• Minerva anestesiologica · Apr 2012

    Review

    Myths and facts in neuromuscular pharmacology. New developments in reversing neuromuscular blockade.

    Fink & Hollman describe and refute several commonly-held myths regarding neuromuscular pharmacology. Their evidence-supported arguments are:

    1. Intubating patients without muscle relaxants is less safe and sub-optimal.
    2. Even if you know muscle relaxant pharmacokinetics, it is sufficiently unpredictable that neuromuscular monitoring and reversal is still necessary.
    3. Post-operative residual curarization (PORC) is clinically significant with real consequences.
    4. Postoperative residual curarization (PORC) is common.
    5. Postoperative residual curarisation (PORC) (TOFR < 0.9) can only be diagnosed with a quantitative neuromuscular monitor. Clinical tests are insufficient and poorly sensitive.
    summary
    • H Fink and M W Hollmann.
    • Klinik für Anaesthesiologie, Klinikum rechts der Isar der Technischen Universität München, Germany. h.fink@lrz.tum.de
    • Minerva Anestesiol. 2012 Apr 1;78(4):473-82.

    AbstractPharmacologic reversal of neuromuscular blockade is a topic not very well acknowledged and controversially discussed. Reasons for this are numerous and include missing perception of the potential complications of residual neuromuscular paralysis including an increased morbidity and mortality, as well as low efficacy and numerous unwanted side effects of the available antagonists. Duration of action of muscle relaxants cannot be pharmacologically predicted. Objective neuromuscular monitoring is the only way to detect residual paralysis. This review article would like to discuss in its first part some of the myths which revolve around the use of muscle relaxants, then highlight the problems regarding the use of acetylcholine esterase inhibitors and, in the third part, discuss the steroidal muscle relaxant encapsulator sugammadex.

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    This article appears in the collections: Neuromuscular myths: the lies we tell ourselves and General Stuff.

    Notes

    summary
    1

    Fink & Hollman describe and refute several commonly-held myths regarding neuromuscular pharmacology. Their evidence-supported arguments are:

    1. Intubating patients without muscle relaxants is less safe and sub-optimal.
    2. Even if you know muscle relaxant pharmacokinetics, it is sufficiently unpredictable that neuromuscular monitoring and reversal is still necessary.
    3. Post-operative residual curarization (PORC) is clinically significant with real consequences.
    4. Postoperative residual curarization (PORC) is common.
    5. Postoperative residual curarisation (PORC) (TOFR < 0.9) can only be diagnosed with a quantitative neuromuscular monitor. Clinical tests are insufficient and poorly sensitive.
    Daniel Jolley  Daniel Jolley
    comment
    0

    This is a great review to start with, providing a good overview of many of the myths regarding the use of neuromuscular blocking drugs that are still widely believed and practised by the global anaesthesia community.

    All five of Fink & Hollman's 'myths' still hold today after reviewing the latest research in these areas.

    Daniel Jolley  Daniel Jolley
     
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