Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the American Society of Anesthesiologists.

Monitoring and Antagonism of Neuromuscular Blockade

American Society of Anesthesiologists

Publication Date: Dec 14, 2022

Page Last Updated: Feb 17, 2026

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Implications for:	Strong Recommendation (S)	Conditional Recommendation (C)
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not.
Clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their values and preferences.
Policy	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

Certainty in the Evidence
High	H	Low	L
Moderate	M	Very Low	VL

Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).

Document Overview

Document Title: Monitoring and Antagonism of Neuromuscular Blockade

Authoring Society: American Society of Anesthesiologists

Document Publication Date: Dec 14, 2022

Page Last Reviewed/Updated: Feb 17, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: pubs.asahq.org/anesthesiology/article/138/1/13/137379/2023-American-Society-of-Anesthesiologists

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: https://doi.org/10.1097/ALN.0000000000004379

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

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.

Scope: Management

Diseases/Conditions (MeSH): D019148 - Neuromuscular Blockade

Keywords: neostigmine, neuromuscular blockade, sugammadex, train of four monitoring

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

Health Care Settings: Hospital, Operating and Recovery Room

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resources: Systematic Review Document Project Plan Evidence Tables Methodology Supplement

Number of Source Documents: 277

Literature Search Start Date: Thursday, May 31, 1990

Literature Search End Date: Tuesday, May 31, 2022

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes