monitoring of neuromuscular block in operative …...monitoring of neuromuscular block in operative...
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Monitoring of neuromuscular block in operative room and ICU
Josep Rodiera M.D. Ph.D. MsC
Marrakech 2016
Anesthesia DepartmentCentro Medico Teknon
Barcelona
Conflict of interest
Creator of the TOFCuff Concept
• Do you think that postoperative residual paralysis represents a
significant public health problem?
• Do you think that the routine use of neuromuscular monitoring
devices could decrease the incidence of postoperative residual
paralysis?
Europe n= 739USA n= 1792
Monitorization of NMB:Current situation
Monitorization of NMB:Current situation
Monitorization of NMB:Current situation
Europe n= 739USA n= 1792
EU USA
1. 70% TOF enough for extubate?
2. 80% TOF enough for extubate?
3. 90% TOF enough for extubate?
º
T.O.F. And Receptor occupancy
C. Thompson et al.
Current monitoring systems & devices
Twitch1
(T1) Twitch2
(T2) Twitch3
(T3) Twitch4
(T4)
Peripheral Nerve StimulatorsVisual or Tactile
Assessment
The absence of observed or tactile fade in response to TOFstimulation does not indicate adequacy of recovery fromneuromuscular blockade.Rodney G, Raju PKBC, Ball DR. Not just monitoring; a strategy for managing neuromuscular blockade.Anaesthesia 2015; 70: 1105–118.
Train-of-four fade is indistinguishable, even to experiencedobservers, once the TOF ratio exceeds 40%Viby-Mogenson J, Jenson NH, Engbaek J, Ording H, Skovgaard LT, Chaemmmer-Jorgensen B. Tactile andvisual evaluation of the response to train of four nerve stimulation. Anesthesiology 1985; 63: 440–3.
Stimulating Electrodes
Manual installation needed
Specific polarity to be kept
Using fragile connecting wires
Sensing Device
Manual installation needed
Sensitive to motionartifacts
Force Transducer-based Inertial Sensor-based
The hand needs to be strapped
Inertial Sensor-based
81% 80% 74% 71% 87% 75% 80% 81% 69% 76% 78% 71%
+ 16%
- 12% - 12%
Monitoring Neuromuscular Transmission with TOFCuff
Traditional Method
Como Funciona el TOFCuff?
Neuro Stimulation for Regional Anesthesia
Traditional MethodNeuro Stimulation the motor Nerve
How TOF Cuff work’s?
Flow Diagram
Cuff With Stimulating Electrodes(Qualitative Monitorization)
Muscle ContractionCuff Inflation Impedance OK
Stimulation Visual / Tactile Method
-0,6
-0,4
-0,2
0
0,2
0,4
0,6
0,8
1
1,2
1,4
10:15 AM
10:16 AM
10:17 AM
Pressure Changes in the Cuff during the Stimulation at Humeral level
T1 T2 T3 T4TOF
T1 T2 T3 T4TOF
-0,2
-0,1
0
0,1
0,2
0,3
0,4
0,5
1 88 175 262 349 436 523 610 697 784 871 958
31/03/1998 1:18 PM31/03/1998 1:19 PM31/03/1998 1:20 PM31/03/1998 1:21 PM
Pressure Changes in the Cuff during the Stimulation at Humeral level
Flow Diagram
Monitoring Neuromuscular Blockade with the Cuff(Quantitative Monitoring)
Muscle ContractionCuff Inflation Impedance OK
Stimulation Recording EvokedTOFCuff Pressure
Changes
By means of processing the cuff pressure, it is possible to obtain a quantitative measurement
-0,2
-0,1
0
0,1
0,2
0,3
0,4
0,5
1 86 171 256 341 426 511 596 681 766 851 936
31/03/98 1:18 PM
31/03/98 1:19 PM
31/03/98 1:20 PM
31/03/98 1:21 PM
Brachial plexus stimulation / Evaluation of the evoked response During Recovery
TOF-Cuff vs Mechanomyography
Recovery strategy
Giving time to spontaneous/neostigmine reversal
The average reversal time is approximately 12 minutes, as reported in recent studies.However, a large inter-individual variability exists. 10% of patients might need more than60 minutes to reach a TOF ratio of 0.9.
E.Dubois and J.P. Mulier. A review of the interest of Sugammadex for deep neuromuscular blockade management in Belgium. Acta AnesthesiologicaBelgica, 2013, 64, 49-60.
Fuchs-Buder T., Ziegenfuss T., Lysakowski K., Tassonyi E., Antagonism of vecuronium-induced neuromuscular block in patients pretreated withmagnesium sulphate : dose-effect relationship of neostigmine, b r . J. a naesth ., 82, 61-5, 1999.
Reid J. E., Breslin D. S., Mirakhur R. K., Hayes A. H., Neostigmine antagonism of rocuronium block during anesthesia with sevoflurane,isoflurane or propofol . c an . J. a naesth ., 48, 351-5, 2002.
Suzuki T., Masaki G., Ogawa S., Neostigmine-induced reversal of vecuronium in normal weight, overweight and obese female patients, b r . J. anaesth ., 97, 160-3, 2006.
Neostigmine reversal
Many studies have found a high incidence of residual neuromuscularblockade after anesthesia and surgery, with a range of 4-64%
Rodney G, Raju PKBC, Ball DR. Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia 2015;70: 1105–118.
Naguib et al.’s meta-analysis of 24 studies demonstrated a pooledincidence of 41%
Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis.British Journal of Anaesthesia 2007; 98: 302–16.
Baillard C, Gehan G, Rebou-Marty J, et al. Residual curarisation in the recovery room after vecuronium. British Journal ofAnaesthesia 2000; 84: 394–5.
Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-actingneuromuscular blocking drugs. Anaes-thesia 2001; 56: 312–8.
Sugammadex vs Neostigmine action time
Sugammadex Reversal
Moderate Block
Deep Block
Intense Bloc
Neostigmines Sugammadex
Reversal TimeLong,
UnpredictableShort,
Predictable
Pulmonary Diseases(COPD, Asthma...)
Risk ofBronchospasm
Suitable 2
Cardiac Failureand Arrhythmias
QT prolongation,Brady/Tachycardia
Suitable 3
Renal Insufficiency Not Recommended Suitable 4
Elderly Patients(+75 years)
Risk PORC Unaffected 5
Obese PatientsDelay of Onset,
UnpredictableSuitable 6
Apnea SyndromeRisk of Upper
Airway ObstructionRisk of Upper
Airway Obstruction
Works with ‘Deep’ or ‘Intense’ Blocks?
No Yes1
Risk of PONV Yes No
Tramer M.R., Fuchs-Buder T., Omitting antagonism of neuromuscular block: effect on postoperativenausea and vomiting and risk of residual paralysis. A systematic review. br. J. anaesth., 82, 379-86, 1999.
Gaszynski T., Szewczyk T., Gaszynski W., Randomized comparison of sugammadex and neostigmine forreversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia, br.J. anaesth., 108, 236-9, 2012.
Amao R., Zornow M.H., Cowan R.M., Cheng D.C., Morte J.B., Allard M.W., Use of sugammadex in patientswith a history of pulmonary disease, J.clin. anesth., 24, 289-97, 2012.
Caldwell J.E., Reversal of residual neuromuscular block with neostigmine at one to four hours after asingle intubating dose of vecuronium. anesth. analg., 80, 1168-74, 1995.
Lock G., Loureiro Fialho G., Castro Lima D., Simoes Almeida M.C., Electrocardiographic changes afterneostigmine-atropine mixture. J. anesth. clinic res., 3, 188, 2012.
Staals L.M., Snoeck M.M., Driessen J.J., Flockton E.A., Heeringa M., Hunter J.M., Multicentre, parallel-group, comparative trial evaluating the efficacy and safety of sugammadex in patients with end-stagerenal failure or normal renal function, br. J. anaesth., 101, 492-7, 2008.
Cammu G., Interactions of neuromuscular blocking drugs, acta anaesth. belg., 52, 357-363, 2001..
Suzuki T., Kitajima O., Ueda K., Kondo Y., Kato J., Ogawa S., Reversibility of rocuronium-induced profoundneuromuscular block with sugammadex in younger and older patients, br. J. anaesth., 106, 823-6, 2011.
Bartkowsky R. R., Incomplete reversal of pancuronium neuromuscular blockade by neostigmine,pyridostigmine and edrophonium, anesth. analg., 66, 594-598, 1987.
Eikermann M., Fassbender P., Malhotra A., Takahashi M., Kubo S., Jordan A. S., Gautam S., White D.P.,Chamberlin N. L., Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossusand diaphragm muscle function, anesthesiology, 107, 621-9, 2007.
7
One then might ask oneself• No need to Monitor the NMT!!
• Sugammadex to everyone!!
POWER WITHOUT CONTROL IS NOTHING
Sugammadex – A reversal strategy
One then might ask oneself• No need to Monitor the NMT!!
• Sugammadex to everyone!!
• No need to Monitor the NMT!!
Cost per Patient Low
Neostigmines(Prostigmine®)
Sugammadex(BRIDION®)
Sales Formulation
High
Moderate Block (2 mg/Kg)
Deep Block (4 mg/Kg)
76,96 €
153,92 €
0,44-0,88 €
0,44-0,88 €
Emergency Rev. (16 mg/Kg) 461,76 €Not Applicable
So, an administration rationale needs to be stablished
Sugammadex-mandatory
0,5 mg/ml Vial5 ml (0,44€ per Vial)
200 mg and 500 mg Vials(76,96 € and 192,4 €)
Neostigmine-suitable
1
2 Eikermann M., Fassbender P., Malhotra A., Takahashi M., Kubo S., JordanA. S., Gautam S., White D.P., Chamberlin N. L., Unwarrantedadministration of acetylcholinesterase inhibitors can impair genioglossusand diaphragm muscle function, anesthesiology, 107, 621-9, 2007.
1 Assessment Committee for the uptake of new Hospital-use Drugs.OSAKIDETZA - Health & Consumer Department of the Basque CountryGovernment (Spain).
2 Bartkowsky R. R., Incomplete reversal of pancuronium neuromuscularblockade by neostigmine, pyridostigmine and edrophonium, anesth.analg., 66, 594-598, 1987.
3 4
Cost per Treatment (VAT not included), for an average patient of 70 Kg.
Moderate Block
Deep Block
Intense Bloc
2
Sugammadex-mandatory(no room for saving)
3 Ph. E. Dubois, J.P. Mulier, A review of the interest of Sugammadex fordeep neuromuscular blockade management in Belgium. Acta Anaesth.Belgica, 2013, 64, 49-60.
4 G. Rodney, P.K.B.C. Raju, D.R. Ball, Not just monitoring; a strategy formanaging neuromuscular blockade. Anaesthesia, 2015, 70, 1105-1118.
Reversal Strategy
Neostigmines(Prostigmine®)
Sugammadex(BRIDION®)
Sales Formulation
Moderate Block (2 mg/Kg)
Deep Block (4 mg/Kg)
76,96 €
153,92 €
0,44-0,88 €
0,44-0,88 €
Emergency Rev. (16 mg/Kg) 461,76 €Not Applicable
0,5 mg/ml Vial5 ml (0,44€ per Vial)
200 mg and 500 mg Vials(76,96 € and 192,4 €)
So, an administration rationale needs to be stablished
Sugammadex-mandatory Neostigmine-suitable
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Saving 76 € per patient
Moderate Block
Deep Block
Intense Bloc
Saving 153 € per patient
Saving 76 €per patient
Saving 153 € per patient
Ph. E. Dubois, J.P. Mulier, A review of the interest ofSugammadex for deep neuromuscular blockade managementin Belgium. Acta Anaesth. Belgica, 2013, 64, 49-60.
TOFRATIO > 90%
ROCURONIUMInduction 0,6 mg/Kg.
ROCURONIUM(for levelling the patient at TOF COUNT = 1)
Infusion Pump (100 mg/250mL) 5-10µg/Kg/min
Bolus 0,15 mg/Kg
TOF COUNT = 0Post-Tetanic COUNT = 1-2
TOF COUNT = 1-3 TOF COUNT = 4
HIGH-RiskPatient
Surgery
EXTUBATION TOF RATIO > 90%
SUGAMMADEX4 mg/Kg
SUGAMMADEX2 mg/Kg
TOF RATIO < 40%
NEOSTIGMINE 40 µg/KgATROPINE 1 mg
TOF RATIO > 40%
NEOSTIGMINE 20 µg/Kg
ATROPINE 0,7 mg
NEOSTIGMINE 50 µg/KgATROPINE 1 mg
LOW-RiskPatient
Surgery
Wait for TOF COUNT = 3
HIG
H-R
isk
Pat
ien
t
Pulmonary Diseases (COPD, asthma…)
Sleep Apnea Syndrome
Cardiac failure and arrhythmias
Increased Age (+75 years)
Obesity (BMI >30)
Renal Insufficiency
Thoracotomy
Supraumbilical Laparotomy
Lumbotomy
Hypothermia
HIG
H-R
isk
Surg
erie
s
Reversal Strategy
Conclusions
• Residual paralysis is considered a important problem
• Neuromuscular monitoring could avoid the residual paralysis.
• There are consensus : Nueromuscular Monitoring should be
routine
• The TOFCuff concept has a clear clinical use
•A reversal strategy is recommended