Transcript Practice Update Reversal - Washington Association of Nurse

NEUROMUSCULAR BLOCKADE
REVERSAL PRACTICE
JULIA LIENESCH & CARRIE MCMAHON
GONZAGA UNIVERSITY
PROVIDENCE SACRED HEART MEDICAL CENTER
MARCH 20, 2014
STATEMENT OF THE PROBLEM
 Residual neuromuscular blockade and its
management are well-established topics in current
literature
 The incidence of residual blockade has not
significantly declined even with the introduction of
intermediate acting paralytics
 From 2000-2008, 15 studies revealed 20-65% of
postoperative incidence TOFR <0.9

Associated with hypoxia, weakness, aspiration, impairment of
the hypoxic ventilatory drive, and respiratory failure
RESIDUAL BLOCKADE DEFINITION
 Residual blockade definition


TOFR of < 0.9
Clinical signs and symptoms of muscle weakness in the
postoperative period
 Evolution of TOFR standard for extubation

0.70.8currently 0.9

Increased respiratory events, pharyngeal dysfunction, and
aspiration risk with TOFR <0.9 (Eriksson et al, 1997)
PURPOSE STATEMENT
“The purpose of this study was to assess, through
survey, current practices among CRNAs in states
from various regions regarding the use of reversal
agents after pharmacologic neuromuscular
blockade.”
RESEARCH QUESTIONS
1.
To what degree are reversal agents being given by
CRNAs after the administration of neuromuscular
blocking agents?
2.
What are the benefits and risks of neuromuscular
blockade reversal?
3.
What factors influence CRNAs’ management of
neuromuscular blockade reversal?
4.
How is the dose of reversal agent determined?
REVIEW OF LITERATURE
MONITORING
 Acceleromyography monitoring gold standard
 Tactile fade lost at TOFR 0.3-0.4
 5-second head lift possible at TOFR of <0.6
 Pharyngeal tissue and upper esophageal sphincter dysfunction
at TOFR 0.6-0.9  aspiration risk
 Murphy et al. (2008)
 Compared acceleromyography to conventional tactile TOF
 TOFR ≤0.9 in PACU: 4.5% acceleromyography vs 30%
conventional, P <0.0001
 TOFR <0.7 in PACU: 0% acceleromyography vs 13.3%
conventional, P<0.001
 Acceleromyography had less respiratory events in PACU
REVIEW OF LITERATURE
MONITORING
Clinical Tests
Tidal Volume: recovery of spontaneous
breathing
Not reliable. Unchanged even when
peripheral muscles are fully paralyzed.
Vital Capacity: ability to take deep
breaths
Not sensitive enough. Unchanged with
significant levels of paralysis at
peripheral muscles.
Head or leg lift test >5 s
Not sensitive enough. Corresponds to
TOFR >0.4. Useful to determine the
optimal timing of reversal.
Tongue depressor test
Probably the most reliable clinical test.
Corresponds to TOFR >0.8-0.9.
Difficult to implement routinely.
(Plaud et al, 2010)
REVIEW OF LITERATURE
MONITORING
 Ulnar nerve superior site for planning emergence:
 Less likelihood of direct muscle stimulation
 Increased margin of safety as slower recovery vs diaphragm
 5-fold increased risk of residual block when monitoring at eye
 Placement
 Electrode placement 2-6cm apart
REVIEW OF LITERATURE
TIMING
 Debaene, Plaud, Dilly, & Donati (2003)



Single dose of intermediate acting paralytic to 526 patients
No reversal and > two hours post-administration
16% TOFR of <0.7 and 45% TOFR <0.9 in PACU
 Fuchs-Buder et al. (2010)




Addressed neostigmine dose for shallow levels of paralysis
Normal doses of neostigmine can produce paradoxical weakness at
shallow residual paralysis (Caldwell, 1995)
Groups with TOFR 0.4 and 0.6 given neostigmine 0.01, 0.02, 0.03
mg/kg, or none
Reversal at TOFR 0.4-0.6 with neostigmine 0.02 mg/kg produced
successful reversal within 10 minutes
REVIEW OF LITERATURE
TIMING
 Kim et al. (2004)



Administered neostigmine 0.07 mg/kg to surgical patients at a TOF
of 1,2,3,4
Median times from neostigmine reversal administration until a
TOFR of 0.9

TOF count 1 – 28.6minutes

TOF count 2 – 22.6 minutes

TOF count 3 – 15.6 minutes

TOF count 4 – 9.7 minutes
Authors recommend a TOF count of 4 for adequate reversal from
rocuronium within 15 minutes
 Thilen et al. (2012)

Every 10 minutes since paralytic dose = 10% less residual block
REVIEW OF LITERATURE
NEOSTIGMINE DOSING
 TOF 4/4 with minimal fade: 0.015-0.025 mg/kg
 TOF 2-3/4: 0.04-0.05 mg/kg
 Dosing >0.07 mg/kg unlikely to achieve additional
effect
(Kopman & Eikermann, 2009)
 Avoiding blanket full reversal of light paralysis will
minimize paradoxical weakness effect, risk for
cholinergic crisis, and side effects
 Most effective reversal when given >15-20 minutes
prior to extubation
(Brull & Murphy, 2010)
REVIEW OF LITERATURE
PONV SIDE EFFECT
 King et al. (1988) said Yes to PONV
 38 orthopedic patients: Neostigmine 2.5mg/Atropine 1.2mg, 68% PONV
compared with 32% at 24hr postop, (P<0.01)
 Joshi et al. (1999) said No difference
 100 ambulatory surgery, Neostigmine 2.5mg/Robinul 0.5mg, (P<0.05)
 Hovorka et al. (1997) said No difference
 DB*, 162 hysterectomy cases. Neostigmine 2mg/Robinul 0.4mg (P<0.05)
 Cheng et al. (2005) said No difference
 Lit review, 933 patients, compared Neostigmine 2.5 vs 1.5mg doses and Robinul
vs Atropine (P=0.08)
 Lovstad et al. (2001) said Yes to nausea
 DB, 90 lap-gyn cases, Mivacurium, Neostigmine 0.05mg/kg + Robinul
0.01mg/kg. (P=0.03). First 6hrs, 30% vs 11% nausea. No difference in vomiting.
*(DB=double blind)
METHODOLOGY
 Qualitative study
 Online survey utilizing SurveyMonkey
 Survey distributed via state CRNA organizations
 Participants

289 CRNA survey participants

Participating states: WA, AZ, NC, MD
FINDINGS
REVERSAL AND TIME
Reversal 1 Hour after Paralytic Dose
60%
Percent of Respondents
50%
40%
Experience
0-10 years
30%
11-20 years
>20 years
20%
10%
0%
Always
Frequently
Occasionally
Rarely
Never
FINDINGS
REVERSAL AND TIME
Reversal 3 Hours after Paralytic Dose
35%
Percent of Respondents
30%
25%
Experience
20%
0-10 years
11-20 years
15%
>20 years
10%
5%
0%
Always
Frequently
Occasionally
Rarely
Never
FINDINGS
REVERSAL AND TIME
Reversal of Healthy Patients
50%
45%
40%
35%
30%
Time Since
Paralytic
25%
1 Hour
2 Hours
20%
3 Hours
15%
10%
5%
0%
Always
Frequently
Occasionally
Rarely
Never
FINDINGS
REVERSAL AND TIME
Reversal of Complicated Patients
70%
60%
50%
Time Since
Paralytic
40%
1 Hour
30%
2 Hours
3 Hours
20%
10%
0%
Always
Frequently
Occasionally
Rarely
Never
FINDINGS
TOP 3 FACTORS
Factors Influencing Reversal
38.41%
19.93%
20.29%
#1 Factor
#2 Factor
#3 Factor
28.99%
19.20%
16.30%
Info from twitch monitor
15.22%
15.22%
Time since last paralytic
17.75%
Patient clinical signs
FINDINGS
PATIENT FACTORS
Populations Always Reversed
Children
Out-patient
None
Elderly
Respiratory Disease
Difficult Intubation
Obese
0
20
40
60
80
100
Number of respondents
120
140
160
180
FINDINGS
SIDE EFFECTS
Most Concerning Side Effects of Reversal
Influencing Use
140
Number or Restpondents
120
127
100
91
80
60
58
40
41
38
20
0
Increased N/V
Hemodynamic
Effects
Paradoxical
Weakness
GI Effects
Respiratory Effects
FINDINGS
MONITORING
Availability of Acceleromyographic Monitoring
6%
15%
Yes
No
I Don't Know
79%
RECOMMENDATIONS
 Time from last paralytic dose is not an adequate
determinant of residual blockade
 Monitoring of blockade should be standard practice

Acceleromyography superior as tactile fade lost at TOFR of 0.4
 Not all patients need a full reversal dose



Risk for paradoxical weakness and increased side effects
Majority can benefit from a partial reversal dose
Increased PONV is inconclusive and appears to be dose-dependent
 Faster recovery after reversal with increasing TOF count
 Allow 15-20 minutes after reversal for maximal effect
REFERENCES

Brull, S.J., & Murphy, G.S. (2010). Residual neuromuscular block: lessons unlearned.
Part II: methods to reduce the risk of residual weakness. Anesthesia and Analgesia,
111(1), 129-140.

Cheng, C., Sessler, D. I., & Apfel, C. C. (2005). Does neostigmine administration produce
a clinically important increase in postoperative nausea and vomiting? Anesthesia &
Analgesia, 101, 1349-55.

Debaene, B., Plaud, B., Dilly, M., & Donati, F. (2003). Residual paralysis in the PACU
after a single intubating dose of nondepolarizing muscle relaxant with an intermediate
duration of action. Anesthesiology, 98(5), 1042-1048. Retrieved from
http://journals.lww.com/anesthesiology/Fulltext/2003/05000/Residual_Paralysis_in_t
he_PACU_after_a_Single.4.aspx

Eriksson, L. I., Sundman, E., Olsson, R., Nilsson, L., Witt, H., Ekberg, O., &
Kuylenstierna, R. (1997). Functional assessment of the pharynx at rest and during
swallowing in partially paralyzed humans: Simultaneous videomanometry and
mechanomyography of awake human volunteers. Anesthesiology, 87(5), 1035-1043.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9366453

Fuchs-Buder, T., Meistelman, C., Alla, F., Grandjean, A., Wuthrich, Y., & Donati, F.
(2010). Antagonism of low degrees of Atracurium-induced neuromuscular blockade.
Anesthesiology, 112(1), 34-40.
REFERENCES

Hovorka, J., Korttila, K., Nelskyla, K., Soikkeli, A., Sarvela, J., Paatero, H., ... YliHankala, A. (1997). Reversal of neuromuscular blockade with neostigmine has no effect
on the incidence or severity of postoperative nausea and vomiting. Anesthesia &
Analgesia, 85, 1359-61.

Joshi, G. P., Garg, S. A., Hailey, A., & Yu, S. Y. (1999). The effects of antagonizing residual
neuromuscular blockade by neostigmine and glycopyrrolate on nausea and vomiting after
ambulatory surgery. Anesthesia & Analgesia, 89, 628-31.

Kim, K., Cheong, M., Lee, H., Lee, J. (2004) Tactile assessment for the reversibility of
rocuronium induced neuromuscular blockade during propofol or sevoflurane anesthesia.
Anesthesia Analgesia, 99, 1080-1085.

King, M. T., Milazkiewicz, R., Carli, F., & Deacock, A. R. (1988). Influence of neostigmine
on postoperative vomiting. British Journal of Anaesthesia, 61, 403-6.

Kopman, A.F., & Eikermann, M. (2009). Antagonism of non-depolarising neuromuscular
block: current practice. Anaesthesia, 64, 22-30.
REFERENCES

Lovstad, R. Z., Thagaard, K. S., Berner, N. S., & Raeder, J. C. (2001). Neostigmine
5mcg/kg with glycopyrrolate increases postoperative nausea in women after laparoscopic
gynaecological surgery. Acta Anaesthesiologica, 45, 495-500.

Murphy, G. S., Szokol, J. W., Marymont, J. H., Greenberg, S. B., Avram, M. J., Vender, J.
S., & Nisman, M. (2008). Intraoperative Acceleromyographic Monitoring Reduces the
Risk of Residual Neuromuscular Blockade and Adverse Respiratory Events in the
Postanesthesia Care Unit. Anesthesiology, 109, 389-398.

Plaud, B., Debane, B., Donati, F., Marty, J. (2010) Residual paralysis after emergence
from anesthesia. Anesthesiology, 112(4), 1013-1022.

Thilen, S. R., Hansen, B. E., Ramaiah, R., Kent, C. D., Treggiari, M. M., & Bhananker, S.
M. (2012). Intraoperative neuromuscular monitoring site and residual paralysis.
Anesthesiology, 117, 964-972.