Clinical signs such as head lift, grip strength or tidal volume can look normal while significant residual block remains. Residual paralysis raises the risk of hypoxaemia, aspiration and postoperative pulmonary complications. Quantitative monitoring at the adductor pollicis, aiming for a train-of-four ratio of at least 0.9, is the reliable standard. Subjective assessment of fade by touch or sight misses ratios well below that.
- Use quantitative train-of-four monitoring whenever a neuromuscular blocking drug is given.
- Confirm a ratio of at least 0.9 before extubation.
- Do not rely on head lift, grip or tidal volume to exclude residual block.
- Give reversal guided by the depth of block measured at the end of surgery.
Why it matters
Residual block remains common and is invisible without measurement, especially when deep block is used.
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