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Recommendations from the ASA guidelines for neuromuscular blockade

Recommendations from the ASA guidelines for neuromuscular blockade
  1. When neuromuscular blocking drugs are administered, we recommend against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment.
  1. We recommend quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade.
  1. When using quantitative monitoring, we recommend confirming a train-of-four ratio greater than or equal to 0.9 before extubation.
  1. We recommend using the adductor pollicis muscle for neuromuscular monitoring.
  1. We recommend against using eye muscles for neuromuscular monitoring.
  1. We recommend sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade.*
  1. We suggest neostigmine as a reasonable alternative to sugammadex at minimal depth of neuromuscular blockade.
  1. To avoid residual neuromuscular blockade when atracurium or cisatracurium are administered and qualitative assessment is used, we suggest antagonism with neostigmine at minimal neuromuscular blockade depth. In the absence of quantitative monitoring, at least 10 minutes should elapse from antagonism to extubation. When quantitative monitoring is utilized, extubation can be done as soon as a train-of-four ratio greater than or equal to 0.9 is confirmed before extubation.
* Deep: posttetanic count greater than or equal to 1 and train-of-four count 0; moderate: train-of-four count 1 to 3; shallow: train-of-four count 4 and train-of-four ratio less than 0.4; minimal: train-of-four ratio 0.4 to less than 0.9.
Adapted with permission from Wolters Kluwer Health, Inc.: Thilen SR, Weigel WA, Todd MM, et al. 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. Anesthesiology 2023; 138(1):13-41. Copyright © 2023 American Society of Anesthesiologists. pubs.asahq.org/anesthesiology.
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