[Monitoring of neuromuscular blocking]

Neuromuscular blockade monitoring aims should be based on effectiveness criteria, that is, to administer the lowest effective dose, and on security criteria, avoiding overdosage and detecting possible residual blockade before patient extubation. A neuromuscular blockade monitoring and usage protocol should be available with predefined objectives for each patient to achieve the minimum effective doses. Maintenance of a light blockade level probably influences the decrease in complications associated with these drugs' use. Train-of-four monitoring, along with muscular movement detection allow adjustment to meet these aims. Ulnar nerve stimulation with response detection in the adductor pollicis muscle is the recommended neurostimulation in critically ill patients, while facial neurostimulation is recommended in situations where edema or skin temperature prevent correct ulnar nerve stimulation. Ensuring adequate sedation and analgesia in a paralysed patient is essential. An inadequately sedated but paralysed patient may subsequently suffer serious psychological and emotional stress. Bispectral index monitoring with sedative doses adjusted to 40-60 values assures, in most situations, correct sedation.