Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review

Abstract

Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.

Keywords: anesthesia; neuromuscular blocking agent; perioperative care; quantitative monitoring; residual neuromuscular block.

Figure 3

Online simulation course depiction of a quantitative EMG neuromuscular monitor (Adapted with permission from Ref. [37] 2023, APSF).

Figure 1

Neuromuscular junction: (A) normal; (B) activity of depolarizing neuromuscular blocking agent; (C) activity of nondepolarizing neuromuscular blocking agent as well as the activity of both neuromuscular blockade reversal agents (i.e., sugammadex and acetylcholinesterase inhibitors) [6,7,8,9,10].

Figure 2

Pharmacokinetics of nondepolarizing agents. Factors that increase the duration of these agents include dosing, age >65 years, hepatic and renal disease, hypothermia, inhaled anesthetics, and medications including but not limited to antibiotics, antidepressants, magnesium, and antiepileptics. The ranges provided for onset and duration times are exclusionary of outliers [11,12,13,14,15,16,17,18,19,20,21,22,23].

Figure 4

The various types of monitoring and the suggested threshold TOFR equivalent. These TOFR ratio cutoffs are approximate ranges and vary based on different studies performed. The “X” denotes the threshold in which the literature reports reliable detection of the respective TOFR equivalent. Providers should use their own clinical judgement when treating patients [6,34,46,53].