What rules of thumb do clinicians use to decide whether to antagonize nondepolarizing neuromuscular blocking drugs?

In anesthesia practice, inadequate antagonism of neuromuscular blocking drugs (NMBD) may lead to frequent prevalence of residual neuromuscular block that is associated with morbidity and death. In this study we analyzed the clinical decision on antagonizing NMBD to generate hypotheses about barriers to the introduction of experts' recommendations into clinical practice.

Sequential surveys were conducted among 108 clinical anesthesiologists to elicit the rules of thumb (heuristics) that support their decisions and provide a measurement of the confidence the clinicians have in their own decisions in comparison with their peers' decisions.

The 2 most frequently used heuristics for administering reversal were "the interval since the last NMBD dose was short" and "the breathing pattern is inadequate," chosen by 73% and 71% of the clinicians, respectively. Clinicians considered that the prevalence of clinically significant residual block is higher in their colleagues' practices than in their own practice (60% vs 16%, odds ratio=7.8, 95% confidence interval, 3.8 to 16.2, P=0.0001). The clinicians were less likely to use antagonists if >60 minutes had elapsed after a single dose of atracurium (0.5 mg/kg) (31%) in comparison with after rocuronium 0.6 mg/kg (53%) (P=0.0035).

In our institution, the clinical decision to antagonize NMBD is mainly based on the pharmacological forecast and a qualitative judgment of the adequacy of the breathing pattern. Clinicians judge themselves as better skilled at avoiding residual block than they do their colleagues, making them overconfident in their capacity to estimate the duration of action of intermediate-acting NMBD. Awareness of these systematic errors related to clinical intuition may facilitate the adoption of experts' recommendations into clinical practice.