The Block Stops Here: A Deep Dive into Neuromuscular Blockades

A Deep Dive into Neuromuscular Blockades

On This Episode:

In this episode of Anesthesia Alchemy, Garry and Terry briefly discuss the history, physiology, and pharmacology of using non-depolarizing neuromuscular blocking drugs as anesthesia adjuncts. They focus on the pitfalls of administrating these agents to surgical patients and the problems associated with residual neuromuscular blockade in the post-anesthesia care unit.

We will also provide an in-depth review of the new guidelines published by the American Society of Anesthesiologists for monitoring neuromuscular blockade and the practical recommendations for preventing residual neuromuscular blockade. We really need to dig into what this means for everyone standing at the head of the table, the folks in the pharmacy, and the purchasing office, which we’ll get to during the show today.

Here’s some of what we discuss in this episode:

  • What are cyclodextrins and why are they useful?
  • Understanding the essentials of neuromuscular transmission.
  • What some of the newer intermediate-acting neuromuscular drugs do and how they work.
  • How the treatment has changed through the years.
  • Monitoring recovery from neuromuscular blockade.
  • Running through the eight recommendations that were published.


References for this episode:

  1. Abdellatif, FH, and Abdellatif, MM. (2021). In: Utilization of sustainable biopolymers in textile processing. Green Chemistry for Sustainable Textiles. Elsevier Ltd.


  1. Beecher, HK, and Todd DP. (1954) A study of deaths associated with anesthesia and surgery. Annals of Surgery. 140:1. Pp 2-34.


  1. Abajian, J., Barrett, RH, et al. (1955). Critique of “Deaths Associated with anesthesia and surgery”. Annals of Surgery. 142:1. Pp 138-141.


  1. Taylor, DB. (1959). The mechanism of action of muscle relaxants and their antagonists. Anesthesiology. 20:4. 439-452.


  1. Murphy, GS, Brull SJ. (2010). Residual neuromuscular blockade: Lessons unlearned. Part I: Definitions, incidence, and adverse physiologic effects of neuromuscular blockade. Anesthesia and Analgesia. 111:1. Pp. 120-128.


  1. Brull, SJ and Murphy, GS. (2010). Residual neuromuscular blockade: Lessons unlearned. Part II. Methods to reduce the risk of residual weakness. Anesthesiology. 111:1. Pp. 129-140.


  1. Thilen, SR., Weigel, WA, et al. (2023). 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. 138:1. Pp 13-41.


  1. Haerter, F., Simons, JCP., et al. (2015). Comparative effectiveness of calabadion and sugammadex to reverse non-depolarizing neuromuscular blocking agents. Anesthesiology. 123:6. Pp. 1337-1349.


  1. Joo, H., Sooyoung, C., et al. (2023). Comparison of contralateral acceleromyography and electromyography for posttetanic count measurement. Anesthesiology. 138:3. Pp. 241-248.


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When we look at these things, all of these years we’ve been using methods to assess recovery neuromuscular blockade, which are totally unreliable. At that time, we thought we’re doing the right thing, but in reality, we were probably setting the patient up for failure, certainly in the recovery room.





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J. Cross CRNA
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