A Practical, Evidence-Based Framework for Reducing Residual Neuromuscular Block and Standardizing Perioperative Neuromuscular Management

Residual neuromuscular block remains a common and preventable patient safety challenge in anesthesia. Despite advances in drugs, reversal agents, and clinical guidelines, incomplete recovery persists because many institutions still rely on subjective assessments rather than objective measurement. 

This white paper proposes a practical, evidence-based framework for developing a best-in-class institutional protocol for quantitative neuromuscular monitoring. The protocol is intentionally broader than a dosing algorithm. It addresses technology selection, baseline measurement, induction readiness, maintenance dosing of neuromuscular blocking agents (NMBAs), deep block management, reversal (antagonism) strategy and agents, extubation criteria, documentation, performance metrics, and implementation science. 

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