• Clinical Practice Guideline for Utilizing Sugammadex in Reversal of Neuromuscular Blocking Agents

      Hansen, Karissa; Pellegrini, Joseph (2019-05)
      Background: Residual paralysis is ongoing presence of muscle weakness postoperatively following the administration of a neuromuscular blocker and subsequent reversal agent during the intraoperative period. Presence of residual neuromuscular blockade postoperatively has been associated with increased mortality and morbidity, low oxygenation, and respiratory complications. Recent studies have shown incidences of residual neuromuscular blockade ranging from 16 to 60 percent. Local Problem: A medium sized hospital in Maryland reported postoperative complications associated with residual paralysis. Increased side effects such as muscle weakness, increased length of stay in Post Anesthesia Care Unit, and delay in discharge may be due to the lack of guidelines for reversal of non-depolarizing neuromuscular blockers. A meeting with institutional key stakeholders identified the need for a guideline for the use of sugammadex in prevention of residual paralysis. Development of CPG: The focus of this project was to develop a Clinical Practice Guideline for the use of sugammadex in the prevention of residual paralysis for high risk patients and in emergent situations such as cannot intubate, cannot ventilate scenarios. A literature review was conducted to support evidence for the Clinical Practice Guideline, gathered data was presented to the key stakeholders. The project proposal was then submitted to the University of Maryland, Institutional Review Board and granted a Non-Human Subjects determination. The quality of the Clinical Practice Guideline was assessed by institutional key stakeholder and analyzed using the AGREE II tool and then presented to the entire anesthesia department for further evaluation. Adjustments to the Clinical Practice Guideline were made following departmental feedback and a final Clinical Practice Guideline along with algorithms were developed for this project and were distributed throughout the perioperative arena. A further assessment was done by the department using Practitioner Feedback Questionnaires. All data collected from the AGREE II tool and the Practitioner Feedback Questionnaires were synthesized, analyzed, and evaluated. The final project manuscript was submitted to the University of Maryland School of Nursing Doctorate of Nursing Practice committee for review. Results: The results of the final AGREE II Tool were 100% across the 6 domains and for the overall assessment. Each appraiser had a total score of 161/161 points and an overall of 322/322 points. The anesthesia providers, the end users of the guideline, evaluated the Clinical Practice Guideline using the Practitioner Feedback Questionnaires. Majority of anesthesia providers felt the guideline should be approved for practice (95.5%) and felt if the guideline was approved, they would use it in their own practice (100%) and would apply the recommendations to their patients (100%). This analysis demonstrated buy-in and acceptance of the Clinical Practice Guideline by the department. Conclusion: Study results indicate sugammadex compared to current reversal, neostigmine, is safe and effective in the reversal of neuromuscular blocking agents and reduces adverse events and undesirable side effects. The approval of the Clinical Practice Guideline can change clinical practice and improve patient care. A standardized approach for reversal of neuromuscular blockade with the use of sugammadex will decrease the incidence of residual paralysis in this institution.
    • Implementation of a Sugammadex Clinical Practice Guideline

      Goeren, Danielle; Pellegrini, Joseph (2019-05)
      Background: Residual paralysis is the presence of muscle weakness postoperatively and leads to increased rates of respiratory complications. In a study of more than 200,000 cases where paralytics were administered, 64% of cardiac arrests were related to airway complications secondary to residual paralysis in the post anesthesia care unit. Of these cases, there was a mortality rate of 29%. A medium-sized hospital in Maryland reported postoperative complications associated with residual paralysis. It was identified that sugammadex was used 103 times over an 8-month period due to failed neostigmine reversal resulting in low tidal volumes and muscle weakness. Currently there is no guideline for the use of sugammadex at this institution. Sugammadex offers a definitive solution to the safety profile found lacking with neostigmine. If the use of neostigmine was replaced by sugammadex administration, these negative consequences would be abated—especially in high-risk populations. High risk populations include: can’t intubate, can’t ventilate situations, deep blockade, elderly, morbidly obese, pulmonary disease and neuromuscular disease. The focus of this doctorate project was to develop a Clinical Practice Guideline for the use of sugammadex in the prevention of residual paralysis for high risk patients. Intervention: A residual paralysis problem was identified. The solution was to develop a guideline for the use of sugammadex. A literature review was conducted for supporting evidence for the guideline. The project proposal was then submitted for a Non-Human Subjects Research determination. The guideline was revised and assessed using the gold standard guideline evaluation tool. The final guideline was presented to the anesthesia department. Practitioner Feedback Questionnaires were distributed to those in attendance. All data collected from the evaluation phase was then synthesized, analyzed, and evaluated. The final manuscript was submitted for review. Results: The results of the Appraisal of Guidelines for Research and Evaluation II Tool were 100% across the six domains and for overall assessment. Each appraiser had a total score of 161/161 and an overall of 322/322. The project leaders received 100% return rate of the Practitioner Feedback Questionnaires (n=22). In reviewing the data, majority of anesthesia providers felt the guideline should be approved for practice (95.5%), they would use it in their own practice (100%) and they would apply the recommendations to their patients (100%). This analysis demonstrated buy-in and acceptance of the guideline by the department. Conclusion: Study results indicate sugammadex compared to neostigmine is safe and effective in the reversal of muscle relaxants and reduces adverse events—especially in high-risk populations. The ability of sugammadex to rapidly reverse blockade can play a critical role in high-risk patients. A guideline of sugammadex use will help decrease postoperative complications at the local hospital. The guideline, the sugammadex algorithm and patient education handout will be incorporated into provider daily practice and placed in all operating rooms as a result.