Top

Published in:

01-06-2018 | Neuromuscular Blockade (GS Murphy, Section Editor)

Profound Neuromuscular Blockade: Advantages and Challenges for Patients, Anesthesiologists, and Surgeons

Author: Cynthia A. Lien

Published in: Current Anesthesiology Reports | Issue 2/2018

Abstract

Rarely has the introduction of an anesthetic agent or adjunct been as anticipated or needed as that of sugammadex. Residual paralysis after neuromuscular blockade (NMB) occurs frequently and is associated with a range of adverse effects ranging from patient discomfort to respiratory complications and death. Residual neuromuscular block is due to a number of factors that include overdosing of neuromuscular blocking agents (NMBAs), inadequate monitoring of the effect of NMBAs, and the limitations of anticholinesterses to antagonize neuromuscular block (relatively slow onset of effect and inability to antagonize deep levels of NMB. Sugammadex, a selective relaxant binding agent, will, when dosed appropriately, rapidly and completely reverse the effects of vecuronium and rocuronium, steroidal NMBAs, from any depth of NMB. While this approach has the potential to increase safety in the perioperative use of NMBAs, it also allows clinicians to revise dosing paradigms to improve surgical conditions and, importantly, patient outcome.

Cullen S. The use of curare for the improvement of abdominal muscle relaxation during inhalation anesthesia. Surgery. 1943;14:216.

Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg. 1954;140:2–35.PubMedPubMedCentral

Foldes FF, B-HJ MNPG, Foldes FF, McNall PG, Borrego-Hinojosa JM. Succinylcholine: a new approach to muscular relaxation in anesthesiology. N Engl J Med. 1952;247:596–600.PubMed

•• Sasaki N, Meyer MJ, Malviya SA, Stanislaus AB, MacDonald T, Doran ME, et al. Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes: a prospective study. Anesthesiology. 2014;121:959–68. Administration of excessive or unnecessary doses of neostigmine increased postoperative atelectasis but did not impact postoperative oxygenation.

•• Bronsert MR, Henderson WG, Monk TG, Richman JS, Nguyen JD, Sum-Ping JT, et al. Intermediate-acting nondepolarizing neuromuscular blocking agents and risk of postoperative 30-day morbidity and mortality, and long-term survival. Anesth Analg. 2017;124:1476–1483. In this retrospective study, when neostigmine was not administered to patients who had received NMBAs, risk of respiratory complications was increased.

McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent association between intermediate-acting neuromuscular-blocking agents and postoperative respiratory complications. Anesthesiology. 2015;122:1201–13.PubMed

Ginsberg B, Glass PS, Quill T, Shafron D, Ossey KD. Onset and duration of neuromuscular blockade following high-dose vecuronium administration. Anesthesiology. 1989;71:201–5.PubMed

Koller ME, Husby P. High-dose vecuronium may be an alternative to suxamethonium for rapid sequence intubation. Acta Anaesthesiol Scand. 1993;37:465–8.PubMed

McCourt KC, Salmela L, Mirakhur RK, Carroll M, Mäkinen MT, Kansanaho M, et al. Comparison of rocuronium and suxamethonium for use during rapid sequence induction of anaesthesia. Anaesthesia. 1998;53:867–71.PubMed

10.

Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg. 2000;90:175–9.PubMed

11.

Goo EK, Lee JS, Koh JC. The optimal exhaled concentration of sevoflurane for intubation without neuromuscular blockade using clinical bolus doses of remifentanil: a randomized controlled trial. Med (United States). 2017;96. Published online 2017 Mar 3. doi: https://doi.org/10.1097/MD.0000000000006235. PMID 28248887.

12.

Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg. 1998;86:45–9.PubMed

13.

Schlaich N, Mertzlufft F, Soltész S, Fuchs-Buder T. Remifentanil and propofol without muscle relaxants or with different doses of rocuronium for tracheal intubation in outpatient anaesthesia. Acta Anaesthesiol Scand. 2000;44(6):720–6.PubMed

14.

Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, et al. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102:426–9.PubMed

15.

Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth. 2010;105:304–9.PubMed

16.

Eikaas H, Raeder J. Total intravenous anaesthesia techniques for ambulatory surgery. Curr Opin Anaesthesiol. 2009;22(22):725–9.

17.

Kelly R, Lien CA, Savarese JJ, Belmont MR, Hartman GS, Russo JRHC. Depression of neuromuscular function in a patient during desflurane anesthesia. Anesth Analg. 1993;76:868–71.PubMed

18.

Morita T, Tsukagoshi H, Sugaya T, Saito S, Sato H, Fujita T. Inadequate antagonism of vecuronium-induced neuromuscular block by neostigmine during sevoflurane or isoflurane anesthesia. Anesth Analg. 1995;80:1175–80.PubMed

19.

DeLisle SBD. Impaired neostigmine antagonism of pancuronium during enflurane anaesthesia in man. Br J Anaesth. 1982;54:441–5.PubMed

20.

Gill SS, Bevan DR, Donati F. Edrophonium antagonism of atracurium during enflurane anaesthesia. Br J Anaesth. 1990;64:300–5.PubMed

21.

•• Dubovoy T, Shanks AM, Devine S, Kheterpal S. Frequency of inadequate neuromuscular blockade during general anesthesia. J Clin Anesth. 2017;36:16–20. This was a rerospective study of 9 years of surgical cases that documented a 0.29% occurrence of patient movement (such as coughing) and 0.71% of surgeons requesting a deepening of the lvel on neuromuscular blockade—each of which increased over the course of the 9 years. Depth of neuromuscular block was monitored in the majority of patients but the depth of NMB was not reported in this study. Whether these results are the result of increased awareness of the risk of residual paralysis and more cautious dosing of NMBAs, inadequate dosing of anesthetic agents or a change in surgical expectations regarding depth of NMB is unknown. PubMed

22.

Magorian TT, Lynam DP, Caldwell JE, Miller RD. Can early administration of neostigmine, in single or repeated doses, alter the course of neuromuscular recovery from a vecuronium-induced neuromuscular blockade? Anesthesiology. 1990;73:410–4.PubMed

23.

Bevan JC, Collins L, Fowler C, Kahwaji R, Rosen HD, Smith MF, et al. Early and late reversal of rocuronium and vecuronium with neostigmine in adults and children. Anesth Analg. 1999;89:333–9.

24.

Messner M, Beese U, Romstöck J, Dinkel M, Tschaikowsky K. The bispectral index declines during neuromuscular block in fully awake persons. Anesth Analg. 2003;97:488–91.PubMed

25.

Avidan MS, Zhang L, Burnside BA, Finkel KJ, Searleman AC, Selvidge JA, et al. Anesthesia awareness and the bispectral index. N Engl J Med [Internet]. 2008;358:1097–108.

26.

Jonsson M, Gurley D, Dabrowski M, Larsson O, Johnson EC, Eriksson LI. Distinct pharmacologic properties of neuromuscular blocking agents on human neuronal nicotinic acetylcholine receptors: a possible explanation for the train-of-four fade. Anesthesiology. 2006;105:521–33.PubMed

27.

Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS, et al. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesth Analg. 2013;117:133–41.

28.

Berg H, Viby-Mogensen J, Roed J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications a prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095–103.

29.

Bevan DR, Smith CE, Donati F. Postoperative meeting abstracts: a comparison between atracurium, vecuronium, and pancuroniun. Anesthesiology. 1988;69:272–5.PubMed

30.

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;98:1042–8.PubMed

31.

•• Todd MM, Hindman BJ, King BJ. The implementation of quantitative electromyographic neuromuscular monitoring in an academic anesthesia department. Anesth Analg. 2014;119:323–31. In this study of the impact of requiring quantitative monitoring of NMB on reintubation in the PACU, the frequency of patients entering the PACU with a TOFR < 0.9 was decreased and no patients required reintubation once routine monitoring was instituted. PubMed

32.

Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115:946–54.

33.

Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111:110–9.PubMed

34.

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;86:765–71.PubMed

35.

Fruergaard K, Viby-Mogensen J, Berg H, El-Mahdy AM. Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis. Acta Anaesthesiol Scand. 1998;42:1168–74.PubMed

36.

•• Nemes R, Fülesdi B, Pongrácz A, Asztalos L, Szabó-Maák Z, Lengyel S, et al. 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. 2017;34:609–16. When reversal was based on clinical signs, rather than the results of quantitative monitoring of NMB, administration of pharmacologic reversal more effectively guaranteed complete recovery than neuromuscular function. In the absence of monitoring, though, neither neostigmine nor sugammadex guaranteed the elimination of postoperative residual neuromuscular block. PubMed

37.

Milne I, Ong S, Ong JS, Cheung KC, Schauer AA, Buttar SB, et al. The influence of introducing unrestricted access to sugammadex and quantitative neuromuscular monitors on the incidence of residual neuromuscular block at a tertiary teaching hospital. An audit of “real-life.”. Anaesth Intensive Care. 2016;44:784.PubMed

38.

Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, et al. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth Analg. 2013;117:345–51.

39.

Kim HJ, Lee K, Park WK, Lee BR, Joo HM, Koh YW, et al. Deep neuromuscular block improves the surgical conditions for laryngeal microsurgery. Br J Anaesth. 2015;115:867–72.

40.

Laycock JRD, Donati F, Smith CE, Bevan DR. Potency of atracurium and vecuronium at the diaphragm and the adductor pollicis muscle. Br J Anaesth. 1988;61:286–91.PubMed

41.

Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth. 2014;112:498–505.PubMed

42.

Lindekaer AL, Halvor Springborg H, Istre O. Deep neuromuscular blockade leads to a larger intraabdominal volume during laparoscopy. J Vis Exp 2013;(76). PMID: 23851450.

43.

Staehr-Rye AK, Rasmussen LS, Rosenberg J, Juul P, Lindekaer AL, Riber C, et al. Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study. Anesth Analg. 2014;119:1084–92.

44.

Blobner M, Frick CG, Stäuble RB, Feussner H, Schaller SJ, Unterbuchner C, et al. Neuromuscular blockade improves surgical conditions (NISCO). Surg Endosc Other Interv Tech. 2014;29:627–36.

45.

Van Wijk RM, Watts RW, Ledowski T, Trochsler M, Moran JL, Arenas GWN. Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study. Acta Anaesthesiol Scand. 2015;59:434–40.PubMed

46.

Dubois PE, Putz L, Jamart J, Marotta ML, Gourdin M, Donnez O. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial. Eur J Anaesthesiol. 2014;31:430–6.PubMed

47.

Madsen MV, Gätke MR, Springborg HH, Rosenberg J, Lund J, Istre O. Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy—a randomised, blinded crossover study. Acta Anaesthesiol Scand. 2015;59:441–7.PubMed

48.

Barrio J, Errando CL, San Miguel G, Salas BI, Raga J, Carrión JL, et al. Effect of depth of neuromuscular blockade on the abdominal space during pneumoperitoneum establishment in laparoscopic surgery. J Clin Anesth. 2016;34:197–203.

49.

Baete S, Vercruysse G, Vander LM, De Vooght P, Van Melkebeek J, Dylst D, et al. The effect of deep versus moderate neuromuscular block on surgical conditions and postoperative respiratory function in bariatric laparoscopic surgery: a randomized, double blind clinical trial. Anesth Analg. 2017;124:1469–75.PubMed

50.

Bruintjes MH, Van Helden EV, Braat AE, Dahan A, Scheffer GJ, Van Laarhoven CJ, et al. Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis. Br J Anaesth. 2017;118:834–42.PubMed

51.

Kopman AF, Naguib M. Laparoscopic surgery and muscle relaxants: is deep block helpful? Anesth Analg. 2015;120:51–8.PubMed

52.

Chen BZ, Tan L, Zhang L, Shang YC. Is muscle relaxant necessary in patients undergoing laparoscopic gynecological surgery with a ProSeal LMA™? J Clin Anesth. 2013;25:32–5.PubMed

53.

Nishio S, Takeda H, Yokoyama M. Changes in urinary output during laparoscopic adrenalectomny. BJU Int. 1999;83:944–7.PubMed

54.

Ido K, Suzuki T, Kimura K, Taniguchi Y, Kawamoto C, Isoda N, et al. Lower-extremity venous stasis during laparoscopic cholecystectomy as assessed using color Doppler ultrasound. Surg Endosc. 1995;9:310–3.

55.

Woehlck HJ, Otterson M, Yun H, Connolly LA, Eastwood D, Colpaert K. Acetazolamide reduces referred postoperative pain after laparoscopic surgery with carbon dioxide insufflation. Anesthesiology. 2003;99:924–8.PubMed

56.

•• Özdemir-van Brunschot DMD, Scheffer GJ, van der Jagt M, Langenhuijsen H, Dahan A, Mulder JEEA, et al. Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study. World J Surg. 2017;41:2950–8. The quality of surgical contitions for donor nephrectomy and recovery were compared during a standard laparoscopy and a low pressure laparoscopy facilitated by deep neuromuscular blockade. Surgical conditions were rated as being better in the standard laparoscopy group and almost 25% of low pressure laparoscopies were converted to standard pressures (> 10 mmHg). Postoperative pain was not reduced in the low pressure group and the quality of recovery was not improved. PubMedPubMedCentral

57.

Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring. Anesthesiology. 2017;126:173–90.PubMed

58.

Murphy GS. Neuromuscular monitoring in the perioperative period. Anesth Analg. 2018;126:464–8. https://doi.org/10.1213/ANE.0000000000002387.CrossRefPubMed

59.

Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. 2010;112:1013–22.PubMed

60.

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.PubMed

61.

Belcher AW, Leung S, Cohen B, Yang D, Mascha EJ, Turan A, et al. Incidence of complications in the post-anesthesia care unit and associated healthcare utilization in patients undergoing non-cardiac surgery requiring neuromuscular blockade 2005–2013: a single center study. J Clin Anesth. 2017;43:33–8.

62.

Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312–8.PubMed

63.

Maybauer DM, Geldner G, Blobner M, Puhringer F, Hofmockel R, Rex C, et al. Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium. Anaesthesia. 2007;62:12–7.PubMed

64.

Eleveld DJ, Kuizenga K, Proost JH, Wierda JMKH. A temporary decrease in twitch response during reversal of rocuronium-induced muscle relaxation with a small dose of sugammadex. Anesth Analg. 2007;104:582–4.PubMed

65.

•• Thevathasan T, Shih SL, Safavi KC, Berger DL, Burns SM, Grabitz SD, et al. Association between intraoperative non-depolarising neuromuscular blocking agent dose and 30-day readmission after abdominal surgery. Br J Anaesth. 2017;119:595–605. Administration of greater doses of NMBAs and neostigmine in the retrospective study were associated with an increased risk of 30-day readmission. The adjusted odds ratio of readmission in ambulatory surgical patients for high vs low-dose NMBAs was 2.61. Administration of larger doses of NMBAs also prolonged hospital stay and costs. PubMed

66.

Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012;345:e6329–9. Available from:. https://doi.org/10.1136/bmj.e6329.

67.

Kopman AF, Eikermann M. Antagonism of non-depolarising neuromuscular block: current practice. Anaesthesia. 2009;64:22–30.PubMed

68.

Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F. Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine. Anesthesiology. 2010;112:34–40.PubMed

69.

Claudius C, Skovgaard LT, Viby-Mogensen J. Is the performance of acceleromyography improved with preload and normalization?: a comparison with mechanomyography. Anesthesiology. 2009;110:1261–70.PubMed

70.

Eikermann M, Gerwig M, Hasselmann C, Fiedler G, Peters J. Impaired neuromuscular transmission after recovery of the train-of-four ratio. Acta Anaesthesiol Scand. 2007;51:226–34.PubMed

71.

•• Baumüller E, Schaller SJ, Chiquito Lama Y, Frick CG, Bauhofer T, Eikermann M, et al. Postoperative impairment of motor function at train-of-four ratio ≥ 0.9 cannot be improved by sugammadex (1 mg kg⁻¹). Br J Anaesth. 2015;114:785–93. After recovery to a TOFR ≥ 0.9, patients received either placebo or sugammadex. Grip strength was reduced after emergence from anesthesia when compared to baseline. Administration of neither placebo nor sugammadex returned strength to baseline values or improved the quality of recovery. PubMed

Title: Profound Neuromuscular Blockade: Advantages and Challenges for Patients, Anesthesiologists, and Surgeons
Author: Cynthia A. Lien
Publication date: 01-06-2018
Publisher: Springer US
Published in: Current Anesthesiology Reports / Issue 2/2018
Electronic ISSN: 2167-6275
DOI: https://doi.org/10.1007/s40140-018-0276-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Profound Neuromuscular Blockade: Advantages and Challenges for Patients, Anesthesiologists, and Surgeons

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 2/2018

Perioperative Outcome in Geriatric Patients

Mivacurium: a Review

Hematopoietic Stem Cell Transplantation: History and Perioperative Care of Patients Undergoing HSCT

Sugammadex: Clinical Pharmacokinetics and Pharmacodynamics

Qualitative Neuromuscular Monitoring: Patterns of Stimulation, Site of Monitoring, and Accuracy in Detecting Residual Neuromuscular Blockade

Latest Advances in Cardiac Output Monitoring from High-Definition Impedance Cardiography