Anesthesiologists' Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey.

Background: In patients who receive a nondepolarizing neuromuscular blocking drug (NMBD) during anesthesia, undetected postoperative residual neuromuscular block is a common occurrence that carries a risk of potentially serious adverse events, particularly postoperative pulmonary complications. There is abundant evidence that residual block can be prevented when real-time (quantitative) neuromuscular monitoring with measurement of the train-of-four ratio is used to guide NMBD administration and reversal. Nevertheless, a significant percentage of anesthesiologists fail to use quantitative devices or even conventional peripheral nerve stimulators routinely.

Consensus Statement on Perioperative Use of Neuromuscular Monitoring.

A panel of clinician scientists with expertise in neuromuscular blockade (NMB) monitoring was convened with a charge to prepare a consensus statement on indications for and proper use of such monitors. The aims of this article are to: (a) provide the rationale and scientific basis for the use of quantitative NMB monitoring; (b) offer a set of recommendations for quantitative NMB monitoring standards; (c) specify educational goals; and (d) propose training recommendations to ensure proper neuromuscular monitoring and management. The panel believes that whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation.

Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities.

Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.

The Myth of Rescue Reversal in "Can't Intubate, Can't Ventilate" Scenarios.

Background: An unanticipated difficult airway during induction of anesthesia can be a vexing problem. In the setting of can't intubate, can't ventilate (CICV), rapid recovery of spontaneous ventilation is a reasonable goal. The urgency of restoring ventilation is a function of how quickly a patient's hemoglobin oxygen saturation decreases versus how much time is required for the effects of induction drugs to dissipate, namely the duration of unresponsiveness, ventilatory depression, and neuromuscular blockade.

Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not.

Background: There is currently a controversy regarding the need for and clinical benefit of maintaining deep neuromuscular block (post-tetanic counts of 1 or 2) vs. moderate block (train-of-four counts of 1-3) for routine laparoscopic surgery. Two recent review articles on this subject arrived at rather different conclusions.

Laparoscopic surgery and muscle relaxants: is deep block helpful?

It has been hypothesized that providing deep neuromuscular block (a posttetanic count of 1 or more, but a train-of-four [TOF] count of zero) when compared with moderate block (TOF counts of 1-3) for laparoscopic surgery would allow for the use of lower inflation pressures while optimizing surgical space and enhancing patient safety. We conducted a literature search on 6 different medical databases using 3 search strategies in each database in an attempt to find data substantiating this proposition. In addition, we studied the reference lists of the articles retrieved in the search and of other relevant articles known to the authors.

Current recommendations for monitoring depth of neuromuscular blockade.

Purpose Of Review: Residual neuromuscular block is a relatively frequent occurrence and is associated with postoperative pulmonary complications, including aspiration, pneumonia and hypoxia, impaired hypoxic ventilatory drive and decreased patient satisfaction. Although adequate recovery of neuromuscular function has been defined as a train-of-four ratio of at least 0.9, monitoring with a qualitative peripheral nerve stimulator makes it impossible to determine the actual train-of-four ratio.