Guidelines on muscle relaxants and reversal in anaesthesia

Overview

These guidelines address the use of neuromuscular blocking agents and their reversal during anaesthesia. Their main focus is preventing residual neuromuscular blockade, a common and underrecognised cause of postoperative respiratory complications.

Indications

Neuromuscular blockade is recommended to improve intubating conditions and reduce airway injury, and to optimise surgical conditions where muscle relaxation is needed. The choice of agent should take into account the clinical situation, including rapid sequence induction and the patient's comorbidities.

Monitoring

Quantitative neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is given, both to guide dosing during surgery and to confirm adequate recovery before extubation. Clinical signs alone, and subjective assessment of nerve stimulation, are not reliable enough to exclude residual blockade.

Reversal

Reversal should be guided by the depth of blockade measured with monitoring. Spontaneous recovery is acceptable only when monitoring confirms full recovery. The reversal strategy should be matched to the agent used and the level of residual block.

Special situations

Specific advice covers patients with obesity, older adults, patients with neuromuscular disease or renal and hepatic impairment, and the recognition and management of anaphylaxis, for which neuromuscular blocking agents are a leading cause in the perioperative period.