‘Confusion’ reigns for neuromuscular block monitoring
MedWire News: Many anesthesia providers in both Europe and the USA see no need for peri-operative neuromuscular monitoring, say researchers who call on professional bodies to develop guidelines.
"It is clear that despite the voluminous literature published on the subject of neuromuscular monitoring and postoperative residual neuromuscular block, considerable confusion remains within the anesthesia community about the proper clinical use of muscle relaxants," they write in the journal Anesthesia and Analgesia.
Mohamed Naguib (Cleveland Clinic, Ohio, USA) and colleagues obtained completed surveys from 2636 members of the Anesthesia Patient Safety Foundation and The European Society of Anaesthesiology.
About three-quarters of respondents believed that residual postoperative neuromuscular weakness was a significant complication. Yet 79% of European and 88% of US respondents had never actually encountered the problem and 64% and 52%, respectively, believed it occurred in less than 1% of patients in their institution.
After accounting for years of experience, European respondents were 40% more likely than US respondents to say that routine use of either a nerve stimulator or train-of-four (TOF) monitor would reduce the incidence of residual paralysis.
However, 82% and 66% of European and US respondents, respectively, did not routinely reverse neuromuscular block. Factors influencing a decision to not administer a reversal drug included the timing of the last neuromuscular block dose, total dose of the block, lack of clinical signs of weakness, and, less often, the results of TOF monitoring.
European respondents were more likely to have access to a TOF monitor than were US respondents, who more often had access to a conventional nerve stimulator.
If both pieces of equipment were available, 53% of European respondents routinely used a TOF monitor, whereas 63% of US respondents used a nerve stimulator.
However, 19% of European respondents and 9% of US respondents did not use either device, even if both were available. Only about a third of European respondents and half of US respondents thought that nerve stimulators should be part of minimal neuromuscular monitoring standards; the corresponding rates for TOF monitors were 33% and 11%.
"In the absence of 'official' guidelines from professional organizations, we do not expect current clinical attitudes toward monitoring to change," say Naguib et al.
"We recommend that professional organizations develop formal training and publish official guidelines on best practices for peri-operative neuromuscular monitoring. Such efforts should help to reduce the incidence of undetected postoperative neuromuscular block and reduce patient morbidity."
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By Eleanor McDermid