Anesthesiology Department, Virginia Mason Medical Center, Seattle, Washington.
Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington.
Anesthesiology. 2022 Jun 1;136(6):901-915. doi: 10.1097/ALN.0000000000004174.
Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis.
The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes.
From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001).
In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.
通过定量神经肌肉监测可以避免残余神经肌肉阻滞。作者开展了一项专业实践计划，目的是在所有患者中实现记录的四成比大于或等于 0.9，以减少残余瘫痪，从而改善患者预后。
作者利用设备试验、教育视频、所有麻醉位置的定量监测器以及具有实时警报的电子临床决策支持系统，并启动了一项正在进行的专业实践指标。这是对记录在案的四成比大于或等于 0.9 的患者（2016 年至 2020 年）的回顾性评估。手动审查麻醉记录以获取神经肌肉阻滞管理细节。对接受神经肌肉阻滞剂药物的手术患者的病历进行电子搜索，以获取患者特征和结果。
从实施前到实施后，更多的患者被分配到美国麻醉医师协会身体状况 III 至 V 级，更少的患者是住院患者，罗库溴铵的平均剂量更高，更多的患者在反转前的四成计数小于 4。手动审查的麻醉记录（n=2807）中有 2 例（1%）2016 年 11 月记录的四成比大于或等于 0.90，低于 2020 年 12 月的病例（250 例中有 269 例[93%]）。实施后（2020 年 2 月 1 日至 2020 年 12 月 31 日），在 935 例患者中，有 856 例（92%）使用琥珀酸舒更葡糖（650 例中有 935 例）、新斯的明（195 例中有 935 例）和无逆转（90 例中有 935 例）达到四成比大于或等于 0.90。在电子搜索的病历中（n=20181），实施后住院患者的术后恢复室停留时间更短（差异 7%；中位数[分钟] [25%，75%分位数区间]，73[55，102]至 68[49，95]；P<0.001），肺部并发症更少（差异 43%；4381 例中有 94 例[2.3%]，1817 例中有 23 例[1.3%]；P=0.010；-1.0%差异[95%置信区间，-1.7 至-0.3%]），住院时间更短（中位数[天数] [25%，75%]，3[2，5]至 2[1，4]；P<0.001）。
在这项专业实践计划中，繁忙的临床实践中 93%的患者记录了四成比大于或等于 0.90。恢复力量的记录是一个中间结果，只是影响患者预后的众多因素之一。
