Quantitative monitoring of neuromuscular blockade is vital for patients undergoing anesthesia

CHICAGO — Patients receiving neuromuscular blocking medications as part of their anesthetic regimen should be carefully monitored to ensure the best care and outcomes, according to recent—and independently developed—guidelines from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC). Today, the organizations published a joint letter in Anesthesiology, ASA’s peer-reviewed medical journal, encouraging widespread implementation of the recommendations in the guidelines.

Medications that provide neuromuscular blockade are frequently used in anesthesia, both to ease the placement of a breathing tube at the beginning of the anesthetic (intubation) and to provide optimal conditions for the surgery itself. Both ASA and ESAIC guidelines for the management of neuromuscular blockade recommend patients be monitored quantitatively as part of the process, meaning that the degree of muscle relaxation is frequently checked using devices that measure the depth of muscle relaxation.

When neuromuscular blockade is not monitored, patients are at a higher risk of post-procedure weakness and lung problems, such as pneumonia and bronchitis. Current data suggest there is a high incidence of inappropriate management of neuromuscular blockade and, therefore, a higher rate of these complications than if quantitative monitoring were universal. A European survey of 17,150 patients who received neuromuscular blocking drugs found that neuromuscular monitoring was not performed in more than half (10,000) of patients, and the practice was similar in the U.S., the organizations note.

“Despite being developed completely independently, the guidelines from both organizations are nearly identical, which shows the evidence for these guidelines is sound,” said ASA President Michael W. Champeau M.D., FAAP, FASA. “To meaningfully improve patient care and outcomes, these guidelines must be implemented widely through a systematic approach.”

The joint letter recommends:

• Restructuring the clinical environment by placing quantitative monitors in all anesthetizing locations;
• Employing education efforts in anesthesia departments and with individual physicians;
• Providing performance feedback in the department and for individual physicians;
• Appointing a local champion who is supported by leaders. 

“The collaboration between the two leading scientific societies in anaesthesiology, ASA and ESAIC, holds great significance in terms of its impact on patient care and outcomes,” said Prof. Edoardo De Robertis (IT), MD, PhD, ESAIC president 2022-2023, director of anaesthesia and intensive care at the University of Perugia, Italy. “By working in tandem, we can expedite the spread and application of our meticulously crafted guidelines within clinical settings, thereby enhancing the safety and quality of patient care on a global scale. This unified approach will foster seamless cooperation and facilitate the adoption of best practices worldwide.”

Both sets of guidelines recommend:

• Using stimulation of the ulnar nerve – one of the nerves in the hand – with quantitative neuromuscular monitoring at the thumb;
• Using sugammadex instead of neostigmine for deep or moderate neuromuscular blockade induced by rocuronium;
• Using neostigmine as a reasonable alternative to sugammadex for minimal neuromuscular blockade (train of four, or TOF, ratio 0.4 to <0.9) induced by rocuronium;
• Depending on clinical judgement in the context of quantitative monitoring, neostigmine may be considered for a depth of block deeper than minimal, with the understanding that deeper blocks will require more time to attain a TOF ratio greater than or equal to 0.9. 

THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 56,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Like ASA on Facebook, follow ASALifeline on Twitter.

THE EUROPEAN SOCIETY OF ANAESTHESIOLOGY AND INTENSIVE CARE
The European Association of Anaesthesiology and Intensive Care (ESAIC) is the leading European organisation for members and national societies for Anaesthesia, Intensive Care, Pain and Perioperative Medicine. ESAIC aims to: promote the exchange of information between European anaesthesiologists; it serves as the hub to disseminate information in regard to anaesthesiology. The Society helps raise the standards of the speciality by fostering and encouraging education, research, scientific progress and exchange of information while promoting improvements in the safety and quality of care of patients who are under the care of anaesthesiologists inside and outside the operating room by facilitating and harmonising the activities of national and international societies of anaesthesiologists in Europe. Furthermore, ESAIC promotes the professional role of anaesthesiologists to improve the care of patients in the fields of anaesthesiology, intensive care, perioperative medicine, emergency medicine, and pain medicine.

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