Evaluating a Quality Improvement Initiative to Increase Anesthesia Providers' Use of and Understanding of Quantitative Neuromuscular Monitors.

Improved understanding of the monitoring and dosing practices of anesthesia providers regarding neuromuscular blockade is necessary. The use of subjective methods such as peripheral nerve stimulation and clinical assessment tests can increase the risk of residual neuromuscular blockade and adverse postoperative outcomes. Quantitative monitoring of neuromuscular blockade is an alternative tool to peripheral nerve stimulation to guide neuromuscular blockade; however, it is rarely used by providers. We developed an initiative to improve anesthesia providers' knowledge of neuromuscular blockade pharmacology, physiology, monitoring, and management. After the initiative, an analysis assessed for practice change regarding the use of quantitative monitoring and dosing of neuromuscular blocking agents and neostigmine. The use of quantitative monitoring increased significantly from 14.0% in the preinitiative group to 48.0% after the initiative (P < .001). The least squares mean 95% effective dose (ED95) neuromuscular blocking agents dose was compared between pre-initiative and postinitiative groups, and case length was a significant predictor for patients receiving the highest neuromuscular blocking agents doses. Neostigmine doses were compared between preinitiative and postinitiative groups, and body mass index was a significant predictor of the least squares mean neostigmine dose (P = .002) and the likelihood of receiving a high neostigmine dose (odds ratio = 0.911, 95% CI = 0.870-0.955).

Implementation of Acceleromyography to Increase Use of Quantitative Neuromuscular Blockade Monitoring: A Quality Improvement Project.

Residual neuromuscular blockade creates excess perioperative morbidity. Quantitative neuromuscular monitoring devices may help ensure full recovery from neuromuscular blocking agents and have been demonstrated to reduce complications associated with residual neuromuscular blockade. We studied the effectiveness of educational efforts to introduce quantitative monitoring at a large academic medical center, with predefined main outcome measures of self-reported familiarity with use of the device and actual device uptake. Anonymous surveys of knowledge, skills, and attitudes toward the devices were administered before and after the education effort. Monitor use rates were quantitatively assessed through data entry into the electronic medical record. Before-and-after results were compared by run charts, unpaired t tests (correcting for multiple comparisons), and examination of 99% confidence intervals. Users agreed that residual blockade was an important topic before and after education, and reported improvement in their ability to use the devices after education. Clinical utilization of the monitors increased from 23% to 40% of eligible cases, with the increased rate sustained in the follow-up period. Education, assessed as improved self-reported proficiency, was associated with measurable increases in utilization of new technology. However, the rate of uptake, even when applied to a problem the users agreed was important, was modest.

Residual Neuromuscular Blockade in the Critical Care Setting.

Residual neuromuscular blockade is a widespread challenge for providers in the acute care setting that, if left unrecognized or untreated, places patients at higher risk for morbidity and mortality. The condition is estimated to occur in 26% to 88% of patients undergoing general anesthesia. The role of the advanced practice nurse in the acute care setting is to facilitate a safe recovery process by identifying early signs of deterioration and supporting the patient until full muscular strength has returned. This article discusses the prevalence of residual neuromuscular blockade and associated complications and patient risk factors. A review is included of the current uses for neuromuscular blockade, pathophysiology of the neuromuscular junction, pharmacologic characteristics of neuromuscular blocking agents (including drug-drug interactions), monitoring modalities, and effectiveness of reversal agents. Treatment recommendations pertinent to residual neuromuscular blockade are outlined.

An algorithm for train-of-four monitoring in patients receiving continuous neuromuscular blocking agents.

Neuromuscular blocking agents (NMBA) are increasingly being used in the management of critically ill patients. These medications are used to facilitate mechanical ventilation. Strange and colleagues estimated that only 4% of intensive care units utilize train-of-four (TOF) monitoring on a regular basis and that 70% never use this type of monitoring. The ease of use and low cost of the equipment lends itself to the increasingly frequent recommendations for this type of monitoring. Although unwilling to go so far as to establish this as a standard of care, the American College of Critical Care Medicine of the Society of Critical Care Medicine released an executive summary recommending train-of-four monitoring for patients receiving continuous or sustained NMBAs. This protocol and algorithm was developed to facilitate the objective monitoring of patients receiving continuous NMBAs.

Mastering neuromuscular blockade.

Learn how neuromuscular blocking agents work and how to assess and manage a patient receiving these drugs.

Management of pharmacologically induced neuromuscular blockade using peripheral nerve stimulation.

Currently, many critically ill patients are treated with neuromuscular blocking agents to facilitate endotracheal intubation, mechanical ventilation, and manage confused, combative, head injured, and status epileptus patients. To prevent persistent pharmacologically induced paralysis, the aide of a peripheral nerve stimulator and clinical indicators may help determine the minimal effective drug dose to facilitate safe neuromuscular blockade. The purpose of this article is to provide nursing clinicians the essential knowledge to manage patients with neuromuscular blockade effectively using peripheral nerve stimulation monitoring.

Post-anesthesia tracheal extubation.

Caring for the patient in the post-anesthetic period requires an understanding of the intubation and extubation process. The nurse must be knowledgeable of the numerous tracheal extubation-related complications that can occur. Tracheal extubation is a vulnerable period for the patient; there is risk of aspiration, laryngospasm, a cardiovascular response, or hypoventilation occurring. In this article, the author reviews the more common post-extubation difficulties, risk factors, and treatment modalities. After reviewing extubation criteria and the safe extubation process, the nurse can apply this knowledge to patient care. Although nurses are excellent initiators of tracheal extubation, the procedure is ideally performed by an anesthetist or internist who can treat complications that arise, or re-intubate the patient, if required.

Residual neuromuscular blockade in critical care.

Neuromuscular blockade is a pharmacological adjunct for anesthesia and for surgical interventions. Neuromuscular blockers can facilitate ease of instrumentation and reduce complications associated with intubation. An undesirable sequela of these agents is residual neuromuscular blockade. Residual neuromuscular blockade is linked to aspiration, diminished response to hypoxia, and obstruction of the upper airway that may occur soon after extubation. If an operation is particularly complex or requires a long anesthesia time, residual neuromuscular blockade can contribute to longer stays in the intensive care unit and more hours of mechanical ventilation. Given the risks of this medication class, it is essential to have an understanding of the mechanism of action of, assessment of, and factors affecting blockade and to be able to identify factors that affect pharmacokinetics.

A case of pseudocholinesterase deficiency in the PACU.

A 39-year-old patient with unrecognized atypical pseudocholinesterase was given succinylcholine during the rapid-sequence induction process and subsequently had a prolonged neuromuscular blockade. The patient was reassured, sedated, and ventilated in the postanesthesia care unit (PACU). The primary nursing interventions included airway clearance, communication, comfort, and patient education. Several important learning experiences occurred for the nurses in the PACU related to identifying possible causes, ordering the pseudocholinesterase and dibucaine inhibition test, interpreting the results, and developing and delivering patient education. This article will provide the perianesthesia nurse with the fundamental understanding of the physiology, laboratory diagnostic interpretation, and nursing interventions needed to deliver evidence-based, high-quality care to patients diagnosed with pseudocholinesterase deficiency.