Anesthesia Patient Safety Foundation Panel on Neuromuscular Blockade and Patient Safety: ‘Assessing and Analyzing the Perceptions of Perioperative Professionals on Neuromuscular Blockade and Residual Neuromuscular Paralysis’

Identify key risk factors in anesthetic-related morbidity and mortality associated with intraoperative use of neuro-muscular blocking agents (NMBAs).

Describe the current practice of intraoperative monitoring of neuromuscular blockade.

Assess the incidence of postoperative residual neuro-muscular paralysis.

• ■ Determine factors potentially responsible for the variations in practice with regard to neuromuscular management and monitoring.
• ■ Recommend changes in practice designed to decrease residual neuromuscular block and improve patient safety.

A multidisciplinary survey was then developed by the panel and distributed to 50,690 anesthesiologists, nurse anesthetists, anesthesiologist assistants (AAs) and post-operative anesthesia care unit (PACU) nurses. Full responses were received from 2,897 professionals. The results of the survey were then presented to four Expert Discussion Groups (EDGs), each made up of anesthesiologists, nurse anesthetists, PACU nurses, hospital pharmacists and AAs.

The EDGs held several online discussions and developed a summary of findings and recommendations based on the literature review and the results of the national survey. Briefly, almost two-thirds of the survey respondents perceived the incidence of postoperative residual neuromuscular paralysis to be between 1-10 percent, in contrast to the numerous studies that for the past 40 years have documented a much higher incidence of 30-40 percent. Between 31-43 percent of the respondents did correctly identify that residual paralysis is a significant patient safety concern that can lead to negative outcomes. Similarly, most of the respondents (45 percent) assess recovery of neuromuscular function using clinical tests (such as grip strength or five-second head lift) or by subjective means of testing using a peripheral nerve stimulator. Up to 51 percent of respondents believe that clinical tests are very or moderately reliable in excluding incomplete neuromuscular recovery. The vast majority of respondents (88 percent) have at least one peripheral nerve stimulator per O.R., but less than half also have access to a quantitative monitor that measures, calculates and displays the train-of-four (TOF) ratio in real time. Routine pharmacologic reversal is used in less than a third of patients, and the most common reason for not administering antagonists is the “sufficient” time since the last administration of a neuromuscular blocking agent. Upon transfer of care to the PACU nurse, little data about the adequacy of reversal at the time of tracheal extubation were provided. The majority (57 percent) of PACU nurses perform clinical tests of muscle function, and only one in 10 use quantitative monitors (in which they receive little or no training). Overall, 75 percent of the survey responders agreed that their respective national specialty organizations should collaboratively develop clinical practice guidelines for perioperative monitoring of neuromuscular function that will lead to improving patient safety.

The experts’ recommendations were presented by Mohamed Naguib, M.D., and are shown in Table 2. In addition to developing these recommendations, the panel concluded with a final and important finding that 75 percent of practitioners agree clinical guidelines for perioperative management of neuromuscular block are needed.