Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1016/j.bjane.2017.02.003
Brazilian Journal of Anesthesiology
Scientific Article

Use of protocol and evaluation of postoperative residual curarization incidence in the absence of intraoperative acceleromyography - Randomized clinical trial

Aplicação de protocolo e avaliação da incidência de curarização residual pós-operatória na ausência de aceleromiografia intraoperatória - Ensaio clínico randomizado

Filipe Nadir Caparica Santos; Angelica de Fátima de Assunção Braga; Carla Josefine Barbosa de Lima Ribeiro; Franklin Sarmento da Silva Braga; Vanessa Henriques Carvalho; Fernando Eduardo Feres Junqueira

http://dx.doi.org/10.1016/j.bjane.2017.02.003 Braz J Anesthesiol, vol.67, n6, p.592-599, 2017
PDF English
PDF Português
Downloads: 0
Views: 964

Abstract

Abstract Objective Evaluate the incidence of postoperative residual curarization (PORC) in the post-anesthesia care unit (PACU) after the use of protocol and absence of intraoperative acceleromyography (AMG). Methods Randomized clinical trial with 122 patients allocated into two groups (protocol and control). Protocol group received initial and additional doses of rocuronium (0.6 mg·kg-1 and 10 mg, respectively); the use of rocuronium was avoided in the final 45 min; blockade reversal with neostigmine (50 µg·kg-1); time ≥15 min between reversion and extubation. Control: initial and additional doses of rocuronium, blockade reversal, neostigmine dose, and extubation time, all at the discretion of the anesthesiologist. AMG was used in the PACU and PORC considered at T4/T1 ratio <1.0. Results The incidence of PORC was lower in protocol group than in control group (25% vs. 45.2%, p = 0.02). In control group, total dose of rocuronium was higher in patients with PORC than without PORC (0.43 vs. 0.35 mg·kg-1·h-1, p = 0.03) and the time interval between the last administration of rocuronium and neostigmine was lower (75.0 vs. 101.0 min, p < 0.01). In protocol group, there was no difference regarding the analyzed parameters (with PORC vs. without PORC). Considering the entire study population and the presence or absence of PORC, total dose of rocuronium was higher in patients with PORC (0.42 vs. 0.31 mg·kg-1·h-1, p = 0.01), while the time interval between the last administration of rocuronium and neostigmine was lower (72.5 vs. 99.0 min, p ≤ 0.01). Conclusion The proposed systematization reduced PORC incidence in PACU in the absence of intraoperative AMG.

Keywords

Neuromuscular blockers, Rocuronium, Neostigmine, Postoperative residual curarization, Quantitative neuromuscular monitoring, Acceleromyography

Resumo

Resumo Objetivo Avaliou-se a incidência de curarização residual pós-operatória (CRPO) na sala de recuperação pós-anestésica (SRPA) após emprego de protocolo e ausência de aceleromiografia (AMG) intraoperatória. Métodos Ensaio clínico, aleatório, com 122 pacientes, distribuídas em dois grupos: protocolo e controle. Protocolo: dose inicial e adicionais de rocurônio foram de 0,6 mg.kg-1 e 10 mg, respectivamente; evitou-se o uso de rocurônio nos 45 minutos finais; reversão do bloqueio com neostigmina (50 µg.kg-1); tempo ≥ 15 minutos entre reversão e extubação. Controle: doses inicial e adicional de rocurônio, reversão do bloqueio, dose de neostigmina e momento da extubação decididos pelo anestesiologista. Foi usada AMG na SRPA e considerado CRPO razão T4/T1 < 1,0. Resultados A incidência de CRPO foi menor no grupo protocolo em relação ao controle (25% vs. 45,2%; p = 0,02). No grupo controle, a dose total de rocurônio foi maior em pacientes com CRPO em relação àqueles sem CRPO (0,43 vs. 0,35 mg.kg-1.h-1; p = 0,03) e o intervalo entre a última administração de rocurônio e a neostigmina foi menor (75,0 vs. 101,0 min; p < 0,01). No grupo protocolo não houve diferença dos parâmetros analisados (com CRPO vs. sem CRPO). Considerando toda a população de estudo e a presença ou não de CRPO, a dose total de rocurônio foi maior em pacientes com CRPO (0,42 vs. 0,31 mg.kg-1.h-1; p = 0,01), enquanto o intervalo entre a última administração de rocurônio e a neostigmina foi menor (72,5 vs. 99,0 min; p ≤ 0,01). Conclusão A sistematização proposta reduziu a incidência de CRPO na SRPA na ausência de AMG intraoperatória.

Palavras-chave

Bloqueadores neuromusculares, Rocurônio, Neostigmina, Curarização residual pós-operatória, Monitoração neuromuscular quantitativa, Aceleromiografia

References

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.

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.

Yu B, Ouyang B, Ge S. Incidence of postoperative residual neuromuscular blockade after general anesthesia: a prospective, multicenter, anesthetist-blind, observational study. Curr Med Res Opin. 2016;32:1-9.

Debaene B, Plaud B, Dilly MP. 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.

Hayes AH, Mirakhur RK, Breslin DS. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312-8.

Videira RL, Vieira JE. What rules of thumb do clinicians use to decide whether to antagonize nondepolarizing neuromuscular blocking drugs?. Anesth Analg. 2011;113:1192-6.

Murphy GS, Szokol JW, Avram MJ. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology. 2011;115:946-54.

Esteves S, Martins M, Barros F. Incidence of postoperative residual neuromuscular blockade in the postanaesthesia care unit: an observational multicentre study in Portugal. Eur J Anaesthesiol. 2013;30:243-9.

Naguib M, Kopman AF, Lien CA. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111:110-9.

Kim KS, Cheong MA, Lee HJ. Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockade during propofol or sevoflurane anesthesia. Anesth Analg. 2004;99:1080-5.

Sasaki N, Meyer MJ, Malviya SA. Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes: a prospective study. Anesthesiology. 2014;121:959-68.

Kopman AF, Naguib M. Neostigmine: you can't have it both ways. Anesthesiology. 2015;123:231-3.

Meyer MJ, Sasaki N, Eikermann M. In reply. Anesthesiology. 2015;123:233-4.

McLean DJ, Diaz-Gil D, Farhan HN. Dose-dependent association between intermediate-acting neuromuscular-blocking agents and postoperative respiratory complications. Anesthesiology. 2015;122:1201-13.

Butterly A, Bittner EA, George E. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth. 2010;105:304-9.

Lien CA. Neostigmine: how much is necessary for patients who receive a nondepolarizing neuromuscular blocking agent?. Anesthesiology. 2010;112:16-8.

Fuchs-Buder T, Meistelman C, Alla F. Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine. Anesthesiology. 2010;112:34-40.

Fuchs-Buder T, Claudius C, Skovgaard LT. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007;51:789-808.

Piccioni F, Mariani L, Bogno L. An acceleromyographic train-of-four ratio of 1.0 reliably excludes respiratory muscle weakness after major abdominal surgery: a randomized double-blind study. Can J Anaesth. 2014;61:641-9.

Capron F, Alla F, Hottier C. Can acceleromyography detect low levels of residual paralysis? A probability approach to detect a mechanomyographic train-of-four ratio of 0.9. Anesthesiology. 2004;100:1119-24.

Claudius C, Skovgaard LT, Viby-Mogensen J. Is the performance of acceleromyography improved with preload and normalization? A comparison with mechanomyography. Anesthesiology. 2009;110:1261-70.

Kim KS, Lew SH, Cho HY. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656-60.

Arbous MS, Meursing AE, van Kleef JW. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology. 2005;102:257-68.

Kopman AF, Eikermann M. Antagonism of non-depolarising neuromuscular block: current practice. Anaesthesia. 2009;64:22-30.

Kopman AF, Lien CA, Naguib M. Determining the potency of neuromuscular blockers: are traditional methods flawed?. Br J Anaesth. 2010;104:705-10.

Fortier LP, McKeen D, Turner K. The RECITE study: a Canadian prospective, multicenter study of the incidence and severity of residual neuromuscular blockade. Anesth Analg. 2015;121:366-72.

5dcc61360e88252230bf58f1 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections