Current recommendations for preventing residual neuromuscular blockade

The use of neuromuscular blocking agents (NMBAs) offers several advantages during surgery under general anesthesia because they help secure the surgical field and facilitate appropriate mechanical ventilation. Eliminating postoperative residual neuromuscular blockade (rNMB) remains a major challenge for anesthesiologists. Despite the use of intermediate-acting NMBAs and sugammadex, the incidence of rNMB still remains close to 50%. Although it is relatively easy to distinguish rNMB from a serious adverse reaction in healthy patients in the postanesthesia care unit, the effects of anesthesia make it much more difficult to rule out rNMB in critically ill patients. Although there were no comprehensive guidelines for NMBA management for decades, the most crucial step is now no longer the assessment of blockade depth based on subjective clinical tests or qualitative neuromuscular monitoring (NMM), but rather the appropriate use of NMBAs and reversal agents, and extubation guided by objective, quantitative monitoring. Accordingly, the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care have published practical guidelines for preventing rNMB over the past five years, recommending appropriate use of NMBAs and reversal agents and the incorporation of quantitative NMM as standard monitoring whenever NMBAs are used. Furthermore, with recent advances in electromyography and the increasing availability of NMM, education on its proper use is essential.