Ep. 211 - Neuromuskuläres Management

Nach einer etwas längeren Baby-Pause kommt heute ein Input zum neuromuskulären Monitoring. Und zwar beinhaltet es die Zusammenfassung der USZ-Fortbildung vom 8.10.25, welche wirklich sehr informativ war und auf die Thematik der tiefen neuromuskulären Blockade eingeht und die damit verbundenen Vorteile der Low-Impact Laparoskopie.

Ich habe euch die zusammengefasste Transkription der KI Jamie hier aufgeführt.

liebe Grüsse und bis bald :-)

Speaker Introduction and Background

• Kim Albers has conducted extensive research on deep neuromuscular blockade trials.

• They collaborated with a surgeon, leading to a marriage between their departments and ongoing operative research projects.

• In April, Kim Albers met with world experts and founded the International Society of Neuromuscular Management.

Deep Neuromuscular Blockade

Definition and Classification

• Deep neuromuscular block is defined as a post-tetanic count (PTC) of 1 or 2.

• This definition was chosen because:

  • It provides a small, clinically workable range

  • It's not zero (which could indicate overdosing)

  • It's comparable to 28 out of 33 previous clinical trials

  • It correlates with diaphragm paralysis, which is crucial for abdominal surgery

Safety and Evidence

• A Cochrane systematic review of 42 randomized controlled trials (nearly 4,000 participants) was inconclusive due to low reporting of mortality and serious adverse events.

• Kim Albers conducted a large international RCT with 723 patients comparing deep vs. standard neuromuscular block in complex laparoscopic abdominal surgeries.

• Findings:

  • No significant difference in grade 2 intraoperative adverse events

  • Surgeons reported better working conditions with deep block

  • 4.2% of patients in the non-deep block group moved enough to temporarily stop surgery, compared to 0% in the deep block group

Low-Impact Laparoscopy

Concept and Benefits

• Low-impact laparoscopy combines low intraabdominal pressure with deep neuromuscular block.

• A video demonstration showed significantly faster and more intense fluorescence in the low pressure group (8 mmHg) compared to standard pressure (12 mmHg), indicating better peritoneal perfusion.

Clinical Outcomes

• A systematic review and meta-analysis of 85 studies across various abdominal laparoscopic procedures found:

  • Less mild postoperative complications

  • Less postoperative pain

  • Less nausea and vomiting

  • Reduced length of hospital stay by about 1/3 of a day

• Kim Albers's trial in laparoscopic colorectal surgery comparing 8 mmHg vs. 12 mmHg found:

  • Higher quality of recovery

  • Lower acute pain scores

  • 10% fewer 30-day infectious complications (though not statistically significant)

  • Better preserved immune cell function in the low pressure group

Rocurhithm Algorithm

• Kim Albers and colleagues designed the Rocurhithm algorithm for smooth deep neuromuscular block throughout surgery.

• The algorithm requires frequent monitoring and adjustments in continuous rocuronium administration.

• It has been adopted by Nysora, which posted it on Instagram with the heading "Making Surgery Smoother".

Risks and Considerations

Awareness Risk

• Deep neuromuscular block, especially with TIVA, carries a risk of awareness.

• BIS monitoring may be unreliable due to paralyzed forehead muscles.

• Precautions:

  • Use inhalational agents when possible

  • With TIVA, ensure proper propofol dosing and IV function

  • Pay close attention to other clinical signs (heart rate, blood pressure, sweating)

Recarurization

• Risk of recarurization after antagonizing deep block with sugammadex.

• Factors contributing to recarurization:

  • Administration of magnesium or certain antibiotics

  • Rocuronium re-release from the central compartment

  • 
    

International Society of Neuromuscular Management

• Founded in April by Kim Albers and other experts in the field.

• Key members include Thomas Fuchs-Puder, Soren Breu, Béla Fejér Fülöp, and Lars Eriksson.

• Objectives:

  • Discuss current guidelines and their implementation

  • Advance safety in neuromuscular management

  • Standardize assessment of residual neuromuscular block in awake patients on the PACU

Guidelines and Adherence

Current Guidelines

• European Society and American Society of Anesthesiology aligned their recommendations in early 2022.

• Key recommendation: Use quantitative monitoring at the thumb.

• Critical to obtain a TOF ratio of 0.9 or higher before tracheal extubation.

Poor Adherence in Practice

• POPULAR trial (2019, over 17,000 patients) showed:

  • No monitoring used in 10,000 patients

  • Extubation based on clinical evaluation in 12,000 patients

  • Only 16% had documented TOF ratio ≥0.9 at extubation

• Study by Mohamed Leguib:

  • 1,600 anesthesiologists from 80 countries answered only 57% of neuromuscular monitoring questions correctly

  • 84% confidence in their answers, showing unjustified overconfidence

Residual Neuromuscular Block

Complications

• Pulmonary complications due to impaired upper airway muscle function.

• Risks include:

  • Impaired swallowing

  • Accumulation of airway secretions

  • Aspiration

Importance of Monitoring

• Quantitative monitoring at the thumb is critical for patient safety.

• Visual or tactile evaluation of TOF fade is unreliable above a TOF ratio of 0.5.

• Monitoring is essential as anesthesiologists often don't see late complications (e.g., aspiration pneumonia) that occur days after surgery.

Controversy and Challenges in Monitoring

Debate on Monitoring Effectiveness

• Kim Albers notes that there is still a large group of professionals who are not convinced that better monitoring will lead to improved patient outcomes.

• The speaker expresses happiness that the audience is not part of this group that doubts the effectiveness of monitoring.

Defining Postoperative Pulmonary Complications

• Kim Albers mentions a 2021 study that expanded the definition of postoperative pulmonary complications to include unplanned need for oxygen.

• The speaker questions how to distinguish between actual pulmonary problems and other factors like resedation or opioid influence that may increase oxygen demand.

• Kim Albers notes that the inflammatory response to surgery temporarily increases tissue oxygen demand, further complicating the definition.

Current Research Initiatives

Delphi Project on Pulmonary Complications

• Professor Markus Schult, associated with the University of Vienna and based in Switzerland, is working on a Delphi project to define pulmonary complications more clearly.

Multicenter Implementation Trial

• Kim Albers mentions plans for a large multicenter and multinational implementation trial to demonstrate that proper management and implementation of guidelines can lead to a decrease in postoperative pulmonary complications.

Barriers to Guideline Implementation Study

• A Delphi study is being conducted in collaboration with the society to identify barriers to implementing guidelines.

• After identifying barriers, experts will work on consensus solutions to improve monitoring implementation.

Practical Implementation of Monitoring

Hospital Case Study

• Kim Albers's hospital has implemented integrated monitors with TOF and PTC values that are directly recorded in the anesthetic file.

• The system provides non-obtrusive reminders if:

  • No TOF has been registered within the first 45 minutes of surgery when neuromuscular blocking agents are used.

  • No TOF has been registered at the end of the case when neuromuscular blocking agents have been used.

• This implementation has significantly improved monitoring rates in the hospital.

Study on Residual Curarization

• A study of 500 patients in the post-anesthesia care unit found only 11 patients (2.2%) with a TOF ratio below 0.9.

• This result is favorable compared to literature reports of residual block incidence ranging from 3.5% to 53%.

• The improvement is attributed to better monitoring in the OR and identifying patients at risk of recurarization.

Technical Aspects of Neuromuscular Monitoring

Acceleromyography vs. Electromyography

• Acceleromyography often shows baseline TOF above 100% due to the "inverse fade" or "staircase phenomenon".

• The staircase phenomenon occurs because the thumb doesn't fully return to its original position between twitches, leading to stronger subsequent movements.

• Electromyography always measures between 0 and 100%, making it more reliable for accurate measurements.

Device-Specific Considerations

• Kim Albers emphasizes the importance of knowing your device and its quirks.

• Issues mentioned include:

  • Interference with surgical diathermy

  • Waiting periods between PTC measurements (3.5 minutes)

  • Trusting clinical observations and physiology alongside device readings

Deep Neuromuscular Block

• Deep neuromuscular block (PTC of 1 or 2) can be used for smoother surgery and to facilitate low-pressure pneumoperitoneum.

• Caution is advised due to increased risk of awareness and recurarization.

Guidelines and Best Practices

• Guidelines emphasize that monitoring is critical before extubation to prevent postoperative pulmonary complications.

Future Directions

• The International Society of Neuromuscular Management is working on:

  • Identifying barriers for guideline implementation

  • Preparing a large grant for the Quantic trial to gather evidence for guideline implementation across Europe

Q&A Session

Induction Period Monitoring

• Speaker 0 asks about monitoring during the induction period, particularly when administering rocuronium for intubation.

• Kim Albers responds:

  • They haven't specifically looked at outcomes around intubation.

  • Expresses surprise that some anesthesiologists don't measure neuromuscular blockade during induction when devices are available.

  • Compares not measuring to not checking blood pressure, which no anesthesiologist would do.

  • Studies on intraoperative safety show that monitoring makes surgery smoother without increasing risks.

Cost-Benefit Analysis of Sugammadex

• Speaker 1 inquires about the cost aspects of using sugammadex versus electromyography.

• Kim Albers responds:

  • Sugammadex cost has decreased significantly since patent expiration (from 80 euros to 3-5 euros per vial).

  • High doses of sugammadex can lead to QT prolongation, bradycardia, and increased likelihood of allergic reactions (based on case reports).

  • Very high doses can prevent re-paralysis with rocuronium if needed for reoperation.

  • Mild postoperative benefits and earlier hospital discharge after deep neuromuscular block can offset costs.

  • Decreased postoperative complications may outweigh the cost of electromyography sensors, but this can be complicated due to different hospital budget allocations.

Call to Action

• Adherence to guidelines on neuromuscular monitoring is crucial for patient safety.

• Anesthesiologists must recognize the importance of quantitative monitoring and overcome barriers to implementation.

• Continued education and research are needed to improve neuromuscular management practices worldwide.