Peri-operative management of neuromuscular blockade: ESAIC guideline

France: A recent article published in European Journal of Anaesthesiology reports European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on the peri-operative management of neuromuscular blockade. 

Recent studies have suggested a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These findings are alarming in that the available neuromuscular monitoring and myorelaxants with their antagonists allow well tolerated management of neuromuscular blockade. 

"In this first ESAIC guideline on peri-operative management of neuromuscular block, the authors aimed to present aggregated and evidence-based recommendations to help clinicians provide best medical care and ensure patient safety," the article stated. 

The researchers identified three main clinical questions: Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? Are myorelaxants necessary to facilitate tracheal intubation in adults? What are the strategies for the diagnosis and treatment of residual paralysis?

Based on the above, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. The authors used a stepwise approach to reduce the number of trials of the initial research (n = 24 000) to the finally relevant clinical studies (n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for the formulation of the recommendations based on the findings of the included studies in conjunction with their methodological quality. To determine the agreement of panel members with the recommendations, a two-step Delphi process was used. 

The authors conclude, "there is convincing evidence that residual paralysis and relaxation-associated pulmonary complications are less common after sugammadex-based pharmacological reversal than after neostigmine."

"Reliable quantitative NMM is the principal prerequisite of any suitable strategy for the peri-operative neuromuscular management, whether that is spontaneous recovery, sugammadex-based or neostigmine-based recovery."

Reference:

Fuchs-Buder, Thomas; Romero, Carolina S.; Lewald, Heidrun; Lamperti, Massimo; Afshari, Arash; Hristovska, Ana-Marjia; Schmartz, Denis; Hinkelbein, Jochen; Longrois, Dan; Popp, Maria; de Boer, Hans D.; Sorbello, Massimiliano; Jankovic, Radmilo; Kranke, Peter. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology: November 16, 2022 - Volume - Issue - 10.1097/EJA.0000000000001769 doi: 10.1097/EJA.0000000000001769