A patient underwent a haemorrhoidectomy procedure under general anaesthesia, receiving atracurium prior to intubation.  At the end of the procedure, the patient was breathing spontaneously and had 2 twitches measured using a qualitative peripheral nerve stimulator.  Neostigmine/glycopyrrolate was given and the patient was extubated 5 minutes later when they responded to verbal command.  The patient was placed in a sitting position on the trolley and noted to have a lot of secretions in their airway.  The patient appeared to be stable, so the anaesthetist turned their attention away momentarily and turned back to the deteriorating patient who rapidly became cyanosed despite being on supplemental oxygen, developing a severe bradycardia that was unresponsive to atropine and progressed to asystole.  A cardiac arrest was declared and cardiopulmonary resuscitation commenced.  Return of spontaneous circulation occurred after re-intubation and the patient was transferred to the intensive care unit for post-resuscitation care.

Commentary

This case illustrates the importance of continuous patient monitoring in the immediate post-operative period.

A recent meta-analysis showed that one-third of patients evaluated using clinical signs such as spontaneous respiration and movements to command or qualitative peripheral nerve stimulation experienced residual neuromuscular block. ¹ Current Association of Anaesthetists guidelines state that quantitative neuromuscular monitoring must always be used whenever non-depolarising neuromuscular blocking drugs are administered to ensure that the Train of Four ratio is greater than 90% prior to extubation. ² 

Clinical practice has not yet changed, as quantitative neuromuscular monitoring was only used for 24% of cases in NAP7. ³ As this editorial states: it is time to consign residual neuromuscular block to history⁴.

References

1. Carvalho H, Verdonck M, Cools W, Geerts L, Forget P, Poelaert J. Forty years of neuromuscular monitoring and postoperative residual curarisation: a meta-analysis and evaluation of confidence in network meta-analysis. Br J Anaesth, 2020; 125:466–82
2. Klein AA, Meek T, Allcock E, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaes, 2021; 76: 1212–23
3. Kane AD, Davies MT, Armstrong RA, Kursumovic E, Soar J, Cook TM. Observed gaps in UK anaesthetic monitoring practice. Anaes, 2024; 79: 93–5
4. Rodney G, Raju PKBC, Brull SJ. Residual neuromuscular block: time to consign it to history. Anaes, 2024; 79:344-8