Though guidelines from leading professional associations support this practice, many practices still rely on traditional methods of assessment. Read below to discover the enhancements to patient safety offered by adoption of a quantitative neuromuscular monitor.
Neuromuscular monitors in context
Neuromuscular transmission (NMT) involves the transfer of impulses between nerves and muscles. Neuromuscular blocking agents (NMBAs) arrest this process, inducing muscle relaxation and preventing spontaneous patient movements and breathing. This can facilitate airway management, improve surgical conditions, and ensure patient immobility at critical points during surgery.1,2
However, residual levels of NMBAs are associated with adverse outcomes, including upper airway obstruction, the need for re-intubation, atelectasis, pneumonia, patient dissatisfaction, muscle weakness, and even death.2,3 Such complications can lead to increased length of stay in the post-anesthesia care unit (PACU). According to Weigel et al., even though studies have thoroughly established these risks, approximately half of all PACU patients still experience residual paralysis.1
Clearly, residual neuromuscular block poses a patient safety concern; just as clearly, quantitative neuromuscular monitoring can help in managing the risk.
The power of NMT monitoring
Quantitative NMT monitoring enhances anesthesia safety by providing quantifiable data. These continuous, objective measurements of muscle response and the respective level of neuromuscular block help ensure patient paralysis ends before they leave the operating room. This can lead to shorter anesthesia duration and faster patient recovery. Without quantitative data, anesthesiologists may have challenges accurately assessing the patient's level of post-op paralysis consistently, which may result in increased complications and costs.4
The use of NMT monitors may help identify the appropriate dosing of NMBAs and reversal agents like sugammadex, in turn, potentially reducing costs and improving patient safety. In fact, many patients regain mobility without sugammadex or other reversal agents; further, the 15% of patients who do not reverse properly can be identified and treated.1
In recognition of these benefits, several professional societies now advocate for quantitative neuromuscular monitoring to manage administration of NMBAs. For example, the American Society of Anesthesiologists and the European Society of Anesthesiology and Intensive Care published evidence-based guidelines that recommend quantitative neuromuscular monitoring, on the grounds that the intervention enhances anesthesia safety by reducing residual neuromuscular blockade.2,5
The need for change: Quantitative monitoring adoption remains low despite evidence
"The adoption of these practices remains slow.1 However, they are already making a difference in clinical practice," says Stuart Grant, MD, a guideline coauthor and director of clinical research in the Department of Anesthesiology at UNC Chapel Hill. "The guidelines are comprehensive, but the devil is in the details of how people actually put that into practice."
"Although the benefits of improved precision and patient outcomes with the use of quantitative neuromuscular monitors are evident, the low rate of serious complications and the lack of a 'burning platform' for change may make it difficult for some departments to justify the investment," says Richard Dutton, MD, MBA, chief quality officer at U.S. Anesthesia Partners.*
"A patient who has moved beyond postoperative care is no longer under the anesthesiologist's supervision, which may obscure any causal links between post-op complications and anesthesia. This disconnect between anesthesia clinicians and the downstream effects of inadequate muscle relaxation further hinders the urgency for change," Dutton adds. In such a situation, the anesthesiologist may simply not know the problem exists. Further, says Weigel, "when the anesthesiologist does learn about a patient's issues with residual paralysis, they often assume it is the fault of someone else."1
Calling for champions and education
Change is difficult, particularly for clinicians who haven't yet seen the upsides of making the change, Dutton says. For instance, many CRNAs and anesthesiologists rely on subjective clinical assessment, empirically shown to be imprecise. Weigel agrees, explaining that human perception lacks the required precision to note subtle variations in muscle response.
Dutton, Grant, and Weigel each emphasized the importance of champions. Champions need to be dedicated to the cause of eliminating residual paralysis and willing to advocate for the adoption of quantitative NMT monitoring by demonstrating its benefits to colleagues. Such advocacy is an essential part of a larger, comprehensive, sustained educational effort.1 Clinicians, who may be unaware of the value of quantifying NMT, need to understand the incidence and consequences of incomplete neuromuscular recovery, the imprecision of subjective clinical assessment, and the limitations of reversal agents.3
"For example," says Dutton, "such proponents can share that quantitative NMT monitoring solves two pressing anesthesia workflow challenges: 1) determining the appropriate level of neuromuscular blockade during surgery and 2) gauging the required level of reversal at the end."
In addition, Weigel describes that the provider should clearly inform the patient of the risks associated with residual paralysis and the efforts taken to minimize the risk.
NMT monitoring matters, to both patient safety and practices' bottom lines
Quantitative NMT monitoring provides a clear picture of the extent of neuromuscular block for each patient, enabling optimal and cost-effective administration of both NMBAs and reversal agents. The guidelines emphasize the importance of monitoring during anesthesia, regardless of the type of medication used.
Investments in monitoring can lead to more accurate dosing and allow clinicians to manage reversal in a more controlled manner. This can lead to cost savings on sugammadex. Downstream, elimination of postoperative residual blockade will increase patient satisfaction and reduce pulmonary complications, such as aspiration, pneumonia, and pulmonary embolism.
Anesthesiologists and CRNAs need a user-friendly, disposable NMT solution that offers real-time quantification of neuromuscular block. Ideally, this solution seamlessly integrates with the electronic medical record (EMR) to provide quantified data and display it on a single screen. Real-time insights support tailored administration of NMBAs and reversal agents may ultimately help reduce postoperative complications, shorten recovery times, and enhance cost efficiencies.
For Grant, it comes down to this: "Unless you monitor, you do not know. You cannot tell a patient has recovered from sugammadex without [objective quantitative monitoring]."
Finding the right tools
These tools are readily available. For example, GE HealthCare's E-NMT Module supports anesthesiologists with real-time, quantitative, automatic measurement of muscle response to stimuli, using different modalities and yielding next-step certainty.
Quantitative NMT supports personalized and effective administration of NMBAs, leading to better outcomes and long-term cost savings, and aligns with the evolving standards of professional organizations. "I think any anesthesia clinician using it in the right way for the right kind of case is going to feel smarter," says Dutton. "They'll say, 'Oh yeah, that's the future. We need to have that.'"
They won't just feel smarter: They will be following best practices, Grant says. "If you want to be the best provider for your patient, it's important to monitor."
* Dr. Richard Dutton has received consulting fees and honoraria from GE HealthCare.
Resources:
1. Weigel WA, Williams BL, Hanson NA, et al. Quantitative neuromuscular monitoring in clinical practice: A professional practice change initiative. Anesthesiology. 2022;136(6):901-915. doi:https://doi.org/10.1097/aln.0000000000004174
2. Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: A report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023;138(1):13-41. doi:https://doi.org/10.1097/aln.0000000000004379
3. Murphy GS, & Brull SJ. Quantitative neuromuscular monitoring and postoperative outcomes: A narrative review. Anesthesiology. Published online November 22, 2021. https://doi.org/10.1097/aln.0000000000004044
4. Iwasaki H, Renew JR, Kunisawa T, et al. Preparing for the unexpected: Special considerations and complications after sugammadex administration. BMC Anesthesiol. 2017 Oct 17;17(1):140. doi: 10.1186/s12871-017-0429-9.
5. Fuchs-Buder T, Romero CS, Lewald H, et al. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology. 2023;40(2):82–94. https://doi.org/10.1097/EJA.0000000000001769