English - United States

Eliminate Residual Paralysis with Quantitative Neuromuscular Monitoring

Quantitative train of four (TOF) monitoring removes the guesswork in the assessment of neuromuscular block. Using TwitchView, clinicians have increased patient safety and lowered the cost of care in leading hospitals around the globe!1

TwitchView2 Quantitative Neuromuscular Monitor Pediatric Patient
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* The 'Best State' scenario assumes all post-op pulmonary complications attributed to residual neuromuscular blockade are eliminated. The remaining complications are attributed to other causes.

Residual Paralysis is Common, Dangerous, and Expensive

Even today, in the era of sugammadex, residual neuromuscular blockade - also known as residual paralysis - remains a common and often overlooked cause of patient complications.

Multiple studies spanning decades have reported residual paralysis incidence rates ranging from 10 to 60%.2 Even in institutions where sugammadex is used for every reversal, the incidence of residual paralysis remains as high as 10% if neuromuscular monitoring is not used.3

Residual paralysis causes postoperative pulmonary complications at the hospital's expense.2, 4 Edwards et al. determined pulmonary complications cost Temple University Hospital roughly $7 million dollars every year. Preventing a fraction of those complications would cover the capital purchase of quantitative neuromuscular monitoring and the ongoing cost of consumables with the potential for major savings.4

ASA & ESAIC Guidelines Recommend Quantitative Neuromuscular Monitors

A growing consensus of professional anesthesia societies recommend quantitative neuromuscular monitoring as a standard practice.2, 5 There’s a common misconception that sugammadex has eliminated the clinical need for quantitative train of four monitoring. However, quantitative neuromuscular monitors are critical to implement the evidence-based recommendations outlined in the guidelines.

In addition to guideline recommendations, Bowdle et al. demonstrated that 87% of patients (84 out of 97) could be reversed with less than the manufacturer’s recommended dose of sugammadex. Conversely, 13% required more than the manufacturer’s recommended dose.6 The takeaway: Quantitative neuromuscular monitoring is required to confirm adequate patient recovery—even with sugammadex. 

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References
  1. Thilen SR, Sherpa JR, James AM, Cain KC, Treggiari MM, Bhananker SM. Management of Muscle Relaxation With Rocuronium and Reversal With Neostigmine or Sugammadex Guided by Quantitative Neuromuscular Monitoring. Anesth Analg. May 12, 2023
  2. Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: a report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology2023; 138: 13–41.
  3. Kotake Y, Ochiai R, Suzuki T, et al. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesthesia and Analgesia2013; 117: 345–351.
  4. Edwards LA, Ly N, Shinefeld J, Morewood G. Universal quantitative neuromuscular blockade monitoring at an academic medical center - a multimodal analysis of the potential impact on clinical outcomes and total cost of care. Perioperative Care and Operating Room Management2021; 24: 100184.
  5. Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, de Boer HD, Sorbello M, Jankovic R, Kranke P. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2023 Feb 1;40(2):82-94. 
  6. Andrew Bowdle, Kishanee J. Haththotuwegama, Srdjan Jelacic, Sharon T. Nguyen, Kei Togashi, Kelly E. Michaelsen; A Dose-finding Study of Sugammadex for Reversal of Rocuronium in Cardiac Surgery Patients and Postoperative Monitoring for Recurrent Paralysis. Anesthesiology2023; 139:6–15