Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery?

Abstract

Neuromuscular blocking agents are used to facilitate tracheal intubation in patients undergoing ambulatory surgery. The use of high-dose neuromuscular blocking agents to achieve muscle paralysis throughout the case carries an increased risk of residual post-operative neuromuscular blockade, which is associated with increased respiratory morbidity. Visually monitoring the train-of-four (TOF) fade is not sensitive enough to detect a TOF fade between 0.4 and 0.9. A ratio <0.9 indicates inadequate recovery. Quantitative neuromuscular transmission monitoring (e.g., acceleromyography) should be used to exclude residual neuromuscular blockade at the end of the case. Residual neuromuscular blockade needs to be reversed with neostigmine, but it's use must be guided by TOF monitoring results since deep block cannot be reversed, and neostigmine administration after complete recovery of the TOF-ratio can induce muscle weakness. The development and use of new selectively binding reversal agents (sugammadex and calabadion) warrants reevaluation of this area of clinical practice.

Keywords: Ambulatory surgery; Calabadion; NMBA; Neostigmine; PORC; Residual paralysis; Respiratory complications; Sugammadex.

Conflict of interest statement

Conflict of Interest Hassan Farhan, Ingrid Moreno-Duarte and Duncan McLean declare that they have no conflict of interest. Matthias Eikermann has received financial support through a grant from Merck, and has submitted a patent application for Calabadion to reverse NMBA and anesthesia.

Figures

Fig. 1

Mechanisms of residual paralysis induced postoperative respiratory failure. A small level of residual paralysis that cannot be detected without quantitative monitoring of the train-of-four (TOF) response impairs several important facets of respiratory function. The main mechanisms of respiratory failure induced by minimal, residual neuromuscular blockade (TOF: 0.5–0.9) are impairments of hypoxic ventilatory response, and respiratory muscle function. In addition, the coordination between breathing and swallowing is impaired, leading to the inability to protect the airway during swallowing. Consequently, paralysis increases the vulnerability to hypoxia, symptomatic aspiration, pulmonary edema, and reintubation