Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis.


The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes.


From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; −1.0% difference [95% CI, –1.7 to –0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001).


In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

Editor’s Perspective
What We Already Know about This Topic
  • Quantitative (train-of-four ratio) monitoring is the definitive standard for assessing recovery from neuromuscular block
  • Residual neuromuscular block, defined as a train-of-four ratio less than 0.9, is commonly observed in patients given nondepolarizing neuromuscular blocking drugs perioperatively
  • Inadequate reversal of residual neuromuscular block is associated with postoperative morbidity and mortality
  • Despite guidelines from several professional societies advocating quantitative neuromuscular monitoring for neuromuscular blocking drug management, it is infrequently used
What This Article Tells Us That Is New
  • A departmental professional practice initiative began with the goal of documenting a train-of-four ratio greater than or equal to 0.90 for all patients given a nondepolarizing neuromuscular blocking drug
  • This retrospective assessment of the implementation of documenting train-of-four ratios greater than or equal to 0.9 before extubation improved from 1% (2 of 172) of cases in November 2016 to 93% (250 of 269) of cases in December 2020
  • Attaining this endpoint required not only placing a quantitative monitor in each anesthetizing location but also ongoing educational efforts and follow-up