KEY POINTS

1. Residual postoperative neuromuscular block causes decreased chemoreceptor sensitivity to hypoxia, functional impairment of the muscles of the pharynx and upper esophagus, impaired ability to maintain the airway, and an increased risk for the development of postoperative pulmonary complications.
2. It is difficult, and often impossible, by clinical evaluation of recovery of neuromuscular function, to exclude with certainty clinically significant residual curarization.
3. Absence of tactile fade in the response to TOF stimulation, tetanic stimulation and DBS does not exclude significant residual block.
4. Adequate recovery of postoperative neuromuscular function cannot be guaranteed without objective neuromuscular monitoring.
5. Good evidence-based practice dictates that clinicians should always quantitate the extent of neuromuscular blockade using objective monitoring.
6. To exclude clinically significant residual neuromuscular blockade the TOF ratio when measured mechanically or by electromyography must exceed 0.9.
7. Avoid total twitch depression during surgery. Keep, whenever possible one or two TOF responses.
8. Antagonism of the neuromuscular block should not be initiated before at least two, preferably three or four, responses to TOF stimulation are observed.
9. If sufficient recovery (TOF ≥ 0.9) has not been documented objectively at the end of the surgical procedure, the neuromuscular block should be antagonized.