The high incidence of residual paralysis in the post-anesthesia care unit is a problem that needs evidence-based change in a large tertiary medical center. Side effects, including incomplete neuromuscular recovery, increase the length of stay and can occasion permanent brain damage or death due to respiratory complications. A guideline for assessment of this event and Sugammadex administration lacks at the unit.
This project will develop and implement a protocol based on a review of current evidence on residual paralysis management, neuromuscular monitoring best practices, and effective reversal agents. The Stetler model will guide the implementation of the protocol at the unit. The key metrics for evaluating the effectiveness of the project will include compliance rates and post-implementation skill levels, and nurse satisfaction. Sustainability will be enhanced by key stakeholder involvement and presentation to senior leaders at the facility.
Residual Paralysis after Emergence from Anesthesia
Residual paralysis is linked to postoperative complications and is characterized by weakness, respiratory failure, and hypoxia though it is not limited to these complications (Plaud, Debaene, Donati, & Marty, 2010). Other complications are associated with residual paralysis and have an unrecognized role in the neuromuscular block. It is a persistent issue in the post-anesthesia care unit (PACU) even after the administration of acetylcholinesterase inhibitors.
Residual paralysis after emergence from anesthesia frequency is between 4-50% based on the diagnosis criteria, the administration of a reversal agent and the type of non-depolarizing neuromuscular blocking drugs (NMBDs) as well as if there neuromuscular monitoring is done (Plaud et al., 2010). The phenomenon is clinically relevant since residual paralysis could lead to severe permanent brain damage and even death occasioned by oxygen desaturation, pulmonary collapse, muscle weakness, and acute respiratory failure.
Significance of the Issue
Residual paralysis after emergence anesthesia is clinically relevant since it is associated with oxygen desaturation, pulmonary collapse, muscle weakness, and acute respiratory that can lead to severe permanent brain damage or even death.
Although there have been extensive studies on residual paralysis, awareness of the clinical consequences is still not well established (Plaud et al., 2010). Nursing practices in preventing and treating residual paralysis post-emergence anesthesia are usually dictated by local practices and traditions rather than by evidence-based medicine. These practices include the use of reversal agents, neuromuscular monitoring, and the use of NMBDs (Plaud et al., 2010). Therefore, there is an urgent need to formulate a sound strategy to prevent, diagnose, and treat residual paralysis to avert the related postoperative complications.
The study will review extant studies on residues paralysis after emergence from anesthesia to identify agents and practices that are currently available to accelerate neuromuscular recovery. The study is thus significant regarding current practices of care where relevant agents and nursing practices will be identified that can be implemented in the prevention, diagnosis, and treatment of residual paralysis in patients emerging from anesthesia.
The use of neuromuscular relaxation (anesthetic agents) facilitates endotracheal intubation, such that there is improved visualization and manipulation during the surgery and allows the optimization of the patient-ventilator interaction (González-Cárdenas, Salazar-Ramírez, & Coral-Sánchez, 2016). While there are considerable benefits of neuromuscular relaxation agents in facilitating successful surgery, they may lead to postoperative residue paralysis (Debaene et al., 2003; Plaud et al., 2010; Claudius, Garvey, & Viby-Mogensen, 2009).
The incidences of residual paralysis in PACU range from 2 to 88% (Debaene et al., 2003; Donati, 2013; Fortier et al., 2015), with most cases of residual paralysis going unnoticed during the post-anesthesia recovery period, which exacerbates the risk for severe life-threatening conditions in PACU (Debaene et al., 2003; Plaud et al., 2010; Naguib et al., 2010; Murphy & Brull, 2010). The incidence of residual paralysis particularly concerns in older patients who present with impaired organ ability to clear medications and increased sensitivity in aspects of the duration and depth of the relaxation effects.
Based on statistics, relaxation effects in elderly patients are linked to additional economic and healthcare burdens when it is compared to other age groups (González-Cárdenas et al., 2016). The key objective of this study is thus to review the practices that can be used to prevent and diagnose residual paralysis following surgery in elderly patients. The study also focuses on exploring the effectiveness of pharmacological reversal therapy based on the review studies.
To improve care in residual paralysis from anesthesia, this study will apply the Stetler model to utilize research in improving practice at PACU. The Stettler model will guide the review of selected research studies for their applicability and feasibility in clinical practice. The Stetler model will facilitate the implementation of the research findings in the clinical settings and recommend practice change. The model examines how evidence from research can be applied for a formal change in the organization and how individuals can apply evidence from research to improve critical thinking and reflective practice (Stetler, 2001).
Therefore, the Stetler model will link research use and evidence-based practice. This theoretical framework is based on the assumption that a lack of knowledge regarding research use and evidence-based practice can impede an appropriate and effective use of research outcomes (Romp & Kiehl, 2009). Another assumption is that the healthcare organization may or may not be involved in an individual nurse’s use of research to improve practice. The framework consists of five phases, namely, preparation, validation, decision making (comparative evaluation), application (translation), and evaluation. Each of the five phases is designed to facilitate critical thinking during practice, utilize evidence, and mitigate human errors during the decision-making process (Stetler, 2001).
Application of the Theoretical Framework
Stetler and Fairbrother’s (2006) study demonstrates the use of the Stetler model in evidence-based practice for a small community hospital. The evidence gathered in the study is the internal type that sought to help the hospital towards the goal of best practices. Based on the Stetler model, the evidence is in phases that include assessment planning, quality, and evaluation data. The evidence-based practice based on the Stetler model helps the nurse executive to collect and analyze evidence that will help the small community hospital to counter its challenges and provide insights towards the nurse leader’s pursuit for change in practice at the health institution.
The model has also been applied by Romp and Kiehl (2009) towards the goal of staff development. Using the Stetler Model of research utilization, the study was able to obtain evidence to support and revitalize a preceptor program at a large metropolitan tertiary medical center. Using the evidence gathered based on the model, the study reports an improvement in nurses’ satisfaction with their preceptors and an overall increase in their retention rate (Romp & Kiehl, 2009).
Description of the Adapted theory
Overall, the original Stetler model involves five steps that include preparation, validation, comparative evaluation, translation/application, and evaluation. In the adapted Stetler model, phase one of the models (preparation) was included. In this phase, the researcher purposed on identifying measurable outcomes from relevant articles that sought to prevent residual paralysis in patients emerging from anesthesia, improve diagnosis as well improve the management of residual paralysis in the post-anesthesia care unit. The articles could identify the enablers of improving patient care for patients with residual paralysis and identify the pitfalls of managing these patients.
Such barriers to care for patients emerging from anesthesia and presenting with residual paralysis include lack of early diagnosis of the condition, inadequate monitoring of the patient, and incomplete recovery due to inappropriate dosage. The second phase included in this study is validation, where each relevant article on the diagnosis and management of residual paralysis in the PACU is evaluated to identify whether there is sufficient evidence to support practice change. The third step in the adapted theory is the synthesis of the findings to determine the feasibility and desirability of the practice in improving patient care in residual paralysis post-anesthesia.
In an analytical observational study based on a cohort study by González-Cárdenas et al. (2016), it was demonstrated that pharmacological reversal led to 89.4% and 100% success when Neostigmine and Sugammadex were used. This implies that pharmacological reversal therapies are highly effective in treating residual paralysis after emerging from anesthesia. The study established that residual paralysis reversal was more effective with Neostigmine than Sugammadex, with a 10% higher clinical latency (González-Cárdenas et al., 2016). However, relative to Neostigmine, Sugammadex had multiple benefits, including an intense blockade.
Varposhti et al. (2011), in a study involving 216 patients scheduled for elective surgery under general anesthesia, showed that more than two hours between administration of a single intubation dose of atracurium, an intermediate-acting non-depolarizing muscle relaxant, and arrival to the PACU could prevent residual paralysis. The findings of the study imply that a longer duration between the administration of the single dose of atracurium can prevent residual paralysis after emerging from anesthesia.
In a case report, Sugammadex was shown to be effective in reducing recovery from neuromuscular blockade after residual paralyzing following general anesthesia (Green, Venkatesh, & Venkataramani, 2017). In cases where neostigmine and glycopyrrolate did not completely reverse neuromuscular blockade following anesthesia, the study recommends the need to identify the optimal dose of Sugammadex that will reduce the time of recovery. The study has established that the incomplete recovery (residual paralysis), associated with the use of neostigmine and glycopyrrolate, can be prevented through the identification of the appropriate dose of Sugammadex such that the patient will not require postoperative ventilation.
Indeed, the use of a novel cyclodextrin was found to reverse rocuronium-induced NMB in doses of 16 mg/kg, indicating an alteration of Sugammadex dose could help in reversing residual paralysis in patients at various depths of NMB (Green et al., 2017). For this study, Green et al. (2017) demonstrated that the use of a dose of 2 mg/kg allowed for the optimal duration of neostigmine, leading to a significant recovery of patients with residual paralysis within 3 minutes of administration of the drug.
Organization and Individual Culture and Barriers to Translation
The study setting was the PACU of a large metropolitan tertiary medical center. Some institutional factors hinder the diagnosis and treatment of residual paralysis at the unit. Sugammadex is not being used in this practice setting due to perceived high costs of reversal per case. There is also a general view that this treatment may not be clinically needed, as the drug is not included in the pharmacy’s formulary. The facility also lacks a protocol for the administration of a reversal agent to guide practice at the unit. The development and implementation of clinical practice guidelines with evidence-based recommendations for Sugammadex administration can reduce the incidence of this preventable event.
At the individual level, staff attitudes and norms prevent the routine clinical application of best practices at the unit. PICU nurses do not assess residual paralysis as standard care for safe emergence, increasing the risk of respiratory complications such as pharyngeal dysfunction and reduced inspiratory airflow (Saager et al., 2019). The current practice of neuromuscular monitoring is also inadequate, which increases the incidence of this event. Education on residual paralysis can help PACU nurses use technology to monitor neuromuscular activity as a routine practice.
Potential barriers to the translation of the recommendations identified from literature into practice relate to perceived cost, education, and technical challenges at the unit. The perception that incorporating Sugammadex into the treatment protocol will increase the budget must be addressed. Compared to Neostigmine, Sugammadex can reverse any level of neuromuscular blockade within 2-3 minutes (Cammu, 2018). Thus, the performance of this novel agent (time saved) can be a basis for introducing it at the facility as a cost-effective reversal agent.
The lack of education and problem awareness is another barrier that should be addressed for best practices to be adopted in the unit. Anesthesia providers and the PACU nurses will undergo a four-week training on an evidence-based protocol (visual tool) for the assessment and treatment of residual paralysis. Increased awareness of this preventable event can lead to early diagnosis, adequate patient monitoring, and correct dosage administration. Technical challenges limiting the use of technology for quantitative neuromuscular monitoring after emergence will be addressed through in-person education.
Two weeks into the training, nurse compliance level with the protocol will be measured to determine the success of the project. The specific aspects of being evaluated include the frequency with which staff nurses use the assessment tool at the end of a shift, administer an appropriate dosage of the reversal agent (Sugammadex), and monitor neuromuscular function quantitatively using available technology (Murphy, 2018). The results of the performance audit will be compared to baseline scores to determine skill improvement. Another metric of the effectiveness of the project is the improvement in the post-implementation incidence of residual paralysis (after the four-week education) at the unit compared to the pre-implementation rate.
Increased mention of this event in rounding tools will be a useful measure of problem awareness among PACU nurses. After four weeks, the charts will be audited to determine if nurses adhere to correct assessment, monitoring, and documentation of residual paralysis before administering Sugammadex. A post-intervention survey will be conducted to assess nurse skills and satisfaction with the protocol compared to baseline data.
Participating PACU nurses will indicate improvements in understanding of residue paralysis, its symptoms, assessment, and management after the training. Further, their satisfaction with the education and skills acquired will indicate the effectiveness of this project. Using a reliable survey will enhance the accuracy of the evaluation plan. Cronbach’s Alpha will be used to empirically evaluate the internal consistency and reliability of the multi-scale items included this tool, and metrics with a value > 0.5 will be combined to give a final composite score (Polit & Beck, 2017). These items will constitute a true measure of the PACU nurses’ satisfaction with the protocol.
Plans for Sustainability
An effective plan will be needed to maintain the evidence-based protocol for residue paralysis assessment and treatment in the unit. First, key stakeholders with a major influence on clinical protocols and guidelines at the unit, including the PACU manager and educator, will be engaged in the initial implementation of the change project to serve as long-term advocates for the initiative. The unit manager will also monitor nurse compliance with the evidence-based protocol.
Sustainability will also be achieved by presenting the post-implementation outcomes to the clinical nurse leader and hospital administrators. The presentation will emphasize the project’s impact and value to the facility’s mission to secure the resources needed to sustain the initiative. According to Trautman et al. (2018), visible involvement of the senior leadership is critical in maintaining projects that have clear contributions to quality improvement. Therefore, key leaders and staff will be engaged from the onset to gain trust and support for the initiative beyond the first few months.
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