Neuromuscular Blockade Monitoring

Author: Hana Harazim, Tereza Musilová, Adam Predáč

Institution: Faculty of Medicine at Masaryk University in Brno

Medical discipline: Emergency Medicine

Keywords: neuromuscular blockade | residual curarisation | neuromuscular blocking agents | TOF | antagonist

Educational evel: Undergraduate level | Graduate

Neuromuscular blocking agents (NMBA) are drugs with potentially life threatening effects for the patient. Therefore the monitoring of neuromuscular transmission during the operation is done according to the Czech Society of Anaesthesia, Resuscitation and Intensive Care and it is considered to be a standard procedure in patients care. The objective evaluation of the depth of relaxation gives the anaesthesiologist a valuable information that aids in his decision making about the immediate care. The main goal of this algorithm is to introduce the audience to the basic informations and options about neuromuscular monitoring and furthemore, to point to its importance in bringing the best possible care to the patient.

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Neuromuscular blockade (NMB) is one of the components of balanced anaesthesia. To ensure it during the anaesthesia, a special drug called NMBA (neuromuscular blocking agent) is administered, which by the occupancy of the nicotine receptors of the neuromuscular plate causes paralysis of the striated muscles. This will allow for direct laryngoscopy, tracheal intubation, and surgery.
The degree of muscle blockade can not be determined by clinical examination and for safe administration of muscle relaxants, instrumental monitoring of their effect is mandatory.

This algorithm describes how to measure the degree of NMB starting from anaesthesia induction (connecting the relaxometer to the patient, calibration of the device and timing of the tracheal intubation based on NMB measurement), the deep blockade monitoring and the importance of monitoring while maintaining the appropriate NMB depth during the surgery. Particular emphasis is placed on the period of recovery from the NMBA effect and detection of residual curarization at the end of anaesthesia. Described are the options of pharmacological reversal and the choice and timing of the reversal agent according to NMB measurements is defined.

World-wide initiatives of anaesthesia societies increasingly emphasize the requirement for safe anaesthetic care.1-3 It also applies to the up-to-date administration of NMBA that is only possible with instrumental monitoring. I consider this algorithm to be a valuable contribution to achieving this goal.

1. Adamus M, Černý V, Cvachovec K, et al. Stanovisko k přístrojové monitoraci hloubky nervosvalové blokády. Praha: ČSARIM 2017. Available at:
2. Adamus M., Cvachovec K., Černý V. et al. Zásady bezpečné anesteziologické péče. Anest intenziv Med. 2018;29:107–110.
3. Checketts MR, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015 : Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2016;71:85–93.

publikováno: 1. 6. 2018 | last modified on: 14. 5. 2020