Neuromuscular Monitoring: Does the use of acceleromyography in comparison to the unaided clinical assessment result in lower occurrences of postoperative residual neuromuscular blockade in patients admitted to the post anesthesia care unit?

Abstract

The occurrence of postoperative residual neuromuscular blockade continues to affect a considerable percentage of patients admitted to the post anesthesia care unit (PACU). Recent evidence suggest 17-36% of patients that arrive to the PACU present with objective manifestation of incomplete neuromuscular blockade reversal as determined by train-of-four ratios less than 0.90.^1(p389) Patients presenting to the PACU with a train of four (TOF) ratio < 0.90 are considered to have residual neuromuscular blockade and are at an increased risk for experiencing adverse respiratory events such as reduced upper airway volumes, airway obstruction, hypoxemia events, and postoperative pulmonary complications.² Research supports the proponents of quantitative acceleromyography for monitoring neuromuscular blockade and recovery. Qualitative neuromuscular monitoring includes peripheral nerve stimulator and clinical sign assessment such as the 5-second head-lift test, tongue blade stability between the incisors to a quantitative approach (ex. acceleromyography).  However, this change in practice is accompanied by hesitancy and uncertainty from practitioners across the nations who underestimate the occurrence of postoperative residual neuromuscular blockade and its effects. The rationale to switch from the qualitative assessments for a more quantitative approach using an accelerometer needs review. The purpose of this report is to determine if objective acceleromyography in comparison to subjective peripheral twitch monitors and clinical assessment are more effective in decreasing the occurrence of post-operative residual neuromuscular blockade.