Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine

S. R. Thilen, I. C. Ng, K. C. Cain, Miriam Treggiari, S. M. Bhananker

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background: Neuromuscular block using subjective monitoring and neostigmine reversal is commonly associated with postoperative residual neuromuscular block. We tested whether a protocol for the management of neuromuscular block that specified appropriate dosing and optimal neostigmine reversal was associated with a reduction in PRNB. Methods: Rocuronium administration was guided by surgical requirements and based on the ideal body weight, with dose reductions for female sex and age >55 yr. Neostigmine was administered in adjusted doses after a train-of-four count of four was confirmed at the thumb. The protocol ensured a minimum of 10 min between neostigmine administration and tracheal extubation. We measured the PRNB in patients undergoing abdominal surgery before and after the introduction of the protocol. Pre-specified primary and secondary endpoints were incidence of postoperative residual neuromuscular block and severe postoperative residual neuromuscular block at the time of tracheal extubation, defined as normalised train-of-four ratios <0.9 and <0.7, respectively. Results: The incidence of postoperative residual neuromuscular block at tracheal extubation was 14/40 (35%) for patients managed according to the protocol compared with 22/38 (58%) for patients in the control group, odds ratio of 0.39, and 95% confidence interval of 0.14–1.07; P=0.068. The incidence of severe postoperative residual neuromuscular block at tracheal extubation showed a highly significant difference, odds ratio=0.06, and confidence interval of 0.00–0.43; P=0.001. Conclusions: The incidence of severe postoperative residual neuromuscular block was significantly reduced after the protocol was introduced. Given the limitations inherent in this before-and-after study, further research is needed to confirm these results. Clinical trial registration: NCT02660398.

Original languageEnglish (US)
JournalBritish Journal of Anaesthesia
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Delayed Emergence from Anesthesia
Neostigmine
Neuromuscular Blockade
Airway Extubation
Incidence
Odds Ratio
Confidence Intervals
Ideal Body Weight
Thumb
rocuronium
Clinical Trials
Control Groups

Keywords

  • muscle weakness/chemically induced
  • neostigmine
  • neuromuscular blocking agents
  • rocuronium

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine. / Thilen, S. R.; Ng, I. C.; Cain, K. C.; Treggiari, Miriam; Bhananker, S. M.

In: British Journal of Anaesthesia, 01.01.2018.

Research output: Contribution to journalArticle

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abstract = "Background: Neuromuscular block using subjective monitoring and neostigmine reversal is commonly associated with postoperative residual neuromuscular block. We tested whether a protocol for the management of neuromuscular block that specified appropriate dosing and optimal neostigmine reversal was associated with a reduction in PRNB. Methods: Rocuronium administration was guided by surgical requirements and based on the ideal body weight, with dose reductions for female sex and age >55 yr. Neostigmine was administered in adjusted doses after a train-of-four count of four was confirmed at the thumb. The protocol ensured a minimum of 10 min between neostigmine administration and tracheal extubation. We measured the PRNB in patients undergoing abdominal surgery before and after the introduction of the protocol. Pre-specified primary and secondary endpoints were incidence of postoperative residual neuromuscular block and severe postoperative residual neuromuscular block at the time of tracheal extubation, defined as normalised train-of-four ratios <0.9 and <0.7, respectively. Results: The incidence of postoperative residual neuromuscular block at tracheal extubation was 14/40 (35{\%}) for patients managed according to the protocol compared with 22/38 (58{\%}) for patients in the control group, odds ratio of 0.39, and 95{\%} confidence interval of 0.14–1.07; P=0.068. The incidence of severe postoperative residual neuromuscular block at tracheal extubation showed a highly significant difference, odds ratio=0.06, and confidence interval of 0.00–0.43; P=0.001. Conclusions: The incidence of severe postoperative residual neuromuscular block was significantly reduced after the protocol was introduced. Given the limitations inherent in this before-and-after study, further research is needed to confirm these results. Clinical trial registration: NCT02660398.",
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