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POSTOPERATIVE RESPIRATORY COMPLICATIONS –

Sarah Clift, SRNA, RN, BSN

HOW CAN WE PREVENT IT?

Objectives

ü  Describe the KUMC PACU Reintubation data ü  Review NMB and Reversal Agents ü  Discuss ideal technique for twitch monitoring ü  Sugammadex – how it works and

contraindications ü  Brief discussion of other possible contributors:

IVF, opioids, atelectasis, etc.

KUMC PACU Reintubation Data

¨  June 2015-January 2016 ¨  32 total patients/33 occurrences ¨  Emergency Cases (E) 6/33 cases ¨  Average BMI: 34 ¨  Average Age: 60 yrs ¨  No pattern found among

¤  Providers ¤  Surgery type/surgeon ¤  Surgical duration/time

Chart Review Findings

Can probably exclude 5/33 situations for “unavoidable reasons”

n  Surgeon request, GCS 3, cardiac arrest, always left intubated for multiple procedures

The Implications-

¨  Increased wake-up/turn-over time ¨  Decreases patient and family satisfaction ¨  Increased cost to hospital and patient ¨  Can prolong PACU LOS ¨  Can prolong hospital LOS ¨  Increased risk of morbidity and mortality

Senior QI Project Goals

¨  Educate and dispel myths surrounding NMB and their reversal

¨  Distribution of cognitive aid ¨  Provide feedback regarding department progress ¨  Request IRP document TOF just prior to giving

reversal and follow up documentation of post-reversal twitches

Reduction in PACU reintubations and patients remaining on ventilator.

Areas for improvement

¨  Adhere to up-to-date NDMB reversal guidelines ¨  Improve our documentation of TOF ¨  Improve documentation of adverse events ¨  Improve our ability to assess twitches ¨  Follow proper narcotic dosing guidelines ¨  Follow proper fluid replacement guidelines ¨  Prevent medication errors

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Neuromuscular Blockade Agents

¨  Succinylcholine ¨  NDMB

NMB Agents MOA

¨  NMB drugs interact with ACh receptor either by depolarizing the endplate (Sux) or by competing with ACh for binding sites (NDMB)

Nerve depolarization and muscle contraction are caused when an AP travels along the course of a nerve. When the impulse reaches the motor endplate, ACh is released across the synaptic cleft. ACh travels toward receptor sites on the muscle membrane, resulting in depolarizing and this leads to muscle contraction.

Neuromuscular Junction Review

Succinylcholine

¨  Only depolarizing muscle relaxant ¨  Mimics the action of ACh by depolarizing the motor

endplate ¨  It is then hydrolyzed by pseudocholinesterases ¨  Some patients have a genetic variant that causes

prolonged recovery to Sux ¤ MUST check for recovery of twitches prior to

administering NDMB or extubating patient.

Succinylcholine Twitches Succinylcholine Variants

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Succhinylcholine Case study

¨  68 y/o ¨  GETA plus sux (1mg/kg) ¨  Roc 20mg administered ¨  49 mins later TOFr 0.2 ¨  Neostigmine x2, sugammadex ¨  TOFr 0.7, patient still unable to SV ¨  Sugammadex ¨  Transferred to ICU on Vent. Extubated 6 hours later ¨  Pseudocholinesterase level was 2500 U.L. ¨  Dibucaine Number 30.6%

¤  PChE Enzyme activity was decreased by 70%! ¤  Atypical PChE Variant, homozygote A, frequency 0.3%, 1:3200 patients

Example A

¨  66y/o M ASA 4 ¨  TIPS with paracentesis ¨  100kg, BMI 28 ¨  PMHx: ESLD, DM, HRS, HTN, Cancer ¨  Intubated with Sux, no NDBM given ¨  Clinical course: extubated, lethargic/combative, low

pulse ox. Masked and showed improvement. Same symptoms reoccurred. Reintubated in PACU.

NDMB Agents

¨  Rocuronium and Vecuronium most commonly used ¨  Rocuronium DOA with intubating dose of 0.6-1mg/kg is

30-90 minutes ¤ DOA prolonged in patients with significant liver or kidney

disease

¨  Vecuronium DOA with 0.1mg/kg is 36mins +/- 6mins ¨  Cisatracurium is the agent of choice in Renal or Liver

disease ¤  Broken down via Hoffman elimination and non-esterase

dependent hydrolysis

“I don’t need to check twitches”

Caldwell Study ¨  Vec 0.1mg/kg bolus to

healthy patients ¨  TOFr observed ¨  2hrs later 4/20 had

TOFr <0.75 ¤ 2 patients TOFr <0.50

¨  At 3hr 3/10 TOFr of 0.6-0.7

Debaene Study ¨  Single intubating dose

of Vec, Roc, or Atricurium

¨  2hr later 10% had TOFr <0.70 and 30% <0.90

NMBA

¨  NMBA are similar to opioids – they are both “life saving” and “complication producing” drugs.

¨  Unlike opioids, we have the ability to monitor NMB depth and adequate reversal agents.

¨  “We have the technology and the proof – so far we have just not had the resolve”

TOFr >0.9 to be safe to extubate!

Nerve Monitoring

Facial Nerve NMB Testing Ulnar Nerve NMB Testing

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Prior data from KUMC

¨  Sydney Crowell Capstone project ¤ Question: CRNA Vs. SRNA ability to properly detect

number of twitches when TOF stimulation applied. ¤ Results: No difference between years of anesthesia

experience and ability to properly assess. ¤  In general TOF assessment varied greatly ¤  Implications: wrong dosing for reversal leading to

residual NMB in PACU!

Adverse Effects of Residual NMB

¨  Need for tracheal reintubation ¨  Impaired oxygenation and ventilation

¤ Hypoxia, hypercarbia ¨  Impaired pulmonary function

¤  Respiratory failure, pulmonary edema, atelectasis

¨  Increased risk of aspiration and PNA ¨  Pharyngeal dysfunction ¨  Generalized weakness, visual disturbances, difficulty

speaking ¨  Delayed PACU discharge TOFr >0.9 required to be safe to extubate!

Fade Tactile Issues Acceleromyography

¨  Objective numeric reading of TOFr.

¨  Improves chances of successful reversal

¨  Hopefully will be coming soon to KUMC!

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Accelerometer Basic Rules to Follow- Induction

¨  Red lead is positive (+), Black lead is negative (-). ¨  Best response to stimulator is achieved when the black (-) lead is over the most

superficial part of the nerve being stimulated. The positive lead should be placed proximal along the course of the nerve.

¨  Check twitch with single twitch stimuli after patient is asleep but before pushing paralytic to assess each patient’s baseline.

¨  Tactile evaluation is more sensitive than visual to assess response. ¨  The evaluator should use their dominant hand and apply slight preload to

the thumb

¨  Still getting poor signal? ¤  BP cuff should not be on the same extremity ¤  Do not use an extremity affected (paralyzed) by a stroke (shows false resistance

to NDMB) ¤  Scrub skin with alcohol pads till slightly red to improve signal ¤  When stimulator battery is low only 3 pulses are generated in TOF- may lead to

misinterpretation

Basic Rules to Follow- Maintenance

¨  TOF is most useful for maintenance.

¨  Usually 3/4 twitches is adequate for most surgeries if volatile agent is used.

¨  Deeper levels may be needed for upper abdominal or chest surgery or if diaphragmatic paralysis is required.

¨  Most abdominal surgeries 1/4. ¤  Tips for end of case and surgeon requests more “relaxation”

n  Give a bolus of propofol or fentanyl n  Increase volatile anesthetic n  Use smaller dose of paralytic (5mg Roc) if there are 4/4 twitches

¨  Must wait 10-12 seconds before retesting TOF or will be inaccurate.

¨  Maintain normothermia (hypothermia reduces metabolism of paralytics)

Basic Rules to Follow- Emergence

¨  Double-burst stimulation (DBS) best to assess recovery. ¨  TOFr > 0.9 prior to extubation

¨  Do NOT assess Facial Nerve for Recovery ¤  Move twitch monitor to Ulnar N.

¨  Tactile or visual evaluation is of little value over TOF ratio of 0.4 or 0.5.

¨  Acceleromyography (AMG) is ideal.

Obesity

¨  TOFr > 0.9 was delayed in both overweight and obese patients compared to normal weight ¤ Overweight group (12 +/- 4 mins) ¤ Obese group (13 +/- 4 mins)

Consider stopping NMB earlier on overweight or obese patients

Ulnar Nerve

Can be stimulated at elbow, wrist or hand.

Electrodes applied at wrist should be 2 cm apart.

Monitoring the adductor pollicis M.

Monitoring of Ulnar N. is most reliable for NMB offset and recovery.

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Facial Nerve

Relatively resistant to NMB

Look for twitch of corrugator supercilii M.

Should NOT be used to assess recovery.

Assume if there are 1-2 twitches from facial nerve stimulation then there are 2-3 twitches if ulner N. were tested.

Other sites

Posterior Tibial N. – stimulation causes plantar flexion of great toe. Peroneal (lateral popliteal) N. – stimulation causes dorsiflexion of foot.

AANA Standards for Nurse Anesthesia Practice Ve:

Ve. Neuromuscular : When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery.

Remember to document twitches!

“If you didn’t document it, you didn’t do it!”

Reversal Agents

¨  Neostigmine + glycopyrolate ¤ Glycopyrolate: tx antimuscarinic side effects of

neostigmine- n bradycardia n  increased bronchial and pharyngeal secretions n bronchospasm.

¨  Sugammadex

Numerous studies have shown that when quantitative TOF monitoring is performed on patients arriving in PACU as

many as 40% have evidence of residual NMB

Neostigmine

¨  MOA: reversible AChE inhibitor ¨  Quaternary ammonium

compound – so it does not penetrate BBB

¨  Inhibition of acetylcholinesterase à increased amount of ACh reaching the receptor and increases the time ACh remains in synaptic cleft à increases size and duration of of end plate potential.

¨  Recovery time to TOFr >0.9 vary from 5-22 mins with some as long as 143 mins.

¨  You can give TOO much reversal and cause weakness!!

¨  Large doses of ACh à increased upper airway collapsibility and decreases activity of genioglossus muscle. ¤  AKA: CI can cause muscle

weakness!! ¨  It is NOT safe to give

neostigmine to a patient who has spontaneously recovered from NMB.

Updated Reversal Guidelines

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Too much reversal?

¨  After spontaneous recovery (TOFr >0.9) of NM function if neo + glyco is given, the increase in airway collapsibility was similar to a NMB TOFr = 0.5!

¨  Authors recommend using quantitative monitoring to evaluate TOF.

Too Much Reversal?

¨  High dose neostigmine (60 mcg/kg) increased time to PACU discharge and increased hospital LOS

¨  Unwarranted use of neostigmine was a predictor of pulmonary edema and reintubation

PACU Reintubation Data

¨  8/32 patients identified as received too large of dose of reversal. ¤ “Full Reversal” given to ALL patients 8/8 ¤ Multiple serious chronic co-morbidities 7/8 ¤ CKD 2/8 ¤ COPD/Smoking history 3/8 ¤ Emergency procedures 2/8 ¤ Post reversal TOF documentation 1/8 ¤ No TOF documentation for entire case 3/8

Example B

¨  55y/o M ¨  TEE for a-flutter, ASA 4 ¨  70kg, BMI 23 ¨  PMHx: CKD, htn, ASD, HLD, cocaine abuse ¨  Clinical Course - 50mg Roc given with intubation,

incremental 10mg redose. Last redose 1hr prior to reversal ¤  Neostigmine 5mg given with 4/4 TOF twitches pre-reversal

n  Unknown if fade was present ¤  Emergent intubation in PACU, “hypercarbia” ¤  Recommended Neostigmine Dose: 2 mg neostigmine. ¤  Pt was given 70 mcg/kg when he had 4 TOF twitches

documented pre-reversal.

Example C

¨  66 y/o M, ASA 4 ¨  TIPS Procedure ¨  72 kg, BMI 23 ¨  PMHx: ESRD, Hep C, HIV, DM, AI, portal htn, CKD ¨  40mg Roc given for intubation only

¤  “Full” Reversal (5mg Neostigmine) given 1hr 6 mins later n  Calculated “full” dose: 72kg x 50mcg neo = 3.6mg neostigmine n  Gave 70 mcg/kg neostigmine

¤ No twitches documented during entire case n  Likely lower TOF twitch count due to PMHx.

¤ Hypoxia in PACU, intubated CXR shows “pulmonary edema” n  Total IVF 800mL IVF + 25gm albumin

MOA: forms a complex with NMB agents, rocuronium or vecuronium and reduces the amount of NMB available to nicotinic cholinergic receptors in the NMJ.

Sugammadex

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Sugammadex

¨  Dosing Regimen ¤ 2mg/kg if 2 twitches are present in TOF. ¤ 4mg/kg if there are no responses to TOF but there is

1-2 post-tetanic twitches. ¤ For rocuronium only: 16mg/kg if an RSI dose (1.2mg/

kg) and at least 3 minutes have passed.

Do not use a lower dosage as recurrence of NMB after initial reversal can occur!!

Sugammadex

¨  Do not use: ¤ Pediatrics (< 17years

of age) ¤ Pregnancy? ¤ Severe Renal

Impairment ¤ Prior hypersensitivity

n Anaphylaxis n Marked bradycardia,

possible cardiac arrest

Sugammadex

¨  Not compatible in-line with verapamil, ondansetron, and ranitidine.

¨  Toremifene binds with sugammadex and should be held the day before surgery. ¤ Fareston: po SERM for advanced breast cancer ¤ Acapodene: po SERM for prostate cancer prevention

¨  Women of child bearing age on hormonal contraceptives must be informed they need to use an alternative form of birth control for next 7 days.

Sugammadex Works

¨  Adult Patients under going Abdominal Surgery at Massachusetts General Hospital

¨  Rocuronium intra-op ¨  Randomized allocation of 150 patients ¨  TOFr measured upon PACU entry ¨  0/74 sugammadex group had TOFr <0.9 ¨  33/76 Neostigmine/glycopyrolate per usual dosing

practice had TOFr <0.9 ¤  43% had evidence of residual blockade ¤  2 patients had evidence of partial paralysis

Review

¨  Never give reversal if patient received only sux

¨  Follow APSF guidelines for

reversal of NDBM ¤  More is not better!

¨  Don’t under dose sugammadex

Other potential causes…

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Opioids

¨  Fentanyl ¤ DOA: 20-40 mins ¤ Total case: 2.5-5mcg/kg for moderate to severely

painful procedures.

Consider multimodal approach in high risk patients such as obese, elderly, COPD, etc.

IVF Goals

¨  Use goal directed therapy ¤ Maintain MAP with 20% of baseline ¤ UOP 0.5mL-1mL/kg/hr

¨  For longer cases perform the calculations! ¤ Calculate NPO loss ¤ Calculate hourly rate ¤  Replace EBL with 1:3 crystalloid or 1:1 colloid or blood ¤ Calculate insensible loss:

n  Minimal tissue trauma: 0-2mL/kg/hr n  Moderate tissue trauma: 2-4 mL/Kg/hr n  Severe tissue trauma or large exposure area: 4-8mL/kg/hr

Other tips…

¨  Alveolar recruitment breath ¤  Single inflation to -40cm H2O hold x 10

seconds ¤  Especially in those with lung problems, lap sx,

or long surgical duration ¨  Normothermia

¤ Hypothermia decreases metabolism of NMB ¤  Increased risk of bleeding

¨  Optimal positioning en route to PACU ¤ Upright to improve ability to breath and

prevent obstruction

Postoperative Respiratory Complications – How can we prevent it?

Resource Guide References

American Association of Nurse Anesthetists. (2013). Standards for Nurse Anesthesia Practice. Park Ridge, IL: AANA; Retrieved from https://www.aana.com/resources2/professional practice/Documents/PPM%20Standards%20for%20Nurse%20Anesthesia %20Practice.pdf

Bridion (sugammadex): annotated prescribing information. (2016). Merck & Co., Inc. Retrieved from http://www.merck.com/product/usa /pi_circulars/b /bridion /bridion_pi.pdf Brueckmann, B., Sasaki, N., Grobara, P., et al. (2015). Effects of sugammadex on incidence of

postoperative residual neuromuscular blockade: a randomized, controlled study. J Anaesthesia, 115, 743-51. doi: 10.1093/bja/aev104.

Brull S., Prielipp R. (2015). Reversal of neuromuscular blockade: identification friend or foe. Anesthesiology, 122, 1183-1185. doi: 10.1097/ALN.0000000000000675 Butterworth, J., Mackey, D., & Wasnick, J. (2013). Morgan & Mikhail’s clinical anesthesiology (5th

ed.). pp. 199-232. New Delhi: McGraw Hill Education. Caldwell J. (1995). Reversal of residual neuromuscular block with neostigmine at one to four hours

after a single intubating dose of vecuronium. Anesthesia and Analgesia, 1168–74.

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References

Debaene B., Plaud B., Dilly M.P., & Donati F. (2003). Residual paralysis in the PACU after a single intubating dose of non-depolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 98, 1042–8.

Dorsch J. & Dorsch, S. (2011). Neuromuscular transmission monitoring. In A practical approach to anesthesia equipment. (pp. 500-516). Philadelphia: Lippincott Williams & Wilkins.

Joshi, S., Upadhyaya, K., & Manjuladevi, M. (2015). Comparison of neostigmine induced reversal of vecuronium in normal weight, overweight and obese female patients. Indian journal of anaesthesia, 59, 165 - 170. doi: 10.4103/0019-5049.153038 

Herbstreit, F., Zigrahn, D., Peters, D., & Eikermann, M. (2010). Neostigmine/ glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology, 113, 1280 - 1288. doi: 10.1097/ALN. 0b013e3181f70f3d 

Kopman, A. F. and Eikermann, M. (2009), Antagonism of non-depolarizing neuromuscular block: current practice. Anaesthesia, 64, 22–30. doi: 10.1111 /j.1365-2044.2008.05867.x

  

References

Nagelhout, J. (2014). Neuromuscular blocking agents, reversal agents, and their monitoring. In Nagelhout, J. & Plaus, K. (Eds.), Nurse anesthesia (5th ed.) (pp.

158-185). St. Louis: Elsevier Inc.

Pelt, M., Chitilian, H., & Eikerman, M. (2016). Multi-faceted initiative designed to improve safety of neuromuscular blockade. APSF Newsletter, 30, 51-52.

Poon, T. (2012). Perioperative fluid management. In Chu, L. & Fuller, A. (Eds.), Manual

of clinical anesthesia. (pp.193-201). Philadelphia: Lippincott Williams &

Wilkins.

Sabate, A., Koo, M., & Lopez, D. (2016). Succinylcholine and neuromuscular blockade monitoring. Anesthesia 71, 114-115. doi: 10.1111/anae.13353

Sasaki, N., Meyer, M., Malviya, S., et al. (2014). Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes. Anesthesiology, 121, 959-967. doi:10.1097/ALN.0000000000000440

Stimpod NMS 450 stimulator. Xavant technology. Retrieved from http://www.xavant. com/ products/nms450