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Summary: Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block. To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.
CME Credit: 1.00 AMA PRA Category 1 Credit™
Required Hardware / Software:Adobe Acrobat Reader, Internet connection. Web browser version must have been released within the last three years.
Activity Release Date:12/13/2016
Activity Expiration Date:12/12/2019
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Learning Objectives:After successfully completing this activity, the learner will be able to do the following:
- Cite the risk of residual neuromuscular weakness (1)- Describe the mechanism of action and risks associated with reversal for both an anticholinesterase drug and sugammadex (2, 3, 4, 5)-...
- Cite the risk of residual neuromuscular weakness (1)- Describe the mechanism of action and risks associated with reversal for both an anticholinesterase drug and sugammadex (2, 3, 4, 5)- Select an appropriate neuromuscular monitor for his or her practice. (6)
Faculty and Credentials
Editor-in-Chief: Evan D. Kharasch, M.D., Ph.D., has reported receiving consulting fees from TEN Healthcare and The Medicines Co., and honoraria from Astra-Zeneca.
CME Editors: Leslie C. Jameson, M.D. has reported no relevant financial relationships with commercial interests. Dan J. Kopacz, M.D., has an equity position in SoloDex, LLC.
Authors: Sorin J. Brull, M.D., F.C.A.R.C.S.I. (Hon), has reported receiving funded research from Merck, Inc., and is a shareholder of Senzime AB. Aaron F. Kopman, M.D., reports no relevant financial relationships with commercial interests. Mohamed Naguib, M.B., B.Ch., M.Sc., F.C.A.R.C.S.I., M.D., and Ken B. Johnson, M.D., report no relevant financial relationships with commercial interests.
ASA Staff: Kari L. Lee, Editorial Manager, has reported no relevant financial relationships with commercial interests. Ginger Clark, Senior Editor, has an equity position in Merck & Co.
Disclosure Statement The American Society of Anesthesiologists remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our faculty members. It is not the intent of the American Society of Anesthesiologists to eliminate all situations of potential conflict of interest, but rather to enable those who are working with the American Society of Anesthesiologists to recognize situations that may be subject to question by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair to ensure that such situations are properly evaluated and, if necessary, resolved. The American Society of Anesthesiologists educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review process, all American Society of Anesthesiologists CME activities are ensured of independent, objective, scientifically balanced presentations of information. Disclosure of any or no relationships will be made available for all educational activities.
Disclaimer The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.
Core Competencies: Medical knowledge
Target Audience: ANESTHESIOLOGY Journal CME is intended for anesthesiologists. Researchers and other health care professionals with an interest in anesthesiology may also participate.
CME Credit: 1.00 AMA PRA Category 1 Credit™
The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
1.00 Non-physician Credit Non-physicians may receive a Certificate of Completion stating that this activity was designated for 1.00 AMA PRA Category 1 Credit(s)™.
Activity Release Date: 12/13/2016 Activity Expiration Date: 12/12/2019
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