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Residual neuromuscular blockade and postoperative pulmonary outcome: The missing piece of the puzzle

Fuchs-Buder, Thomas

European Journal of Anaesthesiology: August 2014 - Volume 31 - Issue 8 - p 401–403
doi: 10.1097/EJA.0000000000000065
Invited commentary

From the Department of Anaesthesia, Hôpitaux de Brabois, CHU Nancy, Nancy, France

Correspondence to Professor Thomas Fuchs-Buder, Département d’Anesthésie-Réanimation, CHU Nancy - Hôpitaux de Brabois, Rue du Morvan, F-54511 Vandoeuvre-Les-Nancy Cedex, France Tel: +33 383 153942; e-mail: t.fuchs-buder@chu-nancy.fr

This Invited Commentary accompanies the following articles:

• Soltész S, Fraisl P, Noé KG, et al. Dexamethasone decreases the duration of rocuronium-induced neuromuscular block. A randomised controlled study. Eur J Anaesthesiol 2014; 31:417–422.

• Christ B, Guerci P, Baumann C, et al. Influence of neuromuscular block and reversal on bispectral index and NeuroSense values. Eur J Anaesthesiol 2014; 31:437–439.

• Dubois PE, De Bel M, Jamart J, et al. Performance of acceleromyography with a short and light TOF-tube compared with mechanomyography. A clinical comparison. Eur J Anaesthesiol 2014; 31:404–410.

• Armendáriz-Buil I, Lobato-Solares F, Aguilera-Celorrio L, et al. Residual neuromuscular block in type II diabetes mellitus after rocuronium. A prospective observational study. Eur J Anaesthesiol 2014; 31:411–416.

• Ledowski T, Falke L, Johnston F, et al. Retrospective investigation of postoperative outcome after reversal of residual neuromuscular blockade. Sugammadex, neostigmine or no reversal. Eur J Anaesthesiol 2014; 31:423–429.

• Buijs EJ, Scholten JGF, Ros JJW. Successful administration of sugammadex in a patient with acute porphyria. A case report. Eur J Anaesthesiol 2014; 31:439–441.

The current issue of the European Journal of Anaesthesiology groups a series of articles from a variety of centres examining different aspects of neuromuscular pharmacology and physiology.1–6 Soltész et al. 1 give new insights into the interaction between dexamethasone, used to improve outcome during anaesthesia and prevent postoperative nausea and vomiting, and nondepolarising neuromuscular block. Buijs et al. 2 present the first administration of sugammadex to reverse neuromuscular block in a patient with acute porphyria. Because electromyographic activity arising from the muscles of the forehead can interfere with the electroencephalographic signal with the risk of falsely evaluating the depth of anaesthesia, Christ et al. 3 investigate the impact of rocuronium-induced neuromuscular block and sugammadex reversal on electromyographic artefacts during Bispectral Index (BIS) and neurosense monitoring. Dubois et al. 4 add new information to the ongoing controversy on whether the thumb should move freely during acceleromyographic (AMG) neuromuscular monitoring, or whether a predefined load could improve both precision and reproducibility of AMG measurement. They compared AMG values with those simultaneously obtained with the reference method, mechanomyography. Armendáriz-Buil et al. 5 report an increased duration of rocuronium-induced neuromuscular block in patients with diabetes. Recovery after a dose twice the ED95 for rocuronium, 0.6 mg kg−1, took 25 min longer to reach a TOF ratio of 0.9 in patients with diabetes compared with those without (109.9 vs. 84.8 min, respectively). Of interest in this context, the observed differences in the duration of rocuronium were independent of diabetes-related complications. According to their findings, diabetes should be considered as a risk factor for residual paralysis. Similar results have been reported with other nondepolarising neuromuscular blocking agents too.7 Finally, Ledowski et al. 6 present a retrospective investigation into the impact of perioperative management of neuromuscular block on postoperative pulmonary outcome.

Increasing evidence suggests that residual neuromuscular block is a risk factor for postoperative pulmonary complications and may affect the patient outcome.8–10 Impaired function of the upper airway with an increased risk for silent pulmonary inhalation and inspiratory upper airway obstruction, may explain the link between incomplete neuromuscular recovery and poor postoperative pulmonary outcome.11,12 It is still unclear, however, whether the respiratory morbidity associated with neuromuscular blocking agents can be mitigated by better clinical management, chiefly neuromuscular monitoring and, if needed, reversal. In a recently published large-scale cohort study including over 35 000 patients, Grosse-Sundrup et al. 13 found no beneficial effect, but a rather harmful association of the use of neostigmine reversal with respiratory complications. This may surprise, but it is in line with published data; Blobner et al. 14 confirmed a limited predictability of neostigmine reversal for moderate neuromuscular block. Whereas 98% of the patients were sufficiently recovered within 5 min following sugammadex 2 mg kg−1, it was 100 min after neostigmine 50 μg kg−1. In an observational multicentre study, Esteves et al. 15 recently confirmed a high incidence of postoperative residual paralysis (30.5%), despite neostigmine reversal. Moreover, Kopman et al. 16 antagonised rocuronium-induced and cisatracurium-induced neuromuscular block with 50 μg kg−1 neostigmine given at 2/4 TOF responses; 30 min later, the incidence of residual paralysis, defined as a TOF ratio less than 0.9, was still 12%.1 Similar results were reported by Kirkegaard et al. 17 The message is that, in current clinical practice, some of these patients run the risk of extubation before adequate recovery of the upper airway, especially when neostigmine is used without appropriate neuromuscular monitoring. The high incidence of slow responders after neostigmine may, at least partly, explain the findings of Grosse-Sundrup et al. and emphasise the necessity to redefine its therapeutic range.13,18,19

Ledowski et al. identified an American Society of Anesthesiologists (ASA) status of 3 or more and age greater than 60 years as independent risk factors for postoperative pulmonary complications after use of a neuromuscular blocking agent.6 Moreover, according to their findings, reversal with sugammadex, but not with neostigmine, or noreversal led to a significant risk reduction for pulmonary complications in these fragile patients. These findings suggest that sugammadex may improve postoperative pulmonary outcome in a population at risk, most probably by a more efficient reversal of neuromuscular block with less residual paralysis. This is a significant step towards the answer to the unpopular but important question of whether the way that neuromuscular block is managed can affect the postoperative pulmonary outcome. However, the design of their study as a retrospective data analysis with a rather heterogeneous cohort limits the informative value. Thus, these findings should be confirmed by a properly designed and powered prospective randomised controlled trial. That will be the last missing piece of the puzzle!

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Acknowledgements related to this article

Assistance with the commentary: none.

Financial support and sponsorship: none.

Conflicts of interest: TFB has received payments for lectures from Merck.

Comment from the editor: this Invited Commentary was checked by the editors but was not sent for external peer review. TFB is an Associate Editor of the European Journal of Anaesthesiology.

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References

1. Soltész S, Fraisl P, Noé KG, et al. Dexamethasone decreases the duration of rocuronium-induced neuromuscular block. A randomised controlled study. Eur J Anaesthesiol 2014; 31:417–422.
2. Buijs EJ, Scholten JGF, Ros JJW. Successful administration of sugammadex in a patient with acute porphyria. A case report. Eur J Anaesthesiol 2014; 31:439–441.
3. Christ B, Guerci P, Baumann C, et al. Influence of neuromuscular block and reversal on bispectral index and NeuroSense values. Eur J Anaesthesiol 2014; 31:437–439.
4. Dubois PE, De Bel M, Jamart J, et al. Performance of acceleromyography with a short and light TOF-tube compared with mechanomyography. A clinical comparison. Eur J Anaesthesiol 2014; 31:404–410.
5. Armendáriz-Buil I, Lobato-Solares F, Aguilera-Celorrio L, et al. Residual neuromuscular block in type II diabetes mellitus after rocuronium. A prospective observational study. Eur J Anaesthesiol 2014; 31:411–416.
6. Ledowski T, Falke L, Johnston F, et al. Retrospective investigation of postoperative outcome after reversal of residual neuromuscular blockade. Sugammadex, neostigmine or no reversal. Eur J Anaesthesiol 2014; 31:423–429.
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© 2014 European Society of Anaesthesiology