Key points of the new guidelines for neuromuscular blockade management

Two of the leading anesthesia societies in the world have almost simultaneously and independently developed and published guidelines for neuromuscular blockade management. In short, the message is clear: Quantitative monitoring of neuromuscular blockade is vital for patients undergoing anesthesia.

The two societies, the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC), are calling for widespread adoption of the guidelines. But what do these new guidelines include? This article will give you an overview of the key points of the guidelines.

Both the ESAIC and the ASA guidelines are intended to provide evidence-based recommendations to assist you as a clinician, to provide best medical care and to ensure patient safety. 

In short, the ESAIC guidelines includes the following recommendations concerning monitoring:

• Recommendation of the use of ulnar nerve stimulation and quantitative neuromuscular monitor at the adductor pollicis muscle to exclude residual paralysis.
• Quantitative neuromuscular monitoring is needed regardless of type of neuromuscular blocking drug used
• Quantitative neuromuscular monitoring is needed regardless of type of reversal used (neostigmine, sugammadex or spontaneous recovery)
• A TOF ratio at least 0.9 is the minimum neuromuscular recovery required before extubation
• When raw (uncalibrated and nonnormalised) AMG (acceleromyographic) TOF ratios are used, the threshold should be 1.0
• One monitor in each single operating theatre

When it comes to the guidelines from ASA, there are many similarities with the ESAIC guidelines. Here are the key points:

• Strong recommendation against clinical assessment alone to avoid residual neuromuscular blockade
• Strong recommendation for quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade
• Strong recommendation to confirm a train-of-four ratio ≥ 0.9 prior to extubation when using a quantitative monitor
• Strong recommendation for using the adductor pollicis muscle for neuromuscular monitoring
• Strong recommendation against using facial muscles for neuromuscular monitoring
• Patients with adequate spontaneous recovery to train-of-four ratio ≥ 0.9 can be identified with quantitative monitoring and these patients do not require pharmacological antagonism

It’s great to see these strong recommendations for using quantitative neuromuscular monitoring. This will help to eliminate post-operative complications that millions of patients have been affected by for many years.

Not only are the actual guidelines out, the two societies have also joined forces through a joint letter calling for implementing quantitative neuromuscular blockade monitoring on a wide scale.

The joint letter includes these concrete ways to start the transition into quantitative neuromuscular monitoring:

1. Restructure the clinical environment by placing quantitative monitors in all anesthetizing locations
2. Employ education efforts in anesthesia departments and with individual physicians
3. Provide performance feedback in the department and for individual physicians
4. Appoint a local champion who is supported by leaders

To summarize, the guidelines clearly state the need for implementation of quantitative neuromuscular monitoring. Where are you in your transition journey towards safer patient care? What are your next steps? What kind of technology are you using?

It can be a daunting task to change practice, but in the end it’s all about patient safety.

Your patients deserve the best possible care and quantitative monitoring will help you achieve that.

If you want to read the complete guidelines, follow these links: