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Reversal of neuromuscular blockade

Key sources
The following summarized guidelines for the management of reversal 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).
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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
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  • Supraglottic airways

  • Tracheal intubation

  • Prevention of unplanned extubation

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

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  • Glycemic control

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

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  • Physiotherapy

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
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5.Specific circumstances

Critically ill patients: administer neuromuscular blocking agents in the ICU only for specific indications.
B
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  • Pediatric patients

  • Patients with obesity

  • Patients with renal/hepatic failure

  • Patients on mechanical ventilation

  • Patients with ARDS

  • Patients with status asthmaticus

  • Patients with traumatic brain injury

  • Patients with neuromuscular diseases

  • Patients undergoing abdominal surgery

  • Patients undergoing ENT surgery

  • Patients undergoing therapeutic hypothermia

  • Patients undergoing electroconvulsive therapy

  • Brain death and end-of-life care

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
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