Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care

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Full text: https://journals.lww.com/ejanaesthesiology/Fulltext/2023/02000/Peri_operative_management_of_neuromuscular.3.aspx

Methods

A group was appointed to develop guidelines on the peri-operative management of neuromuscular blockade. Clinical queries were developed in the form of three Population/Intervention/Comparison/Outcome (PICO) groups. The literature was searched from 1995 to 2021 and authors were able to add papers they thought were appropriate. All papers underwent screening for bias.

PICO groups and findings

1. Is the use of myorelaxants necessary to facilitate tracheal intubation in adults?
   • Pooled data patients (447) showed 38% intubated with a relaxant-free induction regimen experienced pharyngeal or laryngeal injury compared to 27% when neuromuscular relaxants were used pharyngeal or laryngeal injury
   • The incidence of poor intubation conditions was 27% in the group without muscle relaxants vs. 3% with paralysis
2. Does the intensity of neuromuscular blockade influence a patient’s outcome in abdominal surgery (i.e. laparotomy or laparoscopy)?
   • The majority of surgeries studied were laparoscopic procedures
   • Deep blockade resulted in better conditions, but the authors stressed that this is controversial and multifactorial
   • Studies were too heterogeneous to give results on post operative pain or other adverse outcomes
3. What are the strategies for the diagnosis and treatment of residual neuromuscular paralysis?
   • The pooled incidence of residual paralysis was similar in the qualitative NMM (0.306) when no NMM was used (0.331). The use of a quantitative NMM resulted in an incidence of residual paralysis of 0.115 (95% CI: 0.057 to 0.188)
   • Confirmed that residual paralysis is more common after neostigmine-based reversal of deep to moderate NMB compared with than after sugammadex (24% vs 2%)
   • Found that a significant number of cases reversed with neostigmine at TOF=4 still had a TOF ratio <0.9 at 10-20min later

I was quite surprised to find that this was the first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular blockade. Few readers will find anything controversial in this paper. It does provide good evidence for requesting quantitative neuromuscular monitors in each theatre and appropriate access to sugammadex as required.

Reviewed by Don Hannah