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Monitoring and Antagonism of Neuromuscular Blockade
American Society of Anesthesiologists
Publication Date: March 12, 2025
Introduction
Highlights
Using quantitative neuromuscular monitoring at the adductor pollicis and confirming recovery of a train-of-four ratio greater than or equal to 0.9 before extubating is the only way to ensure acceptable recovery.
Background
Residual paralysis (train of four ratio less than 0.9) has been shown to occur in up to 64% of patients after non depolarizing neuromuscular blockade.
Qualitative assessment of fade using a peripheral nerve stimulator cannot be reliably appreciated until the train-of four ratio is less than 0.4.
Undesirable clinical effects of a train-of-four ratio <0.9 include, but are not limited to, weakness, impaired hypoxic ventilatory response, increased risk of upper airway obstruction and of aspiration, impaired airway protective reflexes, an experience of unpleasant symptoms of muscle weakness, a prolonged stay in the post-anesthesia care unit and decreased patient satisfaction.
Treatment
2023 Guideline Recommendations
Monitoring Modalities
When neuromuscular blocking drugs are administered, we recommend against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment.
We recommend quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade.
When using quantitative monitoring, we recommend confirming a train-of-four ratio greater than or equal to 0.9 before extubation.
Assessment Sites
We recommend using the adductor pollicis muscle for neuromuscular monitoring.
We recommend against using eye muscles for neuromuscular monitoring.
Reversal Options
We recommend sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade.
Shallow: train-of-four count 4 & train-of-four ratio <0.4
Minimal: train-of-four 0.4 to <0.9
We suggest neostigmine as a reasonable alternative to sugammadex at minimal depth of neuromuscular blockade.
Benzylisquinolinium
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.
Strategies for Implementation and Acceptance of Routine Quantitative Monitoring
Educate clinicians on the prevalence and consequences of residual neuromuscular blockade in routine care; provide key references.
Provide in-service training on quantitative monitoring technology, emphasizing the increasing ease of use and interpretation.
Work with the operating room value-based-purchasing committee (or local equivalent) to define appropriate indications and contraindications for quantitative monitoring. Include all patients receiving neuromuscular blocking drugs, with particular focus on patients receiving nondepolarizing neuromuscular blocking drug.
Ensure that monitors are readily available.
Seek opportunities to document and promote results within your group and institution to enable:
A decrease in incidence of postoperative respiratory complications.
A decrease in ICU and hospital length of stay.
An increase in patient satisfaction.
Changes in the use of antagonist drugs.
Provide team and individual feedback on appropriate use of quantitative monitoring.
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).
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
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
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