Residual neuromuscular blockade after a non-depolarising relaxant is common and is linked to hypoxaemia, aspiration and reintubation. Clinical signs such as head lift or grip strength, and subjective counting of twitches, cannot reliably detect a train-of-four ratio below 0.9.
Use quantitative monitoring wherever a relaxant has been given, reverse with neostigmine only once some recovery is present or use sugammadex where available, and extubate only when the measured ratio is at least 0.9.
- Use quantitative train-of-four monitoring whenever a non-depolarising relaxant is given.
- Extubate only when the measured ratio is 0.9 or more.
- Do not rely on head lift, grip or visual twitch counts to confirm recovery.
- Give neostigmine only after spontaneous recovery has begun.
Why it matters
Clinical tests miss residual blockade that causes postoperative respiratory events.
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