The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

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Abstract

Background

Inadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The pilot study aims to understand the baseline incidence of residual neuromuscular blockade (RNMB) and postoperative critical respiratory events (CREs), which are described in a modified Murphy’s criteria in the PACU.

Method

This is a prospective cohort study from January to March 2017 from a tertiary hospital in Saudi Arabia with thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) who were enrolled in the study. The Mann-Whitney U tests, chi-square tests and independent-samples T tests were used. The train-of-four (TOF) ratios were measured upon arrival in the PACU by using acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data and the occurrence of postoperative CREs in the PACU were recorded.

Results

Twenty-six (86.7%) patients out of thirty in the study have received rocuronium as NMBDs whilst neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients ( p = 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation ( p = 0.046) and in patients with a shorter duration of surgery ( p = 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB ( p = 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index ( p = 0.047).

Conclusion

This research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, routine quantitative neuromuscular monitoring is recommended to reduce the incidence of RNMB.

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Most cited references 33

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Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Eva Kirmeier, Lars I Eriksson, Heidrun Lewald … (2018)

Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications.

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Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study

Martina Grosse-Sundrup, Justin Henneman, Warren Sandberg … (2012)

Objective To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications. Design Prospective, propensity score matched cohort study. Setting General teaching hospital in Boston, Massachusetts, United States, 2006-10. Participants 18 579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18 579 reference patients who did not receive such agents. Main outcome measures The main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation 3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade. Results The use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation to values less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26). Conclusion The use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited.

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Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.

Mary Marymont, Joseph Szokol, J Vender … (2008)

Incomplete recovery of neuromuscular function may impair pulmonary and upper airway function and contribute to adverse respiratory events in the postanesthesia care unit (PACU). The aim of this investigation was to assess and quantify the severity of neuromuscular blockade in patients with signs or symptoms of critical respiratory events (CREs) in the PACU. We collected data over a 1-yr period. PACU nurses identified patients with evidence of a predefined CRE during the first 15 min of PACU admission. Train-of-four (TOF) ratios were immediately quantified in these patients using acceleromyography (cases). TOF data were also collected in a control group that consisted of patients undergoing a general anesthetic during the same period who were matched with the cases by age, sex, and surgical procedure. A total of 7459 patients received a general anesthetic during the 1-yr period, of whom 61 developed a CRE. Forty-two of these cases were matched with controls and constituted the study group for statistical analysis. The most common CREs among matched cases were severe hypoxemia (22 of 42 patients; 52.4%) and upper airway obstruction (15 of 42 patients; 35.7%). There were no significant differences between the cases and matched controls in any measured preoperative or intraoperative variables. Mean (+/-sd) TOF ratios were 0.62 (+/-0.20) in the cases, with 73.8% of the cases having TOF ratios <0.70. In contrast, TOF values in the controls were 0.98 (+/-0.07) (a difference of -0.36 with a 95% confidence interval of -0.43 to -0.30, P < 0.0001), and no control patients were observed to have TOF values <0.70 (the 95% confidence interval of the difference was 59%-85%, P < 0.0001). A high incidence of severe residual blockade was observed in patients with CREs, which was absent in control patients without CREs. These findings suggest that incomplete neuromuscular recovery is an important contributing factor in the development of adverse respiratory events in the PACU.

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Author and article information

Contributors

Faraj K Alenezi:

ORCID: http://orcid.org/0000-0001-8596-1983

farajalenezi@gmail.com

Khalid Alnababtah: Kal.Alnababtah@bcu.ac.uk

Mohammed M Alqahtani: Shwail.qahtani@hotmail.com

Lafi Olayan: Olayan.rt@gmail.com

Mohammed Alharbi: harbimk@ngha.med.sa

Journal

Journal ID (nlm-ta): Perioper Med (Lond)

Journal ID (iso-abbrev): Perioper Med (Lond)

Title: Perioperative Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 2047-0525

Publication date (Electronic): 4 May 2021

Publication date PMC-release: 4 May 2021

Publication date Collection: 2021

Volume: 10

Electronic Location Identifier: 14

Affiliations

[1 ]GRID grid.412149.b, ISNI 0000 0004 0608 0662, Anesthesia Technology Program, College of Applied Medical Sciences, , King Saud bin Abdul-Aziz University for Health Sciences, ; Riyadh, Saudi Arabia

[2 ]GRID grid.452607.2, ISNI 0000 0004 0580 0891, King Abdullah International Medical Research Center, ; Riyadh, Saudi Arabia

[3 ]GRID grid.19822.30, ISNI 0000 0001 2180 2449, School of Nursing and Midwifery, Faculty of Health, Education and Life Sciences, BCU, ; Birmingham, UK

[4 ]GRID grid.412149.b, ISNI 0000 0004 0608 0662, Respiratory Therapy Program, College of Applied Medical Sciences, , King Saud bin Abdul-Aziz University for Health Sciences, ; Riyadh, Saudi Arabia

Author information

Faraj K Alenezi http://orcid.org/0000-0001-8596-1983

Article

Publisher ID: 183

DOI: 10.1186/s13741-021-00183-7

PMC ID: 8094541

PubMed ID: 33941287

SO-VID: de5bf686-f382-4a4d-b9a5-baf84c23a6f0

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Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 24 April 2020

Date accepted : 22 March 2021

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Keywords: neuromuscular blocking drugs,residual neuromuscular blockade,critical respiratory events

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Keywords: neuromuscular blocking drugs, residual neuromuscular blockade, critical respiratory events

The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

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European Respiratory Society: COVID-19

Most cited references 33

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study

Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.

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