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

Abstract

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.