Measure ID

Percentage of patients administered neostigmine, sugammadex, and/or edrophonium before extubation and after the last dose of non-depolarizing neuromuscular blockade.

Measure Type
Available for Provider Feedback

Postoperative residual neuromuscular blockade can lead to significant complications such as hypoxemia, impaired pulmonary function, upper airway obstruction, postoperative pneumonia, and respiratory failure.1,2,3  Several studies have found associations between the use of neuromuscular blocking agents (NMBA) and residual neuromuscular blockade in the recovery room.   Adverse postoperative respiratory outcomes are even more frequent when patients receive NMBAs 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.1,4-6 The American Society of Anesthesiologists practice guidelines recommend the use of sugammadex for deep and moderate levels of neuromuscular blockade and recommend neostigmine for patients with a minimal blockade.1 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

All patients that have received a non-depolarizing neuromuscular blocker (NMB) AND were extubated post-operatively. 

The following NMBs given as bolus, defasciculating doses or infusion are included and require reversal:

  • Atracurium
  • Cisatracurium
  • Pancuronium
  • Rocuronium
  • Vecuronium
  • ASA 5 and 6 including Organ Procurement (CPT: 01990)
  • Patients not given NMBs
  • Patients that were not extubated in the immediate postoperative period (as defined by the earliest time resulted from LMA Removal Times or Extubation Times).
  • Procedure Type: Lung Transplant
Success Criteria

Documentation of neostigmine, sugammadex, and/or edrophonium before earliest extubation OR An acceleromyography ratio of ≥ 0.9 documented after last dose of NMB and before earliest extubation.

Other Measure Details

Cases that recieve defasciculating doses of NMBs are included in this measure and require documentation of neostigmine, sugammadex or edrophonium before earliest extubation to pass.

*This measure will include valid MPOG cases defined by the Is Valid Case MPOG phenotype.

Risk Adjustment

Not applicable.

Provider Attribution

Provider(s) signed in at time of earliest extubation.

MPOG Concept Used


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


  • 10170 Edrophonium
  • 10315 Neostigmine
  • 10739 Sugammadex


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

Train of Four

  • 3485  Train-of-four (Acceleromyography)
MPOG Phenotypes Used
  1. Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB: 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13–41
  2. McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications. Anesthesiology. 2015;122(6):1201-1213.
  3. Murphy GS, Szokol JW, Avram MJ, et al. Residual Neuromuscular Block in the Elderly: Incidence and Clinical Implications. Anesthesiology. 2015;123(6):1322-1336.
  4. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesthesia and analgesia. 2010;111(1):129-140.
  5. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM. Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia. Anesthesiology. 2016;125(4):647-655.
  6. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular blockade. Current opinion in anaesthesiology. 2014;27(6):616-622.
Measure Authors

 Meausre Author


 Nirav Shah, MD

 University of Michigan

 Sachin Kheterpal, MD

 University of Michigan

 Jaime Osborne, RN

 University of Michigan 

 Genevieve Bell

 University of Michigan

 MPOG Quality Committee



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


Tim Dubovoy

Michigan Medicine



Published Date: 02/2015
 Date  Criteria  Revision
 03/06/2024  Exclusion

 Remove Lung Transplant Cases

 11/09/2023  Multiple

 Remove Cardiac exclusion: per Cardiac Subcommittee

 Remove 3 hour period of no NMB as marker of success 

 Remove 2 hour period of no NMB as marker of success: per Pediatric Subcommittee 

 Remove defasciculating dose exclusion