Implementation Of An Intraoperative Cognitive Aid To Guide Neostigmine Use For Pharmacologic Reversal Of Neuromuscular Blockade

The incidence of residual neuromuscular blockade following general anesthesia is as high as 60% (Saager, 2019). Residual neuromuscular blockade impairs pulmonary mechanics and places patients at an increased risk to develop postoperative pulmonary complications (PPCs) (Kheterpal et al., 2020; Rudolph et al., 2018; Leslie et al., 2021; Saager et al., 2019). PPCs are associated with an increased readmission rate, hospital length of stay and overall morbidity and mortality. A quality improvement project (QI) was conducted to examine anesthesia providers’ knowledge of clinical recommendations and to assess their current practice habits using neostigmine to reverse neuromuscular blockade. A survey was distributed to all anesthesia providers at a level-1 trauma center and data was collected anonymously during a one-month period. While 96.1% of respondents correctly identified the mechanism of action of neostigmine, about half failed to recognize the correct peak effect of neostigmine. The survey results also revealed an inaccurate understanding of the dosing recommendations for neostigmine according to the number of twitches elicited using a peripheral nerve stimulator in the train-of-four mode. After comparing the survey results to the evidence-based guidelines identified in the literature review and analysis, knowledge deficits from the survey were incorporated to create an intraoperative cognitive aid to guide the reversal of muscle paralysis using neostigmine. This QI project recommends ongoing evaluation and analysis of practice trends to promote best practices that are consistent with contemporary literature.