Guideline sources The following summarized guidelines for the management of neuromuscular blockade are prepared by our editorial team based on guidelines from the American Society of Anesthesiologists (ASA 2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2022), the French Society of Anesthesia and Intensive Care (SFAR 2020), the Society of Critical Care Medicine (SCCM 2016), and the German Society of Anaesthesiology and Intensive Care Medicine (DGAI/DIVI 2015). 1 2 3 4 5 Guidelines 1. Respiratory support Facemask ventilation: Avoid verifying the possibility of mask ventilation before administering a muscle relaxant. D Consider administering a muscle relaxant to facilitate facemask ventilation. C Supraglottic airways: Avoid using muscle relaxants routinely to facilitate the insertion of a supraglottic device. D https://web.pathway.md/diseases/recV0rgBM94280bsf 1/6 6/30/23, 1:16 AM Neuromuscular blockade Pathway Consider administering a muscle relaxant in case of airway obstruction related to a supraglottic device. C Tracheal intubation: As per ESAIC 2022 guidelines: Administer a muscle relaxant to facilitate tracheal intubation A and reduce pharyngeal and/or laryngeal injury following endotracheal intubation. B Administer a fast-acting muscle relaxant (such as succinylcholine 1 mg/kg or rocuronium 0.9- 1.2 mg/kg) for rapid sequence induction and intubation. B As per SFAR 2020 guidelines, administer a muscle relaxant to facilitate tracheal intubation and reduce pharyngeal and/or laryngeal injury. A Show 2 more Prevention of unplanned extubation: implement additional safeguards to attenuate the risk of unplanned extubations in patients receiving neuromuscular blocking agents. E 2. Medical management Sedation and analgesia: Administer analgesic and sedative drugs to achieve deep sedation before and during the neuromuscular blockade. E Insufficient evidence to support the use of EEG-derived parameters as a measure of sedation during continuous administration of neuromuscular blocking agents. I Glycemic control: consider targeting a blood glucose level of < 180 mg/dL in patients receiving neuromuscular blocking agents. C 3. Nonpharmacologic interventions Eye care: provide scheduled eye care, including lubricating drops or gel and eyelid closure, to prevent corneal abrasions in patients receiving continuous infusion of neuromuscular blocking agents. B Physiotherapy: consider providing a structured regimen of physiotherapy in patients receiving continuous infusion of neuromuscular blocking agents. C 4. Perioperative care Neuromuscular monitoring: As per ASA 2023 guidelines, do not obtain clinical assessment alone to avoid residual neuromuscular blockade when neuromuscular blocking drugs are administered, because of the insensitivity of the assessment. D Show 2 more https://web.pathway.md/diseases/recV0rgBM94280bsf 2/6 6/30/23, 1:16 AM Neuromuscular blockade Pathway As per SFAR 2020 guidelines: Obtain intraoperative monitoring of neuromuscular blockade. A Consder obtaining train-of-four stimulation of the ulnar nerve at the adductor pollicis for intraoperative monitoring of neuromuscular blockade. B As per SCCM 2016 guidelines: Avoid obtaining peripheral nerve stimulation with the train-of-four technique alone to monitor the depth of neuromuscular blockade in patients on continuous infusion of neuromuscular blocking agents. D Consider obtaining peripheral nerve stimulation with the train-of-four technique to monitor the depth of neuromuscular blockade only if it is incorporated into a more inclusive assessment of the patient including clinical assessment. C 5. Specific circumstances Critically ill patients: administer neuromuscular blocking agents in the ICU only for specific indications. B Show 2 more Pediatric patients: consider administering a non-depolarizing muscle relaxant to improve intubating conditions during anesthesia in pediatric patients by IV induction, unless rapid sequence induction or the use of a depolarizing muscle relaxant is required. C Show 2 more Patients with obesity: As per SFAR 2020 guidelines, consider administering a short-acting muscle relaxant to facilitate tracheal intubation in patients with severe obesity (BMI 40 kg/m ). Consider administering suxamethonium at a dose of 1.0 mg/kg based on the actual body weight of the patient with obesity. C Show 2 more As per SCCM 2016 guidelines, use a consistent weight (ideal body weight or adjusted body weight) rather than actual body weight when calculating neuromuscular blocking agent doses in patients with obesity. B Patients with renal/hepatic failure: consider administering a benzylisoquinoline muscle relaxant (atracurium/cisatracurium) in cases of renal/hepatic failure. C Show 2 more Patients on mechanical ventilation: insufficient evidence to support the use of neuromuscular blockade to improve the accuracy of intravascular volume assessment in mechanically ventilated patients. I Patients with acute respiratory distress syndrome: consider administering a neuromuscular blocking agent by continuous IV infusion early in the course of ARDS in patients with a PaO /FiO < 150. C https://web.pathway.md/diseases/recV0rgBM94280bsf 3/6 6/30/23, 1:16 AM Neuromuscular blockade Pathway Patients with status asthmaticus: avoid administering neuromuscular blocking agents routinely in mechanically ventilated patients with status asthmaticus. D Patients with traumatic brain injury: insufficient evidence to recommend for or against the use of neuromuscular blockade in patients with acute brain injury and raised ICP. I Patients with neuromuscular diseases: As per SFAR 2020 guidelines, do not use suxamethonium in cases of primary muscle damage (myopathies) or up-regulation of nicotinic AChRs at the motor end plate (chronic motor deficit). D Show 2 more As per SCCM 2016 guidelines: Administer a reduced dose (based on peripheral nerve stimulation with train-of-four monitoring) of a neuromuscular blocking agent in patients with myasthenia gravis. E Insufficient evidence to recommend monitoring a specific muscle group in patients with myasthenia gravis undergoing treatment with neuromuscular blocking agents. I Patients undergoing abdominal surgery: As per ESAIC 2022 guidelines: Deepen neuromuscular blockade if surgical conditions of abdominal surgery require improvement. B Insufficient evidence to recommend deep neuromuscular blockade to reduce postoperative pain or decrease the incidence of perioperative complications. I As per SFAR 2020 guidelines: Administer muscle relaxants to facilitate interventional procedures in abdominal laparotomy or laparoscopy surgery. A Insufficient evidence to recommend on the required intensity of neuromuscular blockade (moderate versus deep) in abdominal laparotomy or laparoscopy surgery. I Patients undergoing ENT surgery: consider administering muscle relaxants to facilitate interventional procedures in ENT laser surgery. C Patients undergoing therapeutic hypothermia: insufficient evidence to support the routine use of neuromuscular blocking agents in patients undergoing therapeutic hypothermia following cardiac arrest. Show 2 more Patients undergoing electroconvulsive therapy: consider administering a short-acting muscle relaxant for electroconvulsive therapy. C Brain death and end-of-life care: Discontinue neuromuscular blocking agents before the clinical determination of brain death. E Consider discontinuing neuromuscular blocking agents at the end of life or when life support is withdrawn. C https://web.pathway.md/diseases/recV0rgBM94280bsf 4/6 6/30/23, 1:16 AM Neuromuscular blockade Pathway 6. Follow-up and surveillance Reversal: As per ASA 2023 guidelines, administer sugammadex rather than neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade. B Show 2 more As per ESAIC 2022 guidelines, obtain ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis. B Show 4 more As per SFAR 2020 guidelines, consider obtaining quantitative adductor pollicis monitoring of the neuromuscular blockade for diagnosing a residual neuromuscular blockade and obtaining a ratio of 0.9 for the fourth to first train-of-four response (T4/T1 ratio) at the adductor pollicis to eliminate the possibility of diagnosing a residual neuromuscular blockade. C Show 6 more Studies 2017 Stockl In adult patients who were resuscitated from non-traumatic out-of-hospital cardiac arrest within six hours prior to arrival at the emergency department, continuous neuromuscular blockade was superior to bolus neuromuscular blockade with respect to shivering episodes. Mathias St ckl et al. Resuscitation. 2017 Nov. References 1. Murray MJ, DeBlock H, Erstad B et al. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med. 2016 Nov;44 11 2079 2103. Open 2. Stephan R Thilen, Wade A Weigel, Michael M Todd et al. 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 Jan 1;138 1 13 41. Open 3. Beno t Plaud, Christophe Baillard, Jean-Louis Bourgain et al. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med. 2020 Feb;39 1 125 142. Open 4. DAS Taskforce, Ralf Baron, Andreas Binder et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 DAS Guideline 2015 short version. Ger Med Sci. 2015 Nov 12;13 Doc19. Open 5. Thomas Fuchs-Buder, Carolina S Romero, Heidrun Lewald et al. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2022 Nov 16. Open https://web.pathway.md/diseases/recV0rgBM94280bsf 5/6 6/30/23, 1:16 AM Neuromuscular blockade Pathway https://web.pathway.md/diseases/recV0rgBM94280bsf 6/6