Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit.

INTRODUCTION: The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU). METHODS: An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed. RESULTS: A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB. CONCLUSION: PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.

Achieving 100 percent compliance to perioperative antibiotic administration: a quality improvement initiative

INTRODUCTION@#Timely administration of prophylactic antibiotics within 60 minutes before surgical incision is important for reducing surgical site infections. This quality improvement initiative aimed to work towards achieving 100% compliance with perioperative antibiotic administration.@*METHODS@#We examined the workflow in our Anaesthesia Information Management System (AIMS) and proposed interventions using cause-and-effect analysis of anonymised anaesthetic records from eligible surgical cases extracted from AIMS. This ultimately led to the implementation of an antibiotic pop-up reminder. The overall process was done in a few small plan-do-study-act cycles involving raising awareness, education and reorganisation of AIMS before implementation of the antibiotic pop-up reminder. Data analysis took place from August 2014 to September 2016. Compliance was defined as documented antibiotic administration within 60 minutes before surgical incision, or as documented reason for omission.@*RESULTS@#The median monthly compliance rate, for 33,038 cases before and 28,315 cases after the reminder was implemented, increased from 67.0% at baseline to 94.5%. This increase was consistent and sustained for a year despite frequent personnel turnover. Documentation of antibiotic administration also improved from 81.7% to 99.3%, allowing us to identify and address novel problems that were initially not apparent, and resulting in several department recommendations. These included administering antibiotics later for cases with predicted longer-than-expected preparation times and bringing forward antibiotic administration in lower-segment Caesarean sections.@*CONCLUSION@#The use of information technology and implementation of an antibiotic pop-up reminder on AIMS streamlined our work processes and brought us closer to achieving 100% on-time compliance with perioperative antibiotic administration.