Clinical signs such as head lift and tactile assessment of fade cannot reliably detect residual block. Quantitative monitoring of the adductor pollicis with a train-of-four ratio is the only dependable way to confirm recovery.
Aim for a train-of-four ratio of at least 0.9 before extubation, choose the reversal agent and dose according to the measured depth of block, and keep monitoring running into recovery if there is any doubt.
- Use quantitative train-of-four monitoring whenever a neuromuscular blocker is given
- Confirm a ratio of at least 0.9 before extubation
- Dose reversal according to measured depth, not elapsed time
- Do not rely on head lift or tactile fade to exclude residual block
Why it matters
Residual block causes postoperative respiratory complications that are entirely preventable.
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