Measure ID

Percentage of patients with a documented Train of Four (TOF) after last dose of non-depolarizing neuromuscular blocker.

Measure Type

Postoperative residual neuromuscular blockade can lead to significant complications. Several studies have found associations between the use of neuromuscular blockade agents (NMBA) and residual neuromuscular blockade in the recovery room. Adverse postoperative respiratory outcomes are even more frequent when patients receive NMBA and reversal agents are not used. A mainstay of residual blockade prevention continues to be monitoring to allow for detection, and use of reversal agents like neostigmine and Sugammadex. Due to variability in duration of muscle relaxants, even in defasciculating doses, we recommend that TOF is monitored when any non-depolarizing neuromuscular blockers are administered.

Measure Time Period

Anesthesia Start to Earliest Extubation


All patients that have received either by bolus or infusion a non-depolarizing neuromuscular blocker (NMB) AND were extubated post-operatively or in the PACU.  The following NMBs are included:

  • Atracurium
  • Cisatracurium
  • Pancuronium
  • Rocuronium
  • Vecuronium
  • ASA 5 and 6 cases
  • Patients not given NMBs
  • Patients that were not extubated in the immediate post-operative period.
Success Criteria

Documentation of a Train of Four count (1, 2, 3, or 4), sustained tetany, or TOF ratio provided by acceleromyography AFTER last dose or stopping of infusion of neuromuscular blocker and before earliest extubation.  Note: A Train of Four value of ‘0’ is accepted for cases in which Sugammadex is administered for reversal.

Other Measure Details
Risk Adjustment

Not Applicable

Provider Attribution

The provider signed in at time of earliest extubation.

MPOG Concept Used

Neuromuscular Blocker Medications

  • 10043 Atracurium
  • 10129 Cisatracurium
  • 10344 Pancuronium
  • 10393 Rocuronium
  • 10446 Vecuronium


  • 50127 Intubation Extubated Awake or Deep
  • 50202 Emergence- Patient Extubated
  • 50145 Airway – Laryngeal mask airway removed (deep or awake)

Train of Four

  • 3033  Train-of-four objective count (acceleromyography, electromyography, other)
  • 3330  Train-of-four (Subjective assessment)
  • 3485  Train-of-four (Acceleromyography)
  1. Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg 1954; 140:2-35.
  2. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010. 111(1): 129-40.
  3. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, Ehrenfeld JM, Martinez EA, Kurth T, Eikermann M. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329
  4. Harrison GG. Death attributable to anaesthesia. A 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041-6.
  5. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular blockade. Curr Opin Anesthesiol. 2014; 27(6): 616-622.
  6. Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical mortality. Anaesthesia 1983; 38:1090-6.
  7. Pedersen T, Viby-Mogensen J, Ringsted C. Anaesthetic practice and postoperative pulmonary complications. Acta Anaesthesiol Scand 1992; 36:812-8.
Measure Authors

 Measure Author


 Nirav Shah, MD

 University of Michigan

 Sachin Kheterpal, MD

 University of Michgan

 Jaime Osborne, RN

 University of Michigan

 Genevieve Bell

 University of Michigan

 MPOG Quality Commiittee



Measure Reviewer(s)
Next Review: 2024
 Date Reviewed  Reviewer  Institution  Summary  QC Vote


 Alvin Stewart

 Peter Panagopolous


 Corewell East - Dearborn


  No change

Published Date: 02/2015
 Date  Criteria  Revision
 02/28/2022  Exclusion  Removed cardiac procedure exclusion
 11/09/2021  Exclusion  Modified cardiac case exclusion to use new Cardiac Phenotype