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Post by emedina1 on Aug 28, 2017 20:03:08 GMT -5
In my practice, i almost always reverse my patients who received a muscle relaxant when they have positive train of 4. except when i only use it for defasiculation . i have seen a lot of incidents in the PACU where some patients had to be re-intubated inspite of regular respiration according to the report given to PACU nurses.
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nanci
Junior Member
Posts: 57
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Post by nanci on Aug 29, 2017 9:06:07 GMT -5
1) I think it should become a gold standard to reverse patients. It's been brought up at AANA for the past few years with new innovative technology to help monitor better than current peripheral nerve stimulators. Be on the look out for 3-Dimensional Acceleromyography for more consistent objective monitoring in the future. There seems to be national issues with adequate reversal and re-intubations, so although we might not see it often here at JHH there certainly are places where residual muscle relaxant becomes problematic.
2)I agree with hearing about the above mentioned reasons of why some providers do not reverse. I've heard that they use less so it decreases PONV the most often. I haven't heard much of it's been longer than the 5 1/2 lives- so not sure if that is common anymore. Also agree that with the availability and use of Suggamadex now in the United States, would be interesting if residual muscle relaxation and it's problems becomes less of an overall national issue within the next few (5-10) years or not. Barriers to compliance may be availability of reversal agents (Big pharma might raise prices and decrease stock availability?).
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Kristen Praesel Lang
Guest
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Post by Kristen Praesel Lang on Aug 30, 2017 9:37:51 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 believe we are at the point where the gold standard is to reverse every patient (unless contraindicated). That is my standard practice. That being said, I would not reverse a defasciculating dose of NDNMBA given on induction following by SUX. That is not my standard practice. Quality measures for reversal may be a positive step in reducing post-operative pneumonia in patients that did not receive reversal agents and should be considered.
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.
Reversal may not be given if a patient received a defacsiculating dose of NDNMBA with no additional dosing of NDNMBA. Reversal in a patient who has poor cardiac function, on vasopressors or dilators, and/or was fragile intraoperatively (and expected postoperatively) may be contraindicated. In these cases, the patient will often go to the ICU intubated and may require some level of sedation in the post-operative period until their hemodynamics stabilize. Barriers to compliance include lack of information, duration of case if a patient only received dose on intubation, and if the patient has 0/4 twitches (the age of sugammadex changes this), or the provider has no knowledge of the patients TOF status.
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Post by krechti1 on Aug 31, 2017 14:29:46 GMT -5
1) Yes, I believe it has become the gold standard to reverse every patient. Since you cannot rely on TOF or Tetanus, in order to prevent postop complications such as pneumonia or respiratory depression, it is the only way to guarantee the patient is adequately reversed.
2) Possible reasons clinicians may elect for non-reversal is if it has been a very long case, and the patient has recovered TOF after an initial intubating dose of muscle relaxant for >4 hours. Also, if the patient has a strong history of PONV, or if it is a sick cardiac patient. I think this article has demonstrated that it is better to reverse in these cases though.
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Post by mdougla5 on Aug 31, 2017 15:25:31 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? I agree that reversal of NMB has become and should continue to be a gold standard of providing quality anesthesia. As the data in the presented article revealed, non-reversed patients are significantly more likely to develop post-operative complications of pneumonia, hypoxemia and longer PACU stays. Also, our common measure of measuring residual neuromuscular blockade can be unreliable and subject to provider bias interpretation. Therefore, for the best interest of our patients and to protect ourselves legally, I think it is a prudent practice to reverse any patient with whom we use NMB agents.
2.) Providers may elect to avoid muscle relaxant reversals for many varied reasons based their training and culture of the clinical institution. For an example, a provider may not reverse a patient prior to emergence if they have received only an induction dose NMB during a 12hour case. The patient may have been breathing spontaneously for several hours with adequate TV. A provider may not want to "risk" giving reversals that have potential adverse effects because they feel that the NMB has worn off. But, like Moishe stated in his entry, a TOF 4/4 only tells you that 30% of the NDMR has worn off and that the patient can still be 70% blocked. Where I trained as an SRNA, we were encouraged to always reverse the patient, even if it is only a partial dose.
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Post by Meginnis on Aug 31, 2017 16:27:32 GMT -5
Reversing neuromuscular blockade should be the standard, I agree with MSH that it is past time. I think all of the reasons that some practitioners don't reverse have been discussed (N/V, muscle weakness, cardiac issues, etc.)
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