EJAEur J Anaesthesio/2023;40:82-94GUIDELINESPeri-operative management of neuromuscular blockadeA guideline from the European Society of Anaesthesiology andIntensive CareThomas Fuchs-Buder,Carolina S.Romero,Heidrun Lewald,Massimo Lamperti,Arash Afshari,Ana-Marjia Hristovska,Denis Schmartz,Jochen Hinkelbein,Dan Longrois,Maria Popp,Hans D.de Boer,Massimiliano Sorbello,Radmilo Jankovic and Peter KrankeRecent data indicated a high incidence of inappropriate manlogical quality.A two-step Delphi process was used toagement of neuromuscular block,with a high rate of residualdetermine the agreement of the panel members with theparalysis and relaxant-associated postoperative complicarecommendations:R1 We recommend using a muscle relax-tions.These data are alarming in that the available neuromus-ant to facilitate tracheal intubation (1A).R2 We recommendcular monitoring,as well as myorelaxants and their antagoniststhe use of muscle relaxants to reduce pharyngeal and/orbasically allow well tolerated management of neuromuscularlaryngeal injury following endotracheal intubation (1C).R3blockade.Inthis first European Societyof AnaesthesiologyandWe recommend the use of a fast-acting muscle relaxant forIntensive Care(ESAIC)guideline on peri-operative manage-rapid sequence induction intubation (RSI)such as succinyl-ment of neuromuscular block,we aim to present aggregatedcholine 1mg kg1 or rocuronium 0.9 to 1.2mg kg-1(1B).R4and evidence-based recommendations to assist cliniciansWe recommend deepening neuromuscular blockade if surgi-provide best medical care and ensure patient safety.Wecal conditions need to be improved (1B).R5 There is insuffi-identified three main clinical questions:Are myorelaxantscient evidence to recommend deep neuromuscular blockadenecessary to facilitate tracheal intubation in adults?Doesin general to reduce postoperative pain or decrease the inci-the intensity of neuromuscular blockade influence a patient'sdence of peri-operative complications.(2C).R6 We recom-outcome in abdominal surgery?What are the strategies for themend the use of ulnar nerve stimulation and quantitativediagnosis and treatment of residual paralysis?On the basis ofneuromuscular monitoring at the adductor pollicis muscle tothis,PICO(patient,intervention,comparator,outcome)ques-exclude residual paralysis (1B).R7 We recommend usingtions were derived that guided a structured literature search.Asugammadex to antagonise deep,moderate and shallow neu-stepwise approach was used to reduce the number of trials ofromuscular blockade induced byaminosteroidalagents(rocur-the initial research(n =24000)to the finally relevant clinicalonium,vecuronium)(1A).R8 We recommend advancedstudies (n=88).GRADE methodology (Grading of Recom-spontaneous recovery (i.e.TOF ratio >0.2)before startingmendations,Assessment,Development and Evaluation)wasneostigmine-based reversal and to continue quantitative mon-used for formulating the recommendations based on the find-itoring of neuromuscular blockade unti
