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Would You Operate On This Patient? - October 2015 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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3 7 O C T O B E R 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T The reality: The consensus of data suggests that we should be reversing all patients who are dosed with non-depolarizing muscle relaxant. TOF ratios of less than 0.9 are associated with post-op residual paralysis complications. But in a meta-analysis, Naguib, et al., (osmag.net/MtkZ6K) discovered providers' estimates of the rate of residual paralysis based on a TOF ratio of less than 0.9 was 34.8%, meaning that 65.2% were at risk for complications had they been extubated. Another study (osmag.net/nQ5HGk) found that only 37% of anesthesia providers could detect fade visually, and only 57% could detect it manu- ally. Clearly, TOF assessments are unreliable, which suggests that resid- ual blockade is probably a common cause of respiratory difficulties in the PACU. The only accurate way to determine 0.9 or higher TOF ratio is with objective EMG, MMG or acceleromyography (AMG), but some patients above 0.9 will still display residual paralysis (osmag.net/VTjm2K). Many believe that if a case goes a certain number of hours, there's no reason to reverse. But the available data doesn't support this assump- tion either. Caldwell, et al., (osmag.net/Jx9VZr) assessed the degree of neuromuscular blockade (NMBD) for up to 4 hours after a single dose of vecuronium (0.1 mg/kg). The TOF ratio was less than 0.75 in • 4 of 20 patients at 2 hours, • 3 of 10 patients at 3 hours, and • 1 of 20 patients at 4 hours. A large clinical study (osmag.net/EWqpE6) examined the inci- dence of residual paralysis after a single intubating dose of an intermediate-acting NMBD and no reversal. Among patients arriving in the PACU, TOF ratios of 0.7 and 0.9 were observed in 16% and 45%, respectively. In patients tested 2 hours after the NMBD administration, TOF ratios of 0.7 and 0.9 were z DON'T TEST Even a tiny dose of cephalosporins could bring on anaphylaxis. Mike MacKinnon, CRNA

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