The investigators undertook a series of audits in postoperative surgical patients, documenting neuromuscular functioning shortly after arrival in the PACU. (Image Source: Anesthesia & Analgesia)

The investigators undertook a series of audits in postoperative surgical patients, documenting neuromuscular functioning shortly after arrival in the PACU. (Image Source: Anesthesia & Analgesia)

How do you perform electromyographic (EMG) monitoring intraoperatively?  Do you use a device you find in the drawer of the anesthesia machine, or do you use quantitative EMG neuromuscular monitoring?  Readers of this journal might recall the publication of an editorial titled “Neuromuscular Monitoring: What Evidence Do We Need to Be Convinced?” in 2010, wherein Dr. François Donati, Department of Anesthesiology, Universitéde Montréal, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada, noted, “Objective monitoring should then be one of the key strategies used by anesthesiologists to avoid the consequences of neuromuscular blockade.” Dr. Michael M. Todd, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, and colleagues describe a multi-year quality improvement project undertaken at the University of Iowa involving the use of quantitative EMG neuromuscular monitoring.  A summary of their results is presented in the article “The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department,” published in Anesthesia & Analgesia.

In response to a number of incidents of postoperative respiratory failure resulting in reintubation in the PACU, quantitative EMG neuromuscular monitoring was made available in all ORs at the authors’ institution.  However, 6 months later, this system was used in only 50% of cases, and in July of 2011, a sentinel event occurred (a patient required emergency reintubation in the PACU due to profound residual paralysis, notwithstanding that neostigmine was given shortly before extubation and the provider had affirmed that the patient had 4 twitches based on the use of a qualitative nerve stimulator).  Prompted by this sentinel case, the investigators undertook a series of audits in postoperative surgical patients, documenting neuromuscular functioning shortly after arrival in the PACU.  These results were presented to the department on a periodic basis.  In the first audit of 96 patients in August 2011, 31% of patients had a train-of-four (TOF) ratio of ≤0.9 and 17% had a ratio ≤0.8, but by the fourth audit of 101 patients in December 2012, this percentage had been substantially reduced (15% had a TOF ratio ≤0.9 and just 5% had ratios ≤0.8), and no further reintubations had been required.

While the science of neuromuscular monitoring is evolving, as illustrated by this article, the real value lies in its description here as an effective departmental quality management activity for anesthesia.  Real clinical data was gathered to demonstrate a patient safety hazard and then it was collected again in a serial fashion in order to document the success of mitigating efforts.  In the process, the authors succeeded in changing their department’s culture.  This kind of change management project is an important skill for any group of practitioners and will be even more so as we move into the era of performance-based payment systems.