September FY19 Journal Club

[Kristen Horsman]

September's journal club is presented by Kristen Praesel. She chose an excellent article that looks into quantitative monitoring of neuromuscular blockade.



A link to the article is:
www.aana.com/docs/default-source/aana-journal-web-documents-1/implementation-of-acceleromyography-to-increase-use-of-quantitative-neuromuscular-blockade-monitoring-a-quality-improvement-project-august-2018.pdf?sfvrsn=6a3e5bb1_4

Questions to encompass in your response are:

1. Tactile or visual assessment of TOF with a peripheral nerve stimulator is the most common evaluation method of NMBA in the United States. What are some of the drawbacks of using this assessment device versus acceleromyographic technology?



2. Patients with a quantitative TOF <0.9 can experience residual neuromuscular blockade. What are some of the complications related to inadequate muscular function that occur post-operatively? Do you think using acceleromyography monitoring in your practice could be useful in enhancing patient care outcomes when NMBDs are administered?

[Kel]

A drawback to using tactile or visual assessment of TOF with a peripheral nerve stimulator is the subjectivity of these methods. What one CRNA sees and feels to be considered one twitch can vary greatly compared to another CRNA .

The major complications to residual muscular blockade are pulmonary related . Hypoxemia, hypercarbia, aspiration, decreased saturations could all lead to a reintubation which will most likely prolong the stay for the patient.

I would be interested in learning more about acceleromyography monitoring and I think it has the potential to be useful in my practice .

[LarSharVeA Bennett]

I agree with Kel in that the visual assessment of TOF is wholly subjective. Variance in interpretation can lead to inadequate reversal dosages, there arising the sequelae of muscle weakness induced hypoventilation. In cases where evoked potentials are being monitored, there is always a significant difference between what I attain with TOF and what the nerve monitor sees on the myograph. This difference, I believe, is more prominent when the reversal agent used is neostigmine rather than sugammadex.

According to the article, patients who received neuromuscular blockers had a higher risk of pneumonia; as well as those patients that were not reversed. In addition to pneumonia, inadequate muscular function could lead to cerebral vascular accidents and myocardial infarctions in patients that are already at risk. Just think of the threat that shivering poses in a patient with coronary artery disease. High oxygen demand and decreased delivery could be catastrophic.

I personally have no interest in using acceleromyography monitoring. With the use of decorated gadgets, basic assessment skills taper. I prefer a more simple approach: paralyze, then reverse; inadequate tidal volume, increased work of breathing, hypercarbia, extremes in respiratory rate, don't extubate!

[Moishe Mayer]

A major drawback of our standard qualitative TOF monitor is its subjectivity. One provider may perceive the TOF differently than another provider. In addition, I wonder if equipment failure would be less of an issue with acceleromyography monitoring, because you either get a number or you do not. As opposed to our TOF monitors that can often be blamed for a fade etc., when in reality the patient is not reversed appropriately. AMG would give a precise number that cannot be discredited.

I would be interested in using an AMG just to get accustomed to it; however, I prefer sticking with TOF in conjunction with clinical judgment. Another specific number can further industrialize anesthesia.

[Ben Waldbaum]

1.) It is subjective and not objective

2.) Pneumonia is the most common. Most imminent in pacu is hypoxia, atelectasis, and possible reintubation. I would find using acceleromyography useful in my practice. it is another data point to help make the best decision for the patient.

With that being said, regardless of what the acceleromygraphy says, if a patient received muscle relaxant, I believe they should be fully reversed with sugammadex unless contraindicated. there is robust data demonstrating post-operative complications from lack of reversal.

[Jocelyn Datud]

Just like what others mentioned, tactile/ visual assessment of TOF utilizing a peripheral nerve stimulator is very subjective. Also there are incidents that the peripheral nerve stimulator doesn't elicit accurate response even though it is placed on the right spot.

Some of the complications related to inadequate muscular function includes pulmonary complication (decreased forced vital capacity and peak expiratory flow, pneumonia, hypoxemia), patient discomfort, prolonged stay in PACU, reintubation, and perioperative mortality.

If the acceleromyography is already available, I think it will be useful for certain cases where we closely monitor relaxation. However, just like the peripheral nerve stimulator, it is only an adjunct to the other assessments that we utilize. We should still stick with our critical thinking and look at the whole scenario.

Awesome discussion!

[Sue Kim]

1. Tactile/visual assessment of TOF can be very subjective. The robustness of the TOF response can also vary based on where your peripheral nerve stimulator is placed for measurement. Acceleromyographic technology appears to provide a more objective and quantifiable measurement of neuromuscular function.

2. Some of the complications of inadequate muscular function are: pneumonia (more than 2 times likely), impairment of respiratory muscle function (leading to hypoventilation and hypoxemia), aspiration, diplopia, trouble speaking, and generalized weakness. In my practice,I can see the value of acceleromyography as it can lead to better patient care outcomes by quantifying RNMB.

[Wai-Ling Lo]

1. Drawbacks of TOF is that the assessment relied on providers' subjective interpretation which may result in inaccurate interpretation and ended up overuse of NMB. As for acceleromyographic technology, drawbacks can be the accessibility to the thumb, providers' knowledge, time required to celebrate the machine, and cost to purchase and maintain the equipment.

2.The complications can be hypoventilation, hypoxemia, impaired hypoxic ventilator drive, misdirected swallowing that lead to aspiration and pneumonia, diplopia, difficulty speaking, and generalized weakness. I think acceleromyography monitoring will be useful in my practice because it provides more quantitative assessment of RNMB so I can dose and reverse NMB more appropriately and reduced potential complications.

[JackieHowell]

1. I feel that both visual and tactile assessment of TOF are subjective and there is a large variability of interpretations amongst providers. There is also a variability in response based on placement of the peripheral nerve monitor.

2. I agree with LarSharVeA, once we implement these "advance" monitoring techniques, basic skill assessments wane. The TOF monitor is one of many assessment tools to indicate residual muscular weakness. Assessment of overall muscular strength, inspiratory force, tidal volume, head lifting for 5 seconds, and tongue movement are all important data. Complications from inadequate neuromuscular function post operatively include hypoxemia, hypercarbia, aspiration, mendelson syndrome, pneumonia, reintubation, lengthened duration of hospital stay, and all the complications associated with prolonged intubation (VAP).

[kty67]

1. Visual and tactile assessment of recovery of the patient from paralysis can have variety of faulty interpretation due to low battery of device, provider different interpretation and other factors. As we all know and it is mentioned in article that most often complications are respiratory complications due to residual weakness from medications and general postop weakness.
2. I would be interested to learn new methods to monitor patients recovery from paralysis but we should not forget basic skills to monitor patients recovery. we live in modern time with use of new gadgets that make our life more fun and easier, so why not use new gadgets to improve patients safety.

[Jennifer Hannon]

1)A drawback for tactile or visual assessment of TOF is that it is pretty subjective to where the provider places the electrodes as well as feel/assessment of the twitches. Also with our young 1976 models, the battery connections to the 9v are patchy at best. The smaller 1982 model bodes better.

2) Some complications to residual muscular blockade are pulmonary related and lengthen the hospital stay for the patient. Hypercarbia, aspiration, hypoxia can all lead to a reintubation.

I'm interested in learning more about acceleromyography monitoring and I think it has the potential to be useful in my practice .

[Jessica Hadley]

1. As was mentioned previously, the subjective nature of TOF monitoring is a major drawback. I have also seen differences in how and where providers place their TOF monitors.

2. Complications of residual neuromuscular blockade include pharyngeal dysfunction which can lead to increased risk of aspiration, hypoventilation, atelectasis, double vision, and prolonged PACU stay. I would definitely be interested in using acceleromyography in my practice to help guide NMB dosing as well as being able to give surgeons a quantitative value when they ask "are they paralyzed?" or request me to "top off my muscle relaxation."

[cvelard1]

Monitoring to4 response with a peripheral nerve stimulator has been the golden standard for monitoring muscle /residual muscle relaxant on board . I agree there are several issues that apply when judging when there is appropriate muscle reversal. The actual pns may not have proper battery power, improper placement and observer bias to the to4 reversal are some issues that create improper reversal. It also is important to note the clinical signs of adequate reversal such as adequate tidal volumes and an awake state that allows a provider to assess respiratory status . I think any new ideas technology to adequately state to4 reversal is great but knowing how long it takes to get new equipment makes me think the pns makes a better choice when choosing a method to decide if there is adequate reversal.
There is some ramifications of inadequate reversal. The fish out of water floppy ness and inadequate ventilation may have a patient be reintubateted as addressed in the article. I think all muscle relaxants should be reversed regardless of when tha last muscle relaxant was given. If had been reported that we must always document to4 responses whenever a muscle relaxant is given to be Q/a compliant

[nanci]

1. Tactile or visual assessment of TOF with a peripheral nerve stimulator is the most common evaluation method of NMBA in the United States. What are some of the drawbacks of using this assessment device versus acceleromyographic technology? Drawbacks include it being subjective (visual and tactile) vs. objective (a train of four ratio greater than 0.90)- many times when at a point of changing providers (breaks, lunches, end of shift, etc...) there is such a difference when someone states there are no twitches and when another checks -there are. Then again, hopefully the acceleromyography monitoring will address unavailability of appropriate electrode placement sites (arms tucked) so that if the system is going to be utilized it will work well.

2. Patients with a quantitative TOF <0.9 can experience residual neuromuscular blockade. What are some of the complications related to inadequate muscular function that occur post-operatively? Possible postoperative complications can include the risk of residual paralysis, impaired airway protective reflexes, possible reintubation and establishment of a protected airway, hypoxemia, symptoms of muscle weakness. Also upper airway obstruction and decreased hypoxic ventilatory response.
Do you think using acceleromyography monitoring in your practice could be useful in enhancing patient care outcomes when NMBDs are administered? Yes if it enhances patient safety would be good to use.

[Beth Medina]

Tactile and visual assessment of TOF with peripheral nerve stimulator is the most common method in USA. I had used this technique in my 43 years of practice. I guess with more vigilance and
keen observation of patient's response helped me a lot . I do agree that there is a lot of subjectivity with this route. When in doubt with how the patient respond, This is when I pause and
think of the next move.
Acceleromyographic technology will be around for a while before I will try to use it.