Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis
2007; Elsevier BV; Volume: 98; Issue: 3 Linguagem: Inglês
10.1093/bja/ael386
ISSN1471-6771
AutoresMohamed Naguib, A. F. Kopman, Joe Ensor,
Tópico(s)Surgical Simulation and Training
ResumoWe conducted a meta-analysis to examine the effect of intraoperative monitoring of neuromuscular function on the incidence of postoperative residual curarisation (PORC). PORC has been considered present when a patient has a train-of-four (TOF) ratio of < 0.7 or < 0.9. We analysed data from 24 trials (3375 patients) that were published between 1979 and 2005. We excluded data on mivacurium from this meta-analysis because only three studies had examined the incidence of PORC associated with its use. Long- and intermediate-acting neuromuscular blocking drugs had been given to 662 and 2713 patients, respectively. Neuromuscular function was monitored in 823 patients (24.4%). A simple peripheral nerve stimulator was used in 543 patients, and an objective monitor was used in 280. The incidence of PORC was found to be significantly lower after the use of intermediate neuromuscular blocking drugs. We could not demonstrate that the use of an intraoperative neuromuscular function monitor decreased the incidence of PORC. We conducted a meta-analysis to examine the effect of intraoperative monitoring of neuromuscular function on the incidence of postoperative residual curarisation (PORC). PORC has been considered present when a patient has a train-of-four (TOF) ratio of < 0.7 or < 0.9. We analysed data from 24 trials (3375 patients) that were published between 1979 and 2005. We excluded data on mivacurium from this meta-analysis because only three studies had examined the incidence of PORC associated with its use. Long- and intermediate-acting neuromuscular blocking drugs had been given to 662 and 2713 patients, respectively. Neuromuscular function was monitored in 823 patients (24.4%). A simple peripheral nerve stimulator was used in 543 patients, and an objective monitor was used in 280. The incidence of PORC was found to be significantly lower after the use of intermediate neuromuscular blocking drugs. We could not demonstrate that the use of an intraoperative neuromuscular function monitor decreased the incidence of PORC. Incomplete recovery from non-depolarizing neuromuscular blocking agents [postoperative residual curarization (PORC)17Egan TD Kern SE Johnson KB Pace NL The pharmacokinetics and pharmacodynamics of propofol in a modified cyclodextrin formulation (Captisol) versus propofol in a lipid formulation (Diprivan): an electroencephalographic and hemodynamic study in a porcine model.Anesth Analg. 2003; 97: 72-79Crossref PubMed Scopus (71) Google Scholar] continues to be a common problem in modern post-anaesthesia care units (PACUs).3Baillard C Gehan G Reboul-Marty J et al.Residual curarization in the recovery room after vecuronium.Br J Anaesth. 2000; 84: 394-395Crossref PubMed Scopus (163) Google Scholar 11Cammu G de Baerdemaeker L den Blauwen N et al.Postoperative residual curarization with cisatracurium and rocuronium infusions.Eur J Anaesthesiol. 2002; 19: 129-134Crossref PubMed Google Scholar 15Debaene B Plaud B Dilly MP Donati F Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action.Anesthesiology. 2003; 98: 1042-1048Crossref PubMed Scopus (384) Google Scholar 27Gatke MR Viby-Mogensen J Rosenstock C Jensen FS Skovgaard LT Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used.Acta Anaesthesiol Scand. 2002; 46: 207-213Crossref PubMed Scopus (92) Google Scholar 29Hayes AH Mirakhur RK Breslin DS Reid JE McCourt KC Postoperative residual block after intermediate-acting neuromuscular blocking drugs.Anaesthesia. 2001; 56: 312-318Crossref PubMed Scopus (180) Google Scholar 36Kim KS Lew SH Cho HY Cheong MA Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine.Anesth Analg. 2002; 95: 1656-1660Crossref PubMed Scopus (77) Google Scholar 43McCaul C Tobin E Boylan JF McShane AJ Atracurium is associated with postoperative residual curarization.Br J Anaesth. 2002; 89: 766-769Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Given that PORC is a potentially preventable patient safety problem,20Eriksson LI The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation.Anesth Analg. 1999; 89: 243-251Crossref PubMed Google Scholar 22Eriksson LI Reduced hypoxic chemosensitivity in partially paralysed man. A new property of muscle relaxants?.Acta Anaesthesiol Scand. 1996; 40: 520-523Crossref PubMed Scopus (85) Google Scholar it is important to find ways to reduce the incidence. Editorial opinion has suggested that the most salient factor contributing to PORC is failing to use objective or quantitative intraoperative monitoring of neuromuscular function.21Eriksson LI Evidence-based practice and neuromuscular monitoring: it’s time for routine quantitative assessment.Anesthesiology. 2003; 98: 1037-1039Crossref PubMed Scopus (150) Google Scholar 53Viby-Mogensen J Postoperative residual curarization and evidence-based anaesthesia.Br J Anaesth. 2000; 84: 301-303Crossref PubMed Scopus (107) Google Scholar The proposition that the proper use of an intraoperative neuromuscular monitor should prevent or at least reduce the incidence of PORC appears reasonable. Unfortunately, objective monitors that can measure the train-of-four (TOF) ratio in real time are not available in many operating rooms. Subjective evaluation of the evoked muscular response to TOF stimulation is extremely inaccurate.54Viby-Mogensen J Jensen NH Engbaek J et al.Tactile and visual evaluation of the response to train-of-four nerve stimulation.Anesthesiology. 1985; 63: 440-443Crossref PubMed Scopus (236) Google Scholar In addition, many practitioners are unclear about the current standards that define adequate recovery from neuromuscular blockade.51Sorgenfrei IF Viby-Mogensen J Swiatek FA [Does evidence lead to a change in clinical practice? Danish anaesthetists’ and nurse anesthetists’ clinical practice and knowledge of postoperative residual curarization].Ugeskr Laeger. 2005; 167: 3878-3882PubMed Google Scholar There is also conflicting evidence as to the utility of conventional peripheral nerve stimulators (PNS) in preventing PORC.24Fawcett WJ Dash A Francis GA Liban JB Cashman JN Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions.Acta Anaesthesiol Scand. 1995; 39: 288-293Crossref PubMed Scopus (46) Google Scholar 26Fruergaard K Viby-Mogensen J Berg H el-Mahdy AM Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis.Acta Anaesthesiol Scand. 1998; 42: 1168-1174Crossref PubMed Scopus (61) Google Scholar 27Gatke MR Viby-Mogensen J Rosenstock C Jensen FS Skovgaard LT Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used.Acta Anaesthesiol Scand. 2002; 46: 207-213Crossref PubMed Scopus (92) Google Scholar 29Hayes AH Mirakhur RK Breslin DS Reid JE McCourt KC Postoperative residual block after intermediate-acting neuromuscular blocking drugs.Anaesthesia. 2001; 56: 312-318Crossref PubMed Scopus (180) Google Scholar 43McCaul C Tobin E Boylan JF McShane AJ Atracurium is associated with postoperative residual curarization.Br J Anaesth. 2002; 89: 766-769Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar 45Mortensen CR Berg H el-Mahdy A Viby-Mogensen J Perioperative monitoring of neuromuscular transmission using acceleromyography prevents residual neuromuscular block following pancuronium.Acta Anaesthesiol Scand. 1995; 39: 797-801Crossref PubMed Scopus (78) Google Scholar 48Pedersen T Viby-Mogensen J Bang U et al.Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade?.Anesthesiology. 1990; 73: 835-839Crossref PubMed Scopus (78) Google Scholar 50Shorten GD Merk H Sieber T Perioperative train-of-four monitoring and residual curarization.Can J Anaesth. 1995; 42: 711-715Crossref PubMed Scopus (43) Google Scholar 52Ueda N Muteki T Tsuda H Inoue S Nishina H Is the diagnosis of significant residual neuromuscular blockade improved by using double-burst nerve stimulation?.Eur J Anaesthesiol. 1991; 8: 213-218PubMed Google Scholar In fact, several studies have suggested that the use of a PNS is not associated with a reduced incidence of PORC.24Fawcett WJ Dash A Francis GA Liban JB Cashman JN Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions.Acta Anaesthesiol Scand. 1995; 39: 288-293Crossref PubMed Scopus (46) Google Scholar 29Hayes AH Mirakhur RK Breslin DS Reid JE McCourt KC Postoperative residual block after intermediate-acting neuromuscular blocking drugs.Anaesthesia. 2001; 56: 312-318Crossref PubMed Scopus (180) Google Scholar 43McCaul C Tobin E Boylan JF McShane AJ Atracurium is associated with postoperative residual curarization.Br J Anaesth. 2002; 89: 766-769Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar 48Pedersen T Viby-Mogensen J Bang U et al.Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade?.Anesthesiology. 1990; 73: 835-839Crossref PubMed Scopus (78) Google Scholar In view of the heterogeneity of the findings in published reports, we conducted a meta-analysis and review of studies to better understand the impact of intraoperative monitoring of neuromuscular function on the incidence of PORC. We combined the results from multiple small and moderate sized studies to increase the statistical power28Halvorsen KT Burdick E Colditz GA Frazier HS Mosteller F Combining results from independent investigations: meta-analysis in clinical research.in: Bailar III, JC Mosteller F Medical Uses of Statistics. NEJM Books, Boston1992: 413-426Google Scholar of our study and also analysed the potentially confounding factors in these studies. We conducted an electronic search of the literature in the National Library of Medicine’s PubMed database (from 1964 to June 2006), the Cochrane Controlled Trials Register, and the ISI Web of Knowledge (from 1975 to 2006). For our search, we used combinations of the following key and text words: curarisation, postoperative, neuromuscular blockers, muscle relaxants, and residual block. We also manually searched the references cited in published papers. All potentially relevant reports were reviewed independently by two investigators (M.N. and A.F.K.). The primary outcome used for the meta-analysis was the incidence of PORC. PORC has been considered present when a patient has a TOF ratio of < 0.7 or < 0.9. Historically, a TOF ratio of 0.7 was used as an indication of adequate recovery of neuromuscular blockade. Current evidence indicates that we need to ensure a recovery of TOF ratio to 0.9 rather than to 0.7.20Eriksson LI The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation.Anesth Analg. 1999; 89: 243-251Crossref PubMed Google Scholar 22Eriksson LI Reduced hypoxic chemosensitivity in partially paralysed man. A new property of muscle relaxants?.Acta Anaesthesiol Scand. 1996; 40: 520-523Crossref PubMed Scopus (85) Google Scholar 40Kopman AF Yee PS Neuman GG Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers.Anesthesiology. 1997; 86: 765-771Crossref PubMed Scopus (316) Google Scholar We included all human adult studies published in English, peer-reviewed literature in which the outcome was rendered as the fraction of patients who had PORC. We initially identified 50 potentially relevant studies and 26 studies were subsequently excluded from meta-analysis. We did not include abstracts, editorials, studies of cardiac or paediatric patients, or studies in which primary outcome variables could not be determined. No duplicate population was included in the analysis. The quality of individual studies was graded according to the criteria that make up the previously validated Jadad 5-point scale.34Jadad AR Moore RA Carroll D et al.Assessing the quality of reports of randomized clinical trials: is blinding necessary?.Control Clin Trials. 1996; 17: 1-12Abstract Full Text PDF PubMed Scopus (13617) Google Scholar These criteria are randomization (0–2 points), double-blinding (0–2 points), and a description of withdrawals or dropouts (0–1 point). The maximum score that can be assigned to any study is 5 and the minimum is 0. The scores for all studies included in this meta-analysis ranged from 1 to 4. Detailed information for each study was entered into an Excel spreadsheet (Microsoft Corporation, Redmond, WA) by one investigator (M.N.) and independently checked by another (A.F.K.). Disagreements regarding the correct categorization of data were resolved by discussion. The data extracted from each article were the first author’s name, year of article’s publication, Jadad score,34Jadad AR Moore RA Carroll D et al.Assessing the quality of reports of randomized clinical trials: is blinding necessary?.Control Clin Trials. 1996; 17: 1-12Abstract Full Text PDF PubMed Scopus (13617) Google Scholar number of patients, body weights, the type of neuromuscular blocker used (long-, intermediate, or short-acting), total dose of neuromuscular blocking drugs used, duration of anaesthesia, types of anaesthesia (total intravenous anaesthesia, inhalational anaesthesia, or both), the use of an intraoperative neuromuscular function monitor, type of the neuromuscular function monitor used (objective or simple), the use of antagonism, and the incidence of PORC (in patients with a TOF ratio of < 0.7 or < 0.9). We converted the dose of each neuromuscular blocker to its respective 95% effective dose and expressed them as ED95 (mg) kg−1 h−1. As noted by Etzel and Guerra,23Etzel CJ Guerra R Meta-analysis of genetic-linkage analysis of quantitative-trait loci.Am J Hum Genet. 2002; 71: 56-65Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar ‘The concept of the combination of results from significance tests, across studies, to obtain consensus is not new’. However, the synthesis of estimates published in the literature of non-comparative studies is less prevalent. The methods of Wolfe, Mantel-Haenszel, and Peto are popular for performing fixed effects meta-analyses, but these methods are not structured to accommodate non-comparative studies. The purpose of this analysis is to combine, in a systematic fashion, the estimated incidence rates of PORC from the available literature including both comparative and non-comparative studies. Separate analyses were conducted to combine the findings of studies defining this incidence rate by a TOF ratio of < 0.70 and for studies defining the rate as a TOF ratio of < 0.90. Egger and colleagues18Egger M Smith GD Altman DG Systematic Reviews in Health Care: Meta-analysis in Context. 2nd Edn. BMJ, London2001Crossref Scopus (291) Google Scholar state ‘In meta-analysis the weight given to each study generally reflects the statistical power of the study, the larger the study, the greater the weight’. However, it has been shown that combining the study findings by weighting each estimate by the inverse of the sampling variance of the estimate is optimal, and weighting in general provides more precise results.30Hedges LV Combining independent estimators in research synthesis.Brit J Math Stat Psyc. 1983; 36: 121-131Google Scholar 31Hedges LV Olkin I Statistical Methods for Meta-analysis. Academic Press, New York1985Google Scholar The Freeman–Tukey double-arcsine variance-stabilizing transformation25Freeman MF Tukey JW Transformations related to the angular and the square root.Ann Math Stat. 1950; 21: 607-611Crossref Google Scholar was used to normalize the study findings before combining the data. This analysis relies heavily on the findings of cohort studies. Sackett49Sackett DL Bias in analytic research.J Chronic Dis. 1979; 32: 51-63Abstract Full Text PDF PubMed Scopus (1660) Google Scholar maintains that confounding is the most important threat to the validity of results from cohort studies. We acknowledge that a confounding factor such as patient population could produce significant between-studies variability. An important aspect of any meta-analysis is an investigation of the inconsistency of the published findings. With the normalized data, study heterogeneity was assessed using both Cochran’s Q χ2 test14Cochran WG The combination of estimates from different experiments.Biometrics. 1954; 10: 101-129Crossref Google Scholar and the inconsistency measure I2 suggested by Higgins32Higgins JP Thompson SG Deeks JJ Altman DG Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560Crossref PubMed Scopus (40126) Google Scholar which measures the proportion of between-studies variability that cannot be explained by chance. In the presence of significant heterogeneity, we used the random effects model approach to combine estimates to explicitly account for said inconsistency; otherwise, a fixed effects model was employed. The pooled incidence rate estimates and the corresponding 95% confidence intervals were achieved using the inverse of the Freeman–Tukey double arcsine transformation suggested by Miller.44Miller JJ The Inverse of the Freeman-Tukey Double Arcsine Transformation.Am Stat. 1978; 32: 138Google Scholar Confidence intervals within studies were achieved using the exact binomial method. Group differences were assessed using a two-tailed pooled t-test on the basis of the normalized data and the weights derived from random–effects model. The relationship of TOF ratio recovery with the use of intraoperative neuromuscular monitor adjusted for other covariates such as anaesthetic technique was assessed by random-effects weighted regression models. Random-effects weighted regression models were also employed to investigate changes in the reported incidence of PORC over time. All analyses were conducted using SAS Release 9.1 (SAS Institute Inc., Cary, NC, USA). The appendix contains the equations used to conduct this analysis. We analysed data from 24 studies (13 randomized and 11 observational studies) that were published between 1979 and 2005.1Andersen BN Madsen JV Schurizek BA Juhl B Residual curarisation: a comparative study of atracurium and pancuronium.Acta Anaesthesiol Scand. 1988; 32: 79-81Crossref PubMed Scopus (54) Google Scholar, 2Baillard C Clec’h C Catineau J et al.Postoperative residual neuromuscular block: a survey of management.Br J Anaesth. 2005; 95: 622-626Crossref PubMed Scopus (170) Google Scholar, 3Baillard C Gehan G Reboul-Marty J et al.Residual curarization in the recovery room after vecuronium.Br J Anaesth. 2000; 84: 394-395Crossref PubMed Scopus (163) Google Scholar, 4Beemer GH Rozental P Postoperative neuromuscular function.Anaesth Intensive Care. 1986; 14: 41-45Crossref PubMed Google Scholar 8Bissinger U Schimek F Lenz G Postoperative residual paralysis and respiratory status: a comparative study of pancuronium and vecuronium.Physiol Res. 2000; 49: 455-462PubMed Google Scholar 10Brull SJ Ehrenwerth J Connelly NR Silverman DG Assessment of residual curarization using low-current stimulation.Can J Anaesth. 1991; 38: 164-168Crossref PubMed Scopus (40) Google Scholar 11Cammu G de Baerdemaeker L den Blauwen N et al.Postoperative residual curarization with cisatracurium and rocuronium infusions.Eur J Anaesthesiol. 2002; 19: 129-134Crossref PubMed Google Scholar 15Debaene B Plaud B Dilly MP Donati F Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action.Anesthesiology. 2003; 98: 1042-1048Crossref PubMed Scopus (384) Google Scholar 24Fawcett WJ Dash A Francis GA Liban JB Cashman JN Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions.Acta Anaesthesiol Scand. 1995; 39: 288-293Crossref PubMed Scopus (46) Google Scholar 27Gatke MR Viby-Mogensen J Rosenstock C Jensen FS Skovgaard LT Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used.Acta Anaesthesiol Scand. 2002; 46: 207-213Crossref PubMed Scopus (92) Google Scholar 29Hayes AH Mirakhur RK Breslin DS Reid JE McCourt KC Postoperative residual block after intermediate-acting neuromuscular blocking drugs.Anaesthesia. 2001; 56: 312-318Crossref PubMed Scopus (180) Google Scholar 33Howardy-Hansen P Rasmussen JA Jensen BN Residual curarization in the recovery room: atracurium versus gallamine.Acta Anaesthesiol Scand. 1989; 33: 167-169Crossref PubMed Scopus (23) Google Scholar 36Kim KS Lew SH Cho HY Cheong MA Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine.Anesth Analg. 2002; 95: 1656-1660Crossref PubMed Scopus (77) Google Scholar 38Kopman AF Kopman DJ Ng J Zank LM Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function.J Clin Anesth. 2005; 17: 30-35Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar 39Kopman AF Ng J Zank LM Neuman GG Yee PS Residual postoperative paralysis. Pancuronium versus mivacurium, does it matter?.Anesthesiology. 1996; 85: 1253-1259Crossref PubMed Scopus (43) Google Scholar 41Kopman AF Zank LM Ng J Neuman GG Antagonism of cisatracurium and rocuronium block at a tactile train-of-four count of 2: should quantitative assessment of neuromuscular function be mandatory?.Anesth Analg. 2004; 98: 102-106Crossref PubMed Scopus (81) Google Scholar 42Lennmarken C Lofstrom JB Partial curarization in the postoperative period.Acta Anaesthesiol Scand. 1984; 28: 260-262Crossref PubMed Scopus (51) Google Scholar 45Mortensen CR Berg H el-Mahdy A Viby-Mogensen J Perioperative monitoring of neuromuscular transmission using acceleromyography prevents residual neuromuscular block following pancuronium.Acta Anaesthesiol Scand. 1995; 39: 797-801Crossref PubMed Scopus (78) Google Scholar 46Murphy GS Szokol JW Marymont JH et al.Residual paralysis at the time of tracheal extubation.Anesth Analg. 2005; 100: 1840-1845Crossref PubMed Scopus (106) Google Scholar 48Pedersen T Viby-Mogensen J Bang U et al.Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade?.Anesthesiology. 1990; 73: 835-839Crossref PubMed Scopus (78) Google Scholar 50Shorten GD Merk H Sieber T Perioperative train-of-four monitoring and residual curarization.Can J Anaesth. 1995; 42: 711-715Crossref PubMed Scopus (43) Google Scholar 52Ueda N Muteki T Tsuda H Inoue S Nishina H Is the diagnosis of significant residual neuromuscular blockade improved by using double-burst nerve stimulation?.Eur J Anaesthesiol. 1991; 8: 213-218PubMed Google Scholar 55Viby-Mogensen J Jorgensen BC Ording H Residual curarization in the recovery room.Anesthesiology. 1979; 50: 539-541Crossref PubMed Scopus (241) Google Scholar (Table 1). A total of 3375 patients were included in these studies.Table 1Description of the studies included in the meta-analysis. PORC, postoperative residual curarisation; TOF, train-of-four; NR, not reported; NEO, Neostigmine. *Data from the year 2004. §Intermediate = atracurium and vecuronium. †Randomized studyStudyNNeuromuscular blockerDose (ED95 equivalent kg−1 h−1)Intraoperative NM monitoringAntagonismIncidence of PORC number (%)Jadad score34Jadad AR Moore RA Carroll D et al.Assessing the quality of reports of randomized clinical trials: is blinding necessary?.Control Clin Trials. 1996; 17: 1-12Abstract Full Text PDF PubMed Scopus (13617) Google ScholarTOF < 0.7TOF < 0.9Viby-Mogensen, 197955Viby-Mogensen J Jorgensen BC Ording H Residual curarization in the recovery room.Anesthesiology. 1979; 50: 539-541Crossref PubMed Scopus (241) Google Scholar11d-tubocurarine0.397NoneNEO30 (41.7)52 (72.2)128Gallamine0.439NoneNEO33Pancuronium0.806NoneNEOLennmarken, 198442Lennmarken C Lofstrom JB Partial curarization in the postoperative period.Acta Anaesthesiol Scand. 1984; 28: 260-262Crossref PubMed Scopus (51) Google Scholar48Pancuronium0.645NoneNEO12 (25)NR2Beemer, 19864Beemer GH Rozental P Postoperative neuromuscular function.Anaesth Intensive Care. 1986; 14: 41-45Crossref PubMed Google Scholar100Different long-actingNRNoneNEO21 (21)40 (40)2†Andersen, 19881Andersen BN Madsen JV Schurizek BA Juhl B Residual curarisation: a comparative study of atracurium and pancuronium.Acta Anaesthesiol Scand. 1988; 32: 79-81Crossref PubMed Scopus (54) Google Scholar30Atracurium2.320NoneNEO0 (0)NR430Pancuronium0.968NoneNEO6 (20)†Howardy-Hansen33Howardy-Hansen P Rasmussen JA Jensen BN Residual curarization in the recovery room: atracurium versus gallamine.Acta Anaesthesiol Scand. 1989; 33: 167-169Crossref PubMed Scopus (23) Google Scholar9Atracurium1.401NRNEO0 (0)NR310Gallamine0.557NRNEO5 (50)NR†Pedersen, 199048Pedersen T Viby-Mogensen J Bang U et al.Does perioperative tactile evaluation of the train-of-four response influence the frequency of postoperative residual neuromuscular blockade?.Anesthesiology. 1990; 73: 835-839Crossref PubMed Scopus (78) Google Scholar20Pancuronium0.645ConventionalNEO12 (60)NR320Pancuronium0.597NoneNEO12 (60)NR20Vecuronium1.169ConventionalNEO8 (40)NR20Vecuronium1.101NoneNEO3 (15)NR†Brull, 199110Brull SJ Ehrenwerth J Connelly NR Silverman DG Assessment of residual curarization using low-current stimulation.Can J Anaesth. 1991; 38: 164-168Crossref PubMed Scopus (40) Google Scholar29PancuroniumNRConventionalNEO13 (45)NR425VecuroniumNRConventionalNEO2 (8)NR†Ueda, 199152Ueda N Muteki T Tsuda H Inoue S Nishina H Is the diagnosis of significant residual neuromuscular blockade improved by using double-burst nerve stimulation?.Eur J Anaesthesiol. 1991; 8: 213-218PubMed Google Scholar30Pancuronium0.548NoneNEO25 (83)28 (93)160Pancuronium0.613ConventionalNEO19 (32)53 (88)†Shorten, 199550Shorten GD Merk H Sieber T Perioperative train-of-four monitoring and residual curarization.Can J Anaesth. 1995; 42: 711-715Crossref PubMed Scopus (43) Google Scholar20Pancuronium0.613ConventionalNEO3 (15)NR219Pancuronium0.726NoneNEO9 (47)NRFawcett, 199524Fawcett WJ Dash A Francis GA Liban JB Cashman JN Recovery from neuromuscular blockade: residual curarisation following atracurium or vecuronium by bolus dosing or infusions.Acta Anaesthesiol Scand. 1995; 39: 288-293Crossref PubMed Scopus (46) Google Scholar88§IntermediateNRConventionalNEO14 (16)74 (84)362§IntermediateNRNoneNEO10 (16)52 (84)†Mortensen, 199545Mortensen CR Berg H el-Mahdy A Viby-Mogensen J Perioperative monitoring of neuromuscular transmission using acceleromyography prevents residual neuromuscular block following pancuronium.Acta Anaesthesiol Scand. 1995; 39: 797-801Crossref PubMed Scopus (78) Google Scholar21Pancuronium0.903NoneNEO11 (52)17 (81)319Pancuronium1.000QuantitativeNEO1 (5)10 (53)Kopman, 199639Kopman AF Ng J Zank LM Neuman GG Yee PS Residual postoperative paralysis. Pancuronium versus mivacurium, does it matter?.Anesthesiology. 1996; 85: 1253-1259Crossref PubMed Scopus (43) Google Scholar56Pancuronium0.635ConventionalNEO2 (4)36 (64)2†Fruergaard, 199826Fruergaard K Viby-Mogensen J Berg H el-Mahdy AM Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis.Acta Anaesthesiol Scand. 1998; 42: 1168-1174Crossref PubMed Scopus (61) Google Scholar30Pancuronium0.694NoneNEO17 (57)25 (83)329Pancuronium0.645QuantitativeNEO7 (24)20 (69)†Bissinger, 20008Bissinger U Schimek F Lenz G Postoperative residual paralysis and respiratory status: a comparative study of pancuronium and vecuronium.Physiol Res. 2000; 49: 455-462PubMed Google Scholar49Pancuronium0.887NoneNEO10 (20)NR127Vecuronium1.978NoneNEO2 (7)NRBaillard, 20003Baillard C Gehan G Reboul-Marty J et al.Residual curarization in the recovery room after vecuronium.Br J Anaesth. 2000; 84: 394-395Crossref PubMed Scopus (163) Google Scholar568VecuroniumNRNone (n = 557) Conventional (n = 11)None (n = 567) NEO (n = 1)239 (42)NR1†Hayes, 200129Hayes AH Mirakhur RK Breslin DS Reid JE McCourt KC Postoperative residual block after intermediate-acting neuromuscular blocking drugs.Anaesthesia. 2001; 56: 312-318Crossref PubMed Scopus (180) Google Scholar19Vecuronium2.022ConventionalNone (n = 47)NR13 (26)318Atracurium2.121ConventionalNEO (n = 101)6 (12)24Rocuronium1.301Conventional8 (17)31Vecuronium2.022None19 (38)32Atracurium2.121None20 (40)24Rocuronium1.301None11 (23)Kim, 200236Kim KS Lew SH Cho HY Cheong MA Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine.Anesth Analg. 2002; 95: 1656-1660Crossref PubMed Scopus (77) Google Scholar364VecuroniumNRNonePyridostigmine90 (25)NR2238RocuroniumNRNonePyridostigmine35 (15)NR†Gatke, 200227Gatke MR Viby-Mogensen J Rosenstock C Jensen FS Skovgaard LT Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used.Acta Anaesthesiol Scand. 2002; 46: 207-213Crossref PubMed Scopus (92) Google Scholar60Rocuronium1.430QuantitativeNEO1 (2)9 (15)360Rocuronium1.246NoneNEO6 (10)18 (30)Cammu, 200211Cammu G de Baerdemaeker L den Blauwen N et al.Postoperative residual curarization with cisatracurium and rocuronium infusions.Eur J Anaesthesiol. 2002; 19: 129-134Crossref PubMed Google Scholar15Cisatracurium1.360QuantitativeNEO (n = 11)0 (0)0 (0)215Rocuronium1.206QuantitativeNEO (n = 14)1 (7)1 (7)Debaene, 200315Debaene B Plaud B Dilly MP Donati F Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action.Anesthesiology. 2003; 98: 1042-1048Crossref PubMed Scopus (384) Google Scholar79Atracurium0.761NoneNone13 (17)33 (42)247Vecuronium0.987NoneNone8 (17)22
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