Neuromuscular Monitoring, Muscle Relaxant Use, and ... · 12/1/2015 · related to the use of neuromuscular blocking agents at the Royal Perth Hospital since this introduction. Results

Research ArticleNeuromuscular Monitoring, Muscle Relaxant Use,and Reversal at a Tertiary Teaching Hospital2.5 Years after Introduction of Sugammadex:Changes in Opinions and Clinical Practice

Thomas Ledowski,1,2 Jing Shen Ong,3 and Tom Flett4

!Department of Anaesthesia, Royal Perth Hospital, Perth, WA "###, Australia$University of Western Australia, Perth, WA "##%, Australia&Royal Perth Hospital, Perth, WA "###, Australia'Department of Intensive Care,(e Alfred Hospital, Melbourne, VIC &###, Australia

Correspondence should be addressed to!omas Ledowski; [email protected]

Received " September #$%&; Revised %' December #$%&; Accepted #& December #$%&

Academic Editor: Yukio Hayashi

Copyright © #$%" !omas Ledowski et al. !is is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Sugammadex was introduced to Royal Perth Hospital in early #$%% without access restriction. Two departmental audits (#(-pageonline survey and %-week in-theatre snapshot audit) were undertaken to investigate the change of beliefs and clinical practicerelated to the use of neuromuscular blocking agents at the Royal Perth Hospital since this introduction. Results were comparedwith data from #$%%. We found that, in the #." years since introduction of Sugammadex, more anesthetists (()." versus *'%) utilizedneuromuscular monitoring, and aminosteroidal neuromuscular blocking agents were used in )&.*% of cases (versus ++% in #$%%).Furthermore, "*%of anesthetists identi,ed with a practice of “deeper and longer” intraoperative paralysis of patients. All +% patientsobserved during the "-day in-theatre audit were reversed with Sugammadex. Since the introduction of Sugammadex, ()% (! = 20)of respondents felt it provided “faster turnover,” less postoperative residual neuromuscular blockade (! = 23; +)%), and higheranesthetist satisfaction (! = 17; ")%). &"% (! = 13) of colleagues reported that they would feel professionally impaired without theunrestricted availability of Sugammadex, and % colleague would refuse to work in a hospital without this drug being freely available.In clinical practice Sugammadex was frequently ("+%) mildly overdosed, with #$$mg being the most commonly administereddose.

1. Introduction

Sugammadex was introduced to Royal Perth Hospital (RPH)in early #$%%without access restriction. Since early #$%%, its usehas increased to approximately +$$$ doses (#$$mg) per yearin #$%*. Two previously published audits [%, #] comparing the“pre-” and “post-”Sugammadex practice of neuromuscularblocking agent (NMBA) use and reversal in #$%% identi,edan approximate "$% decline in the use of neostigmine sinceintroduction of Sugammadex. !ey also revealed a low rateof neuromuscular monitoring (*'%) and, correspondingly, avery high incidence of postoperative residual neuromuscularblockade (RNMB) and associated complications.

!e aforementioned investigations investigated changesin anesthesia practice and patient postoperative outcomewithin only a few months from the introduction of Sug-ammadex. In contrast to studying the status quo as well as“short term” changes, it was the aim of the current auditto investigate whether the introduction of Sugammadex hasresulted in a long term (# years) change of anesthetists’NMBA associated practice and beliefs.

2. Methods

Both projects were approved by the RPH Department ofQuality and Safety as clinical audits. Firstly, a #(-page

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Anesthesiology Research and Practice

Volume 2015, Article ID 367937, 4 pages

http://dx.doi.org/10.1155/2015/367937

# Anesthesiology Research and Practice

web-based (Survey Monkey) questionnaire (see full survey inSupplementary Material available online at http://dx.doi.org/%$.%%""/#$%"/*(+)*+) asking questions around the matter ofNMBA and reversal use was sent to all RPH anesthetistsin mid-#$%*. Secondly, a one-week (Monday to Friday; 'a.m.–" p.m.) prospective “snapshot” audit was performedwithin RPH theatres in October #$%*. !e latter included allnoncardiothoracic patients receiving NMBA at RPH duringthe speci,ed time. !is project aimed to gather informationabout the practice of neuromuscularmonitoring,NMBA, andreversal use and the incidence of RNMB. Data for this “in-theatre” audit was gathered by a research assistant presentduring the phase of patients’ tracheal extubation. However,the decision whether or not to monitor or reverse RNMBwas entirely le- to the attending anesthetist. If neuromuscu-lar monitoring was applied, the kinemyometric monitoring(KMG; quantitative monitoring) module (GE Healthcare,Helsinki, Finland) was used.

Wherever meaningful, and in order to achieve a longitu-dinal view of changes in anesthesia practice, results frombothaudits were compared with those of the two similar projectspublished by us previously [%, #].

3. Results

&.!. Online Survey. Twenty-four consultants as well as %&registrars replied to the online survey, resulting in an overallresponse rate of *# percent.

&.!.!. NMBA Use. +#% (! = 26) of colleagues replied thatthey would use muscle relaxants more o-en than in #$%%and stated “optimizing anesthesia and surgery” as the mainreason for doing so. "&.*% (! = 19) speci,cally statedthat they paralyze patients intraoperatively deeper and forlonger, with ("% (! = 24) of all respondents believing thatdoing so may improve surgical conditions without the needto increase the depth of anesthesia. However, only #".'%(! = 8) of the above-mentioned ("% (! = 24) stated thatthey had actually seen such bene,ts in their own practice.!e remaining respondents did see a potential bene,t, butwithout this being evident in their daily life. Interestingly,and unin.uenced by the introduction of Sugammadex, morethan )$% of respondents did not rate Succinylcholine as asuperseded drug for rapid sequence induction.

&.!.$. Monitoring. Neuromuscular monitoring was stated tobe the single most important instrument to make a decisionabout NMBA reversal by the majority (! = 22) of respon-dents. Only a few respondents preferred timing (! = 1),clinical evidence (! = 2), and type of NMBA based reversal(! = 1).&.!.&. Reversal. Overall, reversal rates were relatively highwith &'% (! = 12) respondents stating that they practiceNMBA reversal in +(–%$$% of general anesthetics and *%%(! = 8) respondents reversing NMBA in "%–+"% cases. ""%(! = 21) of respondents stated that they use reversal agentsmore o-en compared to #$%%.

Interestingly, and despite making Sugammadex availablewithout restriction in #$%%, many (&%%; ! = 16) respondentsreported only having used the drug “routinely” since #$%#.

Sugammadex was chosen in more than +"% of reversalcases by +*.&% (! = 27) of respondents.!ough '(% (! = 25)of respondents stated using a nerve stimulator to determineneed and dose for Sugammadex-based reversal, a relativelyhigh proportion (&%%; ! = 12) stated not using suchmethodsto check the success of the reversal due to the high reliabilityof the drug.

In the context of Sugammadex reversal, personal expe-riences of faster “case turnover,” less postoperative residualneuromuscular blockade, and higher anaesthetist satisfactionwere quoted by ()% (! = 20), +)% (! = 23), and")% (! = 17), respectively. &"% (! = 13) of colleaguesreported that they would feel professionally impairedwithoutthe unrestricted availability of Sugammadex, and % colleaguewould even refuse to work in a hospital without this drugbeing freely available. In clinical practice Sugammadex wasfrequently ("+%) mildly overdosed (based on the o/cialprescription information), with #$$mg being the mostcommonly administered dose. ('% of respondents statedknowing the price of Sugammadex to the RPH anaesthesiadepartment, but only &*% saw this as an important factorin.uencing their practice.

&.$. In-(eatre Audit. Data of +% patients (52 ± 18 (%(–'")years) were analyzed.

&.$.!. NMBA Use. NMBA were used during plastic surgery(%).+%), general surgery (#*.)%), orthopedic surgery (%(.)%),or other surgical specialty procedures (*).&%). Rocuroniumwas used for intubation in ''.+% of patients, Vecuroniumin ".(%, Succinylcholine in #.'%, and Cisatracurium andMivacurium in %.&% of cases. A second dose of NMBA wasgiven in #$ patients, with Rocuronium chosen in %) of those.

&.$.$. Monitoring. !e need for reversal was determinedusing clinical signs only in *$."%, whereas in ()."% ofpatients neuromuscular monitoring was used. Train of four(TOF) “fade” was detected at the end of surgery in *' patients("*.*%).

&.$.&. Reversal. Sugammadex was administered in all *'patients in whom a TOF fade had been detected and in #$patients in whom either no fade had been found (! = 2)or no monitoring had been used (! = 18). Remarkably, noNeostigmine or other cholinesterase-inhibitor was used at all(despite introduction of Sugammadex in #$%%, the choice ofreversal agent is fully at the discretion of the attending anes-thesiologist). Rated by the o/cial prescription information(PI) for Sugammadex the drug was slightly overdosed in **and underdosed in + cases. Main reasons for incorrect dosingincluded the desire not to waste Sugammadex, personaldosing experience that di0ered from the o/cial PI, and thelack of any monitoring available. !e doses administeredwere documented correctly in the vast majority of anesthetics()&.#%). However, the use and result of neuromuscular

Anesthesiology Research and Practice *

monitoring were only documented with su/cient detail inabout half of the patients.

4. Discussion

#." years a-er the introduction of Sugammadex withoutaccess restriction our results support that the vast majority ofRPH anaesthetists were choosing an aminosteroidal NMBA()&.*%), Sugammadex (%$$%) combination when paralyzingpatients. !is usage pattern constitutes a signi,cant increaseof aminosteroidal NMBA use from (%% (#$%$) [%] and '&%(#$%%) [%], as well as a very large increment in the use ofSugammadex (usage in #$%$: %$%, and usage in #$%%: (*% [%]).

("% of the surveyed anesthetists stated their belief thatdeep and extended neuromuscular blockade may result inbetter surgical conditions. Despite this, many colleaguesstated that although they believed in the bene,ts of deepneuromuscular blockade, they had not seen such e0ectsin their own practice. !ough the evidence for improvedsurgical conditions bymeans ofmuscle relaxation is relativelysparse, more recently, studies have identi,ed measurablebene,ts [#–(]. In fact, within just one year (#$%&), variousauthors [&–(] described signi,cantly improved surgical con-ditions during laparoscopic surgery under deep (no TOFtwitch) versus moderate (TOF #–& twitches) neuromuscularblockade. Compared to these seemingly unanimous resultsit is interesting to ,nd that such changes had only beenobserved by aminority of anesthetists (#".'%) in this audit. Apossible explanation for these observations may be that deep(versus moderate) blockade is not yet routinely practiced bymany anesthetists, and secondly these audit reviews did notsurvey any surgical opinions.

A second hypothetical bene,t for using more intraop-erative NMBA quoted by the surveyed anesthetists was apotentially improved patient outcome due to a reduced useof hypnotic anesthetic agents resulting in a more appropriate(monitored) depth of anesthesia. !ough direct evidencefor this point is missing, previous data have linked (deep)anesthesia with impaired patient outcome [+] and a largeinternational multicenter study (Balanced trial; Australianand New Zealand College of Anaesthetists).

A very encouraging result of our audits was that theattitude of anesthetists towards neuromuscular monitoringhad signi,cantly improved from April #$%% to October #$%*with only a minority of colleagues (! = 1 in the web-based survey) rating clinical signs of adequate neuromuscularrecovery as su/ciently reliable tools for clinical practice.!elatter rating is surprisingly low compared to a #$%$ surveyperformed by Naguib et al. ['] who identi,ed that &*."%of European and even ('.#% of US anesthetists believedclinical signs to be su/ciently accurate. However, in realitythe sensitivity of various clinical signs (i.e., " s leg li-) to detectinadequate neuromuscular recovery has been found to beextremely poor [)].

In the context of neuromuscular monitoring, &*% ofsurveyed anesthetists stated limiting monitoring to intraop-erative (prereversal) use only and omitting using neuromus-cular monitors to check the adequacy of Sugammadex-based

reversal. !ough Sugammadex has been shown to result insigni,cantly lower rates of RNMB [#] when compared totiming of NMBA use or neostigmine, it has also been doc-umented that not monitoring the success of Sugammadex-based reversal was still correlated with an '–).&% RNMBrate [#, %$]. Our survey also observed the trend to a “onesize ,ts all” approach in dosing Sugammadex. !e mostcommonly chosen dose of #$$mg frequently constituteda mild overdose and rarely an underdose of the drug.!ough there is no direct evidence to link mild over- orunderdosage of Sugammadex to undesirable patient out-comes, more severe underdosing could potentially resultin recurarization [%%] and should hence be avoided. Moreconcerning than the trend to a #$$mg dose for all patientswas the fact that %' patients received Sugammadex withoutany preceding neuromuscular monitoring. As the results ofsuchmonitoring are imperatively important to determine theneed as well as the correct dose of the drug, a failure tomonitor neuromuscular function may result in unnecessarydrug administration or signi,cant dosing errors. !e latternot only adds to patient risk and healthcare costs, but alsoposes a risk for litigation. In the same context anesthetistsshould also document all neuromuscular monitoring e0ortsand results, as well as the drugs given to reverse RNMB.!erate of monitoring documentation (approximately "$%) wefound in our survey was certainly alarmingly low and needsto drastically improve.

Our “snapshot” in-theatre audit did not directly measureRNMB.However, the high rate of neuromuscularmonitoringas well as the fact that all patients in whom fade was detectedreceived Sugammadex for reversal of NMBA e0ects at leastsuggests that the overall rate of RNMB at our institutionmay have decreased from the very high incidences ("$–($%)reported by us in #$%% [#].

We conclude that the unrestricted introduction of Sug-ammadex at our institution has resulted in a near completeshi- to a Rocuronium-Sugammadex combination.!e trendto use a “one size ,ts all” dose of Sugammadex has beenidenti,ed and requires further sta0 education.

Conflict of Interests

!omas Ledowski has consulted for and accepted a researchgrant from MSD. However, none of the aforementioned hasbeen related to this paper, andMSD has not in any form beeninvolved in planning, analysis, or paper preparation.

Acknowledgment

!e project was funded by the University of Western Aus-tralia.

References

[%] T. Ledowski, S. Hillyard, A. Kozman et al., “Unrestrictedaccess to sugammadex: impact on neuromuscular blockingagent choice, reversal practice and associated healthcare costs,”Anaesthesia and Intensive Care, vol. &$, no. #, pp. *&$–*&*, #$%#.

& Anesthesiology Research and Practice

[#] T. Ledowski, S. Hillyard, B. O’Dea, R. Archer, B. Vilas-Boas,and B. Kyle, “Introduction of sugammadex as standard reversalagent: impact on the incidence of residual neuromuscularblockade and postoperative patient outcome,” Indian Journal ofAnaesthesia, vol. "+, no. %, pp. &(–"%, #$%*.

[*] M. King, N. Sujirattanawimol, D. R. Danielson, B. A. Hall, D. R.Schroeder, and D. O. Warner, “Requirements for muscle relax-ants during radical retropubic prostatectomy,” Anesthesiology,vol. )*, no. (, pp. %*)#–%*)+, #$$$.

[&] C. H. Martini, M. Boon, R. F. Bevers, L. P. Aarts, A. Dahan,and J. P. !ompson, “Evaluation of surgical conditions duringlaparoscopic surgery in patients with moderate vs deep neuro-muscular block,” British Journal of Anaesthesia, vol. %%#, no. *,pp. &)'–"$", #$%&.

["] P. E. Dubois, L. Putz, J. Jamart, M.-L. Marotta, M. Gourdin, andO. Donnez, “Deep neuromuscular block improves surgical con-ditions during laparoscopic hysterectomy,” European Journal ofAnaesthesiology, vol. *%, no. ', pp. &*$–&*(, #$%&.

[(] A. K. Staehr-Rye, L. S. Rasmussen, J. Rosenberg et al., “Surgicalspace conditions during low-pressure laparoscopic cholecystec-tomy with deep versus moderate neuromuscular blockade: arandomized clinical study,” Anesthesia & Analgesia, vol. %%), no.", pp. %$'&–%$)#, #$%&.

[+] K. Leslie, P. S. Myles, A. Forbes, and M. T. V. Chan, “!e e0ectof bispectral index monitoring on long-term survival in the B-aware trial,” Anesthesia and Analgesia, vol. %%$, no. *, pp. '%(–'##, #$%$.

['] M. Naguib, A. F. Kopman, C. A. Lien, J. M. Hunter, A. Lopez,and S. J. Brull, “A survey of current management of neuromus-cular block in the United States and Europe,” Anesthesia andAnalgesia, vol. %%%, no. %, pp. %%$–%%), #$%$.

[)] S. J. Brull and G. S. Murphy, “Residual neuromuscular block:lessons unlearned. Part ii: methods to reduce the risk of residualweakness,” Anesthesia and Analgesia, vol. %%%, no. %, pp. %#)–%&$,#$%$.

[%$] Y. Kotake, R. Ochiai, T. Suzuki et al., “Reversal with sugam-madex in the absence of monitoring did not preclude residualneuromuscular block,” Anesthesia and Analgesia, vol. %%+, no. #,pp. *&"–*"%, #$%*.

[%%] T. Fuchs-Buder, “Less is not always more: sugammadex and therisk of under-dosing,” European Journal of Anaesthesiology, vol.#+, no. %$, pp. '&)–'"$, #$%$.

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Neuromuscular Monitoring, Muscle Relaxant Use, and ... · 12/1/2015 · related to the use of neuromuscular blocking agents at the Royal Perth Hospital since this introduction. Results

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