Monitoring and Antagonism of Neuromuscular Blockade

The purpose of this practice guideline is to provide evidence-based recommendations regarding the appropriate management of neuromuscular monitoring and antagonism of NMBAs during and after general anesthesia. The objective is to provide up-to-date information to guide practice that will enhance patient safety by reducing residual Neuromuscular Blockade.

The guidance focuses primarily on the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade (train-of-four ratio less than 0.9), addressing the appropriate type and site of monitoring and the use and dosing of different antagonist drugs depending on the depth of the neuromuscular blockade. Suggestions for implementation of quantitative monitoring are included. The appropriate use of neuromuscular blocking drugs in the context of difficult airway management is not addressed. Additionally, management of intraoperative neuromuscular blockade to optimize intubating conditions, surgical operating conditions, and patient outcomes is not addressed.

The intended patient population: the recommendations in this guideline are intended to be applied to patients undergoing surgical procedures involving use of neuromuscular blockade.

The following guidelines are aimed at providing basic guidelines for incorporating principles of monitoring and antagonism of neuromuscular blockade, with the aim of improving safety outcomes. They are intended as a framework for reasonable and acceptable patient care and should be interpreted as such to allow for some degree of flexibility in different circumstances and according to local practice.