Skip to main content

Advertisement

Log in

Investigation of intraoperative dosing patterns of neuromuscular blocking agents

  • Original Research
  • Published:
Journal of Clinical Monitoring and Computing Aims and scope Submit manuscript

Abstract

There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four assessment, which can be less reliable in retrospective studies. The goal of our study was to investigate the real-world practice pattern of dosing of neuromuscular blocking agents (NMBA), utilizing the amount of NMBA used during the course of a case, adjusted for patient weight and case duration, as a surrogate measure of depth of NMB. We also aimed to identify case factors associated with larger NMBA doses. In this retrospective observational analysis of our anesthesia information management system, we analyzed all general endotracheal anesthesia cases from 2012 to 2015 in which an intermediate-acting NMBA was used. Cases using a long-acting NMBA or only succinylcholine were excluded. The expected duration of the case was calculated based on the cumulative dose of NMB used, normalized to the patient’s ideal body weight and the ED95 of the drug. If the expected duration of the case was greater than the actual case duration documented in the case record, it was classified as higher dosing (HD). If the expected duration was equal to or less than the actual duration, it was considered predicted dosing (PD). Categorical comparisons between HD and PD groups were made for various patient, procedural, and provider factors. 72,684 cases were included in the final analysis, of which 46,358, or 64% of cases, used HD. Cases with patients who were morbidly obese, younger than 65 years, and who were lower ASA Physical Status classification (I or II) used more HD as opposed to PD. Cases that were non-open, used total intravenous anesthesia, emergent cases, or used non-rapid sequence anesthesia induction had higher rates of HD than their matched counterparts. All results were statistically significant. HD was more common in cases that documented train-of-four and used the reversal agent neostigmine. Approximately two-thirds of general endotracheal anesthesia cases using an intermediate-acting NMBA used HD. Cases with higher rates of HD may be those that are traditionally technically complex or emergent, would benefit from greater paralysis, or do not use adjunctive medications for muscle relaxation. Age greater than 65 years was shown to have lower rates of HD, likely due to provider awareness of age-related changes in pharmacokinetics and pharmacodynamics. Intraoperative monitoring and NMB antagonism with neostigmine were used more frequently with HD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Blobner M, Frick CG, Stauble RB, et al. Neuromuscular blockade improves surgical conditions (NISCO). Surg Endosc. 2015;29(3):627–36.

    Article  PubMed  Google Scholar 

  2. Bruintjes MH, van Helden EV, Braat AE, et al. Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis. Br J Anaesth. 2017;118(6):834–42.

    Article  CAS  PubMed  Google Scholar 

  3. Madsen MV, Staehr-Rye AK, Gatke MR, Claudius C. Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review. Acta Anaesthesiol Scand. 2015;59(1):1–16.

    Article  CAS  PubMed  Google Scholar 

  4. Koo BW, Oh AY, Seo KS, Han JW, Han HS, Yoon YS. Randomized clinical trial of moderate versus deep neuromuscular block for low-pressure pneumoperitoneum during laparoscopic cholecystectomy. World J Surg. 2016;40(12):2898–903.

    Article  PubMed  Google Scholar 

  5. Dubovoy T, Shanks AM, Devine S, Kheterpal S. Frequency of inadequate neuromuscular blockade during general anesthesia. J Clin Anesth. 2017;36:16–20.

    Article  CAS  PubMed  Google Scholar 

  6. Kopman AF, Naguib M. Laparoscopic surgery and muscle relaxants: is deep block helpful? Anesth Analg. 2015;120(1):51–8.

    Article  CAS  PubMed  Google Scholar 

  7. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth. 2014;112(3):498–505.

    Article  CAS  PubMed  Google Scholar 

  8. Barrio J, Errando CL, San Miguel G, et al. Effect of depth of neuromuscular blockade on the abdominal space during pneumoperitoneum establishment in laparoscopic surgery. J Clin Anesth. 2016;34:197–203.

    Article  PubMed  Google Scholar 

  9. Carron M. Respiratory benefits of deep neuromuscular block during laparoscopic surgery in a patient with end-stage lung disease. Br J Anaesth. 2015;114(1):158–9.

    Article  CAS  PubMed  Google Scholar 

  10. McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent association between intermediate-acting neuromuscular-blocking agents and postoperative respiratory complications. Anesthesiology 2015;122(6):1201–13.

    Article  CAS  PubMed  Google Scholar 

  11. Maybauer DM, Geldner G, Blobner M, et al. Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium. Anaesthesia 2007;62(1):12–7.

    Article  CAS  PubMed  Google Scholar 

  12. Cammu G, de Kam PJ, De Graeve K, et al. Repeat dosing of rocuronium 1.2 mg kg-1 after reversal of neuromuscular block by sugammadex 4.0 mg kg-1 in anaesthetized healthy volunteers: a modelling-based pilot study. Br J Anaesth. 2010;105(4):487–92.

    Article  CAS  PubMed  Google Scholar 

  13. Slavov V, Khalil M, Merle JC, Agostini MM, Ruggier R, Duvaldestin P. Comparison of duration of neuromuscular blocking effect of atracurium and vecuronium in young and elderly patients. Br J Anaesth. 1995;74(6):709–11.

    Article  CAS  PubMed  Google Scholar 

  14. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8:CD012763.

    PubMed  Google Scholar 

  15. Fuchs-Buder T, Meistelman C, Schreiber JU. Is sugammadex economically viable for routine use. Curr Opin Anaesthesiol. 2012;25(2):217–20.

    Article  CAS  PubMed  Google Scholar 

  16. Abad-Gurumeta A, Ripolles-Melchor J, Casans-Frances R, et al. A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade. Anaesthesia 2015;70(12):1441–52.

    Article  CAS  PubMed  Google Scholar 

  17. Keating GM. Sugammadex: A review of neuromuscular blockade reversal. Drugs 2016;76(10):1041–52.

    Article  CAS  PubMed  Google Scholar 

  18. Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015;115(5):743–51.

    Article  CAS  PubMed  Google Scholar 

  19. Shanks CA. Pharmacokinetics of the nondepolarizing neuromuscular relaxants applied to calculation of bolus and infusion dosage regimens. Anesthesiology 1986;64(1):72–86.

    Article  CAS  PubMed  Google Scholar 

  20. Mendonca J, Pereira H, Xara D, Santos A, Abelha FJ. Obese patients: respiratory complications in the post-anesthesia care unit. Rev Port Pneumol. 2014;20(1):12–9.

    Article  CAS  PubMed  Google Scholar 

  21. Pereira H, Xara D, Mendonca J, Santos A, Abelha FJ. Patients with a high risk for obstructive sleep apnea syndrome: postoperative respiratory complications. Rev Port Pneumol. 2013;19(4):144–51.

    Article  CAS  PubMed  Google Scholar 

  22. Baykara N, Solak M, Toker K. Predicting recovery from deep neuromuscular block by rocuronium in the elderly. J Clin Anesth. 2003;15(5):328–33.

    Article  CAS  PubMed  Google Scholar 

  23. Lee LA, Athanassoglou V, Pandit JJ. Neuromuscular blockade in the elderly patient. J Pain Res. 2016;9:437–44.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Wulf H, Ledowski T, Linstedt U, Proppe D, Sitzlack D. Neuromuscular blocking effects of rocuronium during desflurane, isoflurane, and sevoflurane anaesthesia. Can J Anaesth. 1998;45(6):526–32.

    Article  CAS  PubMed  Google Scholar 

  25. Donati F, Meistelman C, Plaud B. Vecuronium neuromuscular blockade at the diaphragm, the orbicularis oculi, and adductor pollicis muscles. Anesthesiology 1990; 73(5):870–5.

    Article  CAS  PubMed  Google Scholar 

  26. Martin R, Bourdua I, Theriault S, Tetrault JP, Pilote M. Neuromuscular monitoring: does it make a difference? Can J Anaesth. 1996;43(6):585–8.

    Article  CAS  PubMed  Google Scholar 

  27. Bronsert MR, Henderson WG, Monk TG, et al. Intermediate-acting nondepolarizing neuromuscular blocking agents and risk of postoperative 30-day morbidity and mortality, and long-term survival. Anesth Analg. 2017;124:1476–83

    Article  CAS  PubMed  Google Scholar 

  28. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010;111(1):129–40.

    Article  PubMed  Google Scholar 

  29. Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98(5):1042–8.

    Article  CAS  PubMed  Google Scholar 

  30. Fortier LP, McKeen D, Turner K, et al. The RECITE study: a Canadian prospective, multicenter study of the incidence and severity of residual neuromuscular blockade. Anesth Analg. 2015;121(2):366–72.

    Article  PubMed  Google Scholar 

  31. Leonard PA, Todd MM. Quantitative neuromuscular blockade monitoring: two pictures of unexpected rocuronium effect: a case report. A A Case Rep. 2017;9(7):190–2.

    Article  PubMed  Google Scholar 

  32. Costa ACC, Coelho EB, Lanchote VL, et al. The SLCO1A2-189_-188InsA polymorphism reduces clearance of rocuronium in patients submitted to elective surgeries. Eur J Clin Pharmacol. 2017;73(8):957–63.

    Article  CAS  PubMed  Google Scholar 

  33. Stewart PA, Liang SS, Li QS, et al. The impact of residual neuromuscular blockade, oversedation, and hypothermia on adverse respiratory events in a postanesthetic care unit: a prospective study of prevalence, predictors, and outcomes. Anesth Analg. 2016;123(4):859–68.

    Article  PubMed  Google Scholar 

Download references

Funding

This investigator-initiated study was funded by Merck & Co (Merck Sharp and Dohme).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Richard D. Urman.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Palsen, S., Wu, A., Beutler, S.S. et al. Investigation of intraoperative dosing patterns of neuromuscular blocking agents. J Clin Monit Comput 33, 455–462 (2019). https://doi.org/10.1007/s10877-018-0186-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10877-018-0186-4

Keywords

Navigation