[Algorithm-based preventive strategies for avoidance of residual neuromuscular blocks]

Area of Science:

• Anesthesiology and Perioperative Medicine
• Pharmacology
• Critical Care Medicine

Background:

• Postoperative residual neuromuscular block (defined as a train of four ratio <0.9) is a significant complication in balanced anesthesia.
• This condition is associated with increased postoperative morbidity and mortality.
• Current strategies to mitigate this risk include using shorter-acting muscle relaxants, quantitative neuromuscular monitoring, and pharmacological reversal.

Purpose of the Study:

• To evaluate the feasibility and effectiveness of integrating quantitative neuromuscular monitoring and pharmacological reversal into a pragmatic algorithm to reduce residual neuromuscular block.
• To assess the impact of this integrated approach on paralysis-associated complications.

Main Methods:

• A selective literature search was conducted in PubMed.
• Guidelines from national specialist societies were reviewed.
• The search focused on terms related to neuromuscular block, monitoring, and reversal agents.

Main Results:

• The incidence of residual neuromuscular block can be as high as 93% without intervention.
• Calibrated acceleromyography accurately identifies residual relaxation (97% negative predictive value).
• Pharmacological reversal with neostigmine reduced incidence to 15.4% (3.3% with acceleromyography); sugammadex nearly eliminated it.
• Quantitative monitoring and reversal can be integrated into a stage-based algorithm.

Conclusions:

• An algorithm combining quantitative neuromuscular monitoring with pharmacological reversal (neostigmine or sugammadex) can effectively manage residual neuromuscular block within 10 minutes before extubation.
• Mandatory quantitative monitoring and educational programs are crucial for implementing modern muscle relaxant management.
• Recommendations for integrating these practices into guidelines are encouraged.