Advances in Neuromuscular Monitoring Techniques in Anesthesiology: A 2025 Perspective

Residual neuromuscular blockade occurs in 20-40% of patients following the use of neuromuscular blocking agents (NMBAs) during general anesthesia, with the potential for serious complications. Despite the publication of formal guidelines, routine objective neuromuscular monitoring remains underused in many clinical settings, often due to misconceptions about its necessity, time constraints, and lack of equipment. However, clinical signs alone, such as the ability to perform basic motor tasks, are unreliable, especially in vulnerable populations. Objective methods like acceleromyography (AMG), mechanomyography (MMG), and electromyography (EMG) provide accurate measurements but may still face challenges like artifacts and technological limitations. In 2024, several significant advances were made in this field, including new reviews on the use of neuromuscular blockade in special clinical situations, comparisons of train-of-four (TOF) Scan and TOF-Cuff in different locations, and the development of new device prototypes. Briefly, in clinical practice, the predominant method is acceleromyography, although it is associated with high variability and systematic measurement error. Compressomyography, which also enables simultaneous blood pressure measurement, is of secondary importance. Kinemyography, sonomyography, and sonomechanomyography are rarely used alternatives to the more commonly employed techniques. Despite the abundance of methods and devices, the use of neuromonitoring in clinical practice worldwide remains low. Studies indicate that clinician education alone does not increase the frequency of neuromonitoring in clinical settings. However, a multifaceted intervention - including equipment trials, educational videos, quantitative monitors in all anesthetizing locations, electronic clinical decision support with real-time alerts, and ongoing professional practice metrics - has proven to be effective.