Nursing vs. Physician Mentality

[BLADEMDA]

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The fundamental problem with the majority of Nurses/APRNs/CRNAs is the way they view the practice of "Nursing" or what we call Medicine.

We are taught to evaluate and study the data. Medical School teaches objective thinking and literature review/peer reviewed data. Anecdotal reports and personal case experience are what CRNAS use to practice anesthesia. Physician Anesthesiologists must fundamentally use peer reviewed literature to practice along with experience. It never ceases to amaze me just how ignorant and arrogant a CRNA can be when it comes to the practice of a highly critical specialty like Anesthesiology.

A fundamentally example of Nurse Ignorance and Arrogance is reversal of muscle relaxants. A few MD Anesthesiologists are guilty of this 'CRNA syndrome' but the vast majority recognize the importance of complying with the standard of care in our medicolegal environment.

 

[BLADEMDA]

A number of years back, my partner had to re-intubate in PACU in which the patient suffered from a degree of recall , she (pt) brought suit and subsequently won.

Paralytics had been used (Vec) but TOF, motor strength, long period (>2 hours) since last dose was present and no reversal were given.

The plaintiffs lawyer contested that no reversal had been given which is why the re-intubation occurred (not d/t RR opiate admin, the pts obesity, or COPD) - the jury found for the plaintiff. Now my partner gives reversal to everyone....and still has since re-intubated in the PACU... He says "Tone it just isnt worth the BS of doing that again"

once bitten ...twice shy...

CRNA



Here is the CRNA with a PhD response to the post:

That is your partner:

1. anecdote does not equal data
2. your partner was not John
3. thousands of providers (both MD and CRNA) administer NDMRs without reversing with absolutely no issue whatsoever.
​

 

[BLADEMDA]

What amazes me was that CRNA with PhD was clearly informed of the following:

1. Peer reviewed literature recommending reversal of NMBs
2. Experts in the field agree NMB should be reversed
3. Recent Editorial and data published in July edition of Anesthesia and Analgesia

IMHO, CRNAs should not be practicing solo because they lack the formal educational standards and MINDSET which only a real Medical education can provide.

 

[BLADEMDA]

By using neuromuscular monitoring, persistence of NMB after surgery and anesthesia has been known for many years .However, the clinical importance of residual NMB became more evident in the last few years. Why is this so evident now? The relatively recent availability of large databases of patient outcomes exposed previously unrecognized complications, morbidity, and mortality in the postoperative period, which have been summarized in this issue of Anesthesia & Analgesia. Although these databases found adverse patient outcomes to be multifactorial, residual NMB and reversal (or lack of) issues were frequently a component of these clinical problems. In our opinion, these databases and our own review of many cases of adverse outcomes has led to the conclusion that reversal of NMB with neostigmine should be routine. Conversely, there should be written documentation as to why neostigmine was unnecessary. Administration of neostigmine will facilitate displacement of NMBDs from the nicotinic receptors. In the immediate postoperative period, logic seems to dictate that "when in doubt, we should have as many receptors as possible free of NMBDs."




Monitoring and Pharmacologic Reversal of a Nondepolarizing Neuromuscular Blockade Should Be Routine



Ron Miller, MD

 

[BLADEMDA]

In conclusion, evidence and logic dictate that strong consideration be given to routine monitoring of NMB and pharmacologic antagonism (i.e., reversal) of a nondepolarizing NMB. This combination offers the anesthesiologist the best opportunity to attenuate the occurrence, but probably not eliminate residual NMB in the immediate postoperative period. The 3 excellent conclusions in the Viby-Mogensen and Claudius editorial include routine monitoring. We would add a fourth recommendation—routine administration of neostigmine or sugammadex (if available). We are envious of our colleagues in Europe where sugammadex is approved for clinical use.

 

[BLADEMDA]

REFERENCES

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   1. Sackett DL,
   2. Rosenberg WM,
   3. Gray JA,
   4. Haynes RB,
   5. Richardson WS
   . Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71–2
   
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   1. Murphy GS,
   2. Brull SJ
   . Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010;111:120–8
   
3. 3.
   1. Brull SJ,
   2. Murphy GS
   . Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010;111:129–40
   
4. 4.
   1. Naguib M,
   2. Kopman AF,
   3. Lien CA,
   4. Hunter JM,
   5. Lopez A,
   6. Brull SJ
   . A survey of current neuromuscular block in the United States and Europe. Anesth Analg 2010;111:110–9
   
   
5. 5.
   1. Naguib M,
   2. Kopman AF,
   3. Ensor JE
   . Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth 2007;98:302–16
   
6. 6.
   1. Viby-Mogensen J,
   2. Claudius C,
   3. Eriksson LI
   . Neuromuscular monitoring and postoperative residual curarization. Br J Anaesth 2007;99:297–9
   
7. 7.
   1. Miller RD
   1. Viby-Mogensen J
   . Neuromuscular monitoring. In: Miller RD ed. Miller's Anesthesia (7th ed.). Philadelphia: Elsevier Churchill Livingstone, 2010:1515–31
   
   
8. 8.
   1. Mortensen CR,
   2. Berg H,
   3. el Mahdy A,
   4. Viby-Mogensen J
   . Perioperative monitoring of neuromuscular transmission using acceleromyography prevents residual neuromuscular block following pancuronium. Acta Anaesthesiol Scand 1995;39:797–801
   
9. 9.
   1. Ansermino JM,
   2. Sanderson PM,
   3. Bevan JC,
   4. Bevan DR
   . Acceleromyography improves detection of residual neuromuscular blockade in children. Can J Anaesth 1996;43:589–94
   
10. 10.
    1. Berg H,
    2. Roed J,
    3. Viby-Mogensen J,
    4. Mortensen CR,
    5. Englbaek J,
    6. Skovgaard LT,
    7. Krintel JJ
    . Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997;41:1095–103
    
    
11. 11.
    1. Gaetke MR,
    2. Viby-Mogensen J,
    3. Rosenstock C,
    4. Jensen FS,
    5. Skovgaard LT
    . Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used. Acta Anaesthesiol Scand 2002;46:207–13
    
    
12. 12.
    1. Cammu G,
    2. De Witte J,
    3. De Veylder J,
    4. Byttebier G,
    5. Vandeput D,
    6. Foubert L,
    7. Vandenbroucke G,
    8. Deloof T
    . Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg 2006;102:426–9
    
    
13. 13.
    1. Murphy GS,
    2. Szokol JW,
    3. Marymont JH,
    4. Greenberg SB,
    5. Avram MJ,
    6. Vender JS
    . Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008;107:130–7
    

 

[BLADEMDA]

When you combine Ignorance with Arrogance you get the worst of Solo CRNA practice in a nutshell.

 

[BLADEMDA]

Anesth Analg. 2010 Jul;111(1):120-8. Epub 2010 May 4.
Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block.

Murphy GS, Brull SJ.
Department of Anesthesiology, NorthShore University HealthSystem, 2650 Ridge Ave., Evanston, IL 60201, USA. [email protected]
Abstract

In this review, we summarize the clinical implications of residual neuromuscular block. Data suggest that residual neuromuscular block is a common complication in the postanesthesia care unit, with approximately 40% of patients exhibiting a train-of-four ratio <0.9. Volunteer studies have demonstrated that small degrees of residual paralysis (train-of-four ratios 0.7-0.9) are associated with impaired pharyngeal function and increased risk of aspiration, weakness of upper airway muscles and airway obstruction, attenuation of the hypoxic ventilatory response (approximately 30%), and unpleasant symptoms of muscle weakness. Clinical studies have also identified adverse postoperative events associated with intraoperative neuromuscular management. Large databased investigations have identified intraoperative use of muscle relaxants and residual neuromuscular block as important risk factors in anesthetic-related morbidity and mortality. Furthermore, observational and randomized clinical trials have demonstrated that incomplete neuromuscular recovery during the early postoperative period may result in acute respiratory events (hypoxemia and airway obstruction), unpleasant symptoms of muscle weakness, longer postanesthesia care unit stays, delays in tracheal extubation, and an increased risk of postoperative pulmonary complications. These recent data suggest that residual neuromuscular block is an important patient safety issue and that neuromuscular management affects postoperative outcomes.

 

[BLADEMDA]

Anesth Analg. 2010 Jul;111(1):129-40. Epub 2010 May 4.
Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness.

Brull SJ, Murphy GS.
Department of Anesthesiology, Mayo Clinic College of Medicine, 4500 San Pablo Rd., Jacksonville, FL 32224, USA. [email protected]
Abstract

The aim of the second part of this review is to examine optimal neuromuscular management strategies that can be used by clinicians to reduce the risk of residual paralysis in the early postoperative period. Current evidence has demonstrated that frequently used clinical tests of neuromuscular function (such as head lift or hand grip) cannot reliably exclude the presence of residual paralysis. When qualitative (visual or tactile) neuromuscular monitoring is used (train-of-four [TOF], double-burst, or tetanic stimulation patterns), clinicians often are unable to detect fade when TOF ratios are between 0.6 and 1.0. Furthermore, the effect of qualitative monitoring on postoperative residual paralysis remains controversial. In contrast, there is strong evidence that acceleromyography (quantitative) monitoring improves detection of small degrees (TOF ratios >0.6) of residual blockade. The use of intermediate-acting neuromuscular blocking drugs (NMBDs) can reduce, but do not eliminate, the risk of residual paralysis when compared with long-acting NMBDs. In addition, complete recovery of neuromuscular function is more likely when anticholinesterases are administered early (>15-20 minutes before tracheal extubation) and at a shallower depth of block (TOF count of 4). Finally, the recent development of rapid-onset, short-acting NMBDs and selective neuromuscular reversal drugs that can effectively antagonize deep levels of blockade may provide clinicians with novel pharmacologic approaches for the prevention of postoperative residual weakness and its associated complications

 

[BLADEMDA]

\
]\ CRNA:

I also rarely give reversal. I'll intubate w/SUX if it's a questionable airway, then just give the ED95 for the NDNMB afterwards since I don't need 'intubating conditions' only areflexia. Combined w/adequate anesthesia, either TIVA or a volatile, the patient won't move. Other times I'll intubate w/2x the ED95 and not reverse for a 1hr case. I ensure that the patient has adequate Vt and spontaneous ventilation, and usually extubate deep. If the patient's Vt is inadequate, or I've redosed the NDNMB towards the end of the case, I will give them some reversal.


​

 

[BLADEMDA]

Despite all the rhetoric and propaganda from the AANA the CRNA is ill-prepared for solo practice. Perhaps, the Trial lawyers will be able to accomplish what the ASA has failed to do thus far: expose the dangers of Solo CRNA practice.

 

[BLADEMDA]

"Again, anecdote nor hypothetical rhetoric does not equal data. "

CRNA with PhD


So, after all the posts with references listed above you decide whether our CRNA "colleague" should continue in his usual manner of NOT routinely reversing NMBs.

Perhaps, when the time comes a Jury will make the decsion for him.
​

 

[BLADEMDA]

"When my information changes, I change my opinion. What do you do, Sir?"

 

[BLADEMDA]

John Maynard Keynes, the influential British economist whose ideas are known as Keynesian Economics, sums up how I feel about the overused American political term "flip-flop":

When the facts change, I change my mind. What do you do?
​

 

[BLADEMDA]

\
]\ CRNA:

I also rarely give reversal. I'll intubate w/SUX if it's a questionable airway, then just give the ED95 for the NDNMB afterwards since I don't need 'intubating conditions' only areflexia. Combined w/adequate anesthesia, either TIVA or a volatile, the patient won't move. Other times I'll intubate w/2x the ED95 and not reverse for a 1hr case. I ensure that the patient has adequate Vt and spontaneous ventilation, and usually extubate deep. If the patient's Vt is inadequate, or I've redosed the NDNMB towards the end of the case, I will give them some reversal.


​

So, when I confronted the CRNA who made the above post with the notion that reversal was highly recommended as a routine course of action here was his response:

"If you are saying that I provide poor care to my patients, you are sorely mistaken. I am neither ignorant of the pharmacology involved, nor arrogant in my practice" CRNA


Well, here is a perfect example of a CRNA not knowing what he doesn't know!

 

[BLADEMDA]

Despite dozens of peer reviewed studies on this topic some MD (A)s and many CRNAs are reluctant to administer reversal agents after using NMBs.
However, I am confident that the vast majority of Medical Doctors will change their routine practice once shown the data.

FYI, this topic isn't new or groundbreaking and I have discussed it elsewhere in detail. Here is a nice review article for midlevels and new providers:

http://anesthesiologyrounds.ca/crus/122-047%20English.pdf

 

[Laryngophed]

Could we stop using MD (A)? Doesn't our acceptance and use of the term validate the position of those who use it to bring themselves to the level of anesthesiologists? Why not just say anesthesiologist, since we know you must be a physician to be an anesthesiologist and everyone else is just an pretender assistant.

 

[IlDestriero]

So, when I confronted the CRNA who made the above post with the notion that reversal was highly recommended as a routine course of action here was his response:

"If you are saying that I provide poor care to my patients, you are sorely mistaken. I am neither ignorant of the pharmacology involved, nor arrogant in my practice" CRNA


Well, here is a perfect example of a CRNA not knowing what he doesn't know!

That's a fantastic example. Confront them with recent (but not new) recommendations from leading peer reviewed journals, expert opinion, and a concrete example of why you might want to reverse (lawsuit) and they still don't acknowledge the facts. I'm right, your wrong, blah blah blah.
How about you're an imbecile, and pig headedly refuse to change to the detriment of your patients. That would be the definition of poor care.
He doesn't know that because he's an Imbecile.

 

[alagory]

Just to be clear.

What blade neglects to tell you is that many other CRNAs said the same things to this particular CRNA. Also, to be clear, every study on reversal was also discussed and posted in the journal article section.

Using ONE example to make a broad statement is just silliness. We could all do the same however, the difference between the CRNAs on that website and blades post here is that they do not paint all MDs with the same brush when one does something that isnt standard of care, or is just stupid/ignorant.

Added: Also, those articles, all of which ive read, state it is still common practice among MDs not to reverse. It isnt like this is something that just occurs with one provider type.

 

[BLADEMDA]

Just to be clear.

What blade neglects to tell you is that many other CRNAs said the same things to this particular CRNA. Also, to be clear, every study on reversal was also discussed and posted in the journal article section.

Using ONE example to make a broad statement is just silliness. We could all do the same however, the difference between the CRNAs on that website and blades post here is that they do not paint all MDs with the same brush when one does something that isnt standard of care, or is just stupid/ignorant.

Added: Also, those articles, all of which ive read, state it is still common practice among MDs not to reverse. It isnt like this is something that just occurs with one provider type.

Just to be clear what you are posting is false and reflects general midlevel ignorance and arrogance. Unless you have a device that can proved a TOF of 0.9 or greater at the end of a case just prior to extubation then reversal is both warranted and indicated. The literature is crystal clear on this subject. Most of the Militant midlevels fail to grasp the literature and understand its consequences. This is what makes them dangerous.

 

[BLADEMDA]

Check for sustained tetany; any fade = give some reversal.

CRNA


FALSE/WRONG

Correct Answer: Most CRNAS can't tell the difference between 0.6 and 0.9 with TOF or Tetany/fade. Hence reversal is indicated with standard handheld OR stimulators.

 

[BLADEMDA]

You can to a pubmed search and find research to support whatever side of the debate you are on.... That is the bottom line. There are just as many valid reasons not to reverse a patient as there are to reverse a patient. No pharmacological agent is benign.

CRNA with PhD


FALSE/WRONG


The literature is clear that residual neuromuscular blockade remains an issue for significant number of patients. Unless TOF of 0.9 or greater can be confirmed then low dose reversal (at a minumum) is indicated prior to extubation.


These CRNAS posted those statements after reading all my posts on SDN. Ignorance and Arrogance with a Nursing level education leads to disaster.
​

 

[BLADEMDA]

The only non depolarizer on the market (if you can get it) which does not need reversal is Mivacurium. All other non depolarizers must be reversed or the provider should document a TOF of 0.9 or greater (most operating rooms don't have a device that sensitive).

 

[BLADEMDA]

Anesthesiology. 2003 May;98(5):1042-8. Links

Comment in: Anesthesiology. 2003 May;98(5):1037-9. Anesthesiology. 2004 Feb;100(2):453-4; author reply 454-5. Anesthesiology. 2004 Feb;100(2):453; author reply 454-5. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action.

Debaene B, Plaud B, Dilly MP, Donati F.
Department of Anesthesia and Intensive Care, Hôpital Jean Bernard, Poitiers, France. [email protected]
BACKGROUND: Residual neuromuscular blockade remains a problem even after short surgical procedures. The train-of-four (TOF) ratio at the adductor pollicis required to avoid residual paralysis is now considered to be at least 0.9. The incidence of residual paralysis using this new threshold is not known, especially after a single intubating dose of intermediate-duration nondepolarizing relaxant. Therefore, the aim of the study was to determine the incidence of residual paralysis in the postanesthesia care unit after a single intubating dose of twice the ED(95) of a nondepolarizing muscle relaxant with an intermediate duration of action. METHODS: Five hundred twenty-six patients were enrolled. They received a single dose of vecuronium, rocuronium, or atracurium to facilitate tracheal intubation and received no more relaxant thereafter. Neuromuscular blockade was not reversed at the end of the procedure. On arrival in the postanesthesia care unit, the TOF ratio was measured at the adductor pollicis, using acceleromyography. Head lift, tongue depressor test, and manual assessment of TOF and DBS fade were also performed. The time delay between the injection of muscle relaxant and quantitative measurement of neuromuscular blockade was calculated from computerized anesthetic records. RESULTS: The TOF ratios less than 0.7 and 0.9 were observed in 16% and 45% of the patients, respectively. Two hundred thirty-nine patients were tested 2 h or more after the administration of the muscle relaxant. Ten percent of these patients had a TOF ratio less than 0.7, and 37% had a TOF ratio less than 0.9. Clinical tests (head lift and tongue depressor) and manual assessment of fade showed a poor sensitivity (11-14%) to detect residual blockade (TOF < 0.9). CONCLUSION: After a single dose of intermediate-duration muscle relaxant and no reversal, residual paralysis is common, even more than 2 h after the administration of muscle relaxant. Quantitative measurement of neuromuscular transmission is the only recommended method to diagnose residual block.

 

[BLADEMDA]

Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine.

Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F.
Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire, Institut de la Sante et de la Recherche Medicale, CIC-EC CIE6, Nancy, France. [email protected]

Comment in:

• Anesthesiology. 2010 Jan;112(1):16-8.

Abstract

BACKGROUND: Low degrees of residual paralysis (i.e., a train-of-four [TOF] ratio > 0.4) are relatively frequent, difficult to detect, and still potentially harmful. Unfortunately, the appropriate dose of anticholinesterase for this situation has not been determined. This may be of clinical interest because a high dose of neostigmine given at a shallow level of neuromuscular block may produce neuromuscular weakness. The purpose of this study was to investigate the dose-effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4 and 0.6.
METHODS: Recovery after 10, 20, 30 microg/kg neostigmine or placebo given at either 0.4 or 0.6 TOF ratio was assessed by acceleromyography in 120 patients undergoing intravenous anesthesia. Time to a 0.9 and 1.0 TOF ratio was measured, and the probability of successful reversal within 10 min after the respective neostigmine doses was calculated. In addition, the dose of neostigmine needed to achieve the recovery targets in 5 or 10 min was also determined.
RESULTS: When given at a TOF ratio of either 0.4 or 0.6, time to 0.9 and 1.0 TOF ratio was significantly shorter with any dose of neostigmine than without. The probability of successful reversal after 20 microg/kg neostigmine was 100% when a TOF ratio of 0.9 was the target; for a TOF ratio of 1.0, the probability was 93% and 67%, dependent on whether the dose of neostigmine was given at TOF ratio of 0.6 or 0.4, respectively. With a dose of 30 microg/kg, a TOF ratio of 1.0 is expected to be reached within approximately 5 min. Low doses of neostigmine are required to reach a TOF ratio of 0.9 or to accept an interval of 10 min.
CONCLUSION: Reduced doses (10-30 microg/kg) of neostigmine are effective in antagonizing shallow atracurium block. For successful reversal within 10 min, as little as 20 microg/kg neostigmine may be sufficient. These dose recommendations are specific for atracurium and an intravenous anesthetic background

 

[BLADEMDA]

The authors found that administration of 30 &#956;g/kg of neostigmine at a TOFR = 0.6 resulted in complete recovery of neuromuscular function (TOFR = 1.0) within 7 min and to a TOFR = 0.9 within 6 min. When administered at a TOFR = 0.4, all patients recovered to a TOFR = 1.0 within 11 min and to a TOFR = 0.9 within 6 min. Importantly, no patient developed weakness after administration of anticholinesterase. These results are applicable only to patients who received the NMBA atracurium and are receiving nitrous oxide throughout recovery. Nitrous oxide potentiates nondepolarizing neuromuscular blockers. In its absence, would the administration of neostigmine have increased fade in the TOF? In addition, applicability of these results to the operating room is not apparent as the use of quantitative monitors (monitors that report the TOFR) of neuromuscular blockade is not routine. What happens when small doses of neostigmine are administered at a TOFR = 0.7, 0.8, 0.9, or 1.0 remains to be determined as these different degrees of recovery cannot be distinguished using standard twitch monitors. On the basis of the results of this study, however, clinicians can be reassured that administration of 50 &#956;g/kg of neostigmine is not necessary if a patient has four equal responses to TOF stimulation and that a dose of 30 &#956;g/kg will be sufficient. Routine use of even smaller doses of anticholinesterases when no fade is appreciable in the TOFR requires that quantitative monitors be available to document the depth of block being antagonized as well as the time to complete recovery of neuromuscular function. Even once optimal dosing of neostigmine at all levels of neuromuscular block has not been defined, true safety in the use of NMBAs will be improved only by decreasing the occupancy of acetylcholine receptors by NMBAs. This will require the use of NMBAs that are rapidly broken down in the plasma or reversal agents that render the NMBA unable to bind to acetylcholine receptors.
Cynthia A. Lien, M.D

 

[BLADEMDA]

Blade,

Amazing how you aren't posting any of the opposite side of the debate. That is laughable. But not unexpected

CRNA with PhD


Sir, I referenced most of this material to you prior to your posting ignorant comments on your public forum. In addition, even after posting a vast body of literature with Editorial comments from the leading experts in this area (sorry, no PhD CRNAs qualify) you still persist in your viewpoint. At this point I will let the Medical Students decide if they prefer to be a provider who reads and comprehends the MEDICAL literature or one who ignores it.

 

[BLADEMDA]

Let's hope this "discussion" will spur even a few Solo CRNAs to reverse NMB on a routine basis.

As for "debate" this topic requires little as the peer referenced literature is both exhaustive and authoritative.

 

[BLADEMDA]

July 2010; 111 (1)

Try reading a Medical Journal to get the facts on a Medical Specialty

 

[IlDestriero]

Blade,
In the future can you try to make it more clear who is saying what when you post these things from the other forum. It can be a bit confusing.
Thx.

Perhaps something like
Me: ......
Dunce: ........

 

[BLADEMDA]

Blade,

Amazing how you aren't posting any of the opposite side of the debate. That is laughable. But not unexpected

CRNA with PhD


Sir, I referenced most of this material to you prior to your posting ignorant comments on your public forum. In addition, even after posting a vast body of literature with Editorial comments from the leading experts in this area (sorry, no PhD CRNAs qualify) you still persist in your viewpoint. At this point I will let the Medical Students decide if they prefer to be a provider who reads and comprehends the MEDICAL literature or one who ignores it.

In our opinion, these databases and our own review of many cases of adverse outcomes has led to the conclusion that reversal of NMB with neostigmine should be routine. Conversely, there should be written documentation as to why neostigmine was unnecessary.

Ron Miller, MD

 

[BLADEMDA]

Br J Anaesth. 2005 Nov;95(5):622-6. Epub 2005 Sep 23. Links

Postoperative residual neuromuscular block: a survey of management.

Baillard C, Clec'h C, Catineau J, Salhi F, Gehan G, Cupa M, Samama CM.
Département d'Anesthésie-Réanimation, EA 3409, Hôpital Avicenne, APHP, 93009 Bobigny Cedex, France. [email protected]
BACKGROUND: To avoid postoperative residual neuromuscular block there is a need for a change in clinician's attitude towards monitoring and reversal. This study aims to evaluate changes of perioperative neuromuscular block management during the last decade in our institution and to quantify the incidence of postoperative residual neuromuscular block. METHODS: Patients receiving intermediate-acting neuromuscular blocking agents for scheduled surgical procedures during 3-month periods in 1995 (n=435), 2000 (n=130), 2002 (n=101), and in 2004 (n=218) were prospectively and successively enrolled in our study. The management of neuromuscular block in the operating room and the adequacy of the recovery were at the discretion of the anaesthesiologist. An attempt was made between each study period to promote a change in the management of neuromuscular block. In the post-anaesthesia care unit, train-of-four (TOF) stimulations were used to assess the presence of a residual neuromuscular block. RESULTS: Between 1995 and 2004 quantitative measurement and reversal of neuromuscular block in the operating room increased from 2 to 60% and from 6 to 42%, respectively (P<0.001). During the same time, the incidence of residual neuromuscular block defined as a TOF ratio less than 0.9 decreased from 62 to 3% (P<0.001). Use of objective neuromuscular monitoring and/or anticholinesterase drugs was less likely in patients with an inadequate recovery (P<0.001). CONCLUSIONS: During the last decade the incidence of residual neuromuscular block strongly decreased in our institution. It confirms the positive impact of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice.

 

[BLADEMDA]

The "senior" CRNA leadership over at the militant website still won't admit or tell the SRNAs that reversal of NMB or documentation of a TOF 0.9 or greater is the standard of care in the USA. Despite all the evidence the CRNA with PhD is sticking to his poorly held opinion reversal agents should NOT be routinely administered to patients. This CRNA is both an educator and a solo practitioner.

I can only imagine how many other ignorant and arrogant CRNAs there out there who won't change their practice EVER. When the evidence becomes clear (as it has on NMB reversal/ TOF of 0.9) we need to adjust to the facts.

As many CRNAs like to tell me everyday "good thing it is hard to kill a patient." The sad thing is some of them aren't being sarcastic.

 

[BLADEMDA]

 

[BLADEMDA]

My answer to that is you use a reversal when it is warranted. Again no agent is benign. Remember that anticholinesterases are "competitive nerve gas" ..... Just in IV form.

CRNA with PhD



My response:

The literature is crystal clear on what the term "warranted" means in the field of Anesthesiology. However, in Nurse Anesthesia it must just be another "vague" area left to the discretion of the CRNA.😱

 

[BLADEMDA]

In Europe, contrary to what many people had expected, we have experienced an increased interest in teaching and training in objective neuromuscular monitoring after the introduction of sugammadex, a trend also observed by the manufacturer of one of the commercially available neuromuscular monitors (the TOF–Watch). Therefore, more than ever we see an opportunity to change practices, if and when we get better and easier-to-routinely-use objective neuromuscular monitors and have standards and guidelines developed by professional organizations. But most important, there is a significant educational task ahead for those responsible for specialist training, postgraduate education, and continuing medical education.
On the basis of the evidence presented in the three articles, we would like to present what we consider the key points of the three articles:

1. Potentially clinically significant postoperative residual paralysis is a clinical problem and may pose a threat to the health of the patient.
2. It is not possible by any clinical test or combinations hereof, nor by tactile or visual evaluation of the response to TOF, tetanic (50 or 100 HZ), or double-burst stimulation, to exclude with certainty potentially clinically relevant postoperative residual paralysis.
3. Good evidence-based practice dictates that the anesthesiologist, preferably perioperatively but at least before sending the patients to the recovery ward, should ensure that the TOF ratio is 0.90 or more by using an objective monitor.

Editorial- July 2010 Anesthesia and Analgesia

 

[BLADEMDA]

In Europe, contrary to what many people had expected, we have experienced an increased interest in teaching and training in objective neuromuscular monitoring after the introduction of sugammadex, a trend also observed by the manufacturer of one of the commercially available neuromuscular monitors (the TOF&#8211;Watch). Therefore, more than ever we see an opportunity to change practices, if and when we get better and easier-to-routinely-use objective neuromuscular monitors and have standards and guidelines developed by professional organizations. But most important, there is a significant educational task ahead for those responsible for specialist training, postgraduate education, and continuing medical education.



On the basis of the evidence presented in the three articles, we would like to present what we consider the key points of the three articles:

1. Potentially clinically significant postoperative residual paralysis is a clinical problem and may pose a threat to the health of the patient.
2. It is not possible by any clinical test or combinations hereof, nor by tactile or visual evaluation of the response to TOF, tetanic (50 or 100 HZ), or double-burst stimulation, to exclude with certainty potentially clinically relevant postoperative residual paralysis.
3. Good evidence-based practice dictates that the anesthesiologist, preferably perioperatively but at least before sending the patients to the recovery ward, should ensure that the TOF ratio is 0.90 or more by using an objective monitor.

Editorial- July 2010 Anesthesia and Analgesia

Let me "dumb-down" the editorial for our Community College PhD:

1. Standard twitch monitors aren't reliable for detecting residual NMB. They are useful up to about 0.6 or 0.7 TOF but after that you need a better monitor. There is no way to be certain 0.9 has been reached using STANDARD TWITCH MONITORS

2. Residual NMB has been proven to cause harm to patients. It is below the standard of care in the USA to have a TOF ratio less than 0.9. Is this not your standard as well or do you use third world country standards in rural America?

3. Avoidance of reversl agents is possible after administering non depolarizing NMB but ONLY and I stress ONLY if you have documentation via a monitor like TOF-WATCH that 0.9 or greater has been achieved.


Any CRNA who fails to "routinely" reverse non depolarizing NMBs without documenting why (TOF greater than 0.9 or continued post op ventilation, etc.) is providing poor care to his/her patients.

The practice of Medicine involves "science" and the data is crystal clear.

 

[BLADEMDA]

http://www.bluestarent.com/tof_watch_sx.htm

 

[periopdoc]

Sorry Blade, but I have to call you out on this one. Honestly, S*** like this thread is piling up on SDN and is painting physicians in a bad light. It makes me seriously question my continued association with this site.

You are making unsubstantiated claims about the current practice patterns and critical thinking skills of the majority of CRNAs based (apparently) on your online interaction with a few vocal individuals, and perhaps your personal interaction with a 20-80 or so CRNAs (if you are currently practicing in a ACT model). You are then contrasting that with what? Your opinion of what anesthesiologists are doing?

Give me some data to support your argument that CRNAs are behaving and arguing significantly differently than MD's on this topic.

________________________________________________


Think MD's have changed their behavior in droves? Naguib's survey data (from the July A&A that you are using to beat CRNA's over the head with) would argue otherwise.

Here are some of Donati's editorial comments on Naguib's data

The results of the survey conducted by Naguib et al. show that many anesthesiologists in the US and Europe just do not follow this recommendation. Quantitative monitors are available to only a minority of American practitioners (22.7%), and even if 70.2% of European practitioners have access to such devices, they are not available in all operating rooms. Even if both conventional and quantitative nerve stimulators are available, the latter are used by only half the Europeans and fewer than 20% of Americans, and many on both sides of the Atlantic do not use nerve stimulators at all. One might suspect that the situation might actually be worse, because people who answered the survey probably had some interest in neuromuscular blockade, perhaps more than those who did not participate in the survey.

François Donati - Neuromuscular Monitoring: What Evidence Do We Need to Be Convinced?Anesth Analg July 2010 111:6-8​

​

We don't have complementary data to compare and contrast CRNA's behavior, but it can hardly be worse.

________________________________________________


Think that physicians don't posit the same arguments that you are lambasting CRNA's for making on whatever CRNA forums you frequent?


Some quotes from physician letters to the editor RE the Debaene article (click on the quote boxes for the full text of the letters quoted)

Debaene B, Et Al: Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003; 98: 1042&#8211;8​

What is the morbidity and mortality caused by this "subjective" analysis? What is the morbidity and mortality of fixing the perceived problem? I have not seen a clinical problem with a patient intubated after rocuronium, a subjective train-of-four ratio of one at 1 hour later, and extubation without reversal.

- M. Craig Pinsker, M.D., Ph.D.​

No scientific test will ever replace the clinical ability to comprehensively evaluate the patient's ability to breathe and maintain an airway or clinical experience to appreciate pharmacodynamics in medicine.

- Paul M. Kempen, M.D., Ph.D.​

There are currently no published outcome studies with respect to intermediate-acting muscle relaxants and residual weakness postoperatively. The "consequences" to which Dr. Eriksson refers in his editorial have never been related to any mortality/morbidity differences. His belief that this would improve patient outcome is unsupported.

- Roland R. Rizzi, M.D.​

So we have anesthesiologists positing the same arguments against ubiquitous quantitative TOF that you are criticizing CRNAs for using. We also have data demonstrating that currently, even when available, a significant majority of anesthesiologists are not utilizing quantitative TOF. Both communities are only beginning to move in the direction of quantitative TOF and criticizing them for not doing what we aren't doing is pretty groundless.

It may well be that CRNA's are unable to critically evaluate the scientific literature with the same discernment as a physician, but the illustration that you are using does not support the contention. Come up with GOOD examples of how CRNA and Anesthesiologist critical thinking differs.

You are painting physicians in a bad light by using non-scientific arguments and insults to criticize CRNA's for a lesser ability to understand and evaluate scientific argument. You are smarter than that. You can hopefully come up with better examples than this.

If this is all we have left to differentiate us from the CRNA, then I suppose the war really is lost.

- pod

 

[periopdoc]

It isn't whether your or their argument and actions are right or wrong. It is the fact that their arguments and actions are pretty much in line with the current arguments and actions of anesthesiologists across the country.

How about it? Are you using quantitative TOF? I will as soon as I have it available, but it cannot be considered standard of care yet.

- pod

 

[BLADEMDA]

It isn't whether your or their argument and actions are right or wrong. It is the fact that their arguments and actions are pretty much in line with the current arguments and actions of anesthesiologists across the country.

How about it? Are you using quantitative TOF? I will as soon as I have it available, but it cannot be considered standard of care yet.

- pod

1. You are totally MISSING the point here as the literature was referenced before the discussion.

2. Quantative monitors are NOT used in most ORs but low dose Neostigmine is READILY available and SHOULD be used for reversal.

3. When the facts change so should your opinion.

4. If after reading the peer referenced literature and Editorials you still don't either reverse your patients or document a TOF of 0.9 or greater than you may be causing harm to patients.

5. After July's Anesthesia and Analgesia's publication MANY Anesthesiologists have adjusted their practice of administering reversal agents on a routine basis.

 

[BLADEMDA]

Despite dozens of peer reviewed studies on this topic some MD (A)s and many CRNAs are reluctant to administer reversal agents after using NMBs.
However, I am confident that the vast majority of Medical Doctors will change their routine practice once shown the data.

FYI, this topic isn't new or groundbreaking and I have discussed it elsewhere in detail. Here is a nice review article for midlevels and new providers:

http://anesthesiologyrounds.ca/crus/122-047 English.pdf

Posted 10/17/2010. I clearly state that not all MD Anesthesiologists routinely reverse their patients.

 

[BLADEMDA]

These results clearly demonstrated that the duration of action of intermediate-acting muscle relaxant showed a wide interindividual variability and might be prolonged in some patients. The findings of our study, obtained in a large sample of patients, confirmed those from Caldwell et al.11 A 30% and a 10% residual paralysis rate were observed 1 and 2 h after relaxant (without reversal) when a TOF ratio less than 0.7 was used to confirm the residual blockade. These incidences were increased to 60 and 36% with a 0.9 TOF ratio threshold.

 

[BLADEMDA]

"Give me some data to support your argument that CRNAs are behaving and arguing significantly differently than MD's on this topic. "

PeriopoDoc


________________________________________________


All I can publicly post is the attitude among most Anesthesiologists is that when the Literature begins to strongly recommend/encourage a routine course of action many of us listen. CRNAs are much more reluctant to change well-established "rote" practice patterns. Is this due to Anesthesiologists perception of increased medico-legal liability?
Is it because we deal with the vast majority of post operative/PACU complications? Or, is it we are more accustomed to new developments in the field?

I can assure that only one thing remains constant and that is change. For example, how many letters do you think older Anesthesiologists wrote to Journals about the "safety" of actually inducing a paresthesia to do a block? Yet, how many of us view that approach as safe today? Or, how about the routine use of U/S for Central line placement? How many letters will be written in the future disagreeing with the ASA standard that U/S should be used when available (coming soon from the ASA)?

Don't confuse practice patterns with peer reviewed evidence and the understanding that when the facts change so should your opinion.

 

[BLADEMDA]

It isn't whether your or their argument and actions are right or wrong. It is the fact that their arguments and actions are pretty much in line with the current arguments and actions of anesthesiologists across the country.

How about it? Are you using quantitative TOF? I will as soon as I have it available, but it cannot be considered standard of care yet.

- pod

So, after reading the extensive literature posted you would recommend avoiding "routine" reversal of NMBs? I doubt most Anesthesiologists would agree with you AFTER reading the material.

The Editorial and articles have spurred a lot of discussion about purchasing these quantative monitors so we can AVOID reversal agents in many cases yet still ensure our patients are fully recovered from NMBs (TOF greater than 0.9). Kudos to the Editorial Board of the A and A for taking a tough, unpopular stand on an issue which may improve patient safety or, at the least, patient comfort in the PACU.

I encourage you to join the Anesthesia Nurse website/forum so you can experience first hand the "mentality" of a CRNA. I believe you will find that group quite representative of CRNAs in the USA.

 

[BLADEMDA]

"Think MD's have changed their behavior in droves? Naguib's survey data (from the July A&A that you are using to beat CRNA's over the head with) would argue otherwise." POD


Why do you think the survey was included in the July Edition of A and A?
What was the point the Editors were trying to drive home? Before you can fix a problem you need to recognize there is a problem. Who do you think will be dealing with medicolegal PACU issues which may arise out of the July A and A publication?

Since the vast majority of CRNAs practice under an "Umbrella" of protection/Nursing they are reluctant to change practice patterns. In fact, please give one example of an AANA standard of care which was adopted by the ASA? Please name one MODERN contribution to patient care by the AANA? You can't.

The ASA will continue to advance patient safety as it has done so in the past.
This means new standards will be adopted and followed first by Anesthesiologists then by the AANA/CRNAs. I can guarantee it won't be the CRNAs who advocate/demand a TOF of 0.9 OR routine reversal of NMBs so patients don't suffer in the PACU.

 

[BLADEMDA]

Nevertheless, practice standards and guidelines send a strong message to the anesthesia community. The clinician who consistently ignores them at some point must ask, “Why am I off the bell-shaped curve.” It is time for anesthesia's professional organizations to finally draft evidence-based guidelines detailing how best to monitor and manage the perioperative administration of neuromuscular blocking drugs.

Aaron Kopman, MD

 

[BLADEMDA]

\
]\ CRNA:

I also rarely give reversal. I'll intubate w/SUX if it's a questionable airway, then just give the ED95 for the NDNMB afterwards since I don't need 'intubating conditions' only areflexia. Combined w/adequate anesthesia, either TIVA or a volatile, the patient won't move. Other times I'll intubate w/2x the ED95 and not reverse for a 1hr case. I ensure that the patient has adequate Vt and spontaneous ventilation, and usually extubate deep. If the patient's Vt is inadequate, or I've redosed the NDNMB towards the end of the case, I will give them some reversal.


​

I stand by this thread and the EXPERIENCED CRNAs quoted opinion posted above. I also stand by my opinion that this particular CRNA and many others persist in the wrongly held belief that routine reversal of NMBs are not warranted in many situations.

 

[BLADEMDA]

it seems that if neuromuscular function is assessed in a more rigorous fashion, residual blockade becomes a major risk factor for adverse respiratory events. Murphy et al. measured TOF ratio in patients with respiratory problems such as hypoxemia and airway obstruction in the PACU and matched these cases with patients who did not have the complications. The incidence of such complications was 0.8%. The mean TOF ratio was 0.61 in patients who had respiratory events, compared with 0.98 in patients who did not.
This suggests that residual blockade is a common cause of respiratory difficulties in the PACU. If monitoring is not used, such adverse events are unlikely to be attributed to residual blockade. This might explain why most clinicians claim that they never saw a case of residual blockade in the PACU. One can also imagine that some patients did not show detectable respiratory problems despite inadequate restoration of neuromuscular function, but that they could have had a smoother recovery if they did not have to struggle with residual blockade.

François Donati PhD, MD

 

[BLADEMDA]

"Again if the patient's condition requires it then give it, otherwise why introduce an agent that is not benign?"

CRNA

-----------------------------------------------


So, despite all the posts and comments about how Providers can't "assess" a patient's condition to detect residual NMB this CRNA persists in this potentially harmful, wrongly held opinion. I can guarantee you his AANA won't be issuing a practice recommendation anytime soon. If patient safety is going to be advocated in this area it must come from us.

By the way the CRNA posted that comment after reading all the evidence and literature presented on this thread. Again, Anesthesiologists have to deal with potential Malpractice issues on a daily basis; an issue which most CRNAs somehow seem to think they are immune from.

I may be in the minority but I am looking forward towards an ASA standard in this area.