Book
Monitoring and Antagonism of Neuromuscular Blockade
- METHODOLOGY
A comprehensive search for the guideline was done to identify the most relevant ones to consider for adaptation. For the literature review, potentially relevant clinical studies were identified via electronic and manual searches of the literature. The updated searches covered around 5-year period from January 1, 2020, to May 31, 2026. The inclusion/exclusion criteria that were followed in the search and retrieval of guidelines are adapted.
We selected guidelines only if they are:
- Evidence-based guidelines.
- National and/or international guidelines.
- Guidelines published within the last 5 years.
- Peer reviewed publications.
- Guidelines written in English language.
We Excluded guidelines that are:
- Written by a single author not on behalf of an organization as guideline to be valid and comprehensive, ideally requires multidisciplinary input.
- Published without references as the GDG panel needs to know whether a thorough literature review was conducted and whether the current evidence was used in the preparation of the recommendations.
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members of the GDG. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigor dimension was retained).
Guidelines used in the Adaptation Process:
The basic elements of the Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade published by ASA can be successfully implemented in the practice of anesthesiology. The Guidelines Development Group (GDG) for the Egyptian Board of Anesthetics, Surgical Intensive Care, and Pain Management has adopted with modification:
1. Thilen S R, Weigel W A, Todd MM, et al. 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. January 2023 - Volume 138 - Issue 1 (Reference No. 1)
2.
Fuchs-Buder T, Romero CS, Lewald H, et al.
Peri-operative management of neuromuscular blockade: A guideline from the
European Society of Anaesthesiology and Intensive Care. Eur J
Anaesthesiol. 2023;40(2):82. Epub 2022 Nov 15. (Reference No. 2)
3.
Renew JR. Monitoring neuromuscular blockade. UpToDate. Literature review
current through: May 2026. Topic last amended: Mar 18, 2026. Support Tag: [0605 – 197.134.92.69 – A2E9CA1045 –
PR14 – UPT – NP – 20260610-17:1921UTC] – LG (Reference No. 3)
4. Alenezi FK, Alnababtah K, Alqahtani MM, Olayan L, Alharbi M: The association between residual neuromuscular blockade (RNMB) and critical respiratory events: A prospective cohort study. Perioper Med (Lond) 2021; 10:14 (Reference No. 6)
5. Weigel WA, Williams BL, Hanson NA, Blackmore CC, Johnson RL, Nissen GM, James AB, Strodtbeck WM: Quantitative neuromuscular monitoring in clinical practice: A professional practice change initiative. Anesthesiology 2022; 136:901–15 (Reference No. 10)
➡️Strength of Recommendations
The strength of a recommendation communicates the importance of adherence to the recommendation.
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Strong Recommendations |
The GDG found that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted.
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Conditional Recommendations |
This means that the GDG found that there is: ▪ Greater uncertainty about the strength of evidence, or ▪ The recommendation may account for a greater variety in patient values and preferences, or ▪ The resource use makes the intervention suitable for some, but not for other locations. Conditional recommendations are still the best available evidence to date, and it can be adopted if it meets the conditions mentioned with it.
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Good Practice Statement (GPS) |
Statements based on expert opinion of respected authorities, and the guidelines development groups.
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➡️Evidence Assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations.
WHO Copyright page
Unrestricted materials of the standard disclaimers for WHO publications are used.
Detailed GRADE information is available on the following sites:
• GRADE working group: https://www.gradeworkinggroup.org/
• GRADE online training modules: http://cebgrade.mcmaster.ca/
Quality Definition Implications
Evidence is categorized as High, Moderate, Low and Very low.
Table 1: Quality and Significance of the Four Levels of Evidence in GRADE:
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Quality
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Definition |
Implications |
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High |
The guideline development group is very confident that the true effect lies close to that of the estimate of the effect.
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Further research is very unlikely to change confidence in the estimate of effect.
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Moderate |
The guideline development group is moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
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Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
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Low |
Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the true effect. |
Further research is very likely to have an important impact on confidence in the estimate of effect and is unlikely to change the estimate.
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Very low |
The group has very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect.
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Any estimate of effect is very uncertain.
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