Monitoring and Antagonism of Neuromuscular Blockade

This Guideline deals with the recommendations of Monitoring and Antagonism of Neuromuscular Blockade.

Neuromuscular Monitoring: Patient Outcomes

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

2.     We recommend quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade. (Strong)

Neuromuscular Monitoring: Confirmation of Train-of-four Ratio Greater than or Equal to 0.9 before Extubation

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

Neuromuscular Monitoring: Technical Performance

4.     We recommend using the adductor pollicis muscle for neuromuscular monitoring. (Strong)

5.     We “recommend against” using eye muscles for neuromuscular monitoring. (Strong)

Antagonism of Neuromuscular Blockade

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

7.     We suggest neostigmine as a reasonable alternative to sugammadex at minimal depth of neuromuscular blockade. (Conditional)

Antagonism strategies for Benzylisoquinolinium (Atracurium and Cisatracurium) Neuromuscular Blockade

8.     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. (Conditional)