Current recommendations for monitoring depth of neuromuscular blockade

Residual neuromuscular block is a relatively frequent occurrence and is associated with postoperative pulmonary complications, including aspiration, pneumonia and hypoxia, impaired hypoxic ventilatory drive and decreased patient satisfaction. Although adequate recovery of neuromuscular function has been defined as a train-of-four ratio of at least 0.9, monitoring with a qualitative peripheral nerve stimulator makes it impossible to determine the actual train-of-four ratio. Peripheral nerve stimulators are not routinely used in clinical practice. Without their use, dosing of neuromuscular blocking agents and anticholinesterases is often inappropriate and adequacy of recovery of neuromuscular function upon tracheal extubation cannot be guaranteed. Use of peripheral nerve stimulators allows clinicians to administer neuromuscular blocking and reversal agents in a rational manner. Routine use of quantitative monitors of depth of neuromuscular blockade is the best guarantee of the adequacy of recovery of postoperative muscle strength.