Clinical Spotlight: Quantitative NMB Monitoring

The AAGBI, ASA and ESAIC are all united in their guidance: in any procedure using neuromuscular blocking agents (NMBAs), regardless of the drug used, quantitative neuromuscular block monitoring should be used for the duration of the procedure.

Are you familiar with why this is recommended?

Clinical signs of recovery alone are not sufficient to exclude residual block.

After the train-of-four ratio (TOFR) recovers to greater than 40%, it is no longer possible to detect the presence of twitch fade by subjective evaluation. It is therefore possible to assume that full recovery has been achieved, and the patient is ready for tracheal extubation, when that might not be the case. Read more here.

Using a quantitative monitor allows for patient-specific dosing of NMBAs throughout the procedure.

Onset of block and recovery can vary greatly between patients. Rapid injection, female gender, young age and co-administration of ephedrine are just some of the factors that can affect the onset of rocuronium. In contrast, recovery may be prolonged by factors such as older age, female gender and administration of drugs like magnesium. Explore factors that affect the onset of action of non-depolarising neuromuscular blocking agents here.

Without a quantitative monitor, it is challenging to assess the stage of block or recovery that the patient is at, and therefore tailor dosage accordingly.

Sugammadex administration in the absence of monitoring does not guarantee avoidance of residual neuromuscular block

There are various studies that highlight the incidence of residual neuromuscular block despite Sugammadex administration.

Learn more:
– Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study.

– Is quantitative neuromuscular monitoring mandatory after administration of the recommended dose of sugammadex? A prospective observational study.