Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast Episode 77: Reversal of Neuromuscular Blockade
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Mar 28, 2018 Explore the crucial topic of reversing neuromuscular blockade, emphasizing the importance of objective monitoring over subjective clinical tests. Discover how train-of-four ratios are vital for safe recovery and the limitations of clinical exams. Jed discusses two main reversal strategies: acetylcholinesterase inhibitors and sugammadex, detailing their mechanisms, dosing strategies, and unique considerations for different patient populations. Plus, learn about emerging neuromuscular blockers that may offer rapid reversal options.
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Clinical Tests Mislead On Recovery
- Clinical strength tests (head lift, tidal volume) are poor predictors of true neuromuscular recovery.
- Objective measurement is required because patients can appear strong despite TOF ratios <0.5.
Measure TOF With AMG For Reliable Recovery
- Use acceleromyography (AMG) to measure train-of-four ratio and confirm TOF ≥0.9 before considering full recovery.
- Do not rely on human touch to determine a TOF ratio around 0.7–0.9 because the hand cannot detect that range accurately.
Use Post‑Tetanic To Gauge Deep Block
- If no twitches are present, perform post-tetanic stimulation (50 Hz for 5s then single stimuli) to estimate time to first twitch.
- Use the post-tetanic twitch count (8–12 vs 1–2 vs 0) to judge how soon spontaneous twitches will return.
