Residual Neuromuscular Blockade in Cardiac Surgery Patients

Neuromuscular blocking agents are used as part of most general anesthetics to help facilitate
tracheal intubation and optimal surgical conditions (Barish et al). These medications cause
universal paralysis of patients while unconscious. After most surgeries where extubation is
planned, the standard of care is to "reverse" any residual neuromuscular blockade with either
anticholinesterase treatment (specifically neostigmine) or sugammadex. Despite adequate
reversal, residual neuromuscular blockade is a common problem seen in the post-anesthetic
care unit (PACU). It leads to issues of airway obstruction, hypoxemia, respiratory
complications including atelectasis and pneumonia and muscle weakness (Brull et al). The
investigators posit that these complications are likely amplified in patients who require
post-operative intensive care unit admission. In particular, the investigators hypothesize
that cardiac surgery patients are at risk. Elective cardiac surgery patients are routinely
admitted to the CVICU still intubated and ventilator-dependent immediately following surgery.
The goal of uncomplicated cardiac surgery patients (fast track cardiac surgery patients) is
to extubate them within 6 hours of ICU arrival. However, standard of care throughout the US
does not include reversal of their neuromuscular blockade. By the time these patients meet
extubation criteria, most providers believe that the neuromuscular blockade should have worn
off and therefore do not administer reversal (Murphy et al). The investigators hypothesize
that residual neuromuscular blockade delays time to extubation and increases respiratory
complications in fast track cardiac surgery patients. By administering reversal of
neuromuscular blockade in patients with a Train Of Four ratio of <0.9 we anticipate that
there will be an increase from 60 to 85% of patients being successfully extubated within 6
hours of arrival to the ICU and a decrease in composite respiratory complications.

Inclusion Criteria:

- All outpatients >18 years of age scheduled for elective coronary artery bypass graft
surgery (CABG), aortic valve replacement (AVR), or combination CABG/AVR

Exclusion Criteria:

- Chronic kidney disease stage IV or V

- Liver disease, defined as AST, ALT or ALP > 1.5x upper limit of normal Inpatient
status

- Allergy to rocuronium