Reversing Neuromuscular Blockade without Nerve Stimulator Guidance in a Postsurgical ICU-An Observational Study

Authors

Andrea Calef, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
Rashel Castelgrande, Department of Surgery, Anne Arundel Medical Center, Anne Arundel, MD 21401, USA.
Kristin Crawley, Department of Surgery, Medstar Medical Group, Baltimore, MD 21201, USA.
Sara Dorris, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
Joanna Durham, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
Kaitlin Lee, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
Jen Paras, Department of Surgery, INOVA Fairfax Hospital, Fairfax, VA 22042, USA.
Kristen Piazza, Department of Surgery, University of Maryland St Joseph Hospital, Baltimore, MD 21201, USA.
Abigail Race, Department of Surgery, North Shore University Hospital, Manhasset, NY 11030, USA.
Laura Rider, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
Michael Shelley, Department of Surgery, Maine Medical Center, Portland, ME 04103, USA.Follow

Document Type

Article

Publication Date

5-2-2023

Institution/Department

Surgery

Journal Title

Journal of clinical medicine

Abstract

We aimed to determine if not using residual neuromuscular blockade (RNB) analysis to guide neuromuscular blockade reversal administration in the postsurgical ICU resulted in consequences related to residual weakness. This single-center, prospective study evaluated 104 patients arriving in a postcardiac surgical ICU. After demonstrating spontaneous movement and T > 35.5 °C, all patients underwent RNB evaluation, and neostigmine/glycopyrrolate was then administered. When patients later demonstrated an adequate Rapid Shallow Breathing Index, negative inspiratory force generation, and arterial blood gas values with minimal mechanical ventilatory support, RNB evaluation was repeated in 94 of the 104 patients, and all patients were extubated. Though RNB evaluation was performed, patients were extubated without considering these results. Eleven of one hundred four patients had not achieved a Train-of-Four (TOF) count of four prior to receiving neostigmine. Twenty of ninety-four patients demonstrated a TOF ratio ≤ 90% prior to extubation. Three patients received unplanned postextubation adjunct respiratory support-one for obvious respiratory weakness, one for pain-related splinting compounding baseline disordered breathing but without obvious benefit from BiPAP, and one for a new issue requiring surgery. Residual neuromuscular weakness may have been unrecognized before extubation in 1 of 104 patients administered neostigmine without RNB analysis. ICU-level care may mitigate consequences in such cases.

ISSN

2077-0383

Recommended Citation

Calef A, Castelgrande R, Crawley K, et al. Reversing Neuromuscular Blockade without Nerve Stimulator Guidance in a Postsurgical ICU-An Observational Study. J Clin Med. 2023;12(9):3253. Published 2023 May 2. doi:10.3390/jcm12093253