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Neuromuscular Monitoring Advancement

Rizzi, Roland R. M.D.

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To the Editor:—
I read with interest the editorial view of Lars Eriksson, M.D., on evidence-based practice and neuromuscular monitoring. 1 As Dr. Eriksson correctly presents, current subjective neuromuscular blockade monitoring is clearly inaccurate, often resulting in patients with some residual blockade in the PACU. 2–7 However, to conclude that “the message is short and clear—it is time to move from discussion to action and introduce objective neuromuscular monitoring in all operating rooms” is unfortunate. There are currently no published outcome studies with respect to intermediate-acting muscle relaxants and residual weakness postoperatively. The “consequences” to which Dr. Eriksson refers in his editorial have never been related to any mortality/morbidity differences. His belief that this would improve patient outcome is unsupported.
To advocate a new monitoring standard that would probably cost millions of dollars without outcome data to support such an expenditure is inappropriate. Just because other equipment has been introduced into medicine without outcome research does not justify the continuation of such behavior. That is not evidence-based medicine. Dr. Eriksson’s conclusion, although quite dramatic, is not presently justified.
Roland R. Rizzi, M.D.
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1. Eriksson LI: Evidence-based practice and neuromuscular monitoring: It’s time for routine quantitative assessment. A nesthesiology 2003; 98: 1037–9

2. Debaene B, Plaud B, Dilly M-P, Donati F: Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. A nesthesiology 2003; 98: 1042–8

3. Baillard C, Gehan G, Reboul-Marty J, Larmignat P, Samana CM, Cupa M: Residual curarization in the recovery room after vecuronium. Br J Anaesth 2000; 84: 394–5

4. Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC: Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia 2001; 56: 312–8

5. Cammu G, de Baerdemaeker L, den Blauwen N, de Mey JC, Struys M, Mortier E: Postoperative residual curarization with cisatracurium and rocuronium infusions. Eur J Anaesthesiol 2002; 19: 129–34

6. Kim KS, Lew SH, Cho HY, Cheong MA: Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg 2002; 95: 1656–60

7. McCaul C, Tobin E, Boylan JF McShane AJ: Atracurium associated with postoperative residual curarization. Br J Anaesth 2002; 89: 766–9

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