Identification of Residual Neuromuscular Blockade in Post-Surgical Patients

Abstract

Background: Many surgical procedures require administration of nondepolarizing neuromuscular blocking (NDNMB) agents. NDNMBs are typically reversed when surgery ends, allowing function to be restored. With more precise monitoring, it is now recognized that many patients arrive in Post Anesthesia Care Units (PACUs) with residual levels of neuromuscular blockade (RNMB), or TOF ratio < 0.90. RNMB is associated with poorer post-anesthesia outcomes. Currently, PACU nurses do not typically assess for RNMB and may benefit from guidelines, including use of objective monitoring. Methods: This quality improvement project was based on Roger’s Diffusion of Innovation Theory and Deming’s model of Plan-Do-Study-Act (PDSA). A guideline was established and introduced for PACU nurses to use with patients who have received a NDNMB. A checklist was completed during admission and objective assessment of RNMB was performed. Nursing staff received instruction on proper use of the objective monitor prior to implementation. De-identified data was collected on a form created for this project. Results: The sample included 912 patients, of these 6% (n=55) had RNMB. Five required additional treatment. Of the patients exhibiting RNMB, 62% had subjective or no neuromuscular monitoring recorded in the OR. Only 36% of patients with a TOF ≥ 0.90 had subjective monitoring used. Conclusion: The implementation of the guideline was successful in identifying 55 patients with RNMB. Five required additional treatment. The use of this protocol supports early identification of RNMB and timely intervention. Use of an objective monitor was associated with a higher percentage of patients not exhibiting RNMB. There is an opportunity to implement the guideline and assessment on all patients in the future.