Postoperative residual curarization at the post-anesthetic care unit of a university hospital: A cross-sectional study
Keywords:
Neuromuscular blocking agents, Anesthesia, Perioperative period, Prevalence, Delayed emergence from anesthesia
Abstract
Introduction: Postoperative residual curarization has been related to postoperative complications.
Objective: To determine the prevalence of postoperative residual curarization in a university hospital and its association with perioperative conditions.
Method: A prospective registry of 102 patients in a period of 4 months was designed to include ASA I-II patients who intraoperatively received nondepolarizing neuromuscular blockers. Abductor pollicis response to a train-of-four stimuli based on accelleromyography and thenar eminence temperature (TOF-Watch SX®. Organon, Ireland) was measured immediately upon arrival at the postanesthetic care unit and 30 s later. Uni-bivariate analysis was planned to determine possible associations with residual curarization, defined as two repeated values of T4/T1 ratio <0.90 in response to train-of-four stimuli.
Results: Postoperative residual curarization was detected in 42.2% of the subjects. Pancuronium was associated with a high risk for train-of-four response <0.9 at the arrive at postoperative care unit [RR:2.56 (IC95% 1.99-3.30); p = 0.034]. A significant difference in thenar temperature (°C) was found in subjects with train-of-four <0.9 when compared to those who reach adequate neuromuscular function (29.9 ± 1.6 vs. 31.1 ± 2.2; respectively. p = 0.003). However, we were unable to demonstrate a direct attribution of findings in train-of-four response to temperature (R2 determination coefficient = 0.08%).
Conclusions: A high prevalence of postoperative residual curarization persists in university hospitals, despite a reduced use of "long-lasting" neuromuscular blockers. Strategies to assure neuromuscular monitoring practice and access to therapeutic alternatives in this setting must be considered. Intraoperative neuromuscular blockers using algorithms and continued education in this field must be priorities within anesthesia services.
References
1. Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86:765-71.
2. Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth. 2000;84:301-3.
3. Mathias LAST, Bernardis RCG. Parálisis residual postoperatoria. Rev Brass Anestesiol. 2012;62:439-50.
4. Viby-Mogensen J, J0rgensen BC, Ording H. Residual curarization in the recovery room. Anesthesiology. 1979;50:539-41.
5. Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312-8.
6. Debaene B, Plaud B, Dilly M-P, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98:1042-8.
7. Tsai C-C, Chung H-S, Chen P-L, Yu C-M, Chen M-S, Hong C-L. Postoperative residual curarization: clinical observation in the post-anesthesia care unit. Chang Gung Med J. 2008;31:364-8.
8. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minerva Anestesiol. 2006;72:97-109.
9. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111:120-8.
10. Eriksson LI. The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation. Anesth Analg. 1999;89:243-51.
11. Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth. 2010;105:304-9.
12. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98:302-16.
13. Khan S, Divatia JV, Sareen R. Comparison of residual neuromuscular blockade between two intermediate acting nondepolarizing neuromuscular blocking agents-rocuronium and vecuronium. Indian J Anaesth. 2006;50:115-7.
14. García MP, Sergi N, Finkel DM. Incidencia de bloqueo neuromuscular residual al ingreso en la unidad de recuperación postanestésica. Rev argent anestesiol. 2006;64:121-9.
15. Lema Flórez E, Tafur LA, Lucía Giraldo A. Aproximación al conocimiento de los hábitos que tienen los anestesiólogos en el uso de relajantes neuromusculares no despolarizantes y sus reversores, Valle del Cauca, Colombia. Rev Colomb Anestesiol. 2012;40:113-8.
16. Reyes L, Muñoz L, Orozco D, Arias C, Vergel V,Valencia A. Variabilidad clínica del vecuronio. Experiencia en una institución en Colombia. Rev Colomb Anestesiol. 2012;40:251-5.
17. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010;111:129-40.
18. Helbo-Hansen HS, Bang U, Nielsen HK, Skovgaard LT. The accuracy of train-of-four monitoring at varying stimulating currents. Anesthesiology. 1992;76:199-203.
19. Taylor NAS, Tipton MJ, Kenny GP. Considerations for the measurement of core, skin and mean body temperatures. J Therm Biol. 2014;46:72-101.
20. Bevan DR, Smith CE, Donati F. Postoperative neuromuscular blockade: a comparison between atracurium, vecuronium, and pancuronium. Anesthesiology. 1988;69:272-6.
21. Howardy-Hansen P, M0ller J, Hansen B. Pretreatment with atracurium: the influence on neuromuscular transmission and pulmonary function. Acta Anaesthesiol Scand. 1987;31:642-4.
22. Pedersen T, Viby-Mogensen J, Bang U, Olsen NV, Jensen E, Engboek J. Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade? Anesthesiology. 1990;73:835-9.
23. Kopman AF, Ng J, Zank LM, Neuman GG, Yee PS. Residual postoperative paralysis. Pancuronium versus mivacurium, does it matter? Anesthesiology. 1996;85:1253-9.
24. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095-103.
25. McEwin L, Merrick PM, Bevan DR. Residual neuromuscular blockade after cardiac surgery: pancuronium vs. rocuronium. Can J Anaesth. 1997;44:891-5.
26. Bissinger U, Schimek F, Lenz G. Postoperative residual paralysis and respiratory status: a comparative study of pancuronium and vecuronium. Physiol Res. 2000;49:455-62.
27. Baillard C, Gehan G, Reboul-Marty J, Larmignat P, Samama CM, Cupa M. Residual curarization in the recovery room after vecuronium. Br J Anaesth. 2000;84:394-5.
28. Kim KS, Lew SH, Cho HY, Cheong MA. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656-60.
29. Murphy GS, Szokol JW, Marymont JH, Vender JS, Avram MJ, Rosengart TK, et al. Recovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium. Anesth Analg. 2003;96:1301-7.
30. Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia care unit recovery times and neuromuscular blocking drugs: a prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium. Anesth Analg. 2004;98:193-200.
31. Barajas R, Camarena J, Castellanos A, Castilleros OA, Castorena G, de Anda D, et al. Determinación de la incidencia de la parálisis residual postanestésica con el uso de agentes bloqueadores neuromusculares en méxico. Rev Mex Anestesiol. 2011;34:181-8.
32. Fabregat López J, Candia Arana CA, Castillo Monzón CG. La monitorización neuromuscular y su importancia en el uso de los bloqueantes neuromusculares. Re Colomb Anestesiol. 2012;40:293-303.
33. Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49:312-5.
34. Pühringer FK, Heier T, Dodgson M, Erkola O, Goonetilleke P, Hofmockel R, et al. Double-blind comparison of the variability in spontaneous recovery of cisatracurium- and vecuronium-induced neuromuscular block in adult and elderly patients. Acta Anaesthesiol Scand. 2002;46:364-71.
35. Ariza Cadena F. Estrategias para disminuir los eventos adversos más frecuentes relacionados con bloqueadores neuromusculares. Rev Colomb Anestesiol. 2012;40:127-30.
36. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008;109:389-98.
37. Rincón PG. Incidencia de bloqueo neuromuscular residual en recuperacion con relajantes de accion intermedia en la practica diaria. Rev Colomb Anestesiol. 1999;27:309-17.
38. Van Oldenbeek C, Knowles P, Harper NJ. Residual neuromuscular block caused by pancuronium after cardiac surgery. Br J Anaesth. 1999;83:338-9.
2. Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth. 2000;84:301-3.
3. Mathias LAST, Bernardis RCG. Parálisis residual postoperatoria. Rev Brass Anestesiol. 2012;62:439-50.
4. Viby-Mogensen J, J0rgensen BC, Ording H. Residual curarization in the recovery room. Anesthesiology. 1979;50:539-41.
5. Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312-8.
6. Debaene B, Plaud B, Dilly M-P, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003;98:1042-8.
7. Tsai C-C, Chung H-S, Chen P-L, Yu C-M, Chen M-S, Hong C-L. Postoperative residual curarization: clinical observation in the post-anesthesia care unit. Chang Gung Med J. 2008;31:364-8.
8. Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period. Minerva Anestesiol. 2006;72:97-109.
9. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111:120-8.
10. Eriksson LI. The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation. Anesth Analg. 1999;89:243-51.
11. Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth. 2010;105:304-9.
12. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98:302-16.
13. Khan S, Divatia JV, Sareen R. Comparison of residual neuromuscular blockade between two intermediate acting nondepolarizing neuromuscular blocking agents-rocuronium and vecuronium. Indian J Anaesth. 2006;50:115-7.
14. García MP, Sergi N, Finkel DM. Incidencia de bloqueo neuromuscular residual al ingreso en la unidad de recuperación postanestésica. Rev argent anestesiol. 2006;64:121-9.
15. Lema Flórez E, Tafur LA, Lucía Giraldo A. Aproximación al conocimiento de los hábitos que tienen los anestesiólogos en el uso de relajantes neuromusculares no despolarizantes y sus reversores, Valle del Cauca, Colombia. Rev Colomb Anestesiol. 2012;40:113-8.
16. Reyes L, Muñoz L, Orozco D, Arias C, Vergel V,Valencia A. Variabilidad clínica del vecuronio. Experiencia en una institución en Colombia. Rev Colomb Anestesiol. 2012;40:251-5.
17. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010;111:129-40.
18. Helbo-Hansen HS, Bang U, Nielsen HK, Skovgaard LT. The accuracy of train-of-four monitoring at varying stimulating currents. Anesthesiology. 1992;76:199-203.
19. Taylor NAS, Tipton MJ, Kenny GP. Considerations for the measurement of core, skin and mean body temperatures. J Therm Biol. 2014;46:72-101.
20. Bevan DR, Smith CE, Donati F. Postoperative neuromuscular blockade: a comparison between atracurium, vecuronium, and pancuronium. Anesthesiology. 1988;69:272-6.
21. Howardy-Hansen P, M0ller J, Hansen B. Pretreatment with atracurium: the influence on neuromuscular transmission and pulmonary function. Acta Anaesthesiol Scand. 1987;31:642-4.
22. Pedersen T, Viby-Mogensen J, Bang U, Olsen NV, Jensen E, Engboek J. Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade? Anesthesiology. 1990;73:835-9.
23. Kopman AF, Ng J, Zank LM, Neuman GG, Yee PS. Residual postoperative paralysis. Pancuronium versus mivacurium, does it matter? Anesthesiology. 1996;85:1253-9.
24. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095-103.
25. McEwin L, Merrick PM, Bevan DR. Residual neuromuscular blockade after cardiac surgery: pancuronium vs. rocuronium. Can J Anaesth. 1997;44:891-5.
26. Bissinger U, Schimek F, Lenz G. Postoperative residual paralysis and respiratory status: a comparative study of pancuronium and vecuronium. Physiol Res. 2000;49:455-62.
27. Baillard C, Gehan G, Reboul-Marty J, Larmignat P, Samama CM, Cupa M. Residual curarization in the recovery room after vecuronium. Br J Anaesth. 2000;84:394-5.
28. Kim KS, Lew SH, Cho HY, Cheong MA. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656-60.
29. Murphy GS, Szokol JW, Marymont JH, Vender JS, Avram MJ, Rosengart TK, et al. Recovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium. Anesth Analg. 2003;96:1301-7.
30. Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia care unit recovery times and neuromuscular blocking drugs: a prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium. Anesth Analg. 2004;98:193-200.
31. Barajas R, Camarena J, Castellanos A, Castilleros OA, Castorena G, de Anda D, et al. Determinación de la incidencia de la parálisis residual postanestésica con el uso de agentes bloqueadores neuromusculares en méxico. Rev Mex Anestesiol. 2011;34:181-8.
32. Fabregat López J, Candia Arana CA, Castillo Monzón CG. La monitorización neuromuscular y su importancia en el uso de los bloqueantes neuromusculares. Re Colomb Anestesiol. 2012;40:293-303.
33. Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49:312-5.
34. Pühringer FK, Heier T, Dodgson M, Erkola O, Goonetilleke P, Hofmockel R, et al. Double-blind comparison of the variability in spontaneous recovery of cisatracurium- and vecuronium-induced neuromuscular block in adult and elderly patients. Acta Anaesthesiol Scand. 2002;46:364-71.
35. Ariza Cadena F. Estrategias para disminuir los eventos adversos más frecuentes relacionados con bloqueadores neuromusculares. Rev Colomb Anestesiol. 2012;40:127-30.
36. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008;109:389-98.
37. Rincón PG. Incidencia de bloqueo neuromuscular residual en recuperacion con relajantes de accion intermedia en la practica diaria. Rev Colomb Anestesiol. 1999;27:309-17.
38. Van Oldenbeek C, Knowles P, Harper NJ. Residual neuromuscular block caused by pancuronium after cardiac surgery. Br J Anaesth. 1999;83:338-9.
How to Cite
1.
Ariza F, Dorado F, Enríquez LE, González V, Gómez JM, Chaparro-Mendoza K, et al. Postoperative residual curarization at the post-anesthetic care unit of a university hospital: A cross-sectional study. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Apr. 23];45(1):15-21. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/42
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2017-01-01
How to Cite
1.
Ariza F, Dorado F, Enríquez LE, González V, Gómez JM, Chaparro-Mendoza K, et al. Postoperative residual curarization at the post-anesthetic care unit of a university hospital: A cross-sectional study. Colomb. J. Anesthesiol. [Internet]. 2017 Jan. 1 [cited 2024 Apr. 23];45(1):15-21. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/42
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