Neuromuscular Blocking Agents in Anesthesia: A Narrative Review of Contemporary Challenges and Reversal Approaches

Medical errors are inevitable and will happen to almost every specialist. In anesthesiology, one of the main concerns is the inappropriate application of muscle relaxants (MRs). As this group of drugs plays a significant role in facilitating endotracheal intubation and optimizing surgical conditions, it is widely and commonly used in the medical field. To prevent residual neuromuscular block, anesthesiologists may pharmacologically reverse the neuromuscular block (NMB) by administering reversal agents. Lately, sugammadex is becoming more popular due to its ability to reverse various levels of NMB more rapidly than traditionally used acetylcholinesterase inhibitors such as neostigmine. The common challenges and errors associated with the administration of neuromuscular blocking agents (NMBAs) and muscle reversal agents include the absence of neuromuscular monitoring, underestimation of the residual block (RB), misinterpretation of DUR25, inappropriate size descriptors for muscle relaxants and reversal agents requiring weight-based dosing, the wrong dosing of rocuronium, poor usage of cisatracurium among patients with renal or hepatic failure, and the wrong usage of succinylcholine. Another source of mistakes may be inaccurate knowledge about the pharmacokinetics and pharmacodynamics of the administered drugs. Medication errors may occur not only when it comes to the usage of muscle relaxants but also with the use of reversal agents, including lack of neuromuscular monitoring, choosing the wrong antagonist strategy, "too early" administration of neostigmine, inappropriate dosing, and insufficient knowledge about drug interactions. Improving the knowledge of administered drugs and adhering to the latest recommendations could prevent many complications. This article aims to review the current challenges in the use of muscle relaxants and reversal agents in anesthesia.