the metablog

Thoughts, news and musings from metajournal.

Neuromuscular myths: We need to do better

The rise of sugammadex has lead me down a path looking into wider aspects of my own neuromuscular blocking drug (NMBD) use. The evidence for NMBD use, monitoring and reversal is interesting, both for how consistently the same messages have been repeated over the past three decades – and for how little we have improved our practice in spite of mounting evidence demanding that we should.1

I need to do better and you probably also need to do better with how we manage NMBDs.

What is PORC?

Post-operative residual curarisation (PORC) or residual paralysis, refers to persisting neuromuscular blockade in a patient after extubation. It is considered present when the Train-of-four (TOF) ratio is less than 0.9, usually measured in recovery or the post anesthesia care unit (PACU).

The historical comparison of studies investigating PORC is difficult because for many years a TOF ratio of 0.7 was considered the cutoff value for PORC. Volunteers given d-tubocurarine had normal vital capacity and inspiratory force when the TOFR recovered above 0.7. Then in the mid-1990s a TOF ratio of 0.8 was used in studies investigating PORC.

Now in the 21st century a TOFR 0.9 is considered the cut-off for defining PORC. A TOFR 0.9 has been chosen because consequences of residual paralysis, such as pharyngeal dysfunction and impairment of respiratory function have been shown below this TOF ratio.

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  1. Case in point: Donati F. Neuromuscular monitoring: what evidence do we need to be convinced? Anesth Analg. 2010 Jul;111(1):6-8. (pubmed

Wow! A great response from our beta users!

A big thank you to all those members of metajournal who signed up for our special beta pricing – I am humbled by your support!

Metajournal has been in open beta for only a few weeks, yet the number of articles we have indexed and the number of doctors using metajournal continues to grow.

While metajournal's supernatural-ability to suggest interesting articles is the core of the service, I have many new features currently being worked on – and even more on the drawing board. I am most excited to soon be adding the ability to add notes to articles: summaries, pearls and comments to share with the rest of the metajournal community.

Our special beta pricing will only continue for another couple of weeks, so sign up now for a paid account to save $50 on your first year subscription – and so keep up to date!

On Anaesthesia and Simplicity

It is easy to lose sight of the core of the practice of anaesthesia. As a profession we are easily seduced and distracted by the new and exciting; quickly forgetting that satisfyingly favourable outcomes for our patients occur not because of the advances in the technology and pharmacology of anaesthesia, but rather are owed to our training and performance as anaesthetists and anaesthesiologists managing that complex system.

Our ability to understand the complex model of patient, surgeon, drugs and scalpel; to resist distraction by the blinkenlights of whatever new device has been dragged in by the friendly equipment rep; the exciting kinetics of the latest drug; or the new ventilator modes on the anaesthetic machine - our ability to conceptually simplify these things and achieve good outcomes is at the core of what we do.

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Metajournal now in open beta!

Exciting news for metajournal this week — we're in open beta! This means that now anyone can sign up for a metajournal account and stay up to date with the latest, most personally relevant evidence in anesthesia, critical care and emergency medicine.

To thank all our early access users already using metajournal, we have both new pricing – and for a limited time a further $50 off the first year of your metajournal subscription.

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The quality of metajournal's article recommendations have continued to improve, and get spookily prescient once you are following a critical number of topics. To get (very!) good results follow at least 30 topics. For clairvoyant-quality evidence suggestions aim for 50-100 topics and be delightfully surprised!

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We just indexed our 50,000th article

The number of new articles published keeps increasing everyday. In fact PubMed adds roughly one new article to its 23-million-strong database every minute!

Metajournal indexes, qualifies and assesses each new article from (currently) more than 70 critical care specialty journals – each and everyday. Today we just indexed our 50,000th article from which metajournal can recommend to you the highest quality, most significant and personally relevant evidence for you and your unique practice.

Each day we add another 20 to 100 new articles to that repository – to keep us all up to date.

And if you are reading this in the future (queue Dr Who theme music...) the metajournal article library right now stands at an impressive 937,140 articles!

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