Postoperative Residual Paralysis-What it is, How to Recognize it, and How to Treat it: Evidence-based Summary

To summarize the evidence on postoperative residual paralysis: what it is, how to recognize it, and how to intervene if suspected.

This is a summary of the best evidence on postoperative residual paralysis.

Databases such as PubMed, Embase, CINAHL, and a University digital library were searched to collect the relevant guidelines for professional practice change, clinical practice update, systematic review, meta-analysis, evidence summary, and expert consensus about postoperative residual paralysis. The retrieval time was from June 2022 to December 2024. A reviewer evaluated the quality of the literature included and extracted and summarized the evidence that met the quality criteria. Randomized controlled trials were assessed utilizing the Cochrane RoB2 bias assessment tool and all extracted literature received a level of evidence grade via the Johns Hopkins Evidence-based Model for Nursing and Healthcare Professionals.

An initial search resulted in a total of 5,072 articles for review. A total of 22 studies, including 1 professional practice change, 1 clinical practice update, 1 expert consensus statement, 2 prospective observational studies, 1 retrospective observational study, 13 randomized controlled trials, 1 systematic review, and 2 meta-analyses, were included in the final assessment. The summary of evidence demonstrated (1) sugammadex administration reduced the incidence of postoperative residual paralysis when compared to neostigmine administration, (2) sugammadex provides a complete recovery of expiratory muscle strength compared to neostigmine, (3) time to recovery with a train-of-four ratio greater than or equal to 0.9 is faster with sugammadex administration, and (4) quantitative (objective) neuromuscular monitoring is superior to qualitative (subjective) neuromuscular monitoring.

Administration of sugammadex reversal appears to decrease the incidence of postoperative residual paralysis more efficiently than neostigmine with glycopyrrolate administration. However, it does not necessarily decrease the overall incidence of pulmonary complications compared to neostigmine with glycopyrrolate. Evidence emphasizes that the most important steps to reduce postoperative residual paralysis are to administer a reversal agent even if spontaneous muscle recovery has been achieved and to monitor a patient's train-of-four ratio with quantitative, not qualitative, neuromuscular monitoring.