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Post by katevaughn on Jul 28, 2017 10:54:38 GMT -5
This month’s journal club is presented by Ben Waldbaum. He chose a relevant article pertaining to the recent proposal of neuromuscular reversal administration monitoring. I know you all will find it as a helpful guide in continuing to improve our patient care. Enjoy! Here is a link to the article. Questions to encompass within your response: 1.) One of the challenges of providing quality anesthesia is knowing not only the immediate effects of our clinical decisions, but also the downstream effects such as the one presented in this article. Based on the data in this article, non-reversed patients are significantly more likely to develop post-operative pneumonia. This is in addition to the more immediate complications such as hypoxemia and longer PACU stays. Note the mean time for the last dose of muscle relaxant in the non-reversed group was 67 minutes and in the reversed group was 69 minutes. Are we at the point where we can say the gold standard is to reverse any patient, unless contraindicated, that has received neuromuscular blockade? Should it be considered a quality measure just as antibiotic dose and its administration time are? 2.) Identify possible reasons clinicians may elect for non-reversal (not for contraindicated patients) and barriers to compliance to a policy requiring that all patients receiving muscle relaxant be reversed unless contraindicated.
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Post by dahlia rouchon on Jul 28, 2017 21:33:33 GMT -5
1. Are we at a point where gold standard is to reverse any patient, unless contraindicated? I would say yes, dependent on last dose and time; if it's a defasiculating dose of rocuronium and no further relaxant given for next 5 hours, I do not think I would reverse that say 10mg zemuron. All patients regardless should be monitored with a peripheral nerve stimulator and even better accelerometer. I would not extubate any case without checking residual blockade. Should it be a quality measure like antibiotics? I would say yes but more like a beta blocker quality measure- i.e. was it given? TOF result? is reversal indicated? 2. Reasons for non reversal- and I would include non appropriate reversal in this answer(even when not contraindicated)no nerve stimulator used for case, no working batteries in nerve stimulator, reversal dose was not appropriate to last NMB dose/time given; false impression adequate spontaneous reversal present because of patient movement or perceived adequate spontaneous tidal volumes. 2b. Barriers to compliance for policy for all to be reversed unless contraindicated may include misinformation, or that no reversal should be given as it will cause added paralysis. Lack of availability of nerve stimulator or accelerometer making a provider hesitant to reverse or not reverse the appropriate dose as mentioned above.
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Post by faresha on Jul 30, 2017 14:12:29 GMT -5
1. I do believe that the gold standard should be to reverse any patient that received neuromuscular blockade. I agree with Dahlia that time and dosage is appropriate to consider in deciding to reverse or not but I would prefer that all patients receive reversal despite the dosage or time of neuromuscular blockade administration. I also agree with Dahlia that it should be a quality measure along with TOF.
2. Some patients are so fragile and sick (i.e. cardiac cripple) that the thought of given Glycopyrrolate when not absolutely necessary seems controversial. Also, patients that are pacemaker dependent with an underlying 3rd degree block and baseline HR in 20s may warrant reconsideration of administering Neostigmine especially if the patient may not be as responsive to Glycopyrrolate. Patients with life-threatening underlying cardiac rhythms are a population that would warrant possible noncompliance. Also, long cases that are >8 hours that only received an induction dose of neuromuscular blockade may result in clinicians not wanting to automatically give reversal agents.
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Post by Kristen Horsman on Jul 31, 2017 7:09:20 GMT -5
1.) Are we at the point where we can say the gold standard is to reverse any patient, unless contraindicated, that has received neuromuscular blockade? Should it be considered a quality measure just as antibiotic dose and its administration time are? Yes, I believe it is the gold standard to reverse any patient unless of course contraindicated. It should be a component of the extubation note and provide a comment box for the provider to explain why they chose not to use reversal.
2.) Identify possible reasons clinicians may elect for non-reversal (not for contraindicated patients) and barriers to compliance to a policy requiring that all patients receiving muscle relaxant be reversed unless contraindicated.
Clinicians may elect for non-reversal if the patient only received a defasiculating dose or enough half-lives have elapsed since the last dose of NDMR along with the patient having an appropriate nerve stimulator response, and is clinically appropriate for extubation without reversal. A barrier to compliance may be experienced providers basing their decisions on personal anecdotal "evidence" of success after no reversal.
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Post by Ben Waldbaum on Aug 2, 2017 10:26:58 GMT -5
At this point in time I feel comfortable saying neuromuscular reversal is the gold standard. Evidence has clearly shown that duration of time since last administration or TOF are not accurate determinants of residual muscle relaxation. Given the advent of sugammadex and its lack of cardiovascular effects along with the traditional neostigmine/glycopyrolate, almost no patient would be contraindicated for reversal. Additionally, I think it would be a best practice to document a reason for not administering reversal similar to how we document not administering antibiotics or beta blockers. Given the downstream complications from failure to reverse a patient, it should absolutely be a quality measure. This is a complication we can avoid by ensuring all patient are reversed unless contraindicated.
With any problem, there are always going to be numerous contributing factors. In this case, I think part of the problem is that clinicians sometimes may rely more on experience than evidence. When a clinician chooses to not reverse, and then successfully delivers the patient safely to PACU with no immediate problems, they may infer that they made the correct choice. But what they cannot see is that the patient is now much more likely to develop pneumonia. In this case, evidence must trump experience. Additionally, clinicians may also assume that since there has been an extended period of time since neuromuscular relaxant was administered, or that the TOF is back to baseline, reversal is not needed. Or that since the patient has significant cardiac disease I want to avoid the tachycardia of glycopyrolate not realizing this patient is an ideal candidate for sugammadex. In my opinion, the underlying them is a need for education.
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Post by jhadley on Aug 3, 2017 11:51:00 GMT -5
1. I do believe that reversal should be routine for patients who have received neuromuscular blockade. I have read several articles that have found residual NMB to be a relatively prevalent problem postoperatively, this article supports that evidence. Additionally, our current practice of TOF monitoring is subjective and measuring a true TOF ratio is near impossible. I do think that this could become a quality metric and I like the aforementioned idea that if for some reason a provider does not give reversal they need to make a comment as to why. I also have found that the dosage for reversal with neostigmine is highly subjective based on provider (eg. well they have 4 twitches and it's been awhile since they received any Vecuronium so I'll give X mg). Thankfully, the introduction of Sugammadex has given us more clear guidelines as to how much to give based on the patients TOF.
2. Possible reasons for not reversing a patient have been touched on previously, patients with severe cardiac disease and prolonged length of time since last administration.
Of interest, I wonder if these findings could be duplicated in a future study that looked at patients receiving Sugammadex for reversal rather than neostigmine.
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kty67
New Member
Posts: 22
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Post by kty67 on Aug 7, 2017 12:26:12 GMT -5
1. I think that reversal should be administered if dose given is more than defasiculating 5-10 mg. Even with this small dose some patients can feel weakness if the case was short duration. I believe that reversal is a standard that we have to adhere and, if we don't, we must have to do some kind of documentation why we deviated from standard, like antibiotics or beta blockers. 2. I agree with above reasons why CRNAs would not revers: severe cardiac disease and renal failure, clinician's assumption that NDMR was administered while ago and patient does not show signs of any paralysis.
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mscotth2---password???
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Post by mscotth2---password??? on Aug 7, 2017 14:19:31 GMT -5
1.) Are we at the point where we can say the gold standard is to reverse any patient, unless contraindicated, that has received neuromuscular blockade? Should it be considered a quality measure just as antibiotic dose and its administration time are? Really, with the abundance of literature supporting reversal use, it is probably past time!
2.) Identify possible reasons clinicians may elect for non-reversal (not for contraindicated patients) and barriers to compliance to a policy requiring that all patients receiving muscle relaxant be reversed unless contraindicated. During my tenure in pediatrics the standard has been to reverse regardless of when relaxant was given. If nothing else, just to get weakness out of a failure to fly differential. Practitioners have all sorts of combination cocktails and reasons to reverse or not. We should study that! What I hear most frequently is to minimize nausea and vomiting.
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Post by AugustineEmmanuel on Aug 10, 2017 11:01:33 GMT -5
1. I think that we should consider reversal of NMB as the gold standard however Dahlia brought out a good point about the small doses that some providers use to minimize fasciculation after succs. That would be a grey area and stir up some confusion and legal troubles. 2. I think that the biggest barrier to compliance is misinformation among providers and myths that we often hear and believe without verifying. I've noted some providers not reversing for patients with severe cardiac comorbidities but then again I think doses need to be tailed specifically for the patient.
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Post by Wai-Ling Lo on Aug 17, 2017 15:01:03 GMT -5
1. With all the well-documented hazards from postop residual neuromuscular block, yes, I agree that it should be gold standard to reverse all neuromuscular blockade unless it is contraindicated. Making it a quality measure can help to reinforce the practice.
2. Possible reasons: worries about the adverse effects from anticholinesterase/antimuscarinic drugs; lack of appreciation of the duration of effect of an intubating dose of an NMBA; conventional peripheral nerve stimulators may provide reassuring but misleading information to clinician (once the TOF ratio exceeds 0.4, most individuals can no longer detect the presence of fade by tactile or visual observation); concerns that neostigmine may produce paradoxical muscle weakness when administered at full neuromuscular recovery (although this effect is probably short lived).
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Post by Soo-Ok Kim on Aug 18, 2017 13:41:54 GMT -5
1.Are we at the point where we can say the gold standard is to reverse any patient, unless contraindicated, that has received neuromuscular blockade? Should it be considered a quality measure just as antibiotic dose and its administration time are? I think "yes" to make it to gold standard since there are bunch documented literature support indicating that residual muscle relaxant can be troublesome including what were described in the article. But, I caution that too much reversal can cause cholinergic crisis, which can actually lead to respiratory failure, described briefly in article (I also witnessed this event.) To implement quality measure with this, we need to have better twitch monitor with qualitative and quantitative measurement. I am wondering subgroup analysis can be done whether different drug (cis, vec and roc) can affect the magnitude of the postop issue since drug action can be variable. There is some case report showing unusually long duration of action in Rocuronium. For defasciculating dose, even though that will be small dose, it can affect swallowing or some vague weakness postop. What about changing in thinking process to identify the need for muscle relaxant. I rarely use muscle relaxant to intubate for pediatric population, unless it is with RSI or surgical procedure indicates. If I am doing young and healthy adult patient, I don't use any muscle relaxant including sux unless case requires it. That will minimize the problem with MR. One more thing to aware is that some of medication we use commonly can prolong NDMR, like clindamycin, gentamycin, & etc, which cannot be reversed by reversal agent.
2.Identify possible reasons clinicians may elect for non-reversal (not for contraindicated patients) and barriers to compliance to a policy requiring that all patients receiving muscle relaxant be reversed unless contraindicated. Most common reason I heard is N/V in outpt setting, which some literature show that less reversal correlates with less nausea in ambulatory care setting. Is there a policy stating such, "all NDMR requires reversal"? I am not aware of that. Like Mary SH said, I would reverse the NDMR for rule out differentials, if last dose was given more than 5hrs.
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Post by Belinda Gardner on Aug 18, 2017 17:48:30 GMT -5
1. Yes. I agree with all the above that unless significant contraindication which is rare NMB reversal should be given, should be a gold standard as well as be a quality measure for the plethora of reasons we well know . Maybe within that documentation if reversal is not given and option for NMB given over X # hours prior could be an answer. Soo-Ok has a good point regarding possibly precluding its use at all if unnecessary.
2. With the availability of Sugammadex now as well as multiple anti-emetics, I feel there is little excuse not to reverse NMB. We all know how innacurate our twitch monitors are at noting potential residual NMB.
Great article!
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Post by faraclarke on Aug 19, 2017 20:43:15 GMT -5
1. Reversal should be the "gold standard", especially when in doubt, as it is better to be safer than sorry. Even when considering factors such as a fasciculating dose having been given, or a great length of time since the last NMB dose, there is a variation among providers as to whether reversal should be administered or not. Having a "gold standard" can reduce the incidence of disputes between providers if an adverse event were to occur in PACU. When considering side-effects of reversal agents, it is also important to consider factors that influence dosing (not every patient needs a "full" reversal dose).
2. Clinicians may opt for non-reversal if there is a concern for side-effects such as bradycardia or PONV, although I believe that the risk/benefit ratio should be strongly considered; the potential to decrease the risk of recurarization or pneumonia outweighs less-concerning or temporary side-effects that can be eased with other drugs.
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Post by Moishe Mayer on Aug 20, 2017 15:41:10 GMT -5
1.) One of the challenges of providing quality anesthesia is knowing not only the immediate effects of our clinical decisions, but also the downstream effects such as the one presented in this article. Based on the data in this article, non-reversed patients are significantly more likely to develop post-operative pneumonia. This is in addition to the more immediate complications such as hypoxemia and longer PACU stays. Note the mean time for the last dose of muscle relaxant in the non-reversed group was 67 minutes and in the reversed group was 69 minutes. Are we at the point where we can say the gold standard is to reverse any patient, unless contraindicated, that has received neuromuscular blockade? Should it be considered a quality measure just as antibiotic dose and its administration time are?
The general consensus from the anesthesia community seems to be that all patients that received a NDMR should be reversed. This would not include a patient that received a defasciculating dose of a NDMR. An AMG would be the best measure of residual neuromuscular blockade. However, an AMG is usually not available, and TOF is the most common measure of residual neuromuscular blockade. The problem is that a TOF 4/4 only tells you that 30% of the NDMR has worn off; they can still be 70% blocked. Even if we use other clinical measures, such as head life for 5 seconds, or biting a tongue depressor firmly, the patient can still be 50% blocked. So, it becomes almost impossible to quantify when a patient would need to be reversed or not. Hence, from a legal standpoint, I do believe that all patients should be reversed, unless an exorbitant amount of time passed since administration of a NDMR, where no clinician would argue that some drug still remains active in the patient.
2.) Identify possible reasons clinicians may elect for non-reversal (not for contraindicated patients) and barriers to compliance to a policy requiring that all patients receiving muscle relaxant be reversed unless contraindicated.
Possible barriers to reversal administration include a patient with confirmed PONV (neostigmine), or patients with CAD (glycopyrrolate). However, if reversal is necessary, something should be given. Bridion may make this less of an issue for majority of patients.
Great Article!
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Post by Vania on Aug 22, 2017 8:16:05 GMT -5
1.) I do believe that it has essentially become a gold standard to reverse patients. As more studies like this are conducted revealing concrete statistics related to costly complications such as pneumonia and longer stays, I think that any educated provider will be more likely to comply. Hospitals are striving to save money and decrease morbidity and mortality, so I definitely think this should be considered a quality measure. We all check with a TOF, but there is much variability in placement, patient habitus, battery strength of the monitor etc. It is not 100% reliable. Unless the blockade was a simple defasiculating dose, I think it is wisest to reverse.
2.) Providers are occasionally reluctant to reverse if it has been several hours since last relaxant dose, if the patient "appears" strong, or if they feel that side effects of such reversals may cause more harm than they're worth. With the increased availability of sugammadex I think this may be less of an issue and more providers will be likely to reverse, although some are less likely to use with patients of childbearing age because of the need for "discussion" regarding hormonal contraceptive use.
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