To the Editor:
The American Society of Anesthesiologists’ recently published Practice Guidelines for Postanesthetic Care1
contains a statement that is at best puzzling and at worst I believe sends the wrong message to the anesthesia community. To quote: “Assessment of neuromuscular function primarily includes physical examination and, on occasion, may include neuromuscular blockade monitoring.”
There is now overwhelming evidence that traditional bedside or clinical tests of neuromuscular function such as head-lift, tidal volume, tongue protrusion, and others are very insensitive tests for the detection of residual neuromuscular weakness.2–5
To cite just one recent study “a reliable clinical test for detection of significant residual block... will probably remain elusive.”6
Thus one must ask what clinical signs the Task Force is referring to when they recommend a “physical examination”?
The answer to the problem of postoperative residual neuromuscular block lies not with a postanesthesia evaluation, but with intelligent intraoperative monitoring of neuromuscular function ideally with a quantitative monitor.
1. American Society of Anesthesiologists Task Force on Postanesthetic Care. . Practice guidelines for postanesthetic care. ANESTHESIOLOGY. 2013;118:291–7
2. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. ANESTHESIOLOGY. 2010;112:1013–22
3. Dupuis JY, Martin R, Tétrault JP. Clinical, electrical and mechanical correlations during recovery from neuromuscular blockade with vecuronium. Can J Anaesth. 1990;37:192–6
4. Sharpe MD, Lam AM, Nicholas JF, Chung DC, Merchant R, Alyafi W, Beauchamp R. Correlation between integrated evoked EMG and respiratory function following atracurium administration in unanaesthetized humans. Can J Anaesth. 1990;37:307–12
5. Beemer GH, Rozental P. Postoperative neuromuscular function. Anaesth Intensive Care. 1986;14:41–5
6. Heier T, Caldwell JE, Feiner JR, Liu L, Ward T, Wright PM. Relationship between normalized adductor pollicis train-of-four ratio and manifestations of residual neuromuscular block: A study using acceleromyography during near steady-state concentrations of mivacurium. ANESTHESIOLOGY. 2010;113:825–32
© 2013 American Society of Anesthesiologists, Inc.