Article Notes

Why is this important?

First, because it identifies new novel risk factors for residual neuromuscular block (experienced surgeon, non-CRNA anesthesia provider...) and secondly, because the subtext reveals the lengths our specialty goes to avoid simply monitoring using qualitative NMB monitoring (TOFR)!

What did they find?

Rudolph et al. created a REsidual neuromuscular block Prediction Score (REPS) using Massachusetts General PACU data, applying covariate analysis to identify 10 risk factors, some more surprising than others:

1. Hepatic failure
2. Neurological disease
3. High-neostigmine dose > 60 mcg/kg
4. Metastatic solid tumour
5. Female sex
6. Less than 120 min between NMBD administration and extubation
7. Aminosteroid NMBD
8. BMI more than 35
9. Absence of nurse anaesthetist (CRNA)
10. Having an experienced surgeon

Be smart:

These risk factors might suggest patients who need more careful monitoring, but you will probably be better off just using qualitative monitoring routinely. The utility of REPS itself is only modest with NPV & PPVs of 85% each.

The other takeaway is that rNMB is still demonstratably common, occurring in 20% of this cohort!

  Daniel Jolley

The majority of anesthesia-related cardiac arrests are due to respiratory events.

  Daniel Jolley

While there is both utility and some interesting insights from the LAS VEGAS risk score research, it also seems to have largely confirmed that higher risk patients, having more invasive or major surgery, and those who misbehave intraoperatively are more likely to experience postoperative pulmonary complications...

  Daniel Jolley

Clonidine improves post-operative analgesia, reduces nausea & vomiting, improves hemodynamic stability, does not prolong wakening, and does not improve cardiac outcomes.

  Daniel Jolley

Sugammadex use does not avoid either the need or benefit of neuromuscular monitoring, although it does result in less residual neuromuscular block than neostigmine reversal.

  Daniel Jolley

Neostigmine administration after clinical recovery of neuromuscular function to TOFR ≥ 0.9 appears to be neither beneficial or detrimental.

  Daniel Jolley

I agree with Allan. This is the best available evidence for Ephedrine vs Phenylephrine to treat hypotension post-spinals in LSCS.

  Chris Tan

Use of intraoperative cerebral oximetry may reduce post-operative cognitive decline.

  Daniel Jolley

Intubation using a tracheal stylet in the ETT significantly increases the incidence of post-operative sore throat.

  Daniel Jolley

Although there remains much conflicting evidence, largely of a low-quality observational nature, the highest quality evidence to date refutes assertions that epidural fentanyl reduces breastfeeding rates.

Notably Lee et al.’s 2017 RCT of over 300 women showed no effect of epidural fentanyl up to 2 mcg/mL and successful maternal breastfeeding up to 6 weeks.

  Daniel Jolley