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all know this quote, but its origin is a little unclear. It has been
attributed to William Shakespeare, Leonardo Da Vinci, the philosopher
Cicero and even the bible.
Whatever the origins of this well-known quote, throughout history we
have been aware that our eyes are incredibly precious organs. Not only
do they allow us to see the world around us but through them we can tell
what a person feels and thinks.
However, despite being aware that somehow our eyes are special, we
have been a bit blasé about protecting them. Eye protection has evolved
over time(1) via several different routes including:
Combat – To lose an eye in battle and wear an eye patch was once considered an honour. The use of helmets did offer some protection. The use of gas during World War 1 resulted in gas masks with glass windows to protect the eyes from the deadly gas. More recently the rise of IEDs resulted in the percentage of combat causalities hospitalised due to ocular trauma increasing from 2% in 1914 to 13% in the 1990s Desert Storm conflict. In modern armies today eye protection is mandatory.
Sports and Recreation – Jousting required the riders to wear helmets with visors, but eye injuries were common. King Henry II, the French-born King of England, suffered an eye injury during a jousting tournament in 1559. The king had not fastened his visor upon returning to the arena and a splinter from his opponent’s lance entered his right orbit. Complications resulted in the death of ‘the young lion’ from his eye injury. His death significantly changed the respective roles of France and England and the course of Western civilisation and history. Recently, ice hockey, Baseball and Basketball were the first sports to embrace eye protection followed by Squash, Cricket Hockey and Lacrosse.
Occupational Eye Injuries – The rise of industry in the late 19th century resulted in a huge increase in mining and metalwork. This led to a surge in corneal abrasions in miners, heat cataracts in foundry workers and arc eye in welders. Gradually, visors and goggles. . Gradually, improved understanding of the impact resistance of materials and the nature of hazards brought about improvements in visors and goggles in the workplace
Thankfully, mainly due to the rise of Health and Safety, eye protection is now mandatory in many workplaces. There is good reason why this is necessary. Thousands of workers suffer painful eye injuries each year around the world. Many are minor but around 10-20% result in partial or full blindness. Equally, we only have two eyes and whilst some parts of the eye can be transplanted, a complete eyeball transplant is not yet possible. So, we need to do everything we can to protect our eyes as much as we can.
The most common types of injuries are:
Invasion of foreign bodies – The eye/s may sometimes be invaded by small foreign particles (e.g. dust from manufacturing activities) which can cause irritation and inflammation. Chemical Eye Burns – Both highly acidic (pH <4) and highly alkaline (pH >10) substances are toxic to the eye and cause chemical eye burns if they come into contact with the surface of the eye. Such substances are commonly found in the workplace, for example in laboratory chemicals or industrial cleaning products.Penetrating Injuries – When an object pierces the eye, penetration occurs, and this can lead to loss of vision or blindness. Staples, nails and flying debris commonly cause this type of injury.Blunt trauma injuries – These are injuries which do not penetrate the skin and do not result in external bleeding. The eye is struck by a heavy object and this can cause the eye to bleed internally.Allergic conjunctivitis – Is common amongst workers in the food handling and agricultural sectors who are regularly exposed to spices, fruits, and vegetables. Eye diseases associated with ultraviolet radiation exposure – Outdoor workers are often exposed to ultraviolet radiation (in the form of sunlight) in excessive quantities. Artificial sources of ultraviolet radiation are also found in a range of workplaces and can damage the eyes. These include welding arcs, germicidal lamps, and lasers. Computer use disorders – Using a computer for extended periods of time is associated with a range of temporary eye disorders including pain and altered vision.
Of course, when we go about our daily lives, we meet all sorts of people wearing eye protection. These can be construction site workers, the mechanic fixing your car, the gardener mowing your lawn, the person mending your shoes. Many jobs now take eye protection seriously.
Eye protection is also taken seriously even if you are unfortunate to be here –
However, can you guess by looking at these photographs what the problem is?
Where is the eye protection for the patient? Everyone else in theatre has eye protection so why not the patient? A nurse will take a roll of non-sterile tape that has been lying in theatre and tape your eyes. A piece of equipment could hit you in the eye or even someone’s elbow. You are the most vulnerable person in the room and yet nothing is done to protect your eyes from an infection, a corneal abrasion or even a trauma blow. Surely, if a gardener or a cobbler has eye protection then patients undergoing surgery should equally have their eyes protected.
Hoskin A.K, Mackey D.A, Agrawal R, Watson S. (2019). Eye Injuries across history and the evolution of eye protection. Acta Ophthalmologica, 97: 637–643.
Author: Niall Shannon, European Business Manager, Innovgas
This article is based on research and opinion available in the public domain.
since the first reports of Covid-19 in China (1) there has been a
great deal of focus on how the virus spreads.
It is now clear that, the virus causing
COVID-19, is primarily transmitted between people through respiratory droplets
and contact routes.
transmission occurs when a person is in close contact (within 1 m) of someone
with respiratory symptoms (e.g. coughing or sneezing) and is therefore at risk
of having their mucosae (mouth and nose) or conjunctiva (eyes) exposed to
potentially infective respiratory droplets. Transmission may also occur through
fomites in the immediate environment around the infected person. Therefore,
transmission of the COVID-19 virus may occur by direct contact with infected
people and indirect contact with surfaces in the immediate environment or with
objects used on the infected person. (2) Studies from a variety of
disciplines investigating viruses clearly support the following:
respiratory and enteric viruses can survive on fomites and hands for varying
lengths of time.
fomites and hands can become contaminated with
viruses from both natural and laboratory sources.
transfer from fomites to hands is possible.
hands come in contact with portals of entry
for viral infection.
If viruses remain viable on surfaces long
enough to come into contact with a host, the virus may only need to be present
in small numbers to infect the host. (3)
virus can also be spread via airborne transmission which is different to
droplet transmission. This refers to the presence of microbes within droplet
nuclei. Droplet nuclei are generally considered to be particles ≤ 5μm in
diameter that can remain in the air for longer periods of time and can be
transmitted to others over distances greater than 1 metre. Airborne
transmission of the COVID-19 virus is possible under circumstances and settings
where aerosol generating procedures (AGPs) are performed. (2)
are all aware of the measures that are being taken in the community to prevent
the transmission of the virus via the droplet and contact routes. (4)
But what is happening in hospitals; particularly when a patient needs emergency
surgery or, as is now happening an elective or planned procedure?
planned procedures the patient should isolate for several days and test
negative for Covid-19 before entering theatre. Emergency patients are
identified as symptomatic or asymptomatic and appropriate Infection Prevention
and Control procedures are put in place. (5)
is being done in hospitals generally and more specifically in operating
theatres to reduce transmission rates. While the rates of overall infection in
a country may be below 1%, (6) in hospitals the rates could be
anywhere between 5% and 15%. (7)
what more could be done in hospitals to bring the rates of infection down? In
my opinion, whilst some effort is being made to reduce fomite spread of
covid-19 in the operating theatre with regular disinfection and greater use of
single use items, much more could be done. (8,9)
of medical tape are often to be found in the operating theatre. Studies have
shown that 51 % of rolls of tape found lying around in theatre may have VRE or
MRSA, so multiple resistant bacterial organisms on them, which we then apply to
patients. (10) These rolls of tape may well have Covid-19 on them
and if applied to the patient’s eyes may well infect them.
would be far safer, and better practice to use our sterile, single use EyePro™
to cover the patient’s eyes (11) thereby removing a potential
Covid-19 transmission route.
theatres make up their own bite blocks using gauze and rolls of tape on the
anaesthetic trolley. All this activity carries a high risk of fomite
transmission. If you use a single wrapped clean BiteMe™ with clean gloves, BiteMe™ should pose less risk
compared to rolled up gauze with respect to viral transmission. (12)
Thus, by making two small changes to
operating theatre procedures you could be doing so much more to reduce the
potential transmission of Covid-19.
Use sterile single use EyePro™, the only sterile eyelid occlusion dressing available and stop using medical tape on your patient’s eyes.
Use single use, clean BiteMe™ as your bite block of choice and stop making your own bite blocks.
Dr Andrew Wallis
BSc., BMedSci., MBBS (hons),
Member of Medical Advisory Committee,
Calvary Hospital, Launceston, Tasmania.
Medical Director Innovgas Pty Ltd
Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 16-24 February 2020. World Health Organisation.
Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed. Interim guidance 29 June 2020. World Health Organisation
S. A. Boone* and C. P. Gerba. Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease. Applied and Environmental Microbiology, Mar. 2007, p. 1687–1696.
Transmission of SARS-CoV-2: implications for infection prevention precautions. Scientific brief 09 July 2020. World Health Organisation.
Operating framework for urgent and planned services in hospital settings during COVID-19. 14 May 2020. NHS England.
Some sort of assessment of neuromuscular transmission (NMT) is
necessary in surgical patients by clinicians and anesthetists to get a
feel for the depth of anesthesia. This assessment can be done using
simple yet subjective clinical parameters or through more advanced and
objective monitoring devices. NMT monitoring is required to
ascertain that anesthesia is appropriate for tracheal intubation
check the adequacy of neuromuscular blockade during a procedure
determine the need for adjusting the dose of neuromuscular blocking agents (NMBAs)
decide the timing and dose of reversal agents
ensure full patient recovery before extubation
When NMT monitoring is absent, inadequate, or inaccurate, it is associated with an increased risk of
adverse respiratory events
prolonged post-anesthesia stays
unpleasant postoperative symptoms including muscle weakness
Almost 40% of patients have incomplete neuromuscular recovery in the early recovery period from anesthesia
said that, it may come as a surprise that anesthesiologists often
overlook the importance of effective monitoring. Research reveals that
less than 40% of patients receive subjective assessment using nerve
stimulators, while objective monitoring is performed in only 17% of
patients. Furthermore, almost 40% of patients have incomplete
neuromuscular recovery in the early recovery period from anesthesia.
Against this backdrop, it is easy to understand why proper NMT
monitoring is the need of the hour in surgical patients. We will now
discuss how such monitoring can be achieved.
Current Approaches to NMT Monitoring
There are three ways to monitor the neuromuscular status:
Clinical assessment—most commonly employed by
clinicians, it is a subjective evaluation of clinical parameters such as
respiratory measures and muscle function. However, none of the tests
has a sensitivity greater than 0.35 or positive predictive value more
than 0.52. Clearly, it’s not the most reliable approach.
Qualitative monitoring/peripheral nerve stimulation—Qualitative
monitoring uses peripheral nerve stimulators (PNSs). The evoked
response of the stimulated muscle is then assessed visually or
tactilely. It’s more reliable than a simple clinical assessment but less
so than quantitative monitoring.
Quantitative monitoring—this involves the use of
devices that quantify the NMT blockade and display the measurements
numerically. Quantitative monitoring offers the virtues of reliability,
accuracy, and objectivity. We describe quantitative monitoring in more
Why Quantitative Monitoring is the Way to Go
Following are just some of the benefits of quantitative neuromuscular monitoring:
Objective measurements—stimulation is provided to a
suitable muscle and the evoked response is quantified objectively. It
can be through measuring the action potentials generated within the
muscle, the strength of its contraction, or even the crackling sounds
associated with muscle movement. Whichever the underlying mechanism for
the monitoring device, nothing is left to the subjective opinion of the
clinician. Hence, the results are consistent and reproducible.
Display of results—quantitative monitoring devices
are smart and internally compute any raw data to display final results
in numerical form that can then be used to guide clinical
Automatic processes—most devices just need their
leads to be attached at the appropriate locations and then they do the
rest themselves, including providing stimuli, recording responses,
computing results, and displaying the same. Modern devices also require
Risk of PRNB nearly eliminated—the risk of
postoperative residual neuromuscular blockade (PRNB) is almost
completely eliminated with the use of quantitative monitors for tracheal
Quantitative NMT Monitoring Devices
There are several methods to perform quantitative NMT monitoring:
Modern quantitative NMT monitoring devices are capable of
automatically providing stimulation to the muscle and recording and
interpreting the response. The impulses can be given in various patterns
such as train of four (TOF), double-burst (DBS), tetanic and
post-tetanic count (PTC), which can be used to determine the
train-of-four count (TOFC) or the degree of fade. The evoked muscle
response can then be measured by using different scientific techniques
giving rise to several types of devices:
Mechanomyography (MMG)—the device detects muscle
isometric force of contraction and converts it into an electrical
signal. The amplitude of the signal reflects contraction strength.
Electromyography (EMG)—it records compound muscle
action potentials generated in the muscle and this electrical activity
is proportional to the contraction force.
Acceleromyography (AMG)—the monitor measures muscle
acceleration via a piezoelectric sensor. The piezoelectric crystal
generates voltage when it is put into motion due to muscle contraction.
Kinemyography (KMG)—such devices quantify muscle movement via a motion sensor strip. The strip once again contains piezoelectric sensors.
Phonomyography (PMG)—it calculates muscle response
based on sounds picked up a by microphone. This is possible because
muscle contraction produces low-frequency sounds.
Decades of research demonstrate that AMG technology can detect residual paralysis in 97% of patients.
While the above seem some fantastic methods to quantitatively monitor
NMT blockade in clinical settings, MMG and PMG monitors are not
commercially available and only used for research purposes, there is
only one EMG monitor available for commercial use but it’s not
standalone, and studies comparing KMG to MMG (the “gold standard”) have
found its data to have a large bias and it cannot be used
interchangeably. In the end, the AMG technology has been the most
successful for commercial and clinical deployment. The Stimpod NMS 450X
is a classic example of a cutting-edge AMG monitor.
Why the Stimpod NMS 450X is the Monitor of Choice for Quantitative NMT Monitoring
There are many features that make the Stimpod NMS 450X the monitor of choice for quantitative neuromuscular transmission monitoring. You can review these features in detail here.
We will go over some of the more pertinent features of this device in
light of what we have discussed so far about neuromuscular monitoring:
The Stimpod NMS450X reduces the incidence of residual paralysis in 97% of patients
Global coverage—There is no point in reading up
about the importance of NMT monitoring and researching a monitor only to
find that either it’s not commercially manufactured or it’s not
available in your area. Xavant’s worldwide coverage ensures Stimpod’s
availability across the globe. In his comprehensive review article
covering NMT monitoring in the perioperative period, Dr. Glenn Murphy, a
senior anesthesiologist affiliated with the NorthShore University
HealthSystem, points out, “At the present time, only one stand-alone
portable device is available in the United States, the STIMPOD (Xavant
Technologies, Pretoria, South Africa).”
Fully automated—The Stimpod NMS 450X’s OneTouch
NMT™ technology allows users to monitor an entire case from electrode
placement to extubation by pressing a single button. The device
automatically verifies optimal electrode placement, provides the
appropriate supramaximal current, begins TOF monitoring and moves to PTC
when a deep block is reached. Upon reversal, it automatically
reinitiates monitoring until the patient is 90%+ recovered.
3D AMG transducer—The Stimpod NMS 450X uses a 3D
AMG transducer which is most effective in capturing the full force of
muscle contraction. In his seminal article, Dr. Murphy observes, “An
important disadvantage of first-generation AMG monitors … is that
acceleration of a muscle following nerve stimulation is only measured in
a single direction (perpendicular to the face of the transducer).
However, stimulation of the ulnar nerve results in isotonic contractions
of the adductor pollicis that are often in three dimensions, involving
three joints, frictional forces, and deformation of tissues.”
Decades of research demonstrate that AMG technology can detect
residual paralysis in 97% of patients. The Stimpod NMS450X is an
embodiment of that technology and an all-in-one solution for
neuromuscular monitoring. Please contact us to know more about NMT
monitoring, train of four monitoring and our solutions.
Murphy GS. Neuromuscular monitoring in the perioperative period. Anesth Analg. 2018;126:464–468.
Duţu M, Ivaşcu R, Tudorache O, et al. Neuromuscular monitoring: an
update. Rom J Anaesth Intensive Care. 2018;25(1):55–60.
Thilen SR, Bhananker SM. Qualitative Neuromuscular Monitoring: How to
Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of
Residual Neuromuscular Blockade. Curr Anesthesiol Rep. 2016;6:164–169.
Hemmerling TM, Le N. Brief review: Neuromuscular monitoring: an
update for the clinician. Canadian Journal of Anesthesia.
Respiratory impairment following general anaesthesia can pose a
significant problem. Adverse and critical respiratory events (AREs and
CREs) have been responsible for increased morbidity and mortality. The
main cause of AREs after surgery is related to the use of neuromuscular
blockers (NMBAs) during general anaesthesia. The action of NMBAs might
not cease completely at the end of the procedure, leading to residual
muscle paralysis. Postoperative residual neuromuscular blockade, aka
postoperative residual curarization (PORC), ranks among the top three
critical events in the post-anesthesia care unit (PACU) that require
emergency intervention.1 It has been estimated that approximately 40% of the patients brought to the PACU have residual blockages.2
Apart from the obvious effects on patients’ life and health, AREs can
have other consequences. Caregivers have to undergo increased physical
and emotional stress, which can affect delivery of care to other
patients in the PACU. Financial costs can increase for both patients and
hospitals as substantial critical care resources are devoted to solving
How big is the problem of residual neuromuscular blockade?
Muscle paralysis is estimated using a clinical tool called
train-of-four ratio (TOFR). Residual neuromuscular blockade is believed
to have significant clinical effects if the TOFR goes below 0.9.3
With just a single dose of intermediate acting NMBAs, it has been shown
that up to 45% of patients can have residual blockade (TOFR < 0.9).4
Lower TOFRs have been associated with increased risk of CREs. This was
demonstrated by Murphy et al, who collected data of over 7400 patients
who had received general anaesthesia.5 They found that the
incidence of critical respiratory events in this group of patients due
to residual blockade was 0.8%. Based on these statistics, Brull et al
estimated that each year about 81,000 people in the United States and
almost 0.5 million people worldwide experience CREs after general
What is the main cause of CRE after surgery?
It was shown that the incidence of CREs was higher by 50% in patients who had TOFR less than 0.76
While there can be several causes of CRE, a large proportion of cases
have been associated with residual neuromuscular blockade. In one study
by Bissenger et al, it was shown that the incidence of CREs was higher
by 50% in patients who had TOFR less than 0.7.6 In a separate
case-control study, Murphy et al compared TOFRs in patients who had
developed CREs and controls who did not have CREs. They showed that
while patients in the control group had TOFRs above 0.7, 78.3% of
patients who had CREs had TOFRs that were below 0.7.3 Xara et
al also investigated the determinants of AREs in 340 patients who
underwent surgery. They found that patients who were administered NMBAs
during the surgical procedure had increased incidence of AREs (79%) as
compared to those who did not receive them (55%).7 They also
noted that the incidence of ARE was increased in patients who had
received neostigmine. Grosse-Sundrup et al showed that the use of
intermediate NMBAs increased the risk of postoperative desaturation and
What are the costs involved?
Residual neuromuscular blockade can cause upper airway obstruction,
aspiration and pharyngeal dysfunction. These situations may require
emergency intervention in the form of re-intubation and positive
pressure ventilation. The costs associated with these interventions can
be considerable. Patients who develop respiratory complications after
surgery generally often have to be hospitalised for longer, which
cost of treatment for patients with respiratory complications was
$62,000, compared to $5000 without complications, with an additional
92,000 more ICU admissions per year10
et al found that postoperative respiratory failure (that did not
include pulmonary embolism) increased hospital stay by nine additional
days, and translated to an additional $53,000 in healthcare costs.9
A report developed by the National Surgical Quality improvement
program showed that patients with respiratory complications stayed at
the hospital for at least 14 days longer vs. those who did not have
these complications.10 The same report estimated the cost of
treatment for patients with respiratory complications was around
$62,000, while those without such complications were set back by a mere
$5,000 in comparison. On a national level, pulmonary complications after
surgery lead to 92,000 more ICU admissions per year, which alone
imposes a burden of $3.42 billion annually.
What is the best way to deal with the situation?
Residual neuromuscular blockade can be avoided by monitoring
neuromuscular status during the surgical procedure. If neuromuscular
function is allowed to return to optimal levels prior to extubating the
patient, chances of residual blockade in the PACU decrease. Ideally, the
anaesthetist should be able to monitor the TOFR, so that it may be
allowed to reach the critical threshold of 0.9 prior to extubation.
What kind of monitoring works best?
hypoxaemia occurred in 21.1% of patients in the conventional group but
in none of the patients in the acceleromyography group11
There are three methods to monitor neuromuscular function—clinical, qualitative monitoring and quantitative monitoring. Clinical methods
(such as head-lift and grip-strength tests) have low sensitivity and
specificity, and are not really suited for patients prior to extubation.
Qualitative evaluation using peripheral nerve
stimulators is a common practice. However, it involves subjective
assessment of TOFR and studies have shown that TOFRs above 0.4 may not
be effectively detected by this method. Quantitative (or objective) methods
of calculating TOFR, using techniques such as mechanomyography,
electromyography and acceleromyography, have proven more effective.
Murphy et al assessed the risk of residual neuromuscular blockade and
AREs in patients who were monitored by both qualitative and quantitative
means.11 Patients were randomised for NMB monitoring using
either conventional peripheral nerve stimulators or acceleromyography.
Residual NMBs in the PACU were documented in 30% of patients in the
conventional group and only 4.5% of patients in the acceleromyography
group. More significantly, severe hypoxaemia occurred in 21.1% of
patients in the conventional group but in none of the patients in the
The bottom line is this: quantitative
neuromuscular transmission monitoring has the potential to reduce
residual blockades, decrease CRE risk, and reduce costs.
The Stimpod NMS450X Neuromuscular Transmission Monitor
The Stimpod NMS450X is a standalone neuromuscular transmission
monitor that can easily be integrated into the anaesthetic setup. During
reversal of neuromuscular blockade, the monitor automatically initiates
TOFR monitoring, which continues until recovery is complete. Its
portable design makes it easy to shift between the OR and PACU, and it
can easily be attached to the IV pole. Its economical pricing and proven
efficacy make it a sensible investment for hospitals who wish to make
optimum use of resources and cut costs in the long term. For more
details, visit xavant.com or request a quotation.
Strauss P, Lewis M. Identifying and Treating Postanesthesia Emergencies. Or Nurse. 2015 Nov 1;9(6):24-30.
Brull, S. J., & Kopman, A. F. Current Status of Neuromuscular
Reversal and Monitoring: Challenges and Opportunities. Anesthesiology
2017; 126(1): 173-90.
Murphy GS, Szokol JW, Avram MJ, et al. Postoperative Residual
Neuromuscular Blockade is Associated with Impaired Clinical Recovery.
Anesth Analg. 2013;117(1):133–141
Debaene B, Plaud B, Dilly MP, Donati F. Residual Paralysis in the
PACU After a Single Intubating Dose of Nondepolarizing Muscle Relaxant
with an Intermediate Duration of Action. Anesthesiology 2003;98: 1042–8
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender
JS: Residual Neuromuscular Blockade and Critical Respiratory Events in
the Postanesthesia Care Unit. Anesth Analg 2008; 107:130–7
Bissinger U, Schimek F, Lenz G. Postoperative Residual Paralysis and
Respiratory Status: A Comparative Study of Pancuronium and Vecuronium.
Physiol Res/Acad Sci Bohemoslovaca. 2000; 49(4):455–462
Xará D, Santos A, Abelha F. Adverse Respiratory Events in a
Post-anesthesia Care Unit. Archivos de Bronconeumología (English
Edition). 2015 Feb 1;51(2):69-75.
Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate
Acting Non-depolarizing Neuromuscular Blocking Agents and Risk of
Postoperative Respiratory Complications: Prospective Propensity Score
Matched Cohort Study. BMJ. 2012;345:6329.
Zhan C, Miller MR: Excess Length of Stay, Charges, and Mortality
Attributable to Medical Injuries During Hospitalization. JAMA 2003; 290:
Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA.
Hospital Costs Associated with Surgical Complications: A Report from the
Private-sector National Surgical Quality Improvement Program. J Am Coll
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender
JS, Nisman M. Intraoperative Acceleromyographic Monitoring Reduces the
Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the
Postanesthesia Care Unit. Anesthesiology: The Journal of the American
Society of Anesthesiologists. 2008 Sep 1;109(3):389-98.
Postoperative residual curarization (PORC), also known as residual
neuromuscular blockade, refers to the residual muscle paralysis that
occurs after emergence from general anesthesia. PORC stems from the use
of neuromuscular blocking agents (NMBAs). It is defined as a
Train-of-Four (TOF) ratio of <0.9 and may occur in around 41% of
patients who receive intermediate-acting neuromuscular blockers.1 PORC has been associated with critical respiratory events and impaired postoperative respiratory functions.2
It is also independently associated with an increased length of stay
(LOS) in the post-anesthesia care unit (PACU). The increased PACU length
of stay in turn impacts operating room throughput and results in
prolonged waiting time for new PACU admissions.3
The Use of Quantitative NMT Monitoring to Avoid PORC
Subjective tests of NMT monitoring are not sensitive enough to detect residual weakness
Quantitative neuromuscular transmission (NMT) monitoring can help
reduce the incidence of PORC. Neuromuscular monitoring is recommended
when neuromuscular blockers have been administered as a part of general
anesthesia. It can be carried out through subjective techniques, such as
clinical assessment or peripheral nerve stimulation (qualitative
monitoring), or with the help of objective or quantitative NMT monitors
that provide a numeric value representing the depth of neuromuscular
blockade. There is mounting evidence that clinical or subjective tests
of NMT monitoring are not sensitive enough to detect residual weakness
and do not predict adequate neuromuscular recovery. Quantitative or
objective neuromuscular monitors should therefore be used whenever
non-depolarizing NMBAs are administered.4,5,6
The Stimpod NMS 450X is a quantitative neuromuscular monitor that
uses a 3D acceleromyography (AMG) transducer which is effective in
detecting the full force of muscle contraction. It minimizes the risk of
residual neuromuscular blockade and associated adverse respiratory
events.7 As discussed below, this leads to a
decrease in the average length of stay in the PACU and substantial cost
savings for the hospital.
Reduction in the PACU Length of Stay as a Cost-reducing Measure
The economic structure of the PACU determines whether a cost-saving
measure such as reducing the PACU length of stay is likely to reduce
hospital costs. Hospital costs can be divided into fixed and variable
components. Fixed costs are one-time costs that do not
change in relation to the number of surgical cases. These include
capital expenditures, such as gurneys, monitors, and the physical plant
of the PACU. On the other hand, variable costs are directly related to the number of surgical cases, and include X-ray films, pharmaceuticals, dressings, and laundry.
The only real way of reducing PACU costs is to increase the productivity of the PACU and the staff
It is important to bear in mind that reducing the PACU length of stay
will only affect variable costs. Small reductions in the length of time
that patients stay in a PACU are unlikely to impact fixed costs at
ambulatory surgery centers, which include the labor costs of staffing
the PACU with full-time nurses.8 This means
that reducing the length of stay of a patient in the PACU by one minute
is not equivalent to saving one minute of PACU costs. Therefore, the
only real way of reducing PACU costs is increasing the productivity of
the PACU and the staff working in it.
Reduction in the Peak Number of Patients Improves Productivity and Reduces Costs
A reduction in the peak number of patients in the PACU is the most
effective way to increase the productivity of the PACU and its staff.
One way of doing this is to use anesthetic agents that permit a quicker
discharge of patients from the PACU. However, if for example the average
total time a patient stays in the PACU is 120 minutes, then for a
modern anesthetic drug to reduce the peak number of PACU patients by
25%, the drug would have to reduce the mean time to discharge from a
total of 120 minutes to just 34 minutes. Such a drastic change is
unrealistic and therefore this method is limited in its effectiveness to
achieve a substantial increase in PACU productivity.8
Optimization of the time of arrival of patients into the PACU is the single most important measure
For a PACU with salaried or full-time hourly employees, optimization
of the time of arrival of patients into the PACU is the single most
important measure that can reduce the peak number of patients in the
PACU and decrease the peak requirements of nursing staff. This increases
PACU productivity and results in PACU cost savings.8
According to a study conducted by Butterly et al., the mean length of
stay in the PACU for patients with PORC was found to be 323 minutes
whereas the length of stay for patients without PORC was 243 minutes.3
This shows that using the Stimpod NMT monitor for performing objective
monitoring and avoiding residual neuromuscular blockade can save up to
80 minutes of the PACU time per patient. The Stimpod thus makes possible
the “unrealistic” change that results in a significant reduction in
peak patient numbers in the PACU.
Decrease in Operating Room Holding Time Results in Cost Reduction
Postoperative residual curarization results in delayed discharge of
the patient from the PACU. If the PACU gets filled up with patients, the
next patient has to wait before leaving the operating room resulting in
operating room holds. The operating room/PACU system becomes congested.
This has debilitating financial fallout as it increases the operating
room costs. For instance, if all the operating rooms are filled up with
patients waiting for PACU beds, some surgical cases may be delayed or
cancelled. Also, in some situations, incentive salaries may have to be
paid to the nurses and anesthetists for the extra time that they monitor
patients in the operating rooms.3,9,10
The Stimpod quantitative NMT monitor provides an excellent solution
to this problem—it minimizes the incidence of PORC and with it
PORC-induced delay in PACU discharge. The increased availability of beds
in the PACU allows for a quicker release of patients from the operating
room. This cuts down operating room costs.
Stimpod NMS 450X—The Ultimate Cost-Saving Option
The Stimpod NMS450X Neuromuscular Monitor reduces the incidence of residual paralysis in 97% of patients
The Stimpod NMS 450X
is a fully-automated neuromuscular monitor that supports Train-of-Four
(TOF), Double Burst (DB), Post-Tetanic Count (PTC), Tetanus and Twitch
Stimulation modes to perform accurate, real-time neuromuscular
monitoring. It uses OneTouchTM technology that allows an
entire case to be monitored—starting from automatic electrode placement
to extubation—with the press of a single button. The Stimpod begins TOF
monitoring and moves to PTC when a deep block is achieved. It detects
the depth of neuromuscular blockade throughout the procedure and
automatically reinitiates TOF monitoring when the patient begins the
reversal process. The monitoring continues until the patient is more
than 90% recovered.
The Stimpod NMS 450X is an all-in-one solution for quantitative NMT monitoring that can
minimize the incidence of PORC
reduce the length of stay in the PACU
increase the PACU productivity by decreasing the peak number of patients
decrease the operating room hold time
In short, it’s the perfect cost-saving measure for any PACU.
Naguib M, Brull SJ, Johnson KB. Conceptual and technical insights
into the basis of neuromuscular monitoring. Anaesthesia 2017; 72: 16–37.
Boon M, Martini C, Dahan A. Recent advances in neuromuscular block
during anesthesia. F1000Res. 2018;7:167. Published 2018 Feb 9.
Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt
U. Postoperative residual curarization from intermediate-acting
neuromuscular blocking agents delays recovery room discharge. Br J
Anaesth 2010; 105: 304–9.
Duţu M, Ivaşcu R, Tudorache O, et al. Neuromuscular monitoring: an
update. Rom J Anaesth Intensive Care. 2018;25(1):55–60.
Abdulatif M. Neuromuscular transmission monitoring: Beyond the
electric shocks and the shaking hands. Saudi J Anaesth.
Naguib M, Brull SJ, Kopman AF, et al. Consensus statement on
perioperative use of neuromuscular monitoring. Anesth Analg 2018; 127:
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender
JS, Nisman M. Intraoperative acceleromyographic monitoring reduces the
risk of residual neuromuscular blockade and adverse respiratory events
in the postanesthesia care unit. Anesthesiology 2008;109:389–98.
Macario A., D. Glenn and F. Dexter, 1999, What can the
postanesthesia care unit manager do to decrease costs in the
postanesthesia care unit?, J Perianesth, vol 14, pp. 248-93.
McLaren JM, Reynolds JA, Cox MM, et al. Decreasing the length of
stay in phase I postanesthesia care unit: an evidence-based approach. J
Perianesth Nurs. 2015;30:116-123.
Cammu G. Sugammadex: Appropriate Use in the Context of Budgetary
Constraints. Curr Anesthesiol Rep. 2018;8(2):178–185.
Guidance issued by Society for Healthcare Epidemiology of America (SHEA): “…explore the use of disposable covers”
Anesthesia Hygiene machine covers have tear away pouches that hold and contain contaminated supplies such as laryngoscopes and yankauer suction! The use of disposable covers is endorsed by SHEA and ASPF.
“The Procedural Oxygen Mask achieves the triple goal of the following: 1) providing reliable FiO2 delivery of 0.90 to 0.95 at O2 flow rates of 10 to 15 L/min, 2) allowing easy access to the nose and mouth via the self-sealing endoscopy ports, and 3) providing a continuous capnography sampling port.”
René Miguel Gonzalez, MD, Department of Anesthesiology, Hackensack Meridian Health Southern Ocean Medical Center, Stafford Township, N.J.
Benefits of The POM Procedural Sedation Mask:
• Dual oral and nasal entry ports for endoscopes
• Improves O2 concentration during conscious
sedation up to 92%FiO2
• Measures capnography reliably even at high oxygen flows
• Allows easy unobstructed access to the patient
• Ideal for Oral or Nasal fiber optic intubations
Enhanced Patient Safety: The POM provides accurate capnography readings allowing clinicians to intervene proactively, while providing over twice the FiO2 of standard O2/CO2 nasal cannulas. POM reduces the risk of hypoxia during gastrointestinal endoscopy procedures. Now available with Oridion MicroStream capnography sample lines.
Bell Medical’s mission is to introduce innovative technology to anesthesia providers in hospitals and surgery centers. We show our commitment to this mission by supporting anesthesia societies such as the American Association of Anesthesiologist or ASA, the American Association of Nurse Anesthetist or AANA and the American Society of Technicians and Technologists or the ASATT. We also attend numerous state anesthesia meetings for both MDs and CRNAs. We invest over $50,000 annually to attend both national, regional and state association meetings. The listing below is some of the anesthesia meetings we attend to exhibit our innovative technologies. Please visit our booth!