Education  |   January 2017
Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities
Author Notes
  • From the Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida (S.J.B.); and Boca Raton, Florida (A.F.K.).
  • This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.
    This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.×
  • Submitted for publication February 4, 2016. Accepted for publication October 4, 2016.
    Submitted for publication February 4, 2016. Accepted for publication October 4, 2016.×
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • Corresponding article on page 12.
    Corresponding article on page 12.×
  • Address correspondence to Dr. Brull: Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Florida 32224. SJBrull@me.com. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Review Article / Neuromuscular Diseases and Drugs / Neurosurgical Anesthesia / Pharmacology / Technology / Equipment / Monitoring
Education   |   January 2017
Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities
Anesthesiology 1 2017, Vol.126, 173-190. doi:10.1097/ALN.0000000000001409
Anesthesiology 1 2017, Vol.126, 173-190. doi:10.1097/ALN.0000000000001409
Abstract

Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.

To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.