Monitoring of neuromuscular block in operative room and ICU Josep Rodiera M.D. Ph.D. MsC

Transcription

1 Monitoring of neuromuscular block in operative room and ICU Josep Rodiera M.D. Ph.D. MsC Marrakech 2016 Anesthesia Department Centro Medico Teknon Barcelona

2 Conflict of interest Creator of the TOFCuff Concept

3 Do you think that the routine use of neuromuscular monitoring Do you think that postoperative residual paralysis represents a devices could decrease the incidence of postoperative residual significant public health problem? paralysis?

4 Monitorization of NMB: Current situation Europe n= 739 USA n= 1792

5 Monitorization of NMB: Current situation

6 Monitorization of NMB: Current situation

7 EU USA Europe n= 739 USA n= 1792

8 1. 70% TOF enough for extubate? 2. 80% TOF enough for extubate? 3. 90% TOF enough for extubate?

9 T.O.F. And Receptor occupancy C. Thompson et al. º

10 Current monitoring systems & devices

11 Twitch 1 (T1) Twitch 2 (T2) Twitch 3 (T3) Twitch 4 (T4) Peripheral Nerve Stimulators Train-of-four fade is indistinguishable, even to experienced observers, once the TOF ratio exceeds 40% Viby-Mogenson J, Jenson NH, Engbaek J, Ording H, Skovgaard LT, Chaemmmer-Jorgensen B. Tactile and visual evaluation of the response to train of four nerve stimulation. Anesthesiology 1985; 63: Visual or Tactile Assessment The absence of observed or tactile fade in response to TOF stimulation does not indicate adequacy of recovery from neuromuscular blockade. Rodney G, Raju PKBC, Ball DR. Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia 2015; 70:

12 Force Transducer-based Inertial Sensor-based Inertial Sensor-based Sensing Device Manual installation needed Sensitive to motion artifacts The hand needs to be strapped Stimulating Electrodes Manual installation needed Specific polarity to be kept Using fragile connecting wires

13 + 16% 81% 80% 74% 71% 87% 75% 80% 81% 69% 76% 78% 71% - 12% - 12%

14 Monitoring Neuromuscular Transmission with TOFCuff

15 Como Funciona el TOFCuff? Traditional Method Neuro Stimulation for Regional Anesthesia

16 How TOF Cuff work s? Traditional Method Neuro Stimulation the motor Nerve

17 Cuff With Stimulating Electrodes (Qualitative Monitorization) Flow Diagram Cuff Inflation Impedance OK Stimulation Muscle Visual Contraction / Tactile Method

18 Pressure Changes in the Cuff during the Stimulation at Humeral level 1,4 1,2 1 0,8 0,6 0,4 0,2 0-0,2 10:15 AM 10:16 AM 10:17 AM -0,4-0,6 TOF T1 T2 T3 T4

19 Pressure Changes in the Cuff during the Stimulation at Humeral level 0,5 0,4 0,3 0,2 0,1 0-0, /03/1998 1:18 PM 31/03/1998 1:19 PM 31/03/1998 1:20 PM 31/03/1998 1:21 PM -0,2 TOF T1 T2 T3 T4

20 Monitoring Neuromuscular Blockade with the Cuff (Quantitative Monitoring) Cuff Inflation Impedance OK Flow Diagram Stimulation Recording Evoked Muscle Contraction TOFCuff Pressure Changes By means of processing the cuff pressure, it is possible to obtain a quantitative measurement

21 Brachial plexus stimulation / Evaluation of the evoked response During Recovery 0,5 0,4 0,3 0,2 0,1 0-0, /03/98 1:18 PM 31/03/98 1:19 PM 31/03/98 1:20 PM 31/03/98 1:21 PM -0,2

22 TOF-Cuff vs Mechanomyography

23 Recovery strategy Giving time to spontaneous/neostigmine reversal

24 Neostigmine reversal The average reversal time is approximately 12 minutes, as reported in recent studies. However, a large inter-individual variability exists. 10% of patients might need more than 60 minutes to reach a TOF ratio of 0.9. E.Dubois and J.P. Mulier. A review of the interest of Sugammadex for deep neuromuscular blockade management in Belgium. Acta Anesthesiologica Belgica, 2013, 64, Fuchs-Buder T., Ziegenfuss T., Lysakowski K., Tassonyi E., Antagonism of vecuronium-induced neuromuscular block in patients pretreated with magnesium sulphate : dose-effect relationship of neostigmine, b r. J. a naesth., 82, 61-5, Reid J. E., Breslin D. S., Mirakhur R. K., Hayes A. H., Neostigmine antagonism of rocuronium block during anesthesia with sevoflurane, isoflurane or propofol. c an. J. a naesth., 48, 351-5, Suzuki T., Masaki G., Ogawa S., Neostigmine-induced reversal of vecuronium in normal weight, overweight and obese female patients, b r. J. a naesth., 97, 160-3, 2006.

25 Many studies have found a high incidence of residual neuromuscular blockade after anesthesia and surgery, with a range of 4-64% Naguib et al. s meta-analysis of 24 studies demonstrated a pooled incidence of 41% Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. British Journal of Anaesthesia 2007; 98: Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia 2001; 56: Rodney G, Raju PKBC, Ball DR. Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia 2015; 70: Baillard C, Gehan G, Rebou-Marty J, et al. Residual curarisation in the recovery room after vecuronium. British Journal of Anaesthesia 2000; 84:

26 Sugammadex vs Neostigmine action time

27 Sugammadex Reversal Bartkowsky R. R., Incomplete reversal of pancuronium neuromuscular blockade by pyridostigmine and edrophonium, anesth. analg., 66, , Amao R., Zornow M.H., Cowan R.M., Cheng D.C., Morte J.B., Allard M.W., Use of sugammadex in patients with a history of pulmonary disease, J.clin. anesth., 24, , Caldwell J.E., Reversal of residual neuromuscular block with neostigmine at one to four hours after a single intubating dose of vecuronium. anesth. analg., 80, , Lock G., Loureiro Fialho G., Castro Lima D., Simoes Almeida M.C., neostigmine-atropine mixture. J. anesth. clinic res., 3, 188, neostigmine, Eikermann M., Fassbender P., Malhotra A., Takahashi M., Kubo S., Jordan A. S., Gautam S., White D.P., Chamberlin N. L., Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossus and diaphragm muscle function, anesthesiology, 107, 621-9, Electrocardiographic changes after Reversal Time Works with Deep or Intense Blocks? Pulmonary Diseases (COPD, Asthma...) Cardiac Failure and Arrhythmias Neostigmines Long, Unpredictable No Risk of Bronchospasm QT prolongation, Brady/Tachycardia Sugammadex Short, Predictable Suitable 2 Suitable 3 Renal Insufficiency Not Recommended Suitable 4 1 Yes Staals L.M., Snoeck M.M., Driessen J.J., Flockton E.A., Heeringa M., Hunter J.M., Multicentre, parallelgroup, comparative trial evaluating the efficacy and safety of sugammadex in patients with end-stage renal failure or normal renal function, br. J. anaesth., 101, 492-7, Moderate Block Deep Block Cammu G., Interactions of neuromuscular blocking drugs, acta anaesth. belg., 52, , Intense Bloc Elderly Patients (+75 years) Obese Patients Risk PORC Unaffected 5 Delay of Onset, Unpredictable Suitable 6 Suzuki T., Kitajima O., Ueda K., Kondo Y., Kato J., Ogawa S., Reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients, br. J. anaesth., 106, 823-6, Apnea Syndrome Risk of Upper Airway Obstruction Risk of Upper Airway Obstruction Gaszynski T., Szewczyk T., Gaszynski W., Randomized comparison of sugammadex and neostigmine for reversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia, br. J. anaesth., 108, 236-9, Tramer M.R., Fuchs-Buder T., Omitting antagonism of neuromuscular block: effect on postoperative nausea and vomiting and risk ofresidual paralysis. A systematic review. br. J. anaesth., 82, , Risk of PONV Yes 7 No No need to Monitor the NMT!! One then might ask oneself Sugammadex to everyone!!

28 Sugammadex A reversal strategy One then might ask oneself No need to Monitor the NMT!! Sugammadex to everyone!! 1 Assessment Committee for the uptake of new Hospital-use Drugs. OSAKIDETZA - Health & Consumer Department of the Basque Country Government (Spain). 3 Ph. E. Dubois, J.P. Mulier, A review of the interest of Sugammadex for deep neuromuscular blockade management in Belgium. Acta Anaesth. Belgica, 2013, 64, Cost per Treatment (VAT not included), for anaverage patient of 70 Kg. 2 Bartkowsky R. R., Incomplete reversal of pancuronium neuromuscular POWER blockadewithout by neostigmine, CONTROL pyridostigmineis and NOTHING edrophonium, anesth. analg., 66, , Eikermann M., Fassbender P., Malhotra A., Takahashi M., Kubo S., Jordan A. S., Gautam S., White D.P., Chamberlin N. L., Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossus and diaphragm muscle function, anesthesiology, 107, 621-9, Sugammadex-mandatory (no room for saving) 4 G. Rodney, P.K.B.C. Raju, D.R. Ball, Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia, 2015, 70, Neostigmines (Prostigmine ) Sugammadex (BRIDION ) Sales 1Formulation 0,5 mg/ml Vial 5 ml (0,44 per Vial) 200 mg and 500 mg Vials (76,96 and 192,4 ) Moderate Block (2 mg/kg) 0,44-0,88 76,96 Deep Block (4 mg/kg) 0,44-0, ,92 Moderate Block Deep Block Cost per Patient Intense Bloc Low High Emergency Rev. (16 mg/kg) Not Applicable 461,76 So, an administration rationale needs to be stablished Sugammadex-mandatory Neostigmine-suitable 3 4

29 Saving 153 per patient Saving 76 per patient G. Rodney, P.K.B.C. Raju, D.R. Ball, Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia, 2015, 70, Reversal Strategy 1 Ph. E. Dubois, J.P. Mulier, A review of the interest of Sugammadex for deep neuromuscular blockade management in Belgium. Acta Anaesth. Belgica, 2013, 64, TOFRATIO > 90% Neostigmines Sugammadex (Prostigmine ) (BRIDION ) Saving 153 per patient 0,5 mg/ml Vial 5 ml (0,44 per Vial) Sales Formulation Moderate Block (2 mg/kg) 0,44-0,88 Saving 76 per patient Deep Block (4 mg/kg) Emergency Rev. (16 mg/kg) Moderate Block Deep Block Intense Bloc 200 mg and 500 mg Vials (76,96 and 192,4 ) 76,96 0,44-0,88 153,92 Not Applicable 461,76 So, an administration rationale needs to be stablished Neostigmine-suitable Sugammadex-mandatory

30 HIGH-Risk Patient HIGH-Risk Surgeries Reversal Strategy Pulmonary Diseases (COPD, asthma ) Sleep Apnea Syndrome Cardiac failure and arrhythmias Increased Age (+75 years) Obesity (BMI >30) Renal Insufficiency ROCURONIUM Induction 0,6 mg/kg. ROCURONIUM (for levelling the patient at TOF COUNT = 1) Infusion Pump (100 mg/250ml) 5-10µg/Kg/min Bolus 0,15 mg/kg Thoracotomy Supraumbilical Laparotomy Lumbotomy Hypothermia TOF COUNT = 0 Post-Tetanic COUNT = 1-2 TOF COUNT = 1-3 TOF COUNT = 4 HIGH-Risk Patient Surgery LOW-Risk Patient Surgery TOF RATIO < 40% TOF RATIO > 40% Wait for TOF COUNT = 3 SUGAMMADEX 4 mg/kg SUGAMMADEX 2 mg/kg NEOSTIGMINE 50 µg/kg ATROPINE 1 mg NEOSTIGMINE 40 µg/kg ATROPINE 1 mg NEOSTIGMINE 20 µg/kg ATROPINE 0,7 mg EXTUBATION TOF RATIO > 90%

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32 Conclusions Residual paralysis is considered a important problem Neuromuscular monitoring could avoid the residual paralysis. There are consensus : Nueromuscular Monitoring should be routine The TOFCuff concept has a clear clinical use A reversal strategy is recommended