Residual paralysis at the time of tracheal extubation.
Respiratory and pharyngeal muscle function are impaired during minimal neuromuscular blockade. Tracheal extubation in the presence of residual paresis may contribute to adverse respiratory events. In this investigation, we assessed the incidence and severity of residual neuromuscular block at the time of tracheal extubation. One-hundred-twenty patients presenting for gynecologic or general surgical procedures were enrolled. Neuromuscular blockade was maintained with rocuronium (visual train-of-four [TOF] count of 2) and all subjects were reversed with neostigmine at a TOF count of 2-4. TOF ratios were quantified using acceleromyography immediately before tracheal extubation, after clinicians had determined that complete neuromuscular recovery had occurred using standard clinical criteria (5-s head lift or hand grip, eye opening on command, acceptable negative inspiratory force or vital capacity breath values) and peripheral nerve stimulation (no evidence of fade with TOF or tetanic stimulation). TOF ratios were measured again on arrival to the postanesthesia care unit. Immediately before tracheal extubation, the mean TOF ratio was 0.67 +/- 0.2; among the 120 patients, 70 (58%) had a TOF ratio <0.7 and 105 (88%) had a TOF ratio <0.9. Significantly fewer patients had TOF ratios <0.7 (9 subjects, 8%) and <0.9 (38 subjects, 32%) in the postanesthesia care unit compared with the operating room (P < 0.001). Our results suggest that complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation.
Murphy
Glenn S
GS
*Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, Illinois; and †Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Szokol
Joseph W
JW
Marymont
Jesse H
JH
Franklin
Mark
M
Avram
Michael J
MJ
Vender
Jeffery S
JS
D000293:Adolescent; D000328:Adult; D000368:Aged; D000762:Anesthesia Recovery Period; D000769:Anesthesia, Inhalation; D002800:Cholinesterase Inhibitors / Q000494:pharmacology; D004558:Electric Stimulation; D005260:Female; D013509:Gynecologic Surgical Procedures; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D009388:Neostigmine / Q000494:pharmacology; D019148:Neuromuscular Blockade; D010149:Postoperative Pain / Q000453:epidemiology; D010243:Paralysis / Q000139:chemically induced*; D012727:Sex Characteristics
D002800:Cholinesterase Inhibitors; D009388:Neostigmine