Guidelines: The next logical step in the journey to improve perioperative patient safety
May 14, 2024
Blog by Sorin J. Brull, MD FCARCSI (Hon), CMO at Senzime and Professor Emeritus of Anesthesiology and Perioperative Medicine at Mayo Clinic.
”I cannot teach anybody anything. I can only make them think.”
- Socrates, Greek philosopher and founder of Western philosophy, teacher of Plato (c. 470-399 BC)
The newly released guidelines for perioperative monitoring of neuromuscular block represent the next logical step in the journey to improve perioperative patient safety and align with the Anesthesia Patient Safety Foundation’s vision that no patient shall be harmed by anesthesia care.
I’d like to reiterate some key points in these guidelines and consensus statements.
The use of neuromuscular monitoring devices is recommended for all patients whenever neuromuscular blocking agents are given. Please note that this recommendation applies to ALL neuromuscular blocking drugs (NMBAs), including nondepolarizing (rocuronium, cisatracurium, etc.) AND to succinylcholine.
Quantitative neuromuscular monitoring is recommended over clinical assessment or qualitative (subjective) evaluation of responses to peripheral nerve stimulation. No, even our own 30-year (or longer) experience with “clinical signs” of recovery does not make us correct, nor does it protect our patients. This is not a matter of ego – but a matter of patient safety and recovery without pulmonary complications.
Quantitative monitoring threshold of recovery is indicated by a TOF ratio ≥0.90 at the adductor pollicis (thumb) muscle; the practice of placing electrodes on the face is specifically discouraged. Even when the arms are not available for monitoring, other monitoring technologies (such as electromyography) are available.
At specific depths of neuromuscular block, both neostigmine and sugammadex are effective antagonists, as long as recovery is guided by quantitative monitors. In other words, we have all seen neostigmine work within a just a couple of minutes, while sugammadex require 5-10 minutes or more – and there is no way to predict how a particular patient will respond. The important point is to measure responses and base tracheal extubation on quantitative data, not simply trust our clinical “gestalt.”
The definition of the well-established levels of neuromuscular block (complete, deep, moderate, shallow, minimal, and acceptable recovery) should be standardized. Subjective evaluation of patient responses and clinical tests of neuromuscular function are NOT predictive of adequate recovery. The transition from clinical evaluation (tidal volume, grip strength, response to verbal stimuli, etc.) of patient responses to quantitative measurement requires clinician education, a local champion, and time.
We should involve the departmental leadership in these patient safety endeavors, and also include the surgical colleagues whose patients’ outcomes are also important, and the institution’s administrators, who are asked to make financial decisions.
To summarize, nearly every major national and international anesthesia organization has, in the past few years, developed and published standards of perioperative quantitative neuromuscular monitoring designed to enhance patient safety.
Let us do more than think – let’s do!
Dr. Sorin J. Brull, , MD, FCARCSI (Hon), is CMO at Senzime as well as a consultant in anesthesiology and Professor Emeritus of Anesthesiology & Perioperative Medicine at Mayo Clinic, USA. Dr. Brull is the founder of Acacia Designs B.V and the TetraGraph system, which was acquired by Senzime AB in 2016.
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