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VOLUME 10 , ISSUE 1 ( January-June, 2021 ) > List of Articles


Prevention or Overcome: Residual Neuromuscular Blockade—A Narrative Review

Rani Ponnusamy, Sindhuri Gali

Keywords : Neuromuscular monitoring, Neuromuscular recovery, Residual neuromuscular paralysis, Reversal of neuromuscular blockade, Train-of-four ratio

Citation Information : Ponnusamy R, Gali S. Prevention or Overcome: Residual Neuromuscular Blockade—A Narrative Review. 2021; 10 (1):20-22.

DOI: 10.5005/jp-journals-10085-8136

License: CC BY-NC 4.0

Published Online: 07-08-2021

Copyright Statement:  Copyright © 2021; The Author(s).


The incidence of residual paralysis remains high in the postoperative period even after reversal of intermediate-acting neuromuscular blockers when reversal and extubation are done based on clinical features and are minimized with neuromuscular monitoring (NMM). Correlation between the clinical features of neuromuscular recovery and train-of-four ratio (TOFR) in NMM is variable. Complete neuromuscular recovery depends upon various factors such as age, the weight of the patient, and anesthesia-related factors such as depth of neuromuscular blockade, an inhalational agent used, the time interval between the last dose of neuromuscular block, and reversal administration. The incidence of residual paralysis was found to be high when the neuromuscular blockade was reversed with a standard dose of reversal and recent studies have demonstrated that low-dose neostigmine is adequate to reverse the shallow neuromuscular blocking effects. Hence, quantitative NMM should be used for safe practice while conducting general anesthesia.

  1. Hayes AH, Mirakhur R, Breslin D, Reid J, McCourt K. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia 2001;56(4):312e8. DOI: 10.1046/j.1365-2044.2001.01921.x.
  2. Aytac I, Postaci A, Aytac B, Sacan O, Alay GH, Celik B, et al. Survey of postoperative residual curarization, acute respiratory events, and approach of anesthesiologists. Rev Bras Anestesiol 2016;66(1):55–62. DOI: 10.1016/j.bjane.2012.06.011.
  3. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, et al. Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology 2011;115(5):946–954. DOI: 10.1097/ALN.0b013e3182342840.
  4. Gatke MR, Viby-Mogensen J, Rosenstock C, Jensen FS, Skovgaard LT. Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used. Acta Anaesthesiol Scand 2002;46(2):207–213. DOI: 10.1034/j.1399-6576.2002.460216.x.
  5. Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg 2010;111(1):110–119. DOI: 10.1213/ANE.0b013e3181c07428.
  6. Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia 2007;62(8):806–809. DOI: 10.1111/j.1365-2044.2007.05101.x.
  7. Fuchs-Buder T, Meistelman C, Alla F, Grandjean A, Wuthrich Y, Donati F. Antagonism of low degrees of atracurium-induced neuromuscular blockade. Anesthesiology 2010;112(1):34–40. DOI: 10.1097/ALN.0b013e3181c53863.
  8. Ali HH, Wilson RS, Savarese JJ, Kitz RJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth 1975;47(5):570–574. DOI: 10.1093/bja/47.5.570.
  9. Brand JB, Cullen DJ, Wilson NE, Ali HH. Spontaneous recovery from nondepolarizing neuromuscular blockade: orrelation between clinical and evoked responses. Anesth Analg 1977;56(1):55–58. DOI: 10.1213/00000539-197701000-00014.
  10. Dam WH, Guldmann N. Inadequate postanesthetic ventilation. Curare, anesthetic, narcotic, diffusion hypoxia. Anesthesiology 1961;22(5):699–707. DOI: 10.1097/00000542-196109000-00005.
  11. Viby-Mogensen J. Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth 2000;84(3):301–303. DOI: 10.1093/oxfordjournals.bja.a013428.
  12. Adekanye O, Dugani S, Wilkes AR, et al. AAGBI guidelines on the use of neuromuscular blockade monitoring. Anaesthesia 2009;64(8): 923–924.
  13. Kopman AF, Eikermann M. Antagonism of non-depolarising neuromuscular block. Anaesthesia 2009;64(1):22–30. DOI: 10.1111/j.1365-2044.2008.05867.x.
  14. Fuchs-Buder T, Nemes R, Schwartz D. Residual neuromuscular blockade: management and impact on the postoperative pulmonary outcome. Curr Opin Anesthesiol 2016;29(6):662–667. DOI: 10.1097/ACO.0000000000000395.
  15. Reid JE, Breslin DS, Mirakhur RK, Hayes AH. Neostigmine antagonism of rocuronium block during anesthesia with sevoflurance, isoflurane or propofol. Can J Anesth 2001;48(4):351. DOI: 10.1007/BF03014962.
  16. Sorgenfrei IF, Viby-Mogensen J, Swiatek FA. Does evidence lead to a change in clinical practice? Danish anaesthetists’ and nurse anesthetists’ clinical practice and knowledge of postoperative residual curarization. Ugeskr Laeger 2005;167(41):3878–3882.
  17. Fuchs-Buder T, Hofmockel R, Geldner G, Diefenbach C, Ulm K, Blobner M. The use of neuromuscular monitoring in Germany. Anaesthesist 2003;52(6):522–526. DOI: 10.1007/s00101-003-0508-9.
  18. Nava-Ocampo A, Ramírez-Mora J, Moyao-García D, Garduño-Espinosa J, Salmerón J. Preferences of Mexican anesthesiologists for vecuronium, rocuronium, or other neuromuscular blocking agents: a survey. BMC Anesthesiol 2002;2(1):2. DOI: 10.1186/1471-2253-2-2.
  19. Philips S, Stewart PA, Bilgin AB. A survey of the management of neuromuscular blockade monitoring in Australia and New Zealand. Anaesthe Inten Care 2013;41(3):374–379. DOI: 10.1177/0310057X1304100316.
  20. Fuchs-Buder T, Schreiber JU, Meistelman C. Monitoring neuromuscular block: an update. Anaesthesia 2009;64(Suppl 1):82–89. DOI: 10.1111/j.1365-2044.2008.05874.x.
  21. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring challenges and opportunities. Anesthesiology 2017;126(1):173–190. DOI: 10.1097/ALN.0000000000001409.
  22. Eriksson LI, Sundman E, Olsson R, Nilsson L, Witt H, Ekberg O, et al. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology 1997;87(5):1035–1043. DOI: 10.1097/00000542-199711000-00005.
  23. Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology 2000;92(4):977–984. DOI: 10.1097/00000542-200004000-00014.
  24. Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med 2007;175(1):9–15. DOI: 10.1164/rccm.200512-1862OC.
  25. Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology 2009;110(6):1253–1260. DOI: 10.1097/ALN.0b013e31819faa71.
  26. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010;111(1):120–128. DOI: 10.1213/ANE.0b013e3181da832d.
  27. Saager L, Maiese EM, Bash LD, Meyer TA, Minkowitz H, Groudine S, et al. Incidence, risk factors, and consequences of residual neuromuscular block in the United States: the prospective, observational, multicenter RECITE-US study. J Clin Anesth 2019;55:33–41. DOI: 10.1016/j.jclinane.2018.12.042.
  28. Baillard C, Clec'h C, Catineau J, Salhi F, Gehan G, Cupa M, et al. Postoperative residual neuromuscular block: a survey of management. Br J Anaesth 2005;95(5):622–626. DOI: 10.1093/bja/aei240.
  29. Raval AD, Uyei J, Karabis A, Bash LD, Brull SJ. Incidence of residual neuromuscular blockade and use of neuromuscular blocking agents with or without antagonists: a systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020;64:109818. DOI: 10.1016/j.jclinane.2020.109818.
  30. Thilen SR, Bhananker. SM. Qualitative neuromuscular monitoring: how to optimize the use of a peripheral nerve stimulator to reduce the risk of residual neuromuscular blockade. Curr Anesthesiol Rep 2016;6(2):164–169. DOI: 10.1007/s40140-016-0155-8.
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