Portal de Periódicos da CAPES

In Response

2019; Lippincott Williams & Wilkins; Volume: 129; Issue: 4 Linguagem: Inglês

10.1213/ane.0000000000004333

1526-7598

Péter Bíró, Albert Dahan, Sorin J. Brull,

Nausea and vomiting management

Plus ça change, plus c’est la même chose (The more things change, the more they stay the same). —Jean-Baptiste Alphonse Karr (January 1849 journal, Les Guêpes) We thank Drs Naguib and Kopman1 for their comments on our proposal2 and point out that their first question “What does ‘deep’ or ‘moderate’ block actually mean?” is rhetorical because they themselves answer it: “The potential benefit … is that investigators … will be more likely to equate similar degrees of depth of relaxation.”1 We appreciate, and agree with, the recommendation to separate train-of-four counts of 1 and 3 “because they represent sufficiently different levels of blockade.”1 The criticism of the term “recurarization” is absolutely justified, and we agree that true reemergence of neuromuscular block is exceedingly rare. The term recurarization is actually a misnomer because we no longer use curare. With regard to deep/profound neuromuscular blockade, we again agree. We do not recommend its routine use unless the surgical benefits outweigh potential anesthetic complications. We specifically emphasized, “the proposal for introducing the profound block level … is not meant to encourage clinicians to achieve deeper block levels than they otherwise would.”2 The more contentious issue refers to our call for “mandated features” of modern neuromuscular monitors. We agree that quantitative monitors “need to be able to display the posttetanic count and train-of-four count/ratio in real time.”1 Some available monitors also have “implemented algorithms that automatically modify both the stimulation pattern and the interval time…” In other words, we are recommending a simplification of the user interface, similar to the recommendations by Naguib and Kopman.1 This automated stimulation and recording process allows clinicians to focus on the patient when attention is needed most: during anesthesia induction. At the same time, having the ability to automatically record the change in the amplitude of the evoked muscle contractions in response to neuromuscular blocking drugs actually represents a major step forward by simplifying neuromuscular monitoring without requiring clinician intervention or complicating patient care. We also subscribe to the “keep it simple” doctrine.1 However, we disagree with the assumption that an automated sequence of stimulation patterns—from train-of-four ratio, to train-of-four count, to posttetanic count during onset, and the reverse sequence during recovery—is complicated. This automated sequence is actually pretty “simple” and requires no user input. The “bells and whistles” that are also available for those few clinicians who wish to use them should not be a deterrent against monitor use by the rest of clinicians. We also should recognize that the trend in anesthesia is to integrate monitoring devices in a modular fashion in a single system, thus reducing stand-alone devices. From both a patient safety and medico-legal perspective, the integration and storing of continual data into the patient’s record represent welcome current and future trends. Finally, we agree about the need for “strong educational efforts regarding neuromuscular protocols” and have made the same recommendations,3 but we also believe that providing clinicians with an automated, intuitive monitor will facilitate adoption of quantitative neuromuscular monitoring in routine anesthetic care. Peter Biro, MD, DESAInstitute of AnesthesiologyUniversity Hospital ZurichZurich, Switzerland[email protected] AlbertDahan, MD, PhDDepartment of AnesthesiologyLeiden University Medical CenterLeiden, the Netherlands Sorin J. Brull, MD, FCARCSI (Hon)Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceJacksonville, Florida