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

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.¹  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.

Anesthesia Start to earliest extubation before Anesthesia End

All patients that have received a non-depolarizing neuromuscular blocker (NMB) AND were extubated before anesthesia end.

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

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 before anesthesia end.

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

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

Not applicable.

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

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.