Sir,

Mr. Welliver and Dr. Jones did a nice job expounding on our discussion of residual neuromuscular blockade and appropriate monitoring of patients who have received neuromuscular blocking agents. A good teaching point is that patient variability is the norm and not the extreme. The majority of patients, barring any significant health issues changing the overall metabolism or function of neuromuscular blocking agents, will fall within a bell shaped curve when it comes to recovery from neuromuscular blockade. However, patients lying at the far ends of that curve will not be uncommon in your practice when enough patients are seen. That is why quantitative clinical indicators of recovery should be followed in all cases. Furthermore, frank discussions need to occur between us and our surgical colleagues when further neuromuscular blockade is requested. It makes sense that the surgeons want the surgical field to be optimized in all cases, but overall patient safety which includes recovery from neuromuscular blockade and the avoidance of inappropriate extubation needs to be considered as well. All have to be on board with the benefits and potential complications when re-administration of neuromuscular blocking agents occurs especially near the end of the surgical case. It should be obvious to all providers that these patients may have a prolonged recovery prior to extubation and more time may be needed in the operating room or in the post anesthesia care unit before appropriate spontaneous respirations are returned. There may be some level of inappropriate communication over the drapes, especially for a young anesthesia provider, when it comes to discussing whether there is a need for further neuromuscular blockade or if the surgery can be finished with some level of return of neuromuscular function. This difficulty when discussing these issues proves that the optimum in equipment to assess quantitative clinical reversal of neuromuscular blockade needs to be present in all operating rooms and operating facilities in order for us to make sure that our patients are cared for in the best possible manner. Furthermore, the teaching of the nuances of neuromuscular blockade and reversal of neuromuscular blockade has to be the mainstay of resident education. With the advances in other aspects of anesthesia equipment and medications, postoperative respiratory complications with many being due to residual neuromuscular blockade have not dramatically declined as a cause of patient morbidity and mortality from anesthesia.

Here are seven points to protect our patients from pulmonary complications of residual neuromuscular blockade:

With the use of neuromuscular blocking agents, patient variability should be considered the norm and not the extreme.\[[@ref1]\]When utilizing strong and potentially dangerous medications such as neuromuscular blocking agents, the provider should have a thorough understanding of those illnesses and situations that may lead to a prolonged response from these drugs.Appropriate quantitative monitors should be available when using neuromuscular blocking agents, and there should be a thorough understanding of their use as well as the interpretation of the results by the provider.\[[@ref2][@ref3]\] The use of a peripheral nerve stimulator is not optional.When utilizing neuromuscular blocking agents, it should be understood that maintenance of neuromuscular blockade throughout the case may not be indicated for all surgical procedures and in all situations. Avoid total twitch suppression.Although the use of acetylcholinesterase inhibitors should not be universal, if there is any question of residual neuromuscular blockade based on clinical findings, the time since last administration of a neuromuscular blocking agent, or patient history, an appropriate dose of these reversal agents should be administered based on the patient\'s weight and residual blockade. Further, attempt to wait until a train-of-four count of at least three is achieved prior to reversal as it can help avoid postoperative residual blockade.When further neuromuscular blockade is requested by our surgical colleagues, an open discussion needs to occur to determine whether the utilization of these agents at that time is appropriate based on the procedure being done and the time to completion.If there is any concern at all of residual neuromuscular blockade, it is prudent to maintain a secure airway until the patient is at a point where their natural airway can be safely maintained.\[[@ref4][@ref5]\]
