Residual neuromuscular blockade in the ICU: a prospective observational study and national survey

Summary Residual neuromuscular blockade is associated with significant morbidity. It has been widely studied in anaesthesia; however, the incidence of residual neuromuscular blockade in patients managed in the ICU is unknown. We conducted a prospective observational study in a tertiary ICU to determ...

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Bibliographic Details
Published in:	Anaesthesia Vol. 77; no. 9; pp. 991 - 998
Main Authors:	Ross, J., Ramsay, D. P., Sutton‐Smith, L. J., Willink, R. D., Moore, J. E.
Format:	Journal Article
Language:	English
Published:	Oxford Blackwell Publishing Ltd 01-09-2022
Subjects:	Anesthesia Atracurium Clinical practice guidelines Extubation Intensive care Monitoring Morbidity neuromuscular monitoring Observational studies Patients residual neuromuscular blockade Risk analysis Risk factors Surveys New Zealand
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Summary:	Summary Residual neuromuscular blockade is associated with significant morbidity. It has been widely studied in anaesthesia; however, the incidence of residual neuromuscular blockade in patients managed in the ICU is unknown. We conducted a prospective observational study in a tertiary ICU to determine the incidence of residual neuromuscular blockade using quantitative accelerographic monitoring. We tested for residual neuromuscular blockade (defined as a train‐of‐four ratio < 0.9) before cessation of sedation in anticipation of tracheal extubation. We also surveyed 16 other ICUs in New Zealand to determine their use of neuromuscular monitoring. A total of 191 patients were included in the final analysis. The incidence (95%CI) of residual neuromuscular blockade was 43% (36–50%), with a similar incidence observed in non‐postoperative and postoperative patients. There was a lower risk of residual neuromuscular blockade with atracurium than rocuronium (risk ratio (95%CI) of 0.39 (0.12–0.78)) and a higher risk with pancuronium than rocuronium (1.59 (1.06–2.49)). Our survey shows that, in New Zealand ICUs, monitoring of neuromuscular function is rarely carried out before tracheal extubation. When neuromuscular monitoring is undertaken, it is based on individual clinician suspicion and performed using qualitative measurements. No ICU reported using a quantitative monitor or a clinical guideline. The results demonstrate a high incidence of residual neuromuscular blockade in our ICU patients and identify the type of neuromuscular blocking drug as a possible risk factor. Monitoring neuromuscular function before tracheal extubation is not currently the standard of care in New Zealand ICUs. These data suggest that residual neuromuscular blockade may be an under‐recognised problem in ICU practice.
Bibliography:	Anaesthesia 77 953–5 This article is accompanied by an editorial by C. R. Bailey. 2022 : . ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 ObjectType-Undefined-3
ISSN:	0003-2409 1365-2044
DOI:	10.1111/anae.15789