Administration of Neostigmine, Sugammadex, and/or Edrophonium before extubation for cases with non-depolarizing neuromuscular blockade.

Postoperative residual neuromuscular blockade can lead to significant complications.^1,2  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.^3-5 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

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 cases.
• Patients that were not extubated in the immediate post-operative period.
• Patients not given NMBs

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.

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.

The provider(s) signed in at time of earliest extubation.

1. 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.
2. Murphy GS, Szokol JW, Avram MJ, et al. Residual Neuromuscular Block in the Elderly: Incidence and Clinical Implications. Anesthesiology. 2015;123(6):1322-1336.
3. 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.
4. 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.
5. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular blockade. Current opinion in anaesthesiology. 2014;27(6):616-622.