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Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
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Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
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Lefort H, Mendibil A, Margerin S, Cuquel AC, Jost D, Tazarourte K, Domanski L, Tourtier JP. [Storing succinylcholine in prehospital settings following the recommendations of the French National Agency for the safety of medicines]. ACTA ACUST UNITED AC 2014; 33:395-9. [PMID: 24930762 DOI: 10.1016/j.annfar.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The French National Pharmaceuticals Agency (ANSM) has recommanded in July 2012 not to break the cold chain before using succinylcholine (Celocurine®). RESEARCH OBJECTIVE to understand the pre-clinical evolution of the conservation modes of this curare. RESEARCH TYPE Descriptive study before (year 2011) and after (year 2012). PATIENTS AND METHOD Online survey to French Samu/Smur. DATA COLLECTED SMUR location, conservation method at clinical base, in the mobile unit (UMH) and at the patient. Principal decision criteria: evolution of the conservation modes before and after the recommendation (qualitatives variables compared with a Fisher test). RESULTS Out of 101 SAMU/SMUR, 62 answered. Conservation modes of succinylcholine vials were significantly different (P<0.001). Proper conservation was observed in 26 % of the cases before and 43 % after. Mobile units (UMH) equipped with a fridge increased from one out of two to 77 %. The lack of conservation modes passive or active on UMH went from 31 % to 3.4 % with isotherms bags with ice when a fridge was not available. The destruction of capsules at current temperature in a 24-hour period increased: 22 % before, 47 % after (P=0.04). CONCLUSION After recommendations from ANSM, conservation modes and destruction of succinylcholine in a prehospital environment were significantly impacted.
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Affiliation(s)
- H Lefort
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France.
| | - A Mendibil
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - S Margerin
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - A-C Cuquel
- Pharmacie centrale, hôpital d'Instruction des Armées du Val-de-Grâce, 74, boulevard de Port-Royal, 75005 Paris, France
| | - D Jost
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - K Tazarourte
- Samu Smur de Melun, rue Fréteau-de-Pény, 77011 Melun, France
| | - L Domanski
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - J-P Tourtier
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
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