TITLE PAGE MONITORING AND REVERSAL OF NEUROMUSCULAR BLOCKADE: A COMPARISON OF CLINICAL VERSUS QUALITATIVE ASSESSMENTS BY DR AYENI, Olajide O. (M.B.B.S., BENIN) A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT FOR THE AWARD OF THE FELLOWSHIP OF THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA, IN THE FACULTY OF ANAESTHESIA (FMCA). NOVEMBER 2015 ATTESTATION We hereby attest that this research titled “MONITORING AND REVERSAL OF NEUROMUSCULAR BLOCKADE: A COMPARISON OF CLINICAL VERSUS QUALITATIVE ASSESSMENTS” was carried out by Dr Olajide O. AYENI. We have reviewed and supervised the conduct of the study. --------------------------------------------------------- PROF O.T KUSHIMO Supervisor Consultant Anaesthetist Lagos University Teaching Hospital (LUTH). -------------------------------------- -------------------------------------- DR A. MAFE DR. AKINTIMEHIN Supervisor Supervisor Consultant Anaesthetist Consultant Anaesthetist Lagos Island General Hospital GbagadaGeneraHospital Hospital Lagos. Lagos. 2 CERTIFICATION I certify that this research titled “MONITORING AND REVERSAL OF NEUROMUSCULAR BLOCKADE: A COMPARISON OF CLINICAL VERSUS QUALITATIVE ASSESSMENTS” by Dr Olajide O. AYENI was conducted in the Department of Anaesthesia, LASUTH. --------------------------------------------------------- DR A.A MAJEKODUNMI Head of Department Department of Anaesthesia, LASUTH. 3 DECLARATION It is hereby declared that this work is original and done by me. I also acknowledge that the work has not been presented to any other College for a Fellowship nor has it been submitted elsewhere for publication. -------------------------------------------------------- DR. AYENI, Olajide Olabosipo 4 TABLE OF CONTENTS Table of Contents TITLE PAGE..................................................................... ...................................................................................... 1 ATTESTATION................................................................. ..................................................................................... 2 CERTIFICATION.............................................................. ..................................................................................... 3 DECLARATION................................................................ ..................................................................................... 4 TABLE OF CONTENTS..................................................... ................................................................................... 5 DEDICATION................................................................... ...................................................................................... 7 AKNOWLEDGEMENTS................................................... .................................................................................... 8 LIST OF ABBREVIATIONS............................................... ................................................................................... 9 LIST OF TABLES.............................................................. ................................................................................... 10 LIST OF FIGURES............................................................. .................................................................................. 11 LIST OF APPENDICES........................................................................................................................................ 12 SUMMARY................................................................... ....................................................................................... 13 CHAPTER ONE............................................................. ..................................................................................... 15 INTRODUCTION............................................................ ................................................................................. 15 AIMS AND OBJECTIVES................................................ ............................................................................... 19 SIGNIFICANCE OF THE STUDY..................................... ............................................................................. 20 CHAPTER TWO............................................................ ..................................................................................... 21 LITERATURE REVIEW................................................... ............................................................................... 21 CHAPTER THREE......................................................... .................................................................................... 43 METHODOLOGY............................................................ ................................................................................ 43 STUDY DESIGN.............................................................. ................................................................................ 43 STUDY SAMPLE............................................................. ................................................................................ 43 SAMPLE SIZE DETERMINATION.................................. .............................................................................. 43 INCLUSION CRITERIA:.................................................. ............................................................................... 44 EXCLUSION CRITERIA:.................................................. .............................................................................. 45 TECHNIQUE.................................................................... 45 ANAESTHETIC PROCEDURE.......................................... ............................................................................. 46 ETHICAL CONSIDERATION............................................ ............................................................................ 51 DATA ANALYSIS............................................................. .............................................................................. 51 CHAPTER FOUR............................................................ ................................................................................... 52 RESULTS......................................................................... ................................................................................. 52 CHAPTER FIVE.....................................................63 DISCUSSION...........................................................63 CHAPTER SIX........................................................78 CONCLUSION AND RECOMMENDATION.............78 LIMITATIONS OF THE STUDY...............................79 5 RECOMMENDATIONS............................................80 REFERENCES.........................................................81 APPENDICES..........................................................91 APPENDIX I - PROFORMA: .......................................................................................................................... 91 APPENDIX II - AUDIT QUESTIONAIRE ..................................................................................................... 94 APPENDIX III - INFORMED CONSENT ...................................................................................................... 95 APPENDIX IV - ETHICAL CONSIDERATIONS .......................................................................................... 98 APPENDIX V - ETHICAL COMMITTEE APPROVAL. ............................................................................... 99 APPENDIX VI - NATIONAL POSTGRADUATE MEDICAL COLLEGE APPROVAL ........................... 100 6 DEDICATION This book is dedicated to God Almighty for the opportunity of a lifetime granted to me; my loving wife and wonderful children, Olanrewaju, Oluwanifemi and Oluwatimilehin. 7 AKNOWLEDGEMENTS I give God almighty the glory for the completion of the work He started in me. I wish to express my sincere appreciation and gratitude to Prof. O.T Kushimo, for her motherly love and patience as well as her encouragement in the writing of this book. I also thank Dr A. A Majekodunmi , Dr A Mafe and Dr Akintimehin for their unrelenting support and input in supervising this book and making it good enough for submission. I equally express my sincere gratitude to all the Residents in the Department of Anaesthesia, Lagos State University Teaching Hospital (LASUTH) for their support. 8 LIST OF ABBREVIATIONS ASA AMERICAN SOCIETY OF ANESTHESIOLOGISTS AMG ACCELEROMYOGRAPHY DBS DOUBLE-BURST-STIMULATION EMG ELECTROMYOGRAPHY LASUTH LAGOS STATE UNIVERSITY TEACHING HOSPITAL MMG MECHANOMYOGRAPHY NMBD NEUROMUSCULAR BLOCKING DRUGS NMJ NEUROMUSCULAR JUNCTION NSA NIGERIAN SOCIETY OF ANAESTHETIST PNS PERIPHERAL NERVE STIMULATOR PORC POSTOPERATIVE RESIDUAL PARALYSIS PTC POST-TETANIC-COUNT TOFC TRAIN OF FOUR COUNT TOFR TRAIN OF FOUR RATIO 9 LIST OF TABLES Table I Demographic and clinical characteristics of patients. Table II The TOF count and TOF ratio between the groups at 20 minutes and 30 minutes interval. Table III The onset of intubation, extubation time interval and time interval to achieve adequate neuromuscular block. Table IV Complications and interventions 10 LIST OF FIGURES Figure 1 Distribution of patients by surgical specialties Figure 2 Distribution of complications and facemask interventions Figure 3 Distribution of complications and Re-intubation