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Monitoring and Antagonism of Neuromuscular Blockade

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"last update: 7 July  2026"                                                                                          Download Guideline

- REFERENCES

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.  Anesthesiology 2023138 (1), 13–41.]

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):894. Epub 2022 Nov 15.

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-

4.      Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, Gray J, Landry E, Gupta DK: Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology 2011; 115:946–54

5.      Wardhana A, Kurniawaty J, Uyun Y: Optimized reversal without train-of-four monitoring versus reversal using quantitative train-of-four monitoring: An equivalence study. Indian J Anaesth 2019; 63:361–742. 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

6.      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

7.      Domenech G, Kampel MA, Garcia Guzzo ME, Novas DS, Terrasa SA, Fornari GG: Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: A retrospective observational study. BMC Anesthesiol 2019; 19:143

8.      Todd MM, Hindman BJ, King BJ: The implementation of quantitative electromyographic neuromuscular monitoring in an academic anesthesia department. Anesth Analg 2014; 119:323–31

9.      Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann M, Meistelman C, Hunter JM, Ulm K, Blobner M; POPULAR Contributors: Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): A multicenter, prospective observational study. Lancet Respir Med 2019; 7:129–40                 

10.   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

11.   Adembesa I, Mung’ayi V, Premji Z, Kamya D: A randomized control trial comparing train of four ratio > 0.9 to clinical assessment of return of neuromuscular function before endotracheal extubation on critical respiratory events in adult patients undergoing elective surgery at a tertiary hospital in Nairobi. Afr Health Sci 2018; 18:807–16

12.   Goyal S, Kothari N, Chaudhary D, Verma S, Bihani P, Rodha MS: Reversal agents: Do we need to administer with neuromuscular monitoring—An observational study. Indian J Anaesth 2018; 62:219–24

13.   Larsen PB, Gatke MR, Fredensborg BB, Berg H, Engbaek J, Viby-Mogensen J: Acceleromyography of the orbicularis oculi muscle II: Comparing the orbicularis oculi and adductor pollicis muscles. Acta Anaesthesiol Scand 2002; 46:1131–6

14.   Plaud B, Debaene B, Donati F: The corrugator supercilii, not the orbicularis oculi, reflects rocuronium neuromuscular blockade at the laryngeal adductor muscles. Anesthesiology 2001; 95:96–101

15.   Yamamoto S, Yamamoto Y, Kitajima O, Maeda T, Suzuki T: Reversal of neuromuscular block with sugammadex: A comparison of the corrugator supercilii and adductor pollicis muscles in a randomized dose–response study. Acta Anaesthesiol Scand 2015; 59:892–901

16.   Le Merrer M, Frasca D, Dupuis M, Debaene B, Boisson M: A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography: A prospective observational study. Eur J Anaesthesiol 2020; 37:38–43

17.   Vega EA, Ibacache ME, Anderson BJ, Holford NH, Nazar CE, Solari S, Allende FA, Cortinez LI: Rocuronium pharmacokinetics and pharmacodynamics in the adductor pollicis and masseter muscles. Acta Anaesthesiol Scand 2016; 60:734–46

18.   Alday E, Munoz M, Planas A, Mata E, Alvarez C: Effects of neuromuscular block reversal with sugammadex versus neostigmine on postoperative respiratory outcomes after major abdominal surgery: A randomized-controlled trial. Can J Anaesth 2019; 66:1328–37

19.   Boggett S, Chahal R, Griffiths J, Lin J, Wang D, Williams Z, Riedel B, Bowyer A, Royse A, Royse C: A randomized controlled trial comparing deep neuromuscular blockade reversed with sugammadex with moderate neuromuscular block reversed with neostigmine. Anaesthesia 2020; 75:1153–63

20.   Lee YJ, Oh AY, Koo BW, Han JW, Park JH, Hong JP, Seo KS: Postoperative residual neuromuscular blockade after reversal based on a qualitative peripheral nerve stimulator response: A randomized controlled trial. Eur J Anaesthesiol 2020; 37:196–202

21.   Jones RK, Caldwell JE, Brull SJ, Soto RG: Reversal of profound rocuronium-induced blockade with sugammadex: A randomized comparison with neostigmine. Anesthesiology 2008; 109:816–24

22.   Geldner G, Niskanen M, Laurila P, Mizikov V, Hubler M, Beck G, Rietbergen H, Nicolayenko E: A randomized controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67:991–8

23.   Woo T, Kim KS, Shim YH, Kim MK, Yoon SM, Lim YJ, Yang HS, Phiri P, Chon JY: Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients. Korean J Anesthesiol 2013; 65:501–7

24.   He J, He H, Li X, Sun M, Lai Z, Xu B: Required dose of sugammadex or neostigmine for reversal of vecuronium-induced shallow residual neuromuscular block at a train-of-four ratio of 0.3. Clin Transl Sci 2022; 15:234–43

25.   Kirkegaard H, Heier T, Caldwell JE: Efficacy of tactile-guided reversal from cisatracurium-induced neuromuscular block. Anesthesiology 2002; 96:45–50

26.   Kim KS, Cheong MA, Lee HJ, Lee JM: Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockade during propofol or sevoflurane anesthesia. Anesth Analg 2004; 99:1080–

27.   Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F: Antagonism of low degrees of atracurium-induced neuromuscular blockade: Dose-effect relationship for neostigmine. Anesthesiology 2010; 112:34–40

28.   Schaller SJ, Fink H, Ulm K, Blobner M: Sugammadex and neostigmine dose-finding study for reversal of shallow residual neuromuscular block. Anesthesiology 2010; 113:1054–60

29.   Fuchs-Buder T, Baumann C, De Guis J, Guerci P, Meistelman C: Low-dose neostigmine to antagonize shallow atracurium neuromuscular block during inhalational anaesthesia: A randomized controlled trial. Eur J Anaesthesiol 2013; 30:594–8

30.   Naguib M, Brull SJ, Kopman AF, Hunter JM, Fülesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB: Consensus statement on perioperative use of neuromuscular monitoring. Anesth Analg 2018; 127:71–80

31.   Flockton EA, Mastronardi P, Hunter JM, Gomar C, Mirakhur RK, Aguilera L, Giunta FG, Meistelman C, Prins ME: Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine. Br J Anaesth 2008; 100:622–30

32.   Goldhill DR, Carter JA, Suresh D, Whitehead JP, Flynn PJ: Antagonism of atracurium with neostigmine: Effect of dose on speed of recovery. Anaesthesia 1991; 46:496–9

33.   Preault A, Capron F, Chantereau C, Donati F, Dimet J: Under sevoflurane anaesthesia, a reduced dose of neostigmine can antagonize a shallow neuromuscular block: A double-blind, randomized study. Anaesth Crit Care Pain Med 2016; 35:269–73

34.   Song IA, Seo KS, Oh AY, No HJ, Hwang JW, Jeon YT, Park SH, Do SH: Timing of reversal with respect to three nerve stimulator end-points from cisatracurium-induced neuromuscular block. Anaesthesia 2015; 70:797–802