quality of prediction. CART analysis showed that three consecutively performed tests (arm lift, head lift and swallowing or eye opening) can predict electromyographical TOF. Prediction coefficients reveal an advantage of the uncalibrated acceleromyography in terms of specificity to identify the EMG measured train-of-four ratio < 0.7 (100% vs. 42.9%) and <0.9 (89.7% vs. 34.5%) compared to the algorithm. However, due to the high sensitivity of the algorithm (100% vs. 94.4%), the risk to overlook an awake patient with a train-of-four ratio < 0.7 was minimal. Tactile judgement of TOF fading showed poorest sensitivity and specifity at train of four ratio < 0.9 (33.7%, 0%) and <0.7 (18.8%, 16.7%).

Conclusions

Residual neuromuscular blockade can be detected by uncalibrated acceleromyography and if not available by a pathway of four clinical muscle function tests in awake patients. The algorithm has a discriminative power comparable to uncalibrated AMG within TOF-values >0.7 and <0.3.

Trial registration

Clinical Trials.​gov (principal investigator’s name: CU, and identifier: NCT03219138) on July 8, 2017.
Literature
1.
Baillard C, Clec’h C, Catineau J, Salhi F, Gehan G, Cupa M, Samama CM. Postoperative residual neuromuscular block: a survey of management. Br J Anaesth. 2005;95(5):622–6.CrossRefPubMed
2.
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Nisman M. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008;109(3):389–98.CrossRefPubMed
3.
Fuchs-Buder T, Fink H, Hofmockel R, Geldner G, Ulm K, Blobner M. Einsatz des neuromuskularen Monitorings in Deutschland. Anaesthesist. 2008;57(9):908–14.CrossRefPubMed
4.
Duvaldestin P, Cunin P, Plaud B, Maison P. French survey of neuromuscular relaxant use in anaesthetic practice in adults. Ann Fr Anesth Reanim. 2008;27(6):483–9.CrossRefPubMed
5.
Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62(8):806–9.CrossRefPubMed
6.
Sorgenfrei IF, Viby-Mogensen J, Swiatek FA. Does evidence lead to a change in clinical practice? Danish anaesthetists’ and nurse anesthetists’ clinical practice and knowledge of postoperative residual curarization. Ugeskr Laeger. 2005;167(41):3878–82.PubMed
7.
American Society of Anesthesiologists. Standards for basic anesthetic monitoring (approved by house of delegates on October 21, 1986, and last amended on October 15, 2003). ASA Standards, Guidelines and Statements. 2003.
8.
Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. und Berufsverband Deutscher Anästhesisten e.V: Mindestanforderungen an den anästhesio­ logischen Arbeitsplatz. Anästh Intensivmed. 2013;54:39–42.
9.
[Consensus conference: Indications for curarization in anesthesia. Saint-Mande, 8 July 1999. Proceedings]. Ann Fr Anesth Reanim. 2000;19 Suppl 2:344s–472s.
10.
Eriksson LI. Evidence-based practice and neuromuscular monitoring: it’s time for routine quantitative assessment. Anesthesiology. 2003;98(5):1037–9.CrossRefPubMed
11.
Kempen PM. Obligate acceleromyography and pharmacologic reversal of all neuromuscular blocking agents: really, and where is the clinical outcome? Anesthesiology. 2004;100(2):453. author reply 454–455CrossRefPubMed
12.
Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98(3):302–16.CrossRefPubMed
13.
Baillard C, Bourdiau S, Le Toumelin P, Ait Kaci F, Riou B, Cupa M, Samama CM. Assessing residual neuromuscular blockade using acceleromyography can be deceptive in postoperative awake patients. Anesth Analg. 2004;98(3):854–7. table of contentsPubMed
14.
Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98(5):1042–8.CrossRefPubMed
15.
Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, Vandenbroucke G, Deloof T. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102(2):426–9.CrossRefPubMed
16.
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107(1):130–7.CrossRefPubMed
17.
Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56(4):312–8.CrossRefPubMed
18.
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS, Gray J, Landry E. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesth Analg. 2013;117(1):133–41.CrossRefPubMed
19.
Fuchs-Buder T, Claudius C, Skovgaard LT, Eriksson LI, Mirakhur RK, Viby-Mogensen J. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007;51(7):789–808.CrossRefPubMed
20.
Hothorn T, Hornik K, Zeileis A. Unbiased Recursive Partitioning: A Conditional Inference Framework. J Comput Graph Stat. 2006;15:651–74.CrossRef
21.
Claudius C, Viby-Mogensen J. Acceleromyography for use in scientific and clinical practice: a systematic review of the evidence. Anesthesiology. 2008;108(6):1117–40.CrossRefPubMed
22.
Le Corre F, Nejmeddine S, Fatahine C, Tayar C, Marty J, Plaud B. Recurarization after sugammadex reversal in an obese patient. Can J Anaesth. 2011;58(10):944–7.CrossRefPubMed
23.
Unterbuchner C, Fink H, Berthele A, Blobner M. Case scenario: residual curarization in diabetic polyneuropathy. Anesthesiology. 2014;120(2):474–9.CrossRefPubMed
24.
Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, Nakatsuka I, Takeda J. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth Analg. 2013 Aug;117(2):345–51.CrossRefPubMed
25.
Liang SS, Stewart PA, Phillips S. An ipsilateral comparison of acceleromyography and electromyography during recovery from nondepolarizing neuromuscular block under general anesthesia in humans. Anesth Analg. 2013;117(2):373–9.CrossRefPubMed
26.
Debaene B, Plaud B, Dilly M-P, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98(5):1042–8.CrossRefPubMed
27.
Eikermann M, Groeben H, Husing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade. Anesthesiology. 2003;98(6):1333–7.CrossRefPubMed
28.
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. Anesthesiology. 2004;100(5):1119–24.CrossRefPubMed
29.
Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jørgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology. 1985;63(4):440–3.CrossRefPubMed
30.
Ali HH, Utting JE, Gray TC. Quantitative assessment of residual antidepolarizing block. II. Br J Anaesth. 1971;43(5):478–85.CrossRefPubMed
31.
Ali HH, Utting JE, Gray TC. Quantitative assessment of residual antidepolarizing block. I. Br J Anaesth. 1971;43(5):473–7.CrossRefPubMed
32.
Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, de Greiff A, Peters J. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med. 2007;175(1):9–15.CrossRefPubMed
33.
Hemmerling TM, Schmidt J, Hanusa C, Wolf T, Schmitt H. Simultaneous determination of neuromuscular block at the larynx, diaphragm, adductor pollicis, orbicularis oculi and corrugator supercilii muscles. Br J Anaesth. 2000;85(6):856–60.CrossRefPubMed
34.
Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology. 2000;92(4):977–84.CrossRefPubMed
35.
Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86(4):765–71.CrossRefPubMed
36.
Eriksson LI, Sundman E, Olsson R, Nilsson L, Witt H, Ekberg O, Kuylenstierna R. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology. 1997;87(5):1035–43.CrossRefPubMed
37.
Tramer MR, Fuchs-Buder T. Omitting antagonism of neuromuscular block: effect on postoperative nausea and vomiting and risk of residual paralysis. A systematic review. Br J Anaesth. 1999;82(3):379–86.CrossRefPubMed
38.
Eikermann M, Zaremba S, Malhotra A, Jordan AS, Rosow C, Chamberlin NL. Neostigmine but not sugammadex impairs upper airway dilator muscle activity and breathing. Br J Anaesth. 2008;101(3):344–9.CrossRefPubMedPubMedCentral
39.
Nemes R, Fülesdi B, Pongracz A, Asztalos L, Szabo-Maak Z, Lengyel S, Tassonyi E. Impact of reversal strategies on the incidence of postoperative residual paralysis after rocuronium relaxation without neuromuscular monitoring. A partially randomised placebo controlled trial. Eur J Anaesthesiol. 2016;33:1–8.CrossRef
Metadata
Title
Development of an algorithm using clinical tests to avoid post-operative residual neuromuscular block
Authors
Christoph Unterbuchner
Manfred Blobner
Friedrich Pühringer
Matthias Janda
Sebastian Bischoff
Berthold Bein
Annette Schmidt
Kurt Ulm
Viktor Pithamitsis
Heidrun Fink
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2017
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-017-0393-4

Other articles of this Issue 1/2017

BMC Anesthesiology 1/2017 Go to the issue

Research article

Bougies as an aid for endotracheal intubation with the Airway Scope: bench and manikin comparison studies

Case report

Surgical anesthesia with a combination of T12 paravertebral block and lumbar plexus, sacral plexus block for hip replacement in ankylosing spondylitis: CARE-compliant 4 case reports

Research article

Intraoperative continuous cerebral microcirculation measurement in patients with aneurysmal subarachnoid hemorrhage: preliminary data on the early administration of magnesium sulfate

Research article

A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery

Research article

Neuroprotective effects of amiodarone in a mouse model of ischemic stroke

Research article

Propofol and sufentanil may affect the patients’ sleep quality independently of the surgical stress response: a prospective nonrandomized controlled trial in 1033 patients’ undergone diagnostic upper gastrointestinal endoscopy