Guideline on the safe use of neuromuscular blocking agents

Inappropriate use of muscle relaxants leads to postoperative residual neuromuscular block (PORNB), which is still a significant problem nowadays and is an independent risk factor for postoperative pulmonary complications. To decrease its incidence, the European Society of Anesthesiology and Intensive Care and the American Society of Anesthesiologists published their guidelines on the safe use of muscle relaxants in 2023. In this publication, the Edomer Tassonyi Neuromuscular Task Force of the University of Debrecen Clinical Center summarizes its recommendations. Based on international guidelines, objective neuromuscular monitoring should be performed in every patient who received non-depolarizing muscle relaxants during surgery. Since postoperative residual neuromuscular block can lead to several complications, it is essential for patient safety to ensure that the effect of the muscle relaxants is gone and train-of-four (TOF) ratio has returned to 0.9 (90%) before extubation. Clinical signs and subjective neuromuscular monitoring are not suitable for diagnosing residual curarization at the end of surgery. Therefore, whenever a patient receives non-depolarizing muscle relaxant, objective neuromuscular monitoring should be performed to exclude residual neuromuscular block. Neuromuscular monitoring should be performed in the hand. Objective neuromuscular monitoring should be started before muscle relaxant administration by calibrating the monitoring device. To ensure optimal intubating conditions and prevent airway injuries, TOF count should drop to 0 (all muscle responses evoked by nerve stimulation should disappear). TOF measurements should be repeated at regular intervals during surgery to follow the course of muscle relaxation. The effect of reversal agents (both neostigmine and sugammadex) should always be objectively monitored. The effect of bensilisoquinolin muscle relaxants can only be reversed with neostigmine when there is twitch response to TOF stimulation. Sugammadex is the most effective reversal agent for steroidal muscle relaxants (vecuronium, rocuronium and pipecuronium), but neostigmine can be used as well when there is twitch response to TOF stimulation. Orv Hetil. 2025; 166(15): 569-577.