Quantitative neuromuscular blockade and implementation science: How to get anesthesiologists to “Drink the Kool-Aid”
Myron Yaster MD, Lynn D. Martin MD, MBA, Debra Faulk MD
"Drinking the Kool-Aid" “is an expression used to refer to a person who believes in a possibly doomed or dangerous idea because of perceived potential high rewards. The phrase often carries a negative connotation (think the Jonestown massacre where the leader of a cult encouraged/forced his followers to drink poison laced Kool-Aid). It can also be used ironically or humorously to refer to accepting an idea or changing a preference due to popularity, peer pressure, or persuasion. In recent years, it has evolved further to mean extreme dedication to a cause or purpose, so extreme that one would "drink the Kool-Aid" and die for the cause”. https://en.wikipedia.org/wiki/Drinking_the_Kool-Aid So, Genie Heitmiller, if you are reading this, I’ve drunk the Kool-Aid. (During her time at Johns Hopkins, Genie as the QI maestro, pushed thru many ideas that required us to “drink the Kool-aid”. Admittedly, I was initially skeptical about many of these initiatives, like wearing full gown and glove, completely draping the patient, prepping with chlorhexidine and not iodine during central line placement, or washing with Purell until our hands bled, or two person validation when giving insulin or heparin…you get the idea. I was absolutely wrong and needed and learned to “drink the Kool-Aid”. Today’s PAAD is about using quantitative neuromuscular monitoring whenever a non-depolarizing muscle relaxant is used and documenting train of four in the anesthetic record. Key to the article and the accompanying editorial is how to implement this process change in practice. I’ve asked two leaders in these fields, Lynn Martin from the Seattle Children’s Hospital and the PAAD’s new quality improvement guru and Debra Faulk of the Children's Hospital Colorado, who is increasingly becoming the “go-to” expert on quantitative monitoring in pediatric practice to join me in today’s PAAD. Myron Yaster MD
Original article
Wade A Weigel, Barbara L Williams, Neil A Hanson, C Craig Blackmore, Randy L Johnson, Gary M Nissen, Andrew B James, Wyndam M Strodtbeck. Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology. 2022 Jun 1;136(6):901-915. PMID: 35188958
Editorial
Meghan B Lane-Fall. What Anesthesiology Has to Learn from Implementation Science and Quality Improvement. Anesthesiology. 2022 Jun 1;136(6):875-876. PMID: 35405007
As discussed in several previous Pediatric Anesthesia Articles of the Day, quantitative assessment of neuromuscular function with electromyography (EMG), mechanomyography, or acceleromyography is the only way to accurately measure a train-of-four ratio.1,2 Even when using quantitative monitors, lead position is crucial too, specifically, the leads must be at the adductor pollicis. The corrugator supercilli (facial muscles) are amongst the most commonly used monitoring sites in pediatric practice because of its easy accessibility. Unfortunately, it is well known that this site overestimates the degree of neuromuscular recovery and often directly stimulates muscle and not nerve.2,3 Because of this, anesthesiologists tend to overestimate the degree of spontaneous recovery from neuromuscular blockade whether they are using qualitative means of assessment such as clinical signs of recovery (“head or leg lift”) or peripheral nerve stimulators.2,4 Indeed, peripheral nerve stimulators are not true monitors, but devices that deliver an electrical impulse to the nerve and rely on the provider’s subjective interpretation of the resulting muscle response, which human senses are unable to accurately perform.1,2,5 The failure to use quantitative monitoring results in residual neuromuscular blockade, defined as a TOF < 0.9, and has real world consequences: Inadequate reversal of residual neuromuscular block is associated with significant postoperative morbidity and mortality. Ok, then we should all use quantitative monitoring in our practices, right?
Well not so fast, partner. Unfortunately, as many of us know, the existence of evidence and creation of guidelines or recommendations are rarely sufficient to change practice. “The reasons for avoidance of monitoring neuromuscular blockade include the belief that it is not necessary, overconfidence in current practice, lack of knowledge/equipment, inability to use equipment, and/or distrust of equipment”.6 Further, in most American pediatric anesthesia practices, quantitative monitors are rarely available and older devices, like the TOF Watch, require calibration, are impractical, and very difficult to use.7
How did Weigel et al in this adult study get more than 90% of their colleagues to “drink the Kool-Aid” and use quantitative monitoring and document the TOF in the anesthetic record? Both the editorial and the article discuss the importance of process in quality improvement studies and in utilizing implementation science to produce these remarkable results. The editorial also points out that the journal Anesthesiology does not routinely publish QI papers.
“Quality improvement and implementation science are similar in that they are focused on behavior change in organizations. They are different in their focus on the creation of local versus transferable knowledge (quality improvement is local); the explicit use of theories, models, and frameworks to guide study design, measurement, and reporting (implementation science relies heavily on theories, models, and frameworks); and the use of qualitative and mixed methods to understand context (implementation science commonly uses these approaches). Quality improvement is often funded locally, while implementation science has enjoyed increasing attention from research funding agencies that see the field as a way to realize the return on investment in basic and clinical research innovations. Despite the fields’ differences, quality improvement– and implementation science–informed approaches to change management are not mutually exclusive; techniques from each can be combined to powerful effect, as demonstrated by Weigel et al.”8
In my opinion (LDM), it is high time Anesthesiology create and support a quality improvement section in their journal and better support efforts like Weigel et al8 to change clinical anesthesia behaviors and practices. I teach implementation science as a critical component of our quality improvement program, but in much simpler terms. Without people hearts, you will never change their minds. The first step is always defining the ‘what’ we want to change followed most importantly by the ‘why’. This “why” is commonly the “evidence” from the literature (when available), but can also be a description of a better, more satisfying future version of our care. The next step is letting the team develop the ‘how’ we will do it. You are able to get better group engagement and ultimate ownership of the change efforts this way. The final step is public sharing of the data, typically blinded (note my group is now so familiar and comfortable with this step we no longer blind the data). This allows individuals to compare their performance to their peers, track their improvement and when necessary, find a top performing peer to serve as a guide or mentor. All these steps (and more) were followed were followed by Weigel et al to their successful practice change.8 I congratulate them!
Again, as many of you may recall, I (MY) recently questioned the use of QI methodology in research. In a reader response, Lynn highlighted why these QI projects, like today’s PAAD, can provide insight into how evidence, here, the use of quantitative neuromuscular blocker monitoring—must reach practice to improve the care and outcomes of our patients. I think it’s past time for all of us to “drink the Kool-Aid” and as the editorial points out: “practice-based evidence does not replace the more conventional, hypothesis-driven controlled trials that provide evidence of efficacy and effectiveness. Rather, these two types of evidence are complementary and reflect the complexity of modern anesthesia practice, which aims to continually improve patient care and outcomes”.9
Finally, the resistance to appropriate quantitative neuromuscular blockade monitoring and the barriers to its implementation are well-laid out by Weigel et al. and have also been noted in past attempts to implement this technology.10 Interestingly, Weigel et al. found a change in the use of antagonists in the pre- and post-implementation periods, switching from neostigmine to a preference for sugammadex. However, data in pediatric patients is specifically excluded.4,10 For pediatric anesthesiologists, sugammadex has become the preferred agent to reverse neuromuscular blockade, and when it is used, monitoring occurs infrequently.7 This may create and even greater hurdle to overcome in pediatric practice where providers may have a false sense of security with the use of sugammadex, creating a more deep-seated belief that monitoring is unnecessary. Never-the-less, there are reports of sugammadex failures in pediatric practice, and this is especially a risk when monitoring is absent.11,12 The lack of current data on neuromuscular blockade use, management and monitoring in pediatric patients may call for a strong batch of Kool-Aid indeed!
Myron Yaster MD, Lynn Martin MD,MBA, Debra Faulk MD
PS from MY: Thank you Genie!
References
1. Brull SJ, Kopman AF: Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities. Anesthesiology 2017; 126: 173-190
2. Murphy GS: Neuromuscular Monitoring in the Perioperative Period. Anesth Analg 2018; 126: 464-468
3. Thilen SR, Hansen BE, Ramaiah R, Kent CD, Treggiari MM, Bhananker SM: Intraoperative neuromuscular monitoring site and residual paralysis. Anesthesiology 2012; 117: 964-72
4. Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jørgensen B: Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985; 63: 440-3
5. Murphy GS, Brull SJ: Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review. Anesthesiology 2022; 136: 345-361
6. Weigel WA, Williams BL, Hanson NA, Blackmore CC, Johnson RL, Nissen GM, James AB, Strodtbeck WM: Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology 2022; 136: 901-915
7. Faulk DJ, Austin TM, Thomas JJ, Strupp K, Macrae AW, Yaster M: A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade. Anesth Analg 2021; 132: 1518-1526
8. Lane-Fall MB: What Anesthesiology Has to Learn from Implementation Science and Quality Improvement. Anesthesiology 2022; 136: 875-876
9. Lane-Fall MB, Gordon EKB, Valentine EA, Black SA, Kapur PA, Fleisher LA: Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists. Br J Anaesth 2020; 124: e155-e159
10. Todd MM, Hindman BJ, King BJ. The implementation of quantitative electromyographic neuromuscular monitoring in an academic anesthesia department. Anesth Analg. 2014 Aug;119(2):323-331
11. Lorinc AN, Lawson KC, Niconchuk JA, Modes KB, Moore JD, Brenn BR. Residual Weakness and Recurarization After Sugammadex Administration in Pediatric Patients: A Case Series. A A Pract. 2020 May;14(7):e01225
12. Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, Nakatsuka I, Takeda J. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth Analg. 2013 Aug;117(2):345-5