REVIEW

CURRENT
OPINION Current recommendations for monitoring depth of
neuromuscular blockade
Cynthia A. Lien a and Aaron F. Kopman

Purpose of review
Residual neuromuscular block is a relatively frequent occurrence and is associated with postoperative
pulmonary complications, including aspiration, pneumonia and hypoxia, impaired hypoxic ventilatory drive
and decreased patient satisfaction. Although adequate recovery of neuromuscular function has been
defined as a train-of-four ratio of at least 0.9, monitoring with a qualitative peripheral nerve stimulator
makes it impossible to determine the actual train-of-four ratio.
Recent findings
Peripheral nerve stimulators are not routinely used in clinical practice. Without their use, dosing of
neuromuscular blocking agents and anticholinesterases is often inappropriate and adequacy of recovery of
neuromuscular function upon tracheal extubation cannot be guaranteed.
Summary
Use of peripheral nerve stimulators allows clinicians to administer neuromuscular blocking and reversal
agents in a rational manner. Routine use of quantitative monitors of depth of neuromuscular blockade is
the best guarantee of the adequacy of recovery of postoperative muscle strength.
Keywords
acceleromyography, qualitative monitors, quantitative monitors, residual neuromuscular block,
train-of-four ratio

INTRODUCTION of the indirectly evoked muscle response is done by

Residual neuromuscular block after surgery is a rela-
tively frequent occurrence and is associated with
numerous complications. Unfortunately, the intra-
operative use of peripheral nerve stimulators is far
from universally practiced, and objective monitors of
neuromuscular function are still not widely available.
In this review, we will try to put current con-
troversies and developments in the area of perioper-
ative neuromuscular monitoring in perspective. We
will define the different types of neuromuscular
monitors and the minimum specifications of these
monitors and discuss how monitors of neuro-
muscular function should be used in clinical prac-
tice and how their routine use may improve patient
management.
a device that displays the train-of-four (TOF) ratio in
real time. Quantitative monitoring may employ
different technologies, including mechanomyo-
graphy, electromyography (EMG) [1], acceleromyo-
graphy (AMG) [2] and kinemyography [3].
Historically, a TOF ratio (TOFR) of 0.7 at the
adductor pollicis muscle was accepted as demon-
strating satisfactory recovery of neuromuscular
function. However, this level of NMB is associated
with subjective symptoms of profound weakness [4]
and objective signs of upper respiratory muscle and
swallowing dysfunction [5,6]. The current standard
of acceptable recovery of strength is a TOFR of at
least 0.90 as measured at the adductor pollicis
muscle.

BACKGROUND INFORMATION
Monitoring of depth neuromuscular blockade
(NMB) can be either qualitative or quantitative.
With qualitative monitoring, the indirectly evoked
muscle response to nerve stimulation by a peri-
pheral nerve stimulator is evaluated visually or by
feel. With quantitative monitoring, the evaluation
a
Department of Anesthesiology, Weill Cornell Medical Center, New York,
New York, USA
Correspondence to Cynthia A. Lien, MD, Department of Anesthesiology,
Weill Cornell Medical Center, Room M-328, 525 East 68th Street, New
York, NY 10065, USA. Tel: +1 212 746 2954; e-mail: calien@med.
cornell.edu
Curr Opin Anesthesiol 2014, 27:616622
DOI:10.1097/ACO.0000000000000132

www.co-anesthesiology.com Volume 27
Number 6
December 2014

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 Recommendations for monitoring depth of NMB Lien and Kopman
KEY POINTS

Monitoring of depth of neuromuscular block should be
done whenever an NMBA is administered to a patient.

Not all monitors are equal and any monitor that is used
must be able to provide a TOF stimulus at an adequate
current and pulse duration, have an output of greater
than 60 mA in the presence of 2000 V inter-electrode
impedance and display the delivered current.

NMBAs should be titrated to maintain at least one
response to TOF stimulation. NMB should not be used
to compensate for an inadequate depth of anesthesia.

Administration of anticholinesterases should be based
on the response to neuromuscular stimulation. Patients
with no response to stimulation should not receive an
anticholinesterase and patients with a TOFR greater
than 0.9 should not receive a maximal dose of
anticholinesterase.

There is increasing evidence that, with the use of
quantitative monitors of NMB, fewer patients will be
admitted to the PACU with residual paralysis.
(1) Following the administration of neuromuscular
blockers of intermediate duration of action, a
significant percentage of patients arrive in the
postanesthesia care unit (PACU) with a TOFR of
less than 0.9. The reported incidence of post-
operative residual neuromuscular block, a TOFR
&
less than 0.90, approximates 2530% [7,8 ] and
&&
can be as high as 62% [9 ]. Ten to 15% of
patients arrive in the PACU with a TOFR of less
than 0.70 [10,11].
(2) Qualitative monitoring has its limitations. Once
the TOFR exceeds 0.40, most clinicians cannot
detect the presence of fade with either visual or
tactile evaluation of the response to stimulation
[12].
(3) Double burst stimulation (DBS) is, like TOF
stimulation, a way to detect residual neuro-
muscular block. The stimulation pattern in
DBS consists of two short bursts of 50 Hz tetanic
stimuli separated by 750 ms. Two responses are
generated in response to this stimulus and the
strength of the second response compared with
the first response is comparable to the strength
of the fourth response relative to that of the first
response with TOF stimulation. The tactile or
visual evaluation of fade in the response to DBS
fade is easier to assess than the TOFR for two
reasons. First, the clinician only has to evaluate
two individual responses rather than four. In
addition, because each response is actually a
brief tetanus, the amplitude of each is greater
than that elicited with TOF stimulation. As a
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result, it is generally possible subjectively to
detect fade at TOF ratios less than 0.60 with
this technique. Unfortunately, a TOF ratio of
0.60 still represents inadequate return of neuro-
muscular function.
(4) The orbicularis oculi and corrugator supercilii
muscles are relatively resistant to nondepolariz-
ing blockers. When the TOF count (TOFC) is
four at the orbicularis oculi or corrugator super-
cilli, it may be only one or two at the adductor
pollicis. Reliance on facial muscles is associated
with an increased incidence of postoperative
residual neuromuscular block in the PACU [13].
(5) Clinical tests of neuromuscular recovery, such
as the 5-s head lift, tidal volume or grip strength,
are insensitive and unreliable [14]. To cite Heier
et al. [15] ... a reliable clinical test for detection
of significant residual block ... will probably
remain elusive.
(6) Although the great majority of young healthy
individuals are unlikely to suffer adverse effects
from mild levels of residual block (TOF values
approximating 0.70), this level of block is associ-
ated with critical respiratory events in the PACU
[16], impaired respiratory muscle function [17],
postoperative hypoxemia [18], increased risk
&&
of pulmonary aspiration [19 ] and impaired
&
clinical recovery [20 ].
(7) Despite the risks associated with undetected
residual NMB, widespread adoption of even qual-
itative monitoring has not occurred. Surveys
from New Zealand and Australia [21 ], Italy,
&
Denmark, the UK and Germany all indicate that
the percentage of individuals who routinely
monitor neuromuscular function intraopera-
tively rarely exceeds 50%. Routine monitoring
is almost nonexistent in Japan [22 ].
&&
(8) When the TOFC (the number of appreciable
responses to TOF stimulation) is less than four,
neostigmine cannot be relied upon to produce
prompt and adequate reversal of NMB. At a TOFC
of two, the average time to achieve a TOFR of
0.90 is 20 min. With reappearance of the fourth
response to TOF stimulation (TOFR 0.150.20),
neostigmine cannot consistently facilitate recov-
ery to a TOFR of 0.90 within 30 min [23]. How-
ever, once the TOFC is four without detectable
tactile or visual fade, recovery occurs within
510 min of administration of neostigmine 30
and 20 mcg/kg, respectively [24].
MINIMUM REQUIREMENTS FOR A
MONITOR OF NEUROMUSCULAR
BLOCKADE
The basic specifications for a monitor of depth of
NMB have long been established and described by
www.co-anesthesiology.com 617
 Technology, education and safety
many authors. These requirements include the
following:
The strength of contraction of a muscle depends
on the number of fibers stimulated. With NMB,
the strength of response decreases relative to the
number of muscle fibers blocked. The stimulus
used must be strong enough to stimulate all of
the nerve fibers supplying that muscle, a supramax-
imal stimulus. This requires a current of 3060 mA
and occasionally more [25]. Although submaximal
stimulation may yield an accurate TOFR as long as
all four responses are present [26], the accuracy of
the response is significantly decreased during partial
block and may indicate a TOFC of two or three when
it is actually four. Therefore, monitors must have
the capacity to deliver an adequate supramaximal
stimulus.
Monitors must also provide a stimulus that is of
proper pulse duration. The pulse duration as well as
the current determine the electrical charge that
is delivered to a nerve. It is the electrical charge
(current  duration) applied to a nerve that deter-
mines neural stimulation [27]. Supramaximal
stimulation is usually achieved when 3060 mA
are applied for 0.2 ms (612 mC). Increasing the
pulse duration from 0.20 to 0.30 ms will increase
the stimulus by 50%. The optimal stimulus is a
square wave of 0.2 to 0.3 ms duration. A stimulation
pulse of greater than 0.3 ms can cause repetitive
firing of the nerve. Additionally, as the pulse
duration gets longer, there is an increased likelihood
of direct muscle stimulation [28].
Monitors must also have more than 60 mA
output in the presence of 2000 V interelectrode
impedance at all frequencies [29]. Without this, they
may not consistently deliver an adequate stimulus
in the presence of changing skin resistance (impe-
dance).
Peripheral nerve stimulators are of two types;
constant voltage or constant current. Constant volt-
age devices deliver a set voltage to the patient. Thus,
either an increase in skin impedance or a partially
depleted battery will result in a decrease in the
delivered current. For this reason, peripheral nerve
stimulators should incorporate a digital ammeter to
display the delivered current. When using constant
current devices, the clinician sets the desired current
to be delivered. The unit then modifies the applied
voltage to maintain the delivered current at the set
value. If for any reason the unit cannot deliver the
predetermined current, an alarm is displayed.
Monitors must be able to provide a TOF
stimulus which is a series of four stimuli given
every 0.5 s (2 Hz).
Although these are minimal standards, they are
not found in all available monitors. The EZStim II
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(Life-Tech International, Stafford, Texas, USA; a
qualitative monitor) and the TOF-Watch (Organon
Ireland Ltd, Dublin, Ireland), which can be used as
either a qualitative or quantitative monitor, meet
these standards.
IMPLEMENTATION OF MONITORING OF
DEPTH OF NEUROMUSCULAR BLOCKADE
&
Although well respected voices [30,31,32 ] strongly
advocate the routine use of objective neuromuscular
monitors in the perioperative period, there are prac-
tical obstacles to adopting this position. Standards
for monitoring vary from one country to another,
from one institution to another and between prac-
titioners in any single institution. The reasons for
this are multifactorial and include the following:
(1) Lack of understanding as to how to correctly use
what is available,
(2) Available monitors are not ideal,
(3) Not knowing how to monitor when access to
the arms is limited,
(4) A sense that monitors are expensive, and
(5) Never having used a quantitative monitor, lack
of appreciation of the significance of discussion
of measured TOFR.
To implement routine monitoring, clinicians
have to believe that monitoring is warranted. In
spite of studies describing the frequency of post-
operative residual NMB, a survey of practitioners
in 2010 found that fewer than 12% of responding
anesthesiologists from the USA reported having
seen a patient with postoperative residual NMB in
the PACU [33].
Widespread adoption of clinical guidelines is
not easily implemented especially if clinicians
do not believe that incorporation of standardized
practices will improve the quality of care delivered
[34]. National guidelines recommending the routine
use of monitors of depth of NMB do not exist but
could motivate clinicians to consider why, when
they are administering neuromuscular blocking
agents (NMBAs), they are not using such a monitor.
Although their absence makes the obstacles to using
monitors of depth of block challenging, with con-
tinuous oversight, clinical practice can be modified
&&
[9 ,35].
The cost of neuromuscular monitors is not insig-
nificant. The least expensive monitor, the MiniStim
1B (Life-Tech International, Stafford, Texas, USA),
costs less than $300. Although widely available, it
has a maximal output of just 30 mA and can provide
only a single twitch and a tetanic stimulus. The
MiniStim IVA (Life-Tech International, Stafford,
Texas, USA), costs $320, has a maximal output of
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 Recommendations for monitoring depth of NMB Lien and Kopman
50 mA and can provide a TOF stimulus. Neither unit,
though, has a digital ammeter. In 2013, the EZStim
II unit cost $850. The acquisition cost of the TOF
Watch, a quantitative monitor, is comparable to
that of the EZStim. Recently, our department
purchased a quantitative monitor for each of
35 anesthetizing locations at a cost of just under
$40 000 including the hardware to mount the
stimulators to the anesthesia machines. The cost of
maintaining these units after instillation, though,
has not been insignificant. With replacement of
broken or lost cables, maintenance costs are expected
to be about 25% of the acquisition cost per year.
Although quantitative monitors are now com-
mercially available, none are ideal. AMG monitors
cannot be used unless the hands are freely accessi-
ble, the accuracy and reliability of kinemyographic
monitors have been questioned [36,37,38], and
neither kinemyographic nor EMG monitors are avail-
able as freestanding units. Additionally, although all
of these units will provide a TOF response, the values
provided will differ. AMG monitors tend to overesti-
mate the TOFR (as compared with the electromyo-
&&
gram or mechanomyogram) by at least 0.15 [39 ].
In spite of the challenges associated with the use
of quantitative monitors, subjective interpretation
of the response to TOF stimulation is prone to error.
Once the TOFR exceeds a value approximating 0.40,
most clinicians are unable to detect residual NMB
through either tactile or visual assessment of the
TOF response [12]. Experience with monitoring
does not improve a clinicians ability to accurately
interpret the response.
Additionally, not all muscles have the same
sensitivity to nondepolarizing NMBAs. Although
depth of NMB can be monitored with stimulation
of any superficially located neuromuscular unit,
sensitivity to NMBAs varies with the muscle being
monitored. The orbicularis oculi and corrugator
supercilii are more resistant to the effects of these
agents than the adductor pollicis [40,41]. This
means that, when monitoring for depth of NMB
at the face, the patient may appear to have signifi-
cant recovery of the TOFR; while, had monitoring
been done at the adductor pollicis, the patient
would have been found to have a greater degree
of NMB. All dosing recommendations for adminis-
tration of anticholinesterases and NMBAs have been
based on the response of the adductor pollicis to
ulnar nerve stimulation. Administering mainten-
ance doses of NMBAs based on the response of
the orbicularis oculi will likely lead to a relative
overdose of the NMBA.
Quantitative monitoring takes the guesswork
out of interpreting the evoked response to TOF
stimulation. As noted previously, the learning curve
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associated with use of these monitors is steep, but
not impossible if their use in a department is man-
&&
dated and support is provided [9 ,42]. An ongoing
educational effort, repeated statement of depart-
ment expectations, and ongoing PACU monitoring
and feedback to providers are essential for these
&&
initiatives to work [9 ,42].
DEPTH OF NEUROMUSCULAR BLOCKADE
AND SURGICAL RELAXATION: WHAT IS
ADEQUATE?
We now have considerable knowledge about the
effect of increasing depth of NMB as the TOFR/count
diminishes [4,15]. A few of these studies have
correlated the changes in neuromuscular function
with the adequacy of abdominal relaxation and
working conditions for the surgeon. de Jong
[43,44] measured twitch height by EMG in 25
patients receiving 11.6 MAC halothane, while the
surgeon estimated abdominal tone. Abdominal re-
laxation decreased as twitch height increased from
T1 of 510% of control to 5175% (the equivalent of
an increase in the TOFC from one to four with fade).
More recently, Tammisto and Olkkola [45] defined a
linear relationship between the end-tidal concen-
tration of enflurane and the degree of NMB necessary
to produce adequate surgical muscle relaxation. All
volatile anesthetics will potentiate NMBAs and can
provide adequate surgical conditions when adminis-
tered without an NMBA. King et al. [46] found that
surgical conditions were good to excellent in approxi-
mately two-thirds of patients receiving 1 MAC
isoflurane and a fentanyl infusion for a radical
retro-pubic prostatectomy and concluded that the
routine use of NMBAs in adequately anesthetized
patients may not be indicated. This is not unique
information [47,48].
Typically, complete suppression of the twitch
response to TOF stimulation is avoided so as to mini-
mize the greater challenge of effectively antagonizing
NMB. Acetylcholinesterases have a limited ability to
antagonize profound NMB [49]. There are instances
in the practice of anesthesia in which deep block (no
response to TOF stimulation) may be preferable to
moderate block (a TOFC of 13). Obtaining favor-
able intubating conditions is an obvious example
[50]. However, historically, profound levels of NMB
throughout surgery, and especially at the conclusion
of surgery, have not been advocated. With the intro-
duction of sugammadex into clinical practice,
though, there has been renewed interest in the poten-
tial indications for intraoperative maintenance of
profound block [51,52].
There are situations where one can argue that
maintaining deep block until the very end of a
www.co-anesthesiology.com 619
 Technology, education and safety
surgical procedure might enhance patient safety
and decrease morbidity. Examples include during
a general anesthetic for open-eye [53] or intracranial
surgery [54,55]. Maintaining low inflation pressures
during laparoscopic surgery may reduce postopera-
tive pain [56]. The evidence for these potential
benefits, though, is marginal at best.
MONITORING DURING MAINTENANCE OF
NEUROMUSCULAR BLOCK
The means by which conventional qualitative
monitors can reduce the incidence of postoperative
residual NMB have been well described [57,58].
There are a few basic rules that include the
following:
(1) The use of a peripheral nerve stimulator is not
optional. The TOFC at the adductor pollicis
muscle should be monitored whenever a non-
&&
depolarizing NMBA is administered [59 ].
(2) Total twitch suppression should be avoided. A
TOFC of one represents greater than 90% twitch
suppression. NMB of this depth cannot be
antagonized promptly by anticholinesterases.
(3) Neostigmine administration should be delayed
until the TOFC has returned spontaneously to
three and preferably four responses.
(4) Detectable fade on TOF stimulation indicates
grossly inadequate recovery (a TOFR < 0.40).
(5) Failure to detect tactile or visual TOF fade does
not mean that reversal is not indicated. In these
circumstances, a reduced dose of neostigmine
(0.02 mg/kg) produces reliable recovery [24,60].
(6) The availability of sugammadex as a reversal
agent does not obviate the need for monitoring
&& &&
[22 ,61 ]. The appropriate dose of sugamma-
dex is determined by a patients response to TOF
and post-tetanic stimulation.
The above remarks are not meant to imply that
quantitative monitoring cannot be very helpful.
Quantitative monitors provide more precise infor-
mation than qualitative monitors and that infor-
mation is especially useful when monitoring
recovery of neuromuscular function, such as:
(1) Ten minutes after antagonism at a TOFC of one,
no fade in the TOFR is appreciated. Is it safe to
extubate this patients trachea? The actual TOFR
under these circumstances can only be deter-
mined with a quantitative monitor [62].
(2) Four hours after administration of a single
dose of an intermediate-acting NMBA, surgery
is finished. Should the patient receive neo-
stigmine? Use of a quantitative monitor when
there are four equal responses to TOF
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stimulation is the only way to determine if
&
reversal should be attempted [60,63 ]. If the
patients muscle strength has fully recovered,
administration of an anticholinesterase may
actually induce weakness [64].
ROUTINE USE OF QUANTITATIVE
MONITORS
The argument for routine quantitative monitoring
of neuromuscular function is based on several fun-
damental truths. First, as noted previously, qualita-
tive assessment of the TOF response is remarkably
insensitive. Even assessment of the TOFC is not
consistently accurate when assessing response to
TOF stimulation [65]. With tactile assessment of
the TOFC, critical care nurses accurately determined
the response to stimulation in only 54% of the
assessments made, and in 17% of assessments, the
response was found to be either two twitches greater
or less than measured by AMG.
Second, recovery to a TOFR of at least 0.9 occurs
more slowly than recovery to a TOFR of 0.7 and it
may occur with more patient variability. Following
antagonism of rocuronium or cisatracurium-
induced NMB at a TOFC of 2 with 50 mg/kg neo-
stigmine, patients have, on average, a TOFR greater
than 0.7 within 10 min and on admission to the
PACU, all have a TOFR greater than 0.7 [58]. In
contrast, recovery to a TOFR of at least 0.9 requires
on average 20 min and as much as 70 min following
administration of 70 mg/kg neostigmine at a TOFC
of 2 [23]. Finally, reliable and effective antagonism
of residual NMB by anticholinesterases at even more
profound levels of block (TOFC <2) is not possible
[66].
Use of a quantitative monitor to guide the tim-
ing of tracheal extubation decreases the risk of both
residual NMB and postoperative critical respiratory
&
events [5,20 ,62,67]. Administration of neostigmine
is not without potential adverse effects. In addition
to the commonly cited risk of bradyarrhythmias,
unnecessary administration of neostigmine can
cause partial NMB [68] and is a reason that decreased
doses of neostigmine are recommended to antagon-
ize more subtle degrees of block [60].
CONCLUSION
The routine use of qualitative and quantitative
neuromuscular monitors allows titration of depth
of NMB so that residual block can be rapidly and
effectively antagonized at the end of a surgical
procedure. However, objective monitoring is clearly
more helpful when trying to answer two basic
clinical questions:
(1) Is reversal of residual block necessary?
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 Recommendations for monitoring depth of NMB Lien and Kopman
(2) Is the degree of neuromuscular recovery com-
patible with safe tracheal extubation?
Even with this additional information, quanti-
tative monitors will produce superior results only if
anesthesiologists are willing to delay extubation in
the operating room and keep their patients asleep
until adequate recovery occurs [69].
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Carter JA, Arnold R, Yate PM, Flynn PJ. Assessment of the Datex Relaxograph
during anesthesia and atracurium induced neuromuscular blockade. Br J
Anaesth 1986; 58:14471452.
2. Jensen E, Viby-Mogensen J, Bang U. The accelograph: a new neuromuscular
transmission monitor. Acta Anaesthesiol Scand 1988; 32:4952.
3. Motamed C, Kirov K, Combes X, Duvaldestin P. Comparison between the
Datex-Ohmeda M-NMT module and a force-displacement transducer for
monitoring neuromuscular blockade. Eur J Anaesthesiol 2003; 20:467
469.
4. Kopman AF, Yee PS, Neuman GG. Correlation of the train-of-four fade ratio
with clinical signs and symptoms of residual curarization in awake volunteers.
Anesthesiology 1997; 86:765771.
5. Eikermann M, Groeben H, Husing J, Peters J. Accelerometry of adductor
pollicis muscle predicts recovery of respiratory function from neuromuscular
blockade. Anesthesiology 2003; 98:13331337.
6. Eriksson LI, Sundman E, Olsson R, et al. Functional assessment of the pharynx
at rest and during swallowing in partially paralyzed humans: simultaneous
videomanometry and mechanomyography of awake human volunteers. An-
esthesiology 1997; 87:10351043.
7. Yip PC, Hannam JA, Cameron AJ, Campbell D. Incidence of residual neu-
romuscular blockade in a postanaesthetic care unit. Anaesth Intensive Care
2010; 38:9195.
8. Esteves S, Martins M, Barros F, et al. Incidence of postoperative residual
& neuromuscular blockade in the postanaesthesia care unit: an observational
multicentre study in Portugal. Eur J Anaesthesiol 2013; 30:243249.
This is a study of 350 patients, men and women, admitted to the PACU after either
propofol or sevoflurane anesthesia and NMB with an intermediate-acting NMBA.
Ninety-one patients arrived in the PACU with a TOFR of less than 0.9. The
frequency of inadequate recovery was greater in the patients who had received
propofol than in those who had received sevoflurane.
9. Todd MM, Hindman BJ, King BJ. The implementation of quantitative electro-
&& myographic neuromuscular monitoring in an academic anesthesia depart-
ment. Anesth Analg 2014; 119:323331.
Introduction of a quantitative monitor, an EMG, as a required monitor in patients
receiving NMBAs required continuous oversight, ongoing education and
repeated feedback but resulted in a decrease in the frequency with which
patients were admitted to the PACU with incomplete recovery of neuromuscular
function.
10. Fezing AK, dHollander A, Boogaerts JG. Assessment of the postoperative
residual curarisation using the train of four stimulation with acceleromyogra-
phy. Acta Anaesthesiol Belg 1999; 50:8386.
11. Kim KS, Lew SH, Cho HY, Cheong MA. Residual paralysis induced by either
vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg
2002; 95:16561660.
12. Viby-Mogensen J, Jensen NH, Engbaek J, et al. Tactile and visual evaluation of
the response to train-of-four nerve stimulation. Anesthesiology 1985;
63:440443.
13. Thilen SR, Hansen BE, Ramaiah R, et al. Intraoperative neuromuscular
monitoring site and residual paralysis. Anesthesiology 2012; 117:964
972.
14. Beemer GH, Rozental P. Postoperative neuromuscular function. Anaesth
Intensive Care 1986; 14:4145.
0952-7907 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
15. Heier T, Caldwell JE, Feiner JR, et al. Relationship between normalized
adductor pollicis train-of-four ratio and manifestations of residual neuro-
muscular block: a study using acceleromyography during near steady-state
concentrations of mivacurium. Anesthesiology 2010; 113:825832.
16. Murphy GS, Szokol JW, Marymount JH, et al. Residual neuromuscular
blockade and critical respiratory events in the postanesthesia care unit.
Anesth Analg 2008; 107:130137.
17. Kumar GV, Nair AP, Murthy HS, et al. Residual neuromuscular blockade affects
postoperative pulmonary function. Anesthesiology 2012; 117:12341244.
18. Sauer M, Stahn A, Soltesz S, et al. The influence of residual neuromuscular
block on the incidence of critical respiratory events. A randomised, prospec-
tive, placebo-controlled trial. Eur J Anaesthesiol 2011; 28:842848.
19. Hardemark Cedborg AI, Sundman E, Boden K, et al. Pharyngeal function and
&& breathing pattern during partial neuromuscular block in the elderly: effects on
airway protection. Anesthesiology 2014; 120:312325.
Partial neuromuscular block in healthy elderly individuals causes an increased
incidence of pharyngeal dysfunction from 37 to 71%, with impaired ability to
protect the airway.
20. Murphy GS, Szokol JW, Avram MJ, et al. Postoperative residual neuromus-
& cular blockade is associated with impaired clinical recovery. Anesth Analg
2013; 117:133141.
Patients who arrive in the PACU with TOFR less than 0.90 are more likely to have
subjective symptoms of muscular weakness.
21. Phillips S, Stewart PA, Bilgin AB. A survey of the management of neuromus-
cular blockade monitoring in Australia and New Zealand. Anaesth Intensive
&
Care 2013; 41:374379.
Survey of 677 anesthetists. Thirty-five percent of respondents never or rarely
monitor neuromuscular function in the operating room. Only 17% often employ
peripheral nerve stimulators.
22. Kotake Y, Ochiai R, Suzuki T, et al. Reversal with sugammadex in the absence
&& of monitoring did not preclude residual neuromuscular block. Anesth Analg
2013; 117:345351.
In Japan, routine clinical care does not normally involve the use of a monitoring
device to guide the administration of neuromuscular blocking drugs or their
antagonists. This study demonstrated that the risk of a TOFR less than 0.9 after
tracheal extubation after sugammadex remains as high as 9.4% in a clinical setting
in which neuromuscular monitoring (objective or subjective) was not used. The
study underscores the importance of neuromuscular monitoring even when
sugammadex is used for antagonism of rocuronium-induced neuromuscular block.
23. Kirkegaard H, Heier T, Caldwell JE. Efficacy of tactile-guided reversal from
cisatracurium-induced neuromuscular block. Anesthesiology 2002; 96:45
50.
24. Fuchs-Buder T, Meistelman C, Alla F, et al. Antagonism of low degrees of
atracurium-induced neuromuscular blockade: dose effect relationship for
neostigmine. Anesthesiology 2009; 112:3440.
25. Helbo-Hansen HS, Bang U, Nielson HK, Skovgaard LT. The accuracy of train
of four monitoring at various stimulation currents. Anesthesiology 1992;
76:199203.
26. Brull SJ, Ehrenwerth J, Silverman DG. Stimulation with submaximal current for
train-of-four monitoring. Anesthesiology 1990; 72:629632.
27. Mylrea KC, Hameroff SR, Calkins JM, et al. Evaluation of peripheral nerve
stimulators and relationship to possible errors in assessing neuromuscular
blockade. Anesthesiology 1984; 60:464466.
28. Mortimer JT. Motor prosthesis. In: Brooks VB, editor. American handbook
of physiology, Supplement 2. Hoboken, New Jersey: Wiley-Blackwell; 1981.
pp. 155187.
29. Pierce PA, Mylrea KC, Watt RC, et al. Effects of pulse duration on neuro-
muscular blockade monitoring: implications for supramaximal stimulation.
J Clin Monit 1986; 2:169173.
30. Viby-Mogensen J. Postoperative residual curarization and evidence-based
anaesthesia. Br J Anaesth 2000; 84:301303.
31. Eriksson LI. Evidence-based practice and neuromuscular monitoring: its time
for routine quantitative assessment. Anesthesiology 2003; 98:10371039.
32. El-Orbany M, Ali HH, Baraka A, Salem MR. Residual neuromuscular block
& should, and can, be a never event. Anesth Analg 2014; 118:691.
The authors strongly urge the adoption of objective (quantitative) monitoring of
neuromuscular transmission as a standard guiding tracheal extubation decisions.
They ask all anesthesia societies (national and international) to create practice
guidelines/standards governing the clinical management and monitoring of NMB.
33. Naguib M, Kopman AF, Lien CA, et al. A survey of current neuromuscular
practice in the United States and Europe. Anesth Analg 2010; 111:110
119.
34. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic
review of theoretic concepts, practical experience and research evidence in
the adoption of clinical practice guidelines. CMAJ 1997; 157:408416.
35. Baillard C, Clech C, Catineau J, et al. Postoperative residual neuromuscular
block: a survey of management. Br J Anaesth 2005; 95:622626.
36. Hemmerling TM, Donati F. The M-NMT mechanosensor cannot be considered
as a reliable clinical neuromuscular monitor in daily anesthesia practice.
Anesth Analg 2002; 95:18262182.
37. Motamed C, Bourgain JL, DHollander A. Survey of muscle relaxant effects
management with a kinemyographic-based data archiving system: a retro-
spective quantitative and contextual quality control approach. J Clin Monit
Comput 2013; 27:669676.
www.co-anesthesiology.com 621
 Technology, education and safety
38. Stewart PA, Freelander N, Liang S, et al. Comparison of electromyography
and kinemyography during recovery from nondepolarizing neuromuscular
blockade. Anaesth Intensive Care 2014; 42:378384.
39. Liang SS, Stewart PA, Phillips S. An ipsilateral comparison of acceleromyo-
&& graphy and electromyography during recovery from nondepolarizing neuro-
muscular block under general anesthesia in humans. Anesth Analg 2013;
117:373379.
This article confirms that AMG monitors overestimate the extent of TOFR recovery
(when compared with gold standard such as the EMG) by a value of 0.15 on
average. Residual neuromuscular block cannot be excluded on reaching an AMG
TOFR of 1.00.
40. Donati F, Meistelman C, Plaud B. Vecuronium neuromuscular blockade at the
adductor muscles of the larynx an adductor pollicis. Anesthesiology 1991;
74.:833837.
41. Hemmerling TM, Schmidt J, Hanusa C, et al. Simultaneous determination of
neuromuscular block at the larynx, diaphragm, adductor pollicis, orbicularis
oculi and corrugator supercilii muscles. Br J Anaesth 2000; 85:856860.
42. Baillard C, Gehan G, Reboul-Marty J, et al. Residual curarization in the
recovery room after vecuronium. Br J Anaesth 2000; 84:394395.
43. de Jong RH. Controlled relaxation. I. Clinical management of muscle-relaxant
administration. JAMA 1966; 197:113115.
44. de Jong RH. Controlled relaxation. II Clinical management of muscle-relaxant
administration. JAMA 1966; 198:11631166.
45. Tammisto T, Olkkola KT. Dependence of the adequacy of muscle relaxation on
the degree of neuromuscular block and depth of enflurane anesthesia during
abdominal surgery. Anesth Analg 1995; 80:543547.
46. King M, Sujirattanawimol N, Danielson DR, et al. Requirements for muscle
relaxants during radical retro-pubic prostatectomy. Anesthesiology 2000;
93:13921397.
47. Chen B, Tan L, Zhang L, Shang Y. Is muscle relaxant necessary in patients
undergoing laparoscopic gynecological surgery with a ProSeal LMATM? J Clin
Anesth 2013; 25:3235.
48. Li Y, Liu Y, Xu C, et al. The effects of neuromuscular blockade on operating
conditions during general anesthesia for spinal surgery. J Neurosurg Anesthe-
siol 2014; 26:4549.
49. Beemer GH, Bjorksten AR, Dawson PJ, et al. Determinants of the reversal time
of competitive neuromuscular block by anticholinesterases. Br J Anaesth
1991; 66:469475.
50. Mencke T, Echternach M, Kleinschmidt S, et al. Laryngeal morbidity and
quality of tracheal intubation: a randomized controlled trial. Anesthesiology
2003; 98:10491056.
51. Geldner G, Niskanen M, Laurila P, et al. A randomized controlled trial
comparing sugammadex and neostigmine at different depths of neuromus-
cular blockade in patients undergoing laparoscopic surgery. Anaesthesia
2012; 67:991998.
52. Dubois PE, Mulier JP. A review of the interest of sugammadex for deep
neuromuscular blockade management in Belgium. Acta Anaesthesiol Belg
2013; 64:4960.
53. von Quillfeldt S, Fohre B, Andrees N, et al. Rocuronium reversed by sugam-
madex versus mivacurium during high-risk eye surgery: an institutional anaes-
thetic practice evaluation. J Int Med Res 2013; 41:17401751.
54. Werba A, Klezl M, Schramm X, et al. The level of neuromuscular block needed
to suppress diaphragmatic movement during tracheal suction in patients with
raised intracranial pressure: a study with vecuronium and atracurium. Anaes-
thesia 1993; 48:301303.
55. Fernando PUE, Viby-Mogensen J, Bonsu AK, et al. Relationship between
posttetanic count and response to carinal stimulation during vecuronium-
induced neuromuscular blockade. Acta Anaesthiol Scand 1987; 31:593
596.
622 www.co-anesthesiology.com
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
56. Yasir M, Mehta KS, Banday VH, et al. Evaluation of post operative shoulder tip
pain in low pressure versus standard pressure pneumoperitoneum during
laparoscopic cholecystectomy. Surgeon 2012; 10:7174.
57. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part
II: methods to reduce the risk of residual weakness. Anesth Analg 2010;
111:129140.
58. Kopman AF, Zank LM, Ng J, Neuman GG. Antagonism of cisatracurium and
rocuronium block at a tactile train-of-four count of 2: should quantitative
assessment of neuromuscular function be mandatory? Anesth Analg 2004;
98:102106.
59. Pietraszewski P, Gasynski T. Residual neuromuscular block in elderly patients
&& after surgical procedures under general anaesthesia with rocuronium. Anaes-
thesiol Intensive Ther 2013; 45:7781.
A cautionary tale from Poland. A large observational study (N 415) in which
neuromuscular monitoring was not used intraoperatively and residual rocuronium
block was not reversed with neostigmine. Sixty-six percent of patients above the
age of 65 arrived in the PACU with TOF ratios less than 0.70. In younger
individuals the incidence of TOF ratios less than 0.70 was still 20%. Only 11
and 2% of patients, respectively, arrived in the PACU with TOF ratios of 0.90 or
higher.
60. Fuchs-Buder T, Meistelman C, Alla F, et al. Antagonism of low degrees of
atracurium-induced neuromuscular blockade: dose-effect relationships for
neostigmine. Anesthesiology 2010; 112:3440.
61. Donati F. Residual paralysis: a real problem or did we invent a new disease?
&& Can J Anaesth 2013; 60:714729.
Review. Although sugammadex has enormous advantages over neostigmine, it
cannot be hailed as a magic drug that will prevent all problems. Meticulous
management of NMB appears to be far safer and a more effective and cost-
conscious approach than indiscriminate use of reversal agents. Neuromuscular
monitoring throughout the anesthetic is an essential part of anesthetic manage-
ment.
62. Kopman AF, Sinha N. Acceleromyography as a guide to anesthetic manage-
ment: a case report. J Clin Anesth 2003; 15:145148.
63. Pongracz A, Szatmari S, Nemes R, et al. Reversal of neuromuscular blockade
& with sugammadex at the reappearance of four twitches to train-of-four
stimulation. Anesthesiology 2013; 119:3642.
Residual rocuronium-induced NMB at the reappearance of the fourth twitch in
response to TOF stimulation can be reversed within 5 min by 1.0 and 2.0 mg/kg of
sugammadex. A sugammadex dose of 0.5 mg/kg can reverse such residual NMB in
less than 10 min. The TOF count allows precise estimation of the dose of
sugammadex required for prompt and adequate reversal of rocuronium.
64. Caldwell JE. Reversal of residual neuromuscular block with neostigmine at
one to four hours after a single intubating dose of vecuronium. Anesth Analg
1995; 80:11681174.
65. Greer R, Harper NJN, Pearson AJ. Neuromuscular monitoring by intensive
care nurses: comparison of acceleromyography and tactile assessment. Br J
Anaesth 1998; 80:384385.
66. Bevan JC, Collins L, Fowler C, et al. Early and late reversal of rocuronium and
vecuronium with neostigmine in adults and children. Anesth Analg 1999;
89:333339.
67. Murphy GS, Szokol JW, Marymount JH, et al. Intraoperative acceleromyo-
graphy monitoring reduces the risk of residual neuromuscular blockade and
adverse respiratory events in the postanesthesia care unit. Anesthesiology
2008; 109:389398.
68. Caldwell JE. Reversal of residual neuromuscular block with neostigmine at
one to four hours after a single intubating dose of vecuronium. Anesth Analg
1995; 80:11681174.
69. Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postopera-
tive residual curarization. Br J Anaesth 2007; 99:297299.
Volume 27
Number 6
December 2014