Incidence, risk factors, and consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study

Leif Saager, Eric M. Maiese, Lori D. Bash, Tricia A. Meyer, Harold Minkowitz, Scott Groudine, Beverly K. Philip, Pedro Tanaka, Tong Joo Gan, Yiliam Rodriguez, Roy Soto, Olaf Heisel

Research output: Contribution to journalArticle

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Abstract

Study objective: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. Design: Blinded multicenter cohort study. Setting: Operating and recovery rooms of ten community and academic U.S. hospitals. Patients: Two-hundred fifty-five adults, ASA PS 1–3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. Interventions: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. Main results: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. Conclusions: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.

Original languageEnglish (US)
Pages (from-to)33-41
Number of pages9
JournalJournal of Clinical Anesthesia
Volume55
DOIs
StatePublished - Aug 1 2019

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Delayed Emergence from Anesthesia
Incidence
Airway Extubation
Neostigmine
Neuromuscular Monitoring
Odds Ratio
Peripheral Nerves
Neuromuscular Blocking Agents
Recovery Room
Intratracheal Intubation
Community Hospital
Operating Rooms
Laparoscopy
General Anesthesia
Multicenter Studies
Anesthetics
Cohort Studies
Logistic Models
Maintenance

Keywords

  • Delayed emergence from anesthesia
  • Neostigmine
  • Neuromuscular block
  • Neuromuscular monitoring
  • Train-of-four monitoring

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Incidence, risk factors, and consequences of residual neuromuscular block in the United States : The prospective, observational, multicenter RECITE-US study. / Saager, Leif; Maiese, Eric M.; Bash, Lori D.; Meyer, Tricia A.; Minkowitz, Harold; Groudine, Scott; Philip, Beverly K.; Tanaka, Pedro; Gan, Tong Joo; Rodriguez, Yiliam; Soto, Roy; Heisel, Olaf.

In: Journal of Clinical Anesthesia, Vol. 55, 01.08.2019, p. 33-41.

Research output: Contribution to journalArticle

Saager, Leif ; Maiese, Eric M. ; Bash, Lori D. ; Meyer, Tricia A. ; Minkowitz, Harold ; Groudine, Scott ; Philip, Beverly K. ; Tanaka, Pedro ; Gan, Tong Joo ; Rodriguez, Yiliam ; Soto, Roy ; Heisel, Olaf. / Incidence, risk factors, and consequences of residual neuromuscular block in the United States : The prospective, observational, multicenter RECITE-US study. In: Journal of Clinical Anesthesia. 2019 ; Vol. 55. pp. 33-41.
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abstract = "Study objective: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. Design: Blinded multicenter cohort study. Setting: Operating and recovery rooms of ten community and academic U.S. hospitals. Patients: Two-hundred fifty-five adults, ASA PS 1–3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. Interventions: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. Main results: Most of the study population, 64.7{\%} (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0{\%} with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0{\%} had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. Conclusions: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7{\%}) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.",
keywords = "Delayed emergence from anesthesia, Neostigmine, Neuromuscular block, Neuromuscular monitoring, Train-of-four monitoring",
author = "Leif Saager and Maiese, {Eric M.} and Bash, {Lori D.} and Meyer, {Tricia A.} and Harold Minkowitz and Scott Groudine and Philip, {Beverly K.} and Pedro Tanaka and Gan, {Tong Joo} and Yiliam Rodriguez and Roy Soto and Olaf Heisel",
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T1 - Incidence, risk factors, and consequences of residual neuromuscular block in the United States

T2 - The prospective, observational, multicenter RECITE-US study

AU - Saager, Leif

AU - Maiese, Eric M.

AU - Bash, Lori D.

AU - Meyer, Tricia A.

AU - Minkowitz, Harold

AU - Groudine, Scott

AU - Philip, Beverly K.

AU - Tanaka, Pedro

AU - Gan, Tong Joo

AU - Rodriguez, Yiliam

AU - Soto, Roy

AU - Heisel, Olaf

PY - 2019/8/1

Y1 - 2019/8/1

N2 - Study objective: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. Design: Blinded multicenter cohort study. Setting: Operating and recovery rooms of ten community and academic U.S. hospitals. Patients: Two-hundred fifty-five adults, ASA PS 1–3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. Interventions: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. Main results: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. Conclusions: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.

AB - Study objective: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. Design: Blinded multicenter cohort study. Setting: Operating and recovery rooms of ten community and academic U.S. hospitals. Patients: Two-hundred fifty-five adults, ASA PS 1–3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. Interventions: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. Main results: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. Conclusions: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.

KW - Delayed emergence from anesthesia

KW - Neostigmine

KW - Neuromuscular block

KW - Neuromuscular monitoring

KW - Train-of-four monitoring

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