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Monitoring Depth of Neuromuscular Blockade and Adequacy of Reversal: Clinical and Pharmacoeconomic Implications

  • Neuromuscular Blockade (CA Lien, Section Editor)
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Abstract

Purpose of Review

This review summarizes current evidence on best practice management of neuromuscular blocking agents (NMBAs). Furthermore, the pharmacoeconomic implications of neuromuscular blockade and reversal to support clinicians and policymakers in ensuring improved patient outcomes and cost-efficient healthcare delivery are discussed.

Recent Findings

There is good evidence supporting a dose-dependent relationship between NMBAs, residual paralysis, and postoperative respiratory complications. The implementation of sugammadex provoked practice changes, but studies are ambiguous on whether the reversal agent reduces neuromuscular blockade-associated complications compared to neostigmine. Current literature supports reversal with sugammadex or neostigmine depending on the degree of residual paralysis and guided by quantitative neuromuscular monitoring.

Summary

Best-practice management of neuromuscular blockade targets avoidance of residual paralysis through (1) utilizing the lowest possible dose of NMBAs; (2) quantitative monitoring of neuromuscular blockade; and (3) ensuring adequacy of recovery or reversal with a train of four-ratio ≥0.95 prior to extubation.

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Authors and Affiliations

  1. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA

    Luca J. Wachtendorf, Elena Ahrens, Aiman Suleiman & Maximilian S. Schaefer

  2. Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, USA

    Luca J. Wachtendorf, Elena Ahrens, Aiman Suleiman & Maximilian S. Schaefer

  3. Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland

    Luca J. Wachtendorf

  4. Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan

    Aiman Suleiman

  5. Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany

    Maximilian S. Schaefer

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Maximilian S. Schaefer received funding for investigator-initiated studies from Merck & Co. He is an associate editor for BMC Anesthesiology. He received honoraria for lectures from Mindray Medical International Limited. He also received an unrestricted philanthropic grant from Jeffrey and Judith Buzen. All other authors declare no conflicts of interest.

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Wachtendorf, L.J., Ahrens, E., Suleiman, A. et al. Monitoring Depth of Neuromuscular Blockade and Adequacy of Reversal: Clinical and Pharmacoeconomic Implications. Curr Anesthesiol Rep 13, 239–256 (2023). https://doi.org/10.1007/s40140-023-00581-1

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