The call for quantitative neuromuscular monitoring

A new standard of medical care

Every operating theatre or location where NMB drugs are used should be equipped with a quantitative neuromuscular monitoring device.
A.A Klein et al | Guideline from Association of Anaesthetists, Anesthesia, 2021
Recommendations for standards of monitoring during anaesthesia and recovery 2021

Why Monitor Neuromuscular Blockade?

Post-operative residual paralysis is an under-recognized event. Monitoring the effects of neuromuscular blocking drugs ensures their appropriate intra-operative use and helps prevent residual neuromuscular weakness.

The accepted definition for “adequate recovery” from neuromuscular block is the return of the train-of-four (TOF) ratio to, or above 0.9 (90%). This level of recovery restores most of the functional integrity of the muscles involved in airway protection.

Quantitative neuromuscular monitoring

The only reliable way to confirm adequate recovery from neuromuscular blockade and avoid postoperative residual weakness is quantitative neuromuscular monitoring.

Prevent the preventable

Every year millions of patients are affected by postoperative respiratory complications. In US alone, more than 100.000 patients annually experience adverse events associated with undetected residual neuromuscular blockade.

Without a quantitative neuromuscular blockade monitor there is an increased risk of:

  • Pneumonia
  • Atelectatis
  • Hypoxia
  • Reintubation
  • Pulmonary aspiration
  • Airway obstruction
  • Pharyngeal dysfunction
  • Prolonged post anesthesia stays
  • Unpleasant postoperative symptoms including muscle weakness

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Proactive decision support

Knowing the current level of muscle paralysis will support you in making proactive and informed decisions concerning:

  • NMBA dosing
  • Type of reversal agent
  • Optimal reversal dose
  • If spontaneous recovery as an option
  • If adequate recovery of breathing muscles is obtained
  • The correct timing for safe tracheal extubation


of patients in a recent study experienced RNMB

+80 min

the lenght of stay in PACU increases by 80 minutes in patients with TOFR´s < 0.9


of patients affected by a serious critical complication have RNMB.


CRE´s were 3 times more likely in patients receiving NMBA´s with TOFR´s < 0.9


A.A Klein et al. Recommendations for standards of monitoring during anaeshtesia and recovery 2021. Anaesthesia 2021; 76,1212-1223

Naguib M, et al. Consensus Statement on perioperative Neuromuscular Monitoring. Anest Analg. 2018; 127(1):71-80

Thilen SR. Neuromuscular Blockade Monitoring, Anesthesiology Clinics 2021,39; P457-76

Weigel WA. Neuromuscular Blockade Monitoring and reversal-a clinical and pharmacoeconomic update. 2021; Advances Anesth 39;169-88

Murphy GS, Brull SJ. Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review, Anesthesiology, Feb 2022, Vol. 136,345-361

Iwasaki H. A comparison between the adductor pollicis muscle using TOF-Watch SX and the Abductor Digiti Minimi Muscle Using TetraGraph in Rocuronium-Induced Neuromuscular Block: A Prospective Observational Study, Anesth Analg, Jan 2022 PAP

Saager L, Maiese EM, Bash LD, et al. Incidence, risk factors and consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study. J Clin Anesth. 2019;55:33-41

Butterly A et al, Postoperative Residual Curarization from inter-mediate acting neuromuscular blocking agents delays recovery from discharge. BR J Aneast; 2010 Sep; 105(3):304-9

Martinez-Ubieto J et al, Prospective study of residual neuromuscular block and postoperative respiratory complications in patients reversed with neostigmine vs sugammadex. Minerva Anesthesiol. 2016;82(7):735-742

Norton et al, Rev Esp Anestesiol Reanim 2013;60(4):3190-196

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