Why a guideline on peri-operative management of neuromuscular blockade? Why now?

This Invited Commentary accompanies the following Guideline:

Fuchs-Buder T. Peri-operative management of neuromuscular blockade. A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anesthesiol 2023; 40:82–94.

A man must be big enough to admit his mistakes, smart enough to profit from them, and strong enough to correct them.

John C. Maxwell (American author, speaker, and pastor; 1947–present).

The European Society of Anaesthesiology and Intensive Care (ESAIC) has finalised its peri-operative management of neuromuscular blockade guideline, which is published in the current issue of this journal.¹ The guideline is the product of 14 experts from 9 different countries and follows publication of other national society practice guidelines.^2–4 Concerns regarding the management of neuromuscular block in paediatric patients will be addressed in a separate guideline.

The newly published European guideline specifically addresses eight different areas of practice in adult surgical patients, including routine and rapid-sequence induction and intubation scenarios, deepening the depth of block according to surgical need, and the use of particular agents for reversal of neuromuscular block in specific clinical situations. From our perspective, the recommendation with perhaps the greatest impact on patient care, healthcare costs and quality of practice, is the recommendation to use ulnar nerve stimulation and QUANTITATIVE (emphasis added) neuromuscular monitoring at the thumb (adductor pollicis muscle) to ‘exclude residual paralysis’.¹ Such calls for quantitative monitoring are not new, and a myriad array of letters, case reports, editorials and clinical studies have called for the routine use of peri-operative quantitative neuromuscular monitoring. To our chagrin (and to our patients’ detriment), such calls have mostly been ignored, and despite training of three to four generations of anaesthesiologists on neuromuscular monitoring best practices, the actual number of clinicians who use quantitative neuromuscular monitoring routinely remains woefully inadequate, leading to unacceptably high rates of postoperative residual neuromuscular block and consequential potentially life-threatening and completely preventable complications.^5–7

The time has come for those clinicians who do not follow best practice recommendations to generate reasonable, clinically validated and outcome-driven safety and financial data that support their anaesthetic practice – that is, guided by clinical intuition and/or subjective assessment of neuromuscular block; we are certain that such data do not exist. In our opinion, the current archaic practice of ‘guided by experience’ should have no place in modern anaesthesia and intensive care because of its high likelihood of producing erroneous results and misleading conclusions. It is time for us to admit our past mistakes, be smart enough to profit from the years of science, and correct our errors. But to correct the practice of neuromuscular management and to improve patient's safety, the recommendations of the present guideline MUST BE IMPLEMENTED in current routine clinical practice.

Sadly, implementation of clinical guidelines is the weakest link between guideline development and better clinical outcomes. Even the best conceived guidelines are rarely fully implemented, despite well known obstacles, which are both systemic and individual.^8,9 At the systemic level, the ESAIC has, for many years, adopted a policy in which clinical guideline implementation is a major goal for the society.¹⁰ The guideline on peri-operative management of neuromuscular blockade is the first to incorporate an explicit implementation strategy and propose implementation tools. The aim of the ESAIC guideline published in this issue is to underscore the current evidence-based knowledge supporting the use of quantitative neuromuscular monitoring in all patients who receive neuromuscular blocking agents and their antagonists. By combining principles of quality improvement and incentive science, evidence-based practices can be implemented in daily clinical care. However, to really reach this objective and put it into practice, anaesthesia team members must be actively involved, and their behaviour must be guided by fundamental safety rules. With such a strategy, a compliance greater than 90% can be achieved in documenting the minimally acceptable degree of neuromuscular recovery (TOF ratio >90) before tracheal extubation.¹¹ Despite a still ongoing (and poorly defended) argument against the routine use of quantitative monitors,¹² there is irrefutable evidence that quantitative monitoring must become routine.⁵

For other currently accepted routine monitoring modalities such as pulse oximetry and end-tidal CO² monitors there is no evidence that they affect patients’ outcomes. Despite an intense methodical collection of data from a relatively large general surgery population, the conflicting subjective and objective study results indicate that the value of peri-operative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency.¹³ Even when we consider these inconclusive evidence-based data on pulse oximetry and end-tidal CO² monitors, can any one of us imagine starting a case without using them? The answer is an obvious and resounding, ‘NO!’ Despite considering the conclusive evidence-based data on neuromuscular monitoring, can any one of us imagine starting a case without its use? The answer, unfortunately, is still ‘YES’. Indeed, most of us, consciously or not, still find it acceptable to start a case without neuromuscular monitoring. Let us accept the reality as it is but more importantly, let us try to change it for the benefit of our patients.

There are several aspects of implementation that this guideline addresses. The first is dissemination through multiple channels, such as the ESAIC Website, the National Anaesthesiology Societies (NAS), the European Journal of Anaesthesiology (EJA), as well as congresses and other educational events (e.g. webinars). A relative novelty of this guideline is that the dissemination process will be iterative.

Beyond dissemination, we need to identify all stakeholders and implement specific actions for each type of stakeholder. First and foremost, we strongly urge the NAS and their leaders to engage with national and institutional policy makers to eliminate barriers to implementation of this clinical practice guideline. The most important current limitation is financing the acquisition and maintenance of the required quantitative neuromuscular monitors.

Within a given department, it is essential that this guideline is disseminated among anaesthesia providers to help improve their theoretical and practical knowledge of neuromuscular monitoring and the appropriate use of drugs. ESAIC has pledged support in building the educational tools dedicated to practical knowledge dissemination but, beyond knowledge dissemination, it will be necessary to analyse obstacles to guideline implementation related to the attitudes and beliefs of anaesthesia providers.

In conclusion, we as providers of medical care and supporters of patient safety are convinced that the time has now come to combine all necessary efforts to support and follow the guideline on perioperative management of neuromuscular block. This guideline combines science with solid evidence-based recommendations and implementation tools. The end-result will be highly improved patient safety.