RationaleWhen paralytic agents are used in surgical procedures, residual neuromuscular blockade poses a significant impact on patient safety with the risk of increasing postoperative respiratory complications. In order to prevent residual neuromuscular paralysis, neuromuscular blockade reversal drugs, including neostigmine or sugammadex, are given to assist in regaining proper function at the neuromuscular junction. Multiple factors related to the administration of these drugs affect the incidence of neuromuscular paralysis. These factors consist of inconsistent weight-based dosing of reversal agents, train of four techniques, and specific pharmacologic considerations of the chosen agent which may lead to respiratory compromise. Purpose The purpose of this quality improvement (QI) project aims to assess current practice at a large level one trauma center and compare it to the most recent clinical guidelines. With this data, the project will determine if anesthesia practitioners are following evidence based guidelines. It is essential providers follow clinical guidelines to ensure patients are not underdosed or overdosed when given neuromuscular reversal agents. In patients aged 18 to 44 years undergoing laparoscopic abdominal surgeries requiring neuromuscular paralysis, how is neostigmine administered for neuromuscular blockade reversal at a large level one trauma center compared to current evidence based guidelines? This includes train of four count, weight-based dosing, and timing of extubation. Methods This QI project followed the plan, do, study, and act (PDSA) theoretical framework model. The project used convenience sampling for its chart reviews. SlicerDicer on Epic was used to obtain 50 charts on patients given neostigmine. This analysis of neostigmine administration was part of a larger QI project that analyzed two different reversal agents, neostigmine and sugammadex (Veith, 2024). The goal of the larger QI project was to determine if practitioners were following current evidence based guidelines when administering reversal agents and if there was any difference in administration between the two reversal agents. The information obtained was transferred directly to RedCaps for data management and storage on a password protected computer. This information was only accessed by those directly involved in the project and its statistics. The demographic variables collected included age, gender, weight, and ASA score. Anesthesia variables collected included reversal agent used, train of four count at time of reversal agent administration, dose of chosen reversal agent, and time in minutes from reversal administration until extubation. Frequencies will be calculated to determine if there is less than eighty percent of providers giving neuromuscular reversal agents according to clinical guidelines.OutcomesThe data collected included 50 charts on patients who received neostigmine as the reversal agent. The participants included 41 females (81%) and 9 males (18%) with an average age of 33.28. The data set included 2% ASA I (n=1), 34 ASA 2 (68%), and 15 ASA III (30%). 50% of patients had recovered to a TOFC of 4 (n=25), whereas the other 50% were reversed with neostigmine with a TOFC less than 4 (n=25). The weight-based dose ranged from 0.025-0.092 mg/kg with an average of 0.05 (SD=0.01). No individuals received more than the FDA recommended maximum dose of 5 mg. Only 13 patients (26%) were within the ASA guidelines recommended dose of 15-40 mcg/kg. The time to extubation from neostigmine administration ranged from 3-25 minutes with an average of 11.86 minutes (SD=5.91). 28 patients (56%) were extubated at 10 or more minutes from administration.Clinical significance will be evaluated based on the resulting frequencies. Dosing neuromuscular reversal agents accurately is essential for safe anesthesia care and to prevent residual paralysis. A future project implementing education may be considered if the resulting frequencies are lower than 80%.ConclusionThe majority of providers were adherent to current evidence-based guidelines for dosing of neostigmine administration, but it was typically administered with inadequate TOF recovery and insufficient time for the medication’s peak effect to take place. Reversal agents are of the utmost importance in anesthetic management when muscle relaxants are used due to the risk for residual paralysis and postoperative respiratory complications. The center would benefit from additional educational or an accessible cognitive aid regarding the most effective use of neostigmine and reevaluation of clinical practice.
