Residual neuromuscular blockade in the ICU: a prospective observational study and national survey.

Residual neuromuscular blockade is associated with significant morbidity. It has been widely studied in anaesthesia; however, the incidence of residual neuromuscular blockade in patients managed in the ICU is unknown. We conducted a prospective observational study in a tertiary ICU to determine the incidence of residual neuromuscular blockade using quantitative accelerographic monitoring. We tested for residual neuromuscular blockade (defined as a train-of-four ratio < 0.9) before cessation of sedation in anticipation of tracheal extubation. We also surveyed 16 other ICUs in New Zealand to determine their use of neuromuscular monitoring. A total of 191 patients were included in the final analysis. The incidence (95%CI) of residual neuromuscular blockade was 43% (36-50%), with a similar incidence observed in non-postoperative and postoperative patients. There was a lower risk of residual neuromuscular blockade with atracurium than rocuronium (risk ratio (95%CI) of 0.39 (0.12-0.78)) and a higher risk with pancuronium than rocuronium (1.59 (1.06-2.49)). Our survey shows that, in New Zealand ICUs, monitoring of neuromuscular function is rarely carried out before tracheal extubation. When neuromuscular monitoring is undertaken, it is based on individual clinician suspicion and performed using qualitative measurements. No ICU reported using a quantitative monitor or a clinical guideline. The results demonstrate a high incidence of residual neuromuscular blockade in our ICU patients and identify the type of neuromuscular blocking drug as a possible risk factor. Monitoring neuromuscular function before tracheal extubation is not currently the standard of care in New Zealand ICUs. These data suggest that residual neuromuscular blockade may be an under-recognised problem in ICU practice.

The effect of noise and high-pass filtering on the estimation of mean blood velocity using wide and narrow ultrasound beams.

Recently, a new method of analysis has been proposed for the calculation of a Doppler frequency proportional to mean blood velocity for the case where the Doppler beam is assumed to be of negligible thickness compared to the vessel diameter, and the velocity profile is axisymmetric and monotonic increasing from the vessel wall to the vessel center. Such analysis of the Doppler signal is an alternative to that commonly performed under the assumption that the beam insonates the vessel uniformly. Errors in each method are found and compared for the case where the Doppler signal is contaminated by noise, and for the case where the signal is subjected to an ideal high-pass filter. The frequency resulting from the new method of analysis is affected by low-frequency perturbations approximately twice as much as that resulting from the standard method. However, the new method is much more immune to high frequency perturbations. If each method is used with the beam shape for which it is appropriate then, for a given velocity profile, each method is equally affected by the use of the same ideal high-pass filter.

The effect of geometrical spectral broadening on the estimation of mean blood velocity using wide and narrow ultrasound beams.

If an ultrasound beam uniformly insonates the cross section of a blood vessel then the Doppler signal can be analyzed to give a frequency proportional to the spatial mean blood velocity. This is also possible if the beam can be thought of as negligibly thin compared to the blood vessel radius, centrally placed, and the blood velocity profile is axisymmetric and monotonic, although the analysis takes a different form. The immunity of these mean velocity estimators to broadening of the ideal frequency spectrum is studied. If the broadening of a frequency component is such that its mean frequency, weighted by intensity, is unchanged then the analysis with a uniformly insonating beam still leads to the correct mean velocity. In contrast, for any such broadening, the analysis if the beam is negligibly thin produces an underestimate of the mean velocity. Error expressions are derived for idealized cases and some practical results given.