Barriers and aidsto routine neuromuscular monitoring and consistent reversal practice: - a qualitative study

BACKGROUND: Neuromuscular monitoring is recommended whenever a neuromuscular blocking agentis administered, but surveys have demonstrated inconsistent monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine neuromuscular monitoring and consistent reversal practice.

METHODS: Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture.Interviews were conducted at 5 Danish and 1 US hospital. Data were analysed using template analysis.

RESULTS: Danish anaesthetists used objective neuromuscular monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective neuromuscular monitoring, objective neuromuscular monitoring was generally not available and most had not used it. Danish anaesthetists used neuromuscular monitoringto assess readiness for extubation while US residents used subjective neuromuscular monitoring, clinical tests like 5-second head lift, and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and monitoring use. Barriers to consistent and correct neuromuscular monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of neuromuscular blocking agents and residual block, lack of standards and guidelines, and departmental culture.

CONCLUSION: Using qualitative methods, we found that though Danish anaesthetists generally apply objective neuromuscular monitoring routinely and residents at the US institution often apply subjective neuromuscular monitoring, barriers to consistent and correct use still exist.

EDITORIAL COMMENT: Inadequate monitoring of neuromuscular blockade and reversal of neuromuscular blocker drug effects can contribute to preventable perioperative patient complications. This qualitative assessment of specialty physician approaches to these issues in 2 high income countries and practices show that these issues remain an area where more education and better implementation of the best practice standards can be needed.