Residual relaxation in the posanesthetic care unit
Relajación residual en la unidad de cuidado posanestésico
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Reyes, L. E., Valencia, A. R., Campo, C. A., & Muñoz, L. A. (2015). Residual relaxation in the posanesthetic care unit. Journal of Medicine and Surgery Repertoire, 24(4), 254–260. https://doi.org/10.31260/RepertMedCir.v24.n4.2015.598
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Abstract
The use of neuromuscular relaxants in clinical practice is becoming more frequent and indispensable in the anesthetic act and the intensive care unit. Although the neuromuscular blockers of both aminosteroids and benzylisoquinolines of last generation have minimal adverse effects, residual relaxation is a complication of considerable incidence associated with an increase in morbidity and mortality. Due to this we raised the importance of knowing the different methods of monitoring the neuromuscular block with its interpretation, emphasizing the monitoring with the train of four (TOF), the ratio between the first and the fourth response T4 / T1 (TOF RATIO) and prevention strategies for residual relaxation. Abbreviations: TOF, train of four; PORC, postoperative residual paralysis; RNMND, non-depolarizing neuromuscular relaxants; UCPA, postoperative care unit.
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References
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2. Combes X, Andriamifidy L, Dufresne E, Suen P, Sauvat S, Scherrer E, et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007;99(2):276-81.
3. Andersen BN, Madsen JV, Schurizek BA, Juhl B. Residual curarisation: a comparative study of atracurium and pancuronium. Acta Anaesthesiol Scand. 1988;32(2):79-81.
4. Claudius C, Garvey LH, Viby-Mogensen J. The undesirable effects of neuromuscular blocking drugs. Anaesthesia. 2009;64 Suppl 1:10-21.
5. Craig RG, Hunter JM. Neuromuscular blocking drugs and their antagonists in patients with organ disease. Anaesthesia. 2009;64 Suppl 1:55-65.
6. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minerva Anestesiol. 2006;72(3):97-109.
7. Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111(1):110-9.
8. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. 2010;112(4):1013-22.
9. Capron F, Alla F, Hottier C, Meistelman C, Fuchs-Buder T. Can acceleromyography detect low levels of residual paralysis? A probability approach to detect a mechanomyographic train-of-four ratio of 0.9. Anesthesiology. 2004;100(5):1119-24.
10. Ali HH, Wilson RS, Savarese JJ, Kitz RJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth. 1975;47(5):570-4.
11. Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis at the time of tracheal extubation. Anesth Analg. 2005;100(6):1840-5.
12. Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, et al. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102(2):426-9.
13. Fuchs-Buder T, Hofmockel R, Geldner G, Diefenbach C, Ulm K, Blobner M. [The use of neuromuscular monitoring in Germany]. Anaesthesist. 2003;52(6):522-6.
14. Maybauer DM, Geldner G, Blobner M, Pühringer F, Hofmockel R, Rex C, 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.
15. Fawcett WJ, Dash A, Francis GA, Liban JB, Cashman JN. Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions. Acta Anaesthesiol Scand. 1995;39(3):288-93.
16. Ronald MD. Miller Anestesia. Elsevier ed2011.
17. Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-fourfade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86(4):765-71.
18. Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62(8):806-9.
19. Fuchs-Buder T, Schreiber JU, Meistelman C. Monitoring neuromuscular block: an update. Anaesthesia. 2009;64 Suppl 1:82-9.
20. Claudius C, Viby-Mogensen J. Acceleromyography for use in scientific and clinical practice: a systematic review of the evidence. Anesthesiology. 2008; 108(6):1117-40.
21 Naguib M, Lien CA, Meistelman C. Anesthesia. 6 ed. Philadelphia: Elsevier/ Churchill Livingstone; 2005. Chapter 34, Pharmacology of Neuromuscular Blocking Drugs; 958-994.e8.
22. Cai YR, Xu J, Chen LH, Chi FL. Electromyographic monitoring of facial nerve under different levels of neuromuscular blockade during middle ear microsurgery. Chin Med J (Engl). 2009;122(3):311-4.
23. Jellish WS, Leonetti JP, Buoy CM, Sincacore JM, Sawicki KJ, Macken MP. Facial nerve electromyographic monitoring to predict movement in patients titrated to a standard anesthetic depth. Anesth Analg. 2009;109(2):551-8.
24. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107(1):130-7.
25. Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F. Antagonism of low degrees of atracurium-induced neuromuscular blockade: doseeffect relationship for neostigmine. Anesthesiology. 2010;112(1):34-40.
26. Caldwell JE. Clinical limitations of acetylcholinesterase antagonists. J Crit Care. 2009;24(1):21-8.
27. Bom A, Hope F, Rutherford S, Thomson K. Preclinical pharmacology of sugammadex. J Crit Care. 2009;24(1):29-35.
28. Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology. 2008;109(5):816-24.
29. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg. 2007;104(3):575-81.
30. Claudius C, Karacan H, Viby-Mogensen J. Prolonged residual paralysis after a single intubating dose of rocuronium. Br J Anaesth. 2007;99(4):514-7.
31. Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49(3):312-5.
32. Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2009;110(6):1253-60.
33. Lee C, Katz RL. Clinical implications of new neuromuscular concepts and agents: so long, neostigmine! So long, sux! J Crit Care. 2009;24(1):43-9.
34. Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med. 2007;175(1):9-15.
2. Combes X, Andriamifidy L, Dufresne E, Suen P, Sauvat S, Scherrer E, et al. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007;99(2):276-81.
3. Andersen BN, Madsen JV, Schurizek BA, Juhl B. Residual curarisation: a comparative study of atracurium and pancuronium. Acta Anaesthesiol Scand. 1988;32(2):79-81.
4. Claudius C, Garvey LH, Viby-Mogensen J. The undesirable effects of neuromuscular blocking drugs. Anaesthesia. 2009;64 Suppl 1:10-21.
5. Craig RG, Hunter JM. Neuromuscular blocking drugs and their antagonists in patients with organ disease. Anaesthesia. 2009;64 Suppl 1:55-65.
6. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minerva Anestesiol. 2006;72(3):97-109.
7. Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111(1):110-9.
8. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. 2010;112(4):1013-22.
9. Capron F, Alla F, Hottier C, Meistelman C, Fuchs-Buder T. Can acceleromyography detect low levels of residual paralysis? A probability approach to detect a mechanomyographic train-of-four ratio of 0.9. Anesthesiology. 2004;100(5):1119-24.
10. Ali HH, Wilson RS, Savarese JJ, Kitz RJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth. 1975;47(5):570-4.
11. Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis at the time of tracheal extubation. Anesth Analg. 2005;100(6):1840-5.
12. Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, et al. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102(2):426-9.
13. Fuchs-Buder T, Hofmockel R, Geldner G, Diefenbach C, Ulm K, Blobner M. [The use of neuromuscular monitoring in Germany]. Anaesthesist. 2003;52(6):522-6.
14. Maybauer DM, Geldner G, Blobner M, Pühringer F, Hofmockel R, Rex C, 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.
15. Fawcett WJ, Dash A, Francis GA, Liban JB, Cashman JN. Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions. Acta Anaesthesiol Scand. 1995;39(3):288-93.
16. Ronald MD. Miller Anestesia. Elsevier ed2011.
17. Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-fourfade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86(4):765-71.
18. Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62(8):806-9.
19. Fuchs-Buder T, Schreiber JU, Meistelman C. Monitoring neuromuscular block: an update. Anaesthesia. 2009;64 Suppl 1:82-9.
20. Claudius C, Viby-Mogensen J. Acceleromyography for use in scientific and clinical practice: a systematic review of the evidence. Anesthesiology. 2008; 108(6):1117-40.
21 Naguib M, Lien CA, Meistelman C. Anesthesia. 6 ed. Philadelphia: Elsevier/ Churchill Livingstone; 2005. Chapter 34, Pharmacology of Neuromuscular Blocking Drugs; 958-994.e8.
22. Cai YR, Xu J, Chen LH, Chi FL. Electromyographic monitoring of facial nerve under different levels of neuromuscular blockade during middle ear microsurgery. Chin Med J (Engl). 2009;122(3):311-4.
23. Jellish WS, Leonetti JP, Buoy CM, Sincacore JM, Sawicki KJ, Macken MP. Facial nerve electromyographic monitoring to predict movement in patients titrated to a standard anesthetic depth. Anesth Analg. 2009;109(2):551-8.
24. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107(1):130-7.
25. Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F. Antagonism of low degrees of atracurium-induced neuromuscular blockade: doseeffect relationship for neostigmine. Anesthesiology. 2010;112(1):34-40.
26. Caldwell JE. Clinical limitations of acetylcholinesterase antagonists. J Crit Care. 2009;24(1):21-8.
27. Bom A, Hope F, Rutherford S, Thomson K. Preclinical pharmacology of sugammadex. J Crit Care. 2009;24(1):29-35.
28. Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology. 2008;109(5):816-24.
29. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg. 2007;104(3):575-81.
30. Claudius C, Karacan H, Viby-Mogensen J. Prolonged residual paralysis after a single intubating dose of rocuronium. Br J Anaesth. 2007;99(4):514-7.
31. Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49(3):312-5.
32. Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2009;110(6):1253-60.
33. Lee C, Katz RL. Clinical implications of new neuromuscular concepts and agents: so long, neostigmine! So long, sux! J Crit Care. 2009;24(1):43-9.
34. Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med. 2007;175(1):9-15.