Indications for Neuromuscular Blocking Agents

©International Anesthesia Research Society. Unauthorized Use Prohibited. Almost thirty years ago, residual neuromuscular blockade was documented in a surprisingly high proportion of patients (30%), despite an almost systematic use of anticholinesterase agents.1 Since then, even with the development of shorter-acting neuromuscular blockers, pharmacological reversal, and more widespread use of nerve stimulation, residual paralysis is still a problem that has been associated with episodes of hypoxia,2 respiratory distress,3 airway obstruction,3 atelectasis,4 and patient discomfort,3 as well as increased mortality.5 Since the introduction of rocuronium and cisatracurium in the mid 1990s, no new blocking agents have been introduced into clinical practice. A new reversal drug, sugammadex, is available in certain countries, but not in the United States or Canada. With this background in mind, three questions should be asked. First, when are neuromuscular blocking agents indicated, and if they are indicated, how should they be used? Second, if neuromuscular blocking agents are used, how can we best avoid residual paralysis? Third, how can current and future reversal agents be used in anesthetic practice?