Monitoring Depth of Neuromuscular Blockade and Adequacy of Reversal: Clinical and Pharmacoeconomic Implications

Purpose of Review This review summarizes current evidence on best practice management of neuromuscular blocking agents (NMBAs). Furthermore, the pharmacoeconomic implications of neuromuscular blockade and reversal to support clinicians and policymakers in ensuring improved patient outcomes and cost-efficient healthcare delivery are discussed. Recent Findings There is good evidence supporting a dose-dependent relationship between NMBAs, residual paralysis, and postoperative respiratory complications. The implementation of sugammadex provoked practice changes, but studies are ambiguous on whether the reversal agent reduces neuromuscular blockade-associated complications compared to neostigmine. Current literature supports reversal with sugammadex or neostigmine depending on the degree of residual paralysis and guided by quantitative neuromuscular monitoring. Summary Best-practice management of neuromuscular blockade targets avoidance of residual paralysis through (1) utilizing the lowest possible dose of NMBAs; (2) quantitative monitoring of neuromuscular blockade; and (3) ensuring adequacy of recovery or reversal with a train of four-ratio ≥0.95 prior to extubation.