New guidance: Quantitative monitoring of neuromuscular blockade is vital for patients undergoing anesthesia (Better practices reduce pneumonia)

Medical Xpress / American Society of Anesthesiologists / Anesthesiology ^ | June 5, 2023 | Thomas Fuchs-Buder et al

[ConservativeMind]

Patients receiving neuromuscular blocking medications as part of their anesthetic regimen should be carefully monitored to ensure best care, according to guidelines from the American Society of Anesthesiologists and the European Society of Anaesthesiology and Intensive Care.

Medications that provide neuromuscular blockade are frequently used in anesthesia, both to ease placement of a breathing tube at the beginning of the anesthetic (intubation) and to provide optimal conditions for the surgery itself. Both ASA and ESAIC guidelines for the management of neuromuscular blockade recommend patients be monitored quantitatively as part of the process, meaning that the degree of muscle relaxation is frequently checked using devices that measure the depth of muscle relaxation.

A European survey of 17,150 patients who received neuromuscular blocking drugs found neuromuscular monitoring was not performed in more than half (10,000) of patients, and the practice was similar in the U.S.

The joint letter recommends:

- Restructuring the clinical environment by placing quantitative monitors in all anesthetizing locations;

- Employing education efforts in anesthesia departments and with individual physicians;

- Providing performance feedback in the department and for individual physicians;

- Appointing a local champion who is supported by leaders.

Both sets of guidelines recommend:

- Using stimulation of the ulnar nerve—one of the nerves in the hand—with quantitative neuromuscular monitoring at the thumb;

- Using sugammadex instead of neostigmine for deep or moderate neuromuscular blockade induced by rocuronium;

- Using neostigmine as a reasonable alternative to sugammadex for minimal neuromuscular blockade (train of four, or TOF, ratio 0.4 to <0.9) induced by rocuronium;

- Depending on clinical judgment in the context of quantitative monitoring, neostigmine may be considered for a depth of block deeper than minimal, with the understanding that deeper blocks will require more time to attain a TOF ratio greater than or equal to 0.9.

[ConservativeMind]

Over half of hospital patients getting anesthesia are not getting quantitative neuromuscular monitoring, which uses additional devices, coupled with more checking, to optimize drug delivery. If more of that level of care was available, it would reduce pneumonia and bronchitis risk.

[ConservativeMind]

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