Percentage of cases with documentation of train-of-four count or ratio provided by a quantitative monitor (acceleromyography, electromyography, kinemyography, or mechanomyography).

Postoperative residual neuromuscular blockade can lead to significant complications such as hypoxemia, impaired pulmonary function, upper airway obstruction, postoperative pneumonia, and respiratory failure. ^{1-4,6-7,13-20} Several studies have found associations between the use of neuromuscular blockade agents (NMBA) and residual neuromuscular blockade in the recovery room.^{1-4,6-7,13-18} A mainstay of residual blockade prevention continues to be monitoring to allow for detection, and use of reversal agents like neostigmine and Sugammadex.^5,7-8 The American Society of Anesthesiologists practice guidelines recommend the use of quantitative monitoring at the adductor pollicis to confirm recovery of train-of-four ≥0.9 before extubation.^{8,10,12-13,21} This informational measure identifies cases and institutions implementing quantitative monitoring into practice.^9,11 Future measures will focus on quantitative NMB monitoring relative to extubation or NMB reversal administration. 

Patient In Room to Patient Out of Room

All patients administered non-depolarizing neuromuscular blocker (NMB) intraoperatively

• ASA 5 & 6 cases including Organ Procurement (CPT: 01990)
• Patients not receiving neuromuscular blockade

Documentation of train-of-four count or ratio provided by a quantitative monitor (acceleromyography, electromyography, kinemyography, or mechanomyography).

Algorithm for determining Measure Start/End Times:

Measure Start: 

Patient in Room. If not available, Anesthesia Start.

Measure End:

Patient Out of Room. If not available, Anesthesia End.

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

Not applicable

All providers signed in during the measure time period.

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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.
8. 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
9. Todd MM, Hindman BJ, King BJ: The implementation of quantitative electromyographic neuromuscular monitoring in an academic anesthesia department. Anesth Analg 2014; 119:323–31
10. Weigel WA, Williams BL, Hanson NA, Blackmore CC, Johnson RL, Nissen GM, James AB, Strodtbeck WM: Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology 2022; 136:901–15
11. Renew JR, Hex K, Johnson P, Lovett P, Pence R: Ease of Application of Various Neuromuscular Devices for Routine Monitoring. Anesth Analg 2021; 132:1421–8
12. Renew JR, Hernandez-Torres V, Chaves-Cardona H, Logvinov I, Brull SJ: Comparison of visual and electromyographic assessments with train-of-four stimulation of the ulnar nerve: a prospective cohort study. Can J Anaesth 2023; 70:878–85
13. Cammu G, De Witte J, De Veylder J, Byttebier G, Vandeput D, Foubert L, Vandenbroucke G, Deloof T: Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg 2006; 102:426–9
14. 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; 122:1201–13
15. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, Krintel JJ: Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997; 41:1095–103
16. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS: Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008; 107:130–7
17. Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI: The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology 2000; 92:977–84
18. Eikermann M, Groeben H, Bünten B, Peters J: Fade of pulmonary function during residual neuromuscular blockade. Chest 2005; 127:1703–9
19. Murphy GS, Avram MJ, Greenberg SB, Bilimoria S, Benson J, Maher CE, Teister KJ, Szokol JW: Neuromuscular and Clinical Recovery in Thoracic Surgical Patients Reversed With Neostigmine or Sugammadex. Anesth Analg 2021; 133:435–44
20. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS, Gray J, Landry E: Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesth Analg 2013; 117:133–41
21. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Marymont JH, Vender JS, Gray J, Landry E, Gupta DK: Intraoperative acceleromyography monitoring reduces symptoms of muscle weakness and improves quality of recovery in the early postoperative period. Anesthesiology 2011; 115:946–54

Published: 03/2024