Suggested management of neuromuscular blockade according to monitoring

Site	Modality	Response	Interpretation	Comments
Prediction of tracheal intubating conditions
Any site	Single twitch, TOF	Present	Adequate conditions not met	Deep blockade is required for intubation
Corrugator supercilii	Single twitch, TOF	Absent	Adequate conditions likely	Corrugator supercilii reflects vocal cords and diaphragm
Adductor pollicis	Single twitch, TOF	Absent	Adequate conditions likely only if high dose given	Adductor pollicis is more sensitive than vocal cords and diaphragm
Flexor hallucis (foot)	Single twitch, TOF	Absent	Adequate conditions likely only if high dose given	Foot muscles are sensitive and block late
Intraoperative conditions
Adductor pollicis	PTC	1 to 2	Deep blockade	Return of diaphragm movements possible, no TOF response at adductor pollicis
Corrugator supercilii	TOF	1 to 2	Deep blockade	Return of abdominal tone possible, no TOF response at adductor polices
Adductor pollicis	TOF	1 to 2	Moderate blockade	Usually sufficient for most procedures
Corrugator supercilii	TOF	4, with or without fade	Moderate to shallow blockade	Difficult to interpret without adductor pollicis data
Adductor pollicis	TOF	4, with or without fade	Shallow blockade	Additional relaxation might be needed
Management of recovery
Adductor pollicis	PTC	0	Wait or sugammadex* 16 mg/kg
Adductor pollicis	PTC	1 to 2	Wait or sugammadex* 4 mg/kg
Corrugator supercilii	TOF	1 to 2	Wait or sugammadex* 4 mg/kg
Adductor pollicis	TOF	2	Wait or sugammadex* 2 mg/kg
Corrugator supercilii	TOF	4, with or without fade	Wait or correlate with adductor pollicis or sugammadex* 4 mg/kg	Corrugator supercilii recovers early Correlation with adductor pollicis preferable
Hypothenar eminence (fifth finger)	TOF	4, with or without fade	Observe thumb motion	Adductor pollicis recovers later
Adductor pollicis	TOF, visual or tactile	4, with fade	Wait or neostigmine^¶ 0.04 to 0.05 mg/kg or sugammadex* 2 mg/kg
Adductor pollicis	TOF, visual or tactile	4, without fade	Wait or neostigmine^¶ 0.020 mg/kg
Adductor pollicis	DBS, visual or tactile	Fade	Wait or neostigmine^¶ 0.02 to 0.05 mg/kg	Less neostigmine needed if no TOF fade
Adductor pollicis	DBS, visual or tactile	No fade	Wait or neostigmine^¶ 0.020 mg/kg	DBS fade detected when TOF ratio = 0.6
Adductor pollicis	TOF, quantitative	TOF ratio <0.90	Wait or neostigmine^¶	Neostigmine 0.04 to 0.05 mg/kg if TOF ratio <0.4; 0.02 mg/kg if TOF ratio >0.4
Adductor pollicis	100 Hz TET	No fade	No reversal necessary	100 Hz TET fade detected when TOF ratio = 0.8 to 0.9
Adductor pollicis	TOF, quantitative	TOF ratio ≥0.9	No reversal necessary	Full recovery

Actual management depends on patient, surgical procedure, and previous response to neuromuscular blocking agents.

TOF: train of four; PTC: posttetanic count; DBS: double burst stimulation; TET: 5-sec tetanic stimulation.
* Sugammadex can be used to reverse only rocuronium or vecuronium.
¶ Neostigmine can be used to reverse any nondepolarizing neuromuscular blocking agent.

Reproduced with permission from: Brull SJ. Neuromuscular blocking agents. In: Clinical Anesthesia, 8th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Wolters Kluwer, Philadelphia 2017. Copyright © 2017 Wolters Kluwer.

Graphic 114082 Version 4.0