The latest survey examined neuromuscular block management practices in Europe. The study and its conclusions along with the latest guidelines by the European Society of Anaesthesiology and Intensive Care (ESAIC) are discussed in this article. 

The study

The most recent study looked at how neuromuscular block management is done in Europe.

In this study, 17,150 patients received a neuromuscular blocking agent. Still, more than 10 000 of them did not have neuromuscular monitoring (NMM), about 12,000 patients had their extubation timing determined solely by clinical criteria, and more than 8300 patients did not receive a reversal agent at the conclusion of their surgery.

Furthermore, only 16.5% of patients (2839/17 150) treated with a neuromuscular blocking drug were extubated with a verified train-of-four (TOF) ratio of at least 0.9. Consequently, the risk of persistent paralysis and relaxant-associated postoperative pulmonary complications (POPCs) rose due to the very high frequency of improper treatment of neuromuscular block.

Is it required to use muscle relaxants to make tracheal intubation easier?

ESAIC guidelines advise:

1. To aid tracheal intubation, employing a muscle relaxant (1A).
2. To lessen pharyngeal and/or laryngeal damage during endotracheal intubation (1C), use muscle relaxants.
3. Using a quick-acting muscle relaxant for RSII, such as succinylcholine 1 mg kg-1 or rocuronium 0.9 to 1.2 mg kg-1 (1B).

Does the degree of neuromuscular blockade during abdominal surgery, such as a laparotomy or a laparoscopy, affect the results for the patient?

1. If surgical circumstances need to be improved, we advise deepening neuromuscular blockade (1B).
2. There is not enough data to support the use of deep neuromuscular blockade to prevent perioperative problems or lessen postoperative pain in general. (2C).

What methods are used to identify and treat residual neuromuscular paralysis?

1. To rule out residual paralysis, ESAIC guidelines advise using ulnar nerve stimulation and quantitative NMM at the adductor pollicis muscle. (1B)
2. Sugammadex is advised to counteract the deep, moderate, and shallow neuromuscular blockade brought on by amino steroidal drugs (rocuronium, vecuronium) (deep: post-tetanic count >1 and TOF count 0; moderate: TOF count 1 to 3; shallow: TOF count 4 and TOF ratio 0.4). (1A)
3. ESAIC guidelines advise delaying the use of neostigmine-based reversal until advanced spontaneous recovery (i.e., a TOF-ratio >0.2) has occurred and delaying quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been reached. (1C)

Concluding remarks

In order to increase patient safety, the European Society of Anesthesiology and Intensive Care has released its first set of guidelines on the peri-operative management of neuromuscular blockade. The guidance has been purposefully restricted to three clinically relevant core issues to make its implementation in current clinical practice easier: the importance of neuromuscular blocking agents for tracheal intubation, the role of neuromuscular blocking agents in improving surgical conditions, and the importance of NMM and pharmacological reversal to reduce POPCs and residual paralysis.

1. The authors' key finding is that any choice about a neuromuscular reversal method, whether it be neostigmine-based, sugammadex-based, or spontaneous, should be based on reliable quantitative NMM.
2. It is necessary to acknowledge the qualitative NMM with PNS's inability to detect a TOF ratio of at least 0.9.
3. Both tactile examinations of TOF and DBS (double burst stimulation) cannot validate these levels of recovery since no fading can be seen when the TOF ratio is greater than 0.4 and 0.6, respectively. Thus, visible fade after TOF or DBS stimulation is a certain indicator of insufficient neuromuscular recovery, but the absence of fade does not rule out the presence of persistent paralysis.
4. The use of 100-Hz, 5-s tetanus also failed to properly rule out any lingering paralysis. It has a low sensitivity since around 50 per cent of individuals with no remaining paralysis will show manually observable fading. In addition, despite the lack of fade after a 100-Hz, 5-s treatment, one of the four patients still showed persistent paralysis.
5. Quantitative NMM is not a silver bullet that magically produces accurate results, however. The majority of devices need calibration or the establishment of a baseline value before relaxing; otherwise, their efficacy is considerably diminished.
6. Quantitative NMM is often only used after the conclusion of surgery in modern clinical practice, especially if many operating rooms share the same instrument. However, even quantitative (uncalibrated, non-normalised) NMM is unable to consistently rule out residual paralysis in this situation. Because of this, the availability of quantitative NMM in every operating room is a must for its proper usage.

Recent research has shown that persistent paralysis occurs in 2% of patients after sugammadex but in 24% of patients when neostigmine was utilised, proving that residual paralysis is more prevalent following neostigmine-based reversal than after sugammadex. This results in a 4.5 NNT (number required to treat) and a 22% absolute risk decrease. In other words, a sugammadex-based reversal technique may avoid residual paralysis in one out of four or five patients; however, this is not the only advantage, since solid data also points to a considerable decrease in the incidence of POPC.

A recent Cochrane review found that sugammadex had a superior safety profile than neostigmine regarding the risk of both reversal techniques (risk ratio, 0.6; 95% CI, 0.49 to 0.74; 28 trials, n = 2298). There are a few incidences of anaphylaxis after sugammadex.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.