Editorial article
Residual neuromuscular block in vulnerable patients: Obesity, obstructive sleep apnea and postoperative pulmonary complications
Bloqueo neuromuscular residual en pacientes vulnerables: complicaciones pulmonares postoperatorias a causa de obesidad y apnea obstructiva del sueño
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TOFR: ratio tren de 4 (train-of-four ratio).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S.J. Brull, B. Fulesdi" "autores" => array:2 [ 0 => array:2 [ "nombre" => "S.J." "apellidos" => "Brull" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Fulesdi" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192919300770" "doi" => "10.1016/j.redare.2019.03.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300770?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935619300751?idApp=UINPBA00004N" "url" => "/00349356/0000006600000005/v1_201904190608/S0034935619300751/v1_201904190608/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192919300745" "issn" => "23411929" "doi" => "10.1016/j.redare.2019.01.003" "estado" => "S300" "fechaPublicacion" => "2019-05-01" "aid" => "1004" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2019;66:241-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Analysis of previous training with simulated models on the success rate of ultrasound-guided supraclavicular block. Prospective cohort study" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "241" "paginaFinal" => "249" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis del entrenamiento previo con modelos simulados en el porcentaje de éxito del bloqueo supraclavicular guiado por ultrasonido. Estudio de cohorte prospectivo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1855 "Ancho" => 1463 "Tamanyo" => 400269 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Accumulated success rates according to year of residency, device management and number of punctures.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Punctures vs. successful blockade (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.842). Year of residency vs. successful blockade (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.224).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V.P. Rueda Rojas, H.J. Meléndez Flórez, E. Orozco Galvis" "autores" => array:3 [ 0 => array:2 [ "nombre" => "V.P." "apellidos" => "Rueda Rojas" ] 1 => array:2 [ "nombre" => "H.J." "apellidos" => "Meléndez Flórez" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Orozco Galvis" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935619300234" "doi" => "10.1016/j.redar.2019.01.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935619300234?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192919300745?idApp=UINPBA00004N" "url" => "/23411929/0000006600000005/v1_201905090612/S2341192919300745/v1_201905090612/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Residual neuromuscular block in vulnerable patients: Obesity, obstructive sleep apnea and postoperative pulmonary complications" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "237" "paginaFinal" => "240" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S.J. Brull, B. Fulesdi" "autores" => array:2 [ 0 => array:4 [ "nombre" => "S.J." "apellidos" => "Brull" "email" => array:1 [ 0 => "SJBrull@me.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Fulesdi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anesthesiology and Intensive Care, University of Debrecen, Medical Advisory Board of the Ministry of Health, Debrecen, Hungary" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo neuromuscular residual en pacientes vulnerables: complicaciones pulmonares postoperatorias a causa de obesidad y apnea obstructiva del sueño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1274 "Ancho" => 2043 "Tamanyo" => 77098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incidence of residual neuromuscular block postoperatively after administration of neostigmine using the recovery threshold of TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.7, and TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>train-of-four ratio.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The definition of residual neuromuscular block (rNMB) has evolved over the past 4 decades. In 1973, Ali and Kitz<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">1</span></a> reported that at a train-of-four (TOF) ratio (TOFR) of 0.71, “the criteria [ability to open eyes, to protrude the tongue, cough and sustain head raising for at least 5<span class="elsevierStyleHsp" style=""></span>sec] were satisfied.” Thereafter, this threshold (TOFR<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.70) was used to indicate that recovery from neuromuscular block was sufficient to allow tracheal extubation and avoid rNMB. Using this definition, however, despite the introduction of intermediate-duration nondepolarizing neuromuscular blocking agents (NMBAs), the incidence of rNMB following neostigmine antagonism remained high (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Later clinical and experimental observations clearly demonstrated that the patency of the upper airways during recovery from neuromuscular block can only be maintained at a TOFR of 0.9 or above, a level that is currently considered the threshold of recovery. Despite the plethora of literature that documents the high incidence of hypoxemia, upper airway obstruction, and pneumonia<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">2,3</span></a> in patients with rNMB, the incidence of this easily preventable complication continues to remain astonishingly high (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">One of the patient characteristics that is a potent risk factor for the development of postoperative respiratory complications is obstructive sleep apnea (OSA),<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">4</span></a> a common disorder with an increasing prevalence that is linked to obesity.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a> Patients with OSA are prone to developing a series of postoperative adverse events; among them, respiratory complications are the most frequent (overall odds ratio, OR, of 6.88). In a recent review, an OR of 7.9 was reported for hypoxemia, OR of 4.2 for hypercapnia and OR of 1.37–1.41 for (aspiration) pneumonia.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">For better understanding of the pathophysiology of these observations, we must recall that OSA patients present airway narrowing at the retropalatal, retroglossal and hypopharyngeal levels even during wakefulness; this worsens during sleep, resulting in a decrease in the critical closing pressure.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">7</span></a> It is widely accepted that there is a difference between the vulnerability of various muscles to neuromuscular blocking agents, the upper airway muscles being more sensitive than peripheral muscles, such as the adductor pollicis.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">8</span></a> While the muscular activity of the genioglossus muscle is quadrupled during inspiration in non-paralyzed individuals, even a shallow (TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.8) neuromuscular block significantly decreases its force, resulting in significant inspiratory flow limitations.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">9</span></a> It also has been shown that during this shallow block, the negative airway pressure generated by the inspiratory movements augments the collapse of the sensitive parts of the airway. In this situation, the opening of the occluded airway depends mainly on the upstream pressure (i.e., the pressure generated through mask ventilation).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">10</span></a> Thus, patients suffering from OSA are prone to developing a critical airway closure in the postoperative phase, even if a shallow neuromuscular block is present. A recent systematic review concluded that patients with OSA who receive NMBAs may be at higher risk of developing postoperative hypoxemia, residual neuromuscular block and respiratory failure.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> In line with these findings, the American Society of Anesthesiologists (ASA) guidelines recommend that tracheal extubation of OSA patients only be performed when they are awake and when complete reversal of the NMB can verified.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">12</span></a> Pharmacologic antagonism is particularly important in obese and OSA patients. In morbidly obese patients, administration of sugammadex resulted in shortening of the time needed to reach the fit-for-extubation stage (TOFR<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>90%) and the time to complete recovery of neuromuscular function on arrival at the PACU, compared to patients receiving neostigmine.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">13</span></a> In a randomized study of OSA patients, a shorter time to TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.9 was needed when using sugammadex compared to neostigmine. Additionally, postoperative desaturation occurred in one third of the patients who received neostigmine antagonism, while the sugammadex group experienced a desaturation rate of 8%.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">14</span></a> Sugammadex reversal was also associated with better respiratory recovery than neostigmine in morbidly obese patients undergoing elective laparoscopic surgery.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">15</span></a> Patients receiving sugammadex for pharmacologic reversal had significantly higher peak expiratory flow rates at 5, 10 and 20<span class="elsevierStyleHsp" style=""></span>min after reversal than the patients receiving neostigmine and glycopyrrolate. Secondary outcomes included shorter time to a TOF<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.90 and lower mean pain scores for the patients receiving sugammadex. A clue to the potential mechanism for the improved recovery characteristics facilitated by sugammadex has been reported. Electromyographic (EMG) activity of the diaphragm, airway pressure and airway flow were measured continuously after administration of 0.6<span class="elsevierStyleHsp" style=""></span>mg/kg or rocuronium, and during recovery facilitated by either sugammadex 2<span class="elsevierStyleHsp" style=""></span>mg/kg or neostigmine 0.07<span class="elsevierStyleHsp" style=""></span>mg/kg. Diaphragmatic EMG, tidal volume and PaO2 were higher after sugammadex compared with neostigmine, suggesting that sugammadex may free up more diaphragmatic acetylcholine receptors by encapsulating the free rocuronium molecules than neostigmine, whose indirect mechanism of action (acetylcholinesterase inhibition) is less effective.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Due to the collapsibility of the upper airway in OSA patients described above, quantitative monitoring of neuromuscular block is crucial. In this particularly vulnerable patient population, initial dosing of NMBAs, supplemental intraoperative doses, maintenance of the optimal depth of intraoperative block, guidance on the timing and dose of pharmacologic agent, and readiness for tracheal extubation (TOFR<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>0.90) can only be assured by using objective (quantitative) means of assessment. Despite abundant evidence that rNMB is a common postoperative complication, a majority of clinicians believe its incidence is less than 1%.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a> In fact, the most recent, large-scale, prospective multicenter study reported an incidence of rNMB as 64.7%<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a>; surprisingly, the incidence of significant postoperative rNMB (defined as TOFR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.6) was reported as 31.0%! As the authors noted, “qualitative neuromuscular monitoring and clinical judgment often fails to detect rNMB after neostigmine reversal, with potential severe consequences”.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a> This preventable complication should be a never-event, because rNMB significantly increases intensive care admissions and healthcare costs, while also increasing the risk of 30-day hospital readmission and prolonging the length of hospital stay.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">19,20</span></a> Second, clinicians continue to rely on clinical tests in order to assess the adequacy of neuromuscular function and readiness for tracheal extubation, despite knowing for decades that clinical tests such as leg-lift, hand-grip strength and 5-second head-lift are not specific for respiratory function. In fact, 92% of volunteers had sustained 5-second head-lift at a TOFR of 0.50,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a> and 84% of patients could sustain head-lift at a TOFR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.50.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> The lack of precision and reliability of clinical testing should, however, not surprise us; the sensitivity of clinical tests is very low (0.18–0.35), while their positive predictive value is also dismally low, 0.47–0.52.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">23</span></a> Similarly, clinicians’ reliance on subjective (qualitative) evaluation of information obtained from peripheral nerve stimulators (PNS) leads to erroneous clinical decisions regarding evaluation of neuromuscular recovery: TOF fade is not detectable by subjective means after a TOFR<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.40.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">24</span></a> In fact, when recovery of neuromuscular function is monitored subjectively with PNS of the facial muscles, the incidence of rNMB (TOFR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.90) measured in the postoperative care unit was 52%. As the authors noted, “patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis”.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">25</span></a> Why, then, despite the wealth of literature that documents the limitations of subjective evaluation and clinical testing, do clinicians insist on maintaining the status quo? A recent world-wide survey of 1629 anesthesiologists from 80 countries completed a 9-question test; the clinicians answered correctly only 57% of the questions. In contrast, their mean confidence in the correctness of their answers was 84%, a figure significantly higher than the clinicians’ accuracy. In fact, 92% of the responding clinicians were overconfident. It is likely that this overconfidence prevents most clinicians from modifying their clinical practice.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">26</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The aforementioned current clinical practice is unlikely to change as long as clinicians remain overconfident in their abilities and refuse to rely on objective data provided by quantitative monitors. The most likely effective strategy for modifying clinical practice to include objective methods is to teach the new generation of students about the unquestionable benefits of quantitative neuromuscular monitoring. Only then, by changing our thinking, will we be able to solve the problems we created!</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Brull SJ, Fulesdi B. Bloqueo neuromuscular residual en pacientes vulnerables: complicaciones pulmonares postoperatorias a causa de obesidad y apnea obstructiva del sueño. Rev Esp Anestesiol Reanim. 2019;66:237–240.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1274 "Ancho" => 2043 "Tamanyo" => 77098 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incidence of residual neuromuscular block postoperatively after administration of neostigmine using the recovery threshold of TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.7, and TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>train-of-four ratio.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1401 "Ancho" => 2069 "Tamanyo" => 88439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Incidence of residual neuromuscular postoperatively after administration of neostigmine using the recovery threshold of TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.9, TOFR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>train-of-four ratio.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In the most recent decade, a new reversal agent (antagonist) has been introduced in clinical practice. Sugammadex, a cyclodextrin-based selective binding agent, has the affinity to encapsulate steroidal NMB agents such as rocuronium, vecuronium and pipecuronium. With the use of this reversal agent, the incidence of rNMB gradually decreased. There was hope that routine administration of sugammadex might render neuromuscular monitoring unnecessary. However, clinical studies have shown that empiric administration of the reversal agent without quantitative monitoring guidance to help properly select the appropriate dose of sugammadex still results in a risk of rNMB of roughly 4%.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of recovery from nondepolarizing neuromuscular block, using a digital neuromuscular transmission analyzer: preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.H. Ali" 1 => "R.J. 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