Across Europe and the United States, professional anesthesia societies are rewriting guidelines to highlight objective, quantitative neuromuscular monitoring as the new standard of care. But what’s driving the change?

Despite major progress in airway management and perioperative safety, postoperative residual neuromuscular blockade (rNMB) remains strikingly common when no monitoring or only subjective qualitative assessment is used. Multiple studies in both the EU and the US continue to show PACU rNMB rates of 20–40% (1), levels that conflict with patient-safety expectations.

Previous barriers to widespread adoption have largely been addressed. Modern electromyography (EMG)-based devices now provide:

• Stable signal acquisition
• Portability
• Reliability even with arm-tucking
• Simple, intuitive workflows that reduce cognitive load

Senzime’s Next-Generation TetraGraph®, for example, offers a Level-of-Block Gauge that visualizes depth of block, recovery, and train-of-four (TOF) progression - helping clinicians confidently confirm recovery at train-of-four ratio (TOFR) ≥ 0.90 before extubation.

Reversal decisions and reversal dosing directly affect patient safety. Updated guidelines increasingly emphasize:

• Dosing based on TOF ratio and TOF count
• Confirming TOFR ≥ 90% prior to extubation
• Avoiding time-based reversal
• Recognizing the risks of inaccurate dosing, especially with the widespread use of sugammadex

Quantitative monitoring provides the objective data needed to help prevent both under-dosing and over-dosing with reversal agents.

European anesthesia societies, such as the European Society of Anaesthesia & Intensive Care (2), have taken a bold position on quantitative monitoring. Current guidelines emphasize that:

• Quantitative monitoring is strongly recommended for all neuromuscular blocking agent (NMBA) use
• Qualitative assessment cannot confirm recovery and should not be relied on for extubation decisions
• System-level adoption is expected
• Quantitative monitoring is considered essential for safe anesthesia practice

This collective stance reflects a broad European commitment to standardized, objective neuromuscular management.

The American Society of Anesthesiology (ASA) (3) and Anesthesia Patient Safety Foundation (APSF) both emphasize that:

•  Quantitative monitoring is the most reliable method of assessing recovery
• A TOFR ≥ 0.90 is required before extubation
• EMG is preferred when the arm is inaccessible
• Implementation should be supported at the institutional level
• They now strongly recommend quantitative monitoring

The direction of neuromuscular block management is unmistakable: objective monitoring is becoming the expected standard.

1. Aragón-Benedí, C., Falcón-Arana, L., Soro, M., Monge-García, M. I., & Calvo-Vecino, J. M. (2022). Incidence of postoperative residual neuromuscular blockade using quantitative monitoring: A prospective observational study. Scientific Reports, 12(1), 1–8.
    
2. Fuchs-Buder, Thomas; Romero, Carolina S.; Lewald, Heidrun; Lamperti, Massimo; Afshari, Arash; Hristovska, Ana-Marjia; Schmartz, Denis; Hinkelbein, Jochen; Longrois, Dan; Popp, Maria; de Boer, Hans D.; Sorbello, Massimiliano; Jankovic, Radmilo; Kranke, Peter. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology 40(2):p 82-94, February 2023. | DOI: 10.1097/EJA.0000000000001769 
    
3. Thilen, Stephan R. M.D., M.S. (co-chair)1; Weigel, Wade A. M.D. (co-chair)2; Todd, Michael M. M.D.3; Dutton, Richard P. M.D., M.B.A.4; Lien, Cynthia A. M.D.5; Grant, Stuart A. M.D.6; Szokol, Joseph W. M.D., J.D., M.B.A., FASA7; Eriksson, Lars I. M.D., Ph.D., FRCA8; Yaster, Myron M.D.9; Grant, Mark D. M.D., Ph.D.10; Agarkar, Madhulika M.P.H.11; Marbella, Anne M. M.S.12; Blanck, Jaime F. M.L.I.S., M.P.A.13; Domino, Karen B. M.D., M.P.H.14. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 138(1):p 13-41, January 2023. | DOI: 10.1097/ALN.0000000000004379