Maybe it’s time to take proper  reversal of neuromuscular blockade more seriously? A study just published in European Journal of Anesthesiology compares patients who have their blockade reversed with patients who are extubated without reversal. A lot of heartbreak can be avoided by paying attention to residual block. 

Most of the time residual neuromuscular blockade is the result of us anesthetists assuming the Vecuronium or Pancuronium has since long been metabolised after a long surgery. Furthermore when we succesfully extubate and awaken the patient in theatre we assume everything is alright based on our clinical observations.

The patients maintains SaO2, breathes properly and tolerates extubation.  We happily send the patient to the post anaesthetic care unit (PACU) and move on to the next case. Finally, many of us don’t actively monitor blockade. Honestly, when was the last time you had TOF-monitoring running?

Time to do better. This study out of European Journal of Anesthesiology should remind us to ensure good reversal at the end of surgery. By doing that we can significantly reduce the incidence of potentially dangerous respiratory events in the PACU.

132 patients due for surgery were randomized into one of two groups. One group was given Neostigmine 20 mcg/kg in order to ensure a complete reversal to a TOF-ratio of 1.0. The other group was given a placebo and as a result of that extubated at lower TOF-ratios (The range 0,46 to 0,9 with a median of 0,7).

The main end point was hypoxia in the PACU. After having some cases disqualified the researchers were left with 57 patients in each group.

The incidence of hypoxic events was significantly higher in the placebo group. Many hypoxic events in the PACU can be avoided by remembering to properly reverse of blockade.

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