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pearl
1
Using an Aspect A-1000 BIS monitor, researchers demonstrated a drop in Bispectral Index Score in awake, paralysed volunteers to low values ranging from 9 to 64.
Messner M, Beese U, Romstöck J et al. The bispectral index declines during neuromuscular block in fully awake persons. Anesth. Analg. 2003 Aug 1;97(2):488-91, table of contents.
  Daniel Jolley
pearl
1
Reversal with sugammadex may dramatically reduce the incidence of post-operative residual paralysis.
Brueckmann B, Sasaki N, Grobara P et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015 Nov 1; 115 (5): 743-51.
  Daniel Jolley
summary
1
A randomised controlled trial of 150 patients undergoing abdominal surgery. On admission to the PACU no patients having received sugammadex demonstrated residual paralysis, however 43% of patients reversed with neostigmine had TOF-ratio < 0.9.
Brueckmann B, Sasaki N, Grobara P et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015 Nov 1; 115 (5): 743-51.
  Daniel Jolley
pearl
1
Recovery of train of four ratio to > 0.9 signifies adequate recovery of muscle function after neuromuscular blockade.
Baumüller E, Schaller SJ, Chiquito Y et al. Postoperative impairment of motor function at train-of-four ratio ≥0.9 cannot be improved by sugammadex (1 mg kg-1). Br J Anaesth. 2015 May 1; 114 (5): 785-93.
  Daniel Jolley
summary
1
Calabadion is a new heterocyclic molecule that offers rapid and complete reversal of both aminosteroids, such as rocuronium, and benzylisoquinoline NMBDS, such as cisatracurium.
Hoffmann U, Grosse-Sundrup M, Eikermann-Haerter K et al. Calabadion: A New Agent to Reverse the Effects of Benzylisoquinoline and Steroidal Neuromuscular-blocking Agents. Anesthesiology. 2013 Aug 1; 119 (2): 317-25.
  Daniel Jolley
pearl
1
Reversal with sugammadex may reduce the incidence of post-operative residual paralysis and consequent morbidity.
Ledowski T, Hillyard S, O'Dea B et al. Introduction of sugammadex as standard reversal agent: Impact on the incidence of residual neuromuscular blockade and postoperative patient outcome. Indian J Anaesth. 2013 Jan 1;57(1):46-51.
  Daniel Jolley
summary
1
An audit of pre-extubation residual paralysis before and after the introduction of sugammadex. Residual paralysis was significantly more common in those not reversed or reversed with neostigmine than in those reversed with sugammadex.
Patients receiving sugammadex were also less likely to desaturate in the PACU and had fewer post-operative chest x-ray changes.
Ledowski T, Hillyard S, O'Dea B et al. Introduction of sugammadex as standard reversal agent: Impact on the incidence of residual neuromuscular blockade and postoperative patient outcome. Indian J Anaesth. 2013 Jan 1;57(1):46-51.
  Daniel Jolley
summary
1
In this review of published perimortem caesarean section cases more than half of the mothers survived to hospital discharge and almost 80% of these with favourable neurological outcome.
PM caesarean section was considered beneficial in 32% of cases.
Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation. 2012 Oct 1;83(10):1191-200.
  Daniel Jolley
pearl
1
Although DBS is more sensitive than TOFC, manual assessment of DBS fade can only detect residual paralysis at TOF ratio < 0.7.
Ueda N, Muteki T, Tsuda H et al. Is the diagnosis of significant residual neuromuscular blockade improved by using double-burst nerve stimulation? Eur J Anaesthesiol. 1991 May 1;8(3):213-8.
  Daniel Jolley
summary
0
The 5-second Head Lift Test and the Tongue Depressor Test, often used to detect PORC in the PACU are of limited use for detecting TOFR < 0.9, having sensitivities of only 11% and 13% and specificities of 87% and 90% respectively.
The Head Lift Test cannot identify POCR with a TOFR > 0.5. Debaene’s study population demonstrated Positive and Negative Predictive Values of the Head Lift and Tongue Depressor Tests of only 53-58%!
Subjective, qualitative neuromuscular monitors fare no better: Tactile TOF Fade and Double Burst Stimulation (DBS) have similar sensitivities (11% and 13% respectively), although high specificities (99% each). This provides a good Positive Predictive Value (93% & 97%) but a very poor Negative Predictive Value (57% & 58%) (depending on the incidence of PORC).
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003 May 1;98(5):1042-8.
  Daniel Jolley