Suggested management of neuromuscular blockade according to monitoring

Modality/response*	Interpretation/management	Comments
Intubating conditions
TOFC 0 TOFR 0	Adequate conditions likely	During onset of neuromuscular block, diaphragm and vocal cords become paralyzed prior to the adductor pollicis muscle. Diaphragm and vocal cords also recover prior to adductor pollicis.
TOFC ≥1 TOFR ≥0	Adequate conditions unlikely	Profound block is required for optimal intubating conditions.
Intraoperative conditions
TOFC 0, PTC 1 to 5	Deep blockade; return of diaphragm movements possible, twitch may return in 5 to 15 minutes, may have twitch response at face with PNS
TOFC 1 to 3	Moderate blockade; sufficient for most procedures	Deeper levels of block may be warranted in specific settings in which any unexpected movement must be avoided (eg, during delicate dissection under the microscope during craniotomy).
TOFC 4 ± fade	Shallow or minimal block; additional NMBA may be needed
Management of recovery and reversal*
TOFC 0, PTC 0	Complete or profound blockade; wait or administer sugammadex 16 mg/kg IV	Sugammadex can be used to reverse only rocuronium or vecuronium. Neostigmine can be used to reverse any nondepolarizing NMBA. Neostigmine should only be used if the TOFC is 4.
TOFC 0, PTC 1 or 2	Deep blockade; wait or administer sugammadex 4 mg/kg IV
TOFC 1	Moderate blockade; wait or administer sugammadex 4 mg/kg IV
TOFC 2 or 3	Moderate blockade; wait or administer sugammadex 2 mg/kg IV
TOFC 4 with fade TOFR <0.4	Shallow blockade; wait or sugammadex 2 mg/kg IV or neostigmine 20 to 50 mcg/kg IV
TOFC 4 without fade TOFR 0.4 to 0.9	Minimal blockade; wait or sugammadex 2 mg/kg IV or neostigmine 15 to 30 mcg/kg IV
TOFR ≥0.9	Fully reversed; no need to administer reversal prior to extubation

This table shows management according to qualitative and/or quantitative neuromuscular monitoring. Qualitative (subjective) monitoring refers to visual or tactile assessment of adduction of the thumb in response to ulnar nerve stimulation and the resulting contraction of the adductor pollicis muscle. Quantitative (objective) monitors measure the response of the muscle to neurostimulation and provide a ratio of the fourth to the first twitch in the train of four stimuli. Quantitative monitors should be used whenever they are available. For further information, refer to UpToDate content on the clinical use of NMBAs and monitoring neuromuscular blockade.

TOFC: train of four count; TOFR: train of four ratio; NMBA: neuromuscular blocking agent; PTC: post tetanic count; PNS: peripheral nerve stimulator.

* Train of four stimulation consists of four successive supramaximal stimuli using a peripheral nerve stimulator. After administration of a full dose of nondepolarizing NMBA, responses show fade, or progressively decreasing amplitude of the responses; with increasing block the number of responses to a train of four stimuli decreases. When the train of four count is zero, further information on the depth of block can be obtained by applying tetanic stimulation, followed by a series of single twitches for 20 seconds. The post tetanic count (PTC) refers to the number of twitches apparent in this series; increasing PTC correlates with less profound block.

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Suggested management of neuromuscular blockade according to monitoring