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Vigilance: the behavioral impact of quantitative monitoring on administration and antagonism of neuromuscular blocking agents

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Abstract

Purpose

The aim of this study was to determine whether use of acceleromyography (1) changes dosing of neuromuscular blocking agents (NMBAs), and (2) increases the time between neostigmine administration and extubation, when compared with subjective assessment of neuromuscular blockade.

Methods

For this retrospective study, data were collected from patient electronic medical records. Patients were included if they had received an NMBA as part of a general anesthetic in 2013 and 2014. Data were analyzed by category of monitoring device: quantitative monitor (acceleromyograph [AMG]) or subjective device (peripheral nerve stimulator [PNS]). Outcomes measured were the total dose of NMBA administered and, the timing of the last dose of NMBA and anticholinesterase relative to tracheal extubation.

Results

Results from multivariate models showed that use of acceleromyography was not associated with a change in the total dose of NMBA administered. In contrast, the number of times any monitor was used, as determined by the frequency with which the train-of-four count (TOFC) was recorded, correlated with the administration of greater amounts of rocuronium (P < 0.01) and vecuronium (P < 0.01). The use of acceleromyography did not prolong the time interval between neostigmine administration and tracheal extubation. The number of times any monitor was used during an anesthetic was associated with a decrease in this time interval. The interval decreased an average of 2.7 min each successive time the TOFC was recorded (P < 0.01).

Conclusions

The data presented provides insight about the behavioral engineering inherent to the practice of anesthesiology. Introduction of neuromuscular blockade assessment appeared to increase provider vigilance in dosing of NMBAs—regardless of assessment method. The frequency of intraoperative monitoring (quantitative or subjective) was associated with an increased total dose of NMBA administered and decreased time interval between the last dose of neostigmine and extubation.

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Acknowledgements

The authors would like to acknowledge Christian P. Tope, BS, Project Manager, Department of Anesthesiology, Weill Cornell Medicine, for his assistance in collecting the data for this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Institutional funding was provided through the Department of Anesthesiology, Weill Cornell Medical Center /NewYork Presbyterian Hospital.

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Authors and Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, 21287, USA

    Anastasia D. Grivoyannis

  2. Department of Anesthesiology, Weill Cornell Medicine, New York, NY, 10065, USA

    Virginia Tangel

  3. Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA

    Cynthia A. Lien

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  1. Anastasia D. Grivoyannis
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Contributions

ADG was involved in the study conceptualization, methodology design, data collection, interpretation of the results and writing of the manuscript. VT was involved in the study conceptualization, methodology design, data collection, statistical analysis, interpretation of the results and writing of the manuscript. CAL was involved in the study conceptualization, methodology design, data collection, interpretation of the results and writing of the manuscript.

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Correspondence to Cynthia A. Lien.

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The authors have no conflicts of interest to report.

Ethical approval

All study activities were approved by the Institutional Review Board at Weill Cornell Medical College (Protocol # 1412015765).

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Grivoyannis, A.D., Tangel, V. & Lien, C.A. Vigilance: the behavioral impact of quantitative monitoring on administration and antagonism of neuromuscular blocking agents. J Clin Monit Comput 36, 1043–1051 (2022). https://doi.org/10.1007/s10877-021-00729-6

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  • DOI: https://doi.org/10.1007/s10877-021-00729-6

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