Percentage of patients with a documented Train of Four (TOF) after last dose of non-depolarizing neuromuscular blocker.

Postoperative residual neuromuscular blockade can lead to significant complications such as hypoxemia, impaired pulmonary function, upper airway obstruction, postoperative pneumonia, and respiratory failure.^1,2 Several studies have found associations between the use of neuromuscular blockade agents (NMBA) and residual neuromuscular blockade in the recovery room. ^{1, 5-6}  Adverse postoperative respiratory outcomes are even more frequent when patients receive NMBA and reversal agents are not used. ^1-4 A mainstay of residual blockade prevention continues to be monitoring to allow for detection, and use of reversal agents like neostigmine and sugammadex. Due to variability in duration of muscle relaxants, even in defasciculating doses, best practice is to assess TOF when any non-depolarizing neuromuscular blockers are administered.

Anesthesia Start to earliest extubation before Anesthesia End

All patients that have received either by bolus or infusion a non-depolarizing neuromuscular blocker (NMB) AND were extubated before anesthesia end.  The following NMBs are included:

• Atracurium
• Cisatracurium
• Pancuronium
• Rocuronium
• Vecuronium

• ASA 5 and 6 including Organ Procurement (CPT: 01990)
• Patients not receiving neuromuscular blockade
• Patients that were not extubated in the immediate postoperative period (as defined by the earliest time resulted from LMA Removal Times or Extubation Times).
• Procedure Type: Lung Transplant

Documentation of a Train of Four count (1, 2, 3, or 4), sustained tetany, or TOF ratio provided by acceleromyography AFTER last dose or stopping of infusion of neuromuscular blocker and before earliest extubation. 

Note: A Train of Four value of ‘0’ is accepted for cases in which sugammadex is administered for reversal.

• A valid TOF value must be documented after the last neuromuscular blockade dose and before extubation for the case to pass.  If TOF values are only documented at the same time or after extubation, the case will flag.
• If the TOF value documented after the last dose of neuromuscular blockade and before extubation is determined to be 'invalid' per the Train of Four values phenotype, the case will be flagged with result reason: 'Unknown TOF Value.'
• If the only TOF value is 0 before extubation and sugammadex is administered, the sugammadex must be documented before extubation time for the case to pass. 
• If tetanic fade is documented prior to extubation, case passes.

*This measure will include valid MPOG cases defined by the Is Valid Case MPOG phenotype.

Not Applicable

The provider(s) signed in at time of earliest extubation.

1. Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB: 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 2023; 138:13–41
2. Harrison GG. Death attributable to anaesthesia. A 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041-6.
3. Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg 1954; 140:2-35.
4. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010. 111(1): 129-40.
5. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, Ehrenfeld JM, Martinez EA, Kurth T, Eikermann M. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329
6. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular blockade. Curr Opin Anesthesiol. 2014; 27(6): 616-622.