Circulation 122,210 • Volume 34, No. 2 • October 2019   Issue PDF

Avoiding Postoperative Residual Weakness—A Cornerstone of Any ERAS Protocol

J. Ross Renew, MD

Postoperative residual weakness persists as a patient safety threat and can be a significant obstacle to a patient’s recovery. Strategies to minimize this threat and its associated complications should be incorporated into enhanced recovery after surgery protocols.

NMB MonitorWhile neuromuscular blocking agents (NMBAs) are a useful class of medications in the perioperative setting, their use is not without risk. Unfortunately, postoperative residual weakness following NMBA administration persists as a significant patient safety threat.1-4 This phenomenon has been implicated in a number of significant complications including prolonged time spent in the recovery room, hypoxemia, and airway obstruction.5,6 Additionally, one of the most common complaints from patients with postoperative residual weakness is unpleasant subjective symptoms related to incomplete neuromuscular recovery that can interfere with early mobilization.7 Despite an abundance of literature documenting the detrimental effects of postoperative residual weakness, many anesthesia professionals underestimate the scope of this problem.8 As such, residual weakness and its associated complications remain a serious patient safety concern.

Significant advances in the field of perioperative care have emerged, even in the face of these unresolved hazards. Enhanced recovery after surgery (ERAS) protocols represent comprehensive, multidisciplinary efforts to expedite postoperative recovery while reducing avoidable complications.9 These standardized efforts have been shown to improve a number of important perioperative outcomes, such as reduced postoperative nausea and vomiting (PONV)10 and improved patient satisfaction.11 While effective, ERAS protocols must be constructed with the best available evidence and conform to the specific context of the implementing institution in order to have significant benefit to patients.12 The avoidance of postoperative residual weakness is an evidence-based practice to improve patient safety and should be a cornerstone of any ERAS protocol.

Several strategies have emerged to reduce the incidence of postoperative residual weakness. Not surprisingly, these strategies overlap with common principles of enhanced recovery programs. The use of reversal agents to antagonize the effects of NMBAs, such as neostigmine or sugammadex, is an evidence-based practice that can reduce the incidence of postoperative residual weakness and its associated complications.13 A recent meta-analysis has expanded on this matter and suggests that the administration of sugammadex results in fewer adverse events, less PONV, and faster return of neuromuscular function when compared to neostigmine.14 In addition to safely expediting recovery and reducing PONV, ERAS also emphasizes the maintenance of homeostasis during the perioperative period. Although not commonly described, the restoration of neuromuscular function may represent a key principle of ERAS. Furthermore, the use of quantitative neuromuscular monitoring can confirm that neuromuscular homeostasis has been restored postoperatively.15 Quantitative monitoring has been linked to reducing postoperative pulmonary complications that would undoubtedly have served as a significant hindrance to a patient’s enhanced recovery.13 These strategies can be implemented to not only reduce adverse events from postoperative residual weakness, but also to expand and advance comprehensive ERAS protocols.

While enhanced recovery protocols are being implemented at an increasing rate and growing in popularity, we cannot overlook persistent patient safety threats that could also prove to be significant impediments to such programs. As ERAS protocols rely upon well-established evidence, well-described strategies to avoid postoperative residual weakness should be incorporated as the perioperative community continues efforts to advance patient safety and improve outcomes.


Dr. Renew is currently an assistant professor in the Department of Anesthesiology and Perioperative Medicine at Mayo Clinic in Jacksonville, FL.

Dr. Renew has received industry funding for research, including from Merck & Co., with all funding accruing to Mayo Clinic.


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