This first article in a three-part clinical review examines the patient safety evidence behind quantitative neuromuscular monitoring, with a focus on why system-wide—not selective—monitoring is necessary to reliably prevent residual neuromuscular blockade.
Study Context and Rationale
Residual neuromuscular blockade is a well-established patient safety risk. Its association with impaired airway protection, postoperative respiratory complications, and delayed recovery is supported by decades of literature. The ongoing challenge in clinical practice is not awareness of risk, but rather the consistent, precise application of monitoring and recovery criteria across patients and providers.
Quantitative neuromuscular monitoring (QNM) has been recommended by the ASA for years, yet real-world practice remains fragmented—monitors are only available in some rooms, used inconsistently by clinicians, or reserved only for select patients.
In their 2021 study, Universal quantitative neuromuscular blockade monitoring at an academic medical center—A multimodal analysis of the potential impact on clinical outcomes and total cost of care, Edwards and colleagues examined this gap directly. Their work makes a compelling case that partial adoption is not enough. The economic and clinical benefits of QNM are realized only when institutions commit to universal, protocol-driven use.
Edwards et al. sought to evaluate the potential impact of universal quantitative monitoring, rather than selective or discretionary use, by combining clinical observation with institutional quality and cost data. Their analysis explicitly frames residual paralysis as a systems reliability issue, rather than a failure of individual clinical judgment.
Phase 1: Variable assessment types and protocols for extubation prove unreliable
The first phase of the analysis assessed neuromuscular recovery at the time of extubation under routine clinical practice. Patients undergoing general endotracheal anesthesia were managed with TwitchView Train of Four monitoring at the discretion of the anesthesia team. Quantitative electromyography-based train-of-four ratios were then measured immediately prior to extubation.
Key findings included:
- 60% of patients had a quantitative TOF ratio (qTOFR) below 0.9 at the time of extubation when clinical assessment alone was used.
- All patients were judged clinically ready for emergence based on clinical assessment and routine practice.
This finding reframes residual paralysis as a system-level reliability issue, not a clinician competency problem. When monitoring practices vary by provider, room, or case type, patient risk and downstream costs rise predictably.
Residual paralysis is a predictable outcome of variable monitoring strategies
By demonstrating a high prevalence of residual blockade despite routine monitoring and reversal, the study reframes residual paralysis as a predictable outcome of variable monitoring strategies.
When neuromuscular assessment depends on:
- Individual clinician preference
- Variable monitoring sites
- Or inconsistent thresholds for recovery
The reliability of patient recovery varies. Edwards et al. argue that this variability, rather than individual decision-making, drives ongoing exposure to residual neuromuscular blockade.
Why residual paralysis matters to patients
Residual weakness following anesthesia is not a theoretical concern. Even modest degrees of neuromuscular impairment can affect a patient’s ability to maintain airway patency and respond to hypoxic or hypercapnic stress.
Clinical studies have linked residual neuromuscular blockade to:
- Increased risk of postoperative pneumonia
- Unplanned reintubation
- Prolonged PACU and ICU stays
- Delayed functional recovery
For anesthesiologists, these outcomes directly challenge the core goal of safe emergence and recovery. For patients, they can translate into extended hospitalization, additional interventions, and increased morbidity.
Residual paralysis is a system problem, not an individual failure
When neuromuscular monitoring is not standardized across a system:
- Risk fluctuates unpredictably from case to case
- Complications appear sporadic rather than preventable
- Safety issues are difficult to identify and improve
Objective measurement changes this dynamic by making neuromuscular recovery visible, measurable, and actionable.
Closing Perspective
Objective evidence shows that incomplete recovery persists despite clinicians acting with the best intentions, and when it leads to complications, both patients and institutions are affected.
Improving the safety of neuromuscular recovery is ultimately about ensuring that the requirements for recovery are consistent and objectively monitored. The downstream economic benefits reflect the value of that safety—not the other way around.
Stay tuned for part 2 for the review of the impactful economic outcomes of this study.
