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

Full text: https://pubs.asahq.org/anesthesiology/article/138/1/13/137379/2023-American-Society-of-Anesthesiologists

This update focuses primarily on the method and site of neuromuscular monitoring and the process of antagonising neuromuscular blockade to reduce residual neuromuscular blockade.


Delineation of methods was clear and exhaustive. The presentation of supplemental digital content aids in a more comprehensive understanding of the data. The major shortcoming is the explicit exclusion of non-English literature.

The recommendations made are as follows:

  • When neuromuscular blocking drugs are administered, we recommend (strong) against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment (moderate evidence)
  • A large multinational prospective cohort study did not detect a difference in a composite pulmonary complication outcome (respiratory failure, hypoxia, pulmonary infection or infiltrates, atelectasis, aspiration pneumonia, bronchospasm, or pulmonary oedema) in patients with quantitative versus qualitative assessment
  • Two of the three randomised studies reported a lower incidence of hypoxia with quantitative monitoring‚ one no events: low strength of evidence)
  • Recommend (strong) confirming a train-of-four ratio greater than or equal to 0.9 before extubation (moderate evidence)
  • When sugammadex was used and a train-of-four ratio (ToF) greater than or equal to 0.9 was confirmed before extubation, the pooled incidence of residual neuromuscular blockade was 0.5% compared to 2.2% without ToF. With neostigmine, the incidence was 5.3% and 44.9% respectively, with and without confirmation
  • Strong recommendation for using the adductor pollicis muscle for neuromuscular monitoring (moderate evidence)
  • Time to reach train-of-four ratio greater than or equal to 0.9 at the adductor pollicis muscle was longer compared with eye muscles and flexor hallucis brevis.
  • Measurements obtained at sites with longer recovery times helps guarantee full neuromuscular function on reversal.
  • Strong recommendation for using sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade (moderate evidence)
  • The incidence of residual neuromuscular blockade was lower and time to recovery was shorter with sugammadex compared to neostigmine. However, there were no differences in re-paralysis and reintubation rates
  • No differences in tachycardia, bradycardia or arrhythmias when comparing neostigmine to sugammadex
  • Low evidence of slightly lower rates of reintubation, postoperative hypoxia and pneumonia with sugammadex compared to neostigmine
  • Pooled anaphylaxis rates of 1.4/10,000 for sugammadex and 0.3/10,000 for neostigmine. (similar to Orihara et al BJA 2020 Feb;124(2):154-163)

A tension always exists with literature of this type between raw presentation of data, which often offers little guidance, and interpretation of data, which can appear biased or be promoting a particular agenda. This paper leans towards the latter but presents enough information for the reader to decide if the conclusions are valid or should change their practice.

Reviewed by Don Hannah