From the Departments of Anesthesiology and Pain Medicine.
Medicine, University of Washington, Seattle, Washington.
Anesth Analg. 2023 Jun 1;136(6):1143-1153. doi: 10.1213/ANE.0000000000006510. Epub 2023 May 19.
Postoperative residual neuromuscular blockade (PRNB) is defined as an adductor pollicis train-of-four ratio (TOFR) <0.9. It is a common postoperative complication when nondepolarizing muscle relaxants are either not reversed or reversed with neostigmine. PRNB has been reported in 25% to 58% of patients who receive intermediate-acting nondepolarizing muscle relaxants, and it is associated with increased morbidity and decreased patient satisfaction. We conducted a prospective descriptive cohort study during the implementation of a practice guideline that included the selective use of sugammadex or neostigmine. The primary study aim of this pragmatic study was to estimate the incidence of PRNB at arrival to the postanesthesia care unit (PACU) when the practice guideline is followed.
We enrolled patients undergoing orthopedic or abdominal surgery requiring neuromuscular blockade. Rocuronium administration was guided by surgical requirements and based on ideal body weight, with dose reductions for women and/or age >55 years. Only qualitative monitoring was available to the anesthesia providers, and selection of sugammadex or neostigmine was guided by tactile assessments of the response to train-of-four (TOF) stimulation by a peripheral nerve stimulator. Neostigmine was administered if no fade was detected in the TOF response at the thumb. Deeper blocks were reversed with sugammadex. The prespecified primary and secondary end points were the incidence of PRNB at arrival to the PACU, defined as a normalized TOFR (nTOFR) < 0.9, and severe PRNB, defined as nTOFR <0.7 on arrival to the PACU. Anesthesia providers were blinded to all quantitative measurements made by research staff.
Analysis included 163 patients, and 145 underwent orthopedic and 18 abdominal surgeries. Of the 163 patients, 92 (56%) were reversed with neostigmine and 71 (44%) with sugammadex. The overall incidence of PRNB at PACU arrival was 5 of 163 or 3% (95% confidence interval [CI], 1-7). The incidence of severe PRNB in PACU was 1% (95% CI, 0-4). Three of the 5 subjects with PRNB had TOFR <0.4 at time of reversal but were given neostigmine since anesthesia providers detected no fade by qualitative assessment.
The use of a protocol that specifies rocuronium dosing and selective use of sugammadex versus neostigmine based on qualitative assessment of TOF count and fade allowed us to achieve an incidence of PRNB of 3% (95% CI, 1-7) at PACU arrival. Quantitative monitoring may be needed to further reduce this incidence.
术后残余神经肌肉阻滞（PRNB）定义为拇内收肌四个成串刺激（TOFR）<0.9。当非去极化肌松药未被逆转或用新斯的明逆转时，这是一种常见的术后并发症。接受中效非去极化肌松药的患者中，有 25%至 58%发生 PRNB，它与发病率增加和患者满意度降低有关。我们在实施一项实践指南时进行了一项前瞻性描述性队列研究，该指南包括选择性使用琥珀胆碱或新斯的明。这项实用研究的主要研究目的是在遵循实践指南时，估计到达麻醉后恢复室（PACU）时 PRNB 的发生率。
我们招募了接受骨科或腹部手术的患者，这些手术需要神经肌肉阻滞。罗库溴铵的给药根据手术要求和理想体重进行指导，对于女性和/或年龄>55 岁的患者进行剂量减少。麻醉提供者只能进行定性监测，琥珀胆碱或新斯的明的选择根据外周神经刺激器对 TOF 刺激的反应的触觉评估进行指导。如果拇指处的 TOF 反应没有衰减，则给予新斯的明。深度阻滞用琥珀胆碱逆转。预定的主要和次要终点是到达 PACU 时 PRNB 的发生率，定义为标准化 TOFR（nTOFR）<0.9，到达 PACU 时严重 PRNB 的发生率，定义为 nTOFR<0.7。麻醉提供者对研究人员进行的所有定量测量均不知情。
分析纳入了 163 名患者，其中 145 名接受了骨科手术，18 名接受了腹部手术。在 163 名患者中，92 名（56%）用新斯的明逆转，71 名（44%）用琥珀胆碱逆转。到达 PACU 时 PRNB 的总体发生率为 163 例中的 5 例或 3%（95%置信区间[CI]，1-7）。PACU 中严重 PRNB 的发生率为 1%（95%CI，0-4）。在 5 名发生 PRNB 的患者中，有 3 名在逆转时 TOFR<0.4，但由于麻醉提供者通过定性评估检测到无衰减，因此给予了新斯的明。
使用一种方案，根据 TOF 计数和衰减的定性评估，指定罗库溴铵的剂量，并选择性使用琥珀胆碱与新斯的明，我们能够使到达 PACU 时的 PRNB 发生率达到 3%（95%CI，1-7）。可能需要进行定量监测以进一步降低这一发生率。
