Evidence-Based Management of Neuromuscular Block

Abstract

experts. Basically, European experts have advocated that objective neuromuscular monitoring should be a standard of care, whereas at least some experts from the U.S. have been more reluctant to accept this. The argument against is that it has never been convincingly documented that intraoperative neuromuscular monitoring actually decreases the incidence of residual paralysis. 3,5,6 Some of this disagreement may be caused by confusion between the two words intraoperative and perioperative. Intraoperative, strictly speaking, includes only the time of the operation itself. The perioperative period includes the time before, during, and immediately after the surgery, before the patient is transferred to the postoperative care unit. It is correct that there is no convincing evidence in the literature that intraoperative monitoring of neuromuscular function, whether subjective (visual or tactile evaluation of the response to nerve stimulation) or objective (mechanomyography, acceleromyography, kinemyography, or electromyography), decreases the incidence of potentially clinically significant postoperative residual paralysis. 3,5,6 However, monitoring does obviously make the evaluation and the management of the neuromuscular block during the operation easier. In this respect it is not critical whether the clinician is using subjective or objective monitoring. The level of block can easily be quantified by tactile evaluation of the response to posttetanic count stimulation for intense and deep block, and TOF stimulation for moderate block. 7 In contrast, during the recovery phase of the neuromuscular block, it is not possible with certainty to quantify the degree of block manually or visually when the TOF ratio is 0.40. 3 There