Monitoring and Antagonism of Neuromuscular Blockade

Publication Date: December 15, 2022
Last Updated: January 31, 2023

Summary of Recommendations

When neuromuscular blocking drugs are administered, we recommend against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment. (S, M)

We recommend quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade. (S, M)

When using quantitative monitoring, we recommend confirming a train-of-four ratio greater than or equal to 0.9 before extubation. (S, M)

We recommend using the adductor pollicis muscle for neuromuscular monitoring. (S, M)

We recommend against using eye muscles for neuromuscular monitoring. (S, M)

We recommend sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade. (S, M)

We suggest neostigmine as a reasonable alternative to sugammadex at minimal depth of neuromuscular blockade. (C, L)

To avoid residual neuromuscular blockade when atracurium or cisatracurium are administered and qualitative assessment is used, we suggest antagonism with neostigmine at minimal neuromuscular blockade depth. In the absence of quantitative monitoring, at least 10 min should elapse from antagonism to extubation. When quantitative monitoring is utilized, extubation can be done as soon as a train-of-four ratio greater than or equal to 0.9 is confirmed before extubation. (C, VL)

Recommendation Grading




Monitoring and Antagonism of Neuromuscular Blockade

Authoring Organization

Publication Month/Year

December 15, 2022

Last Updated Month/Year

May 24, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.

Target Patient Population

Patients receiving neuromuscular blocking drugs in whom antagonism and extubation is intended

Target Provider Population

Anesthesiologists and providers caring for patients receiving neuromuscular blocking drugs

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D019148 - Neuromuscular Blockade


neuromuscular blockade, sugammadex, neostigmine, train of four monitoring

Source Citation

Stephan R. Thilen, Wade A. Weigel, Michael M. Todd, Richard P. Dutton, Cynthia A. Lien, Stuart A. Grant, Joseph W. Szokol, Lars I. Eriksson, Myron Yaster, Mark D. Grant, Madhulika Agarkar, Anne M. Marbella, Jaime F. Blanck, Karen B. Domino; 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13–41 doi:


Number of Source Documents
Literature Search Start Date
June 1, 1990
Literature Search End Date
June 1, 2022