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'
Residual neuromuscular block (RNMB) is a common phenomenon and has been identified as a significant risk factor for adverse postoperative patient outcome. The outcome of a recent randomised, controlled trial suggests that monitor guided, sugammadex based reversal of neuromuscular blocking agents (NMBA) may be able to completely eliminate the risk of RNMB1. However, it is unclear whether such results could be achieved in a 'real life' clinical setting. Prior to the availability of quantitative neuromuscular transmission monitors and the unrestricted availability of sugammadex (2011) the incidence of RNMB at the Royal Perth Hospital after timing, neostigmine or sugammadex based reversal was 53% 59% and 8% respectively2. As a result, Royal Perth Hospital introduced quantitative neuromuscular monitors for each anaesthesia workstation as well as unhindered access to sugammadex. To investigate the effects of these changes four years on (2015) we conducted an audit including all patients receiving NMBA over a two week period. Ethics approval was obtained from the Royal Perth Hospital Ethics Committee for Human Research (RPH HREC A 15.002) RNMB was assessed by an independent researcher using a quantitative neuromuscular transmission monitor (train of four [TOF] supramaximal stimulation of the ulnar nerve) (NMT monitor, GE Healthcare, Helsinki, Finland) once the anaesthetist had declared the patient 'fit for extubation' Choice of NMBA, monitoring and reversal were left to the anaesthetist. Data from 140 cases were analysed. Sugammadex, neostigmine or no reversal were used in 80.7% 2.1% and 17.2% respectively. Monitoring was used in 79% The overall incidence of RNMB was 15% However, failure (versus compliance) to monitor the effects of reversal resulted in 19% (versus 4% P=0.02) severe RNMB (TOF ratio <0.7) and 33% (versus 13% P=0.02) of overall RNMB (TOF ratio <0.9) From 2011 to 2015 the use of neuromuscular transmission monitoring increased from 62% to 78% and the use of sugammadex from 39% to 81% Using the same audit format utilised in 20112, it appears likely that the observed changes in clinical practice contributed to the significantly reduced risk of RNMB found in 2015. However, the results also underline the crucial role of neuromuscular transmission monitoring. Without this, even the unrestricted use of sugammadex appears to be unable to completely abolish the risk of RNMB. Thus, more emphasis and continuous staff education about the dangers of RNMB as well the benefits Correspondence
Anaesthesia and intensive care