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Of Confidence and Consequence: Outcomes and Knowledge of Postoperative Residual Neuromuscular Blockade

Nathan, Naveen MD

doi: 10.1213/ANE.0000000000004209
Infographics: Infographic

Northwestern University Feinberg School of Medicine (

Published ahead of print 28 March 2019.

The Infographic is composed by Naveen Nathan, MD, Northwestern University Feinberg School of Medicine ( Illustration by Naveen Nathan, MD.

The author declares no conflicts of interest.

Postoperative residual neuromuscular blockade (PRNB) continues to place patients at risk for adverse respiratory events. More than 2000 patients were analyzed in a retrospective cohort study by Grabitz et al1 for the presence of PRNB in the postoperative recovery unit. One-fifth of these patients demonstrated PRNB as defined by a train of four (TOF) ratio of <0.9. These patients sustained a 3-fold higher risk of intensive care unit (ICU) admission compared to those without PRNB. The investigation did not clearly show an increase in hospital costs associated with PRNB; however, this parameter was particularly challenging to ascertain as a direct effect of PRNB. Despite the continued presence of measurable PRNB in the postoperative care unit, anesthesiologists are seemingly overconfident in their knowledge of the problem and the fundamental management of reversal intraoperatively. Using a 9-question multinational survey, Naguib et al2 present only a 57% accuracy rate of respondents on this topic, while their solicited confidence level was far in excess of this value. For further depth of understanding on this important component of anesthetic practice, readers are strongly encouraged to review these articles and their accompanying editorials.

ICU indicates intensive care unit; PRNB, postoperative residual neuromuscular blockade; TOF, train of four.

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1. Grabitz SD, Rajaratnam N, Changani K, et al. The effects of postoperative residual neuromuscular blockade on hospital costs and intensive care unit admission: a population-based cohort study. Anesth Analg. 2019;128:11291136.
2. Naguib M, Brull SJ, Hunter JM, et al. Anesthesiologists’ overconfidence in their perceived knowledge of neuromuscular monitoring and its relevance to all aspects of medical practice: an international survey. Anesth Analg. 2019;128:11181126.
    3. Naguib M, Kopman AF. Neuromuscular monitoring: keep it simple! Anesth Analg. 2019;128:10631064.
      4. Harman A, Tung A, Fox C, Lien CA. Heuristics, overconfidence, and experience: impact on monitoring depth of neuromuscular blockade. Anesth Analg. 2019;12810571059:.
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