The interesting comments of Drs. Kempen, Pinsker, and Rizzi regarding my previous editorial in the Journal 1are, to some extent, similar and offer me the opportunity to comment on this issue from another perspective.

Dr. Kempen focuses on whether we have evidence strong enough to support a change in practice. Like Dr. Pinsker, he also thinks that clinical bedside evaluation is superior to the information given by a neuromuscular monitor. He also states that the acceleromyograph is extremely difficult/impossible to quantify and that more complicated devices may lead to serious problems of costs, time consumption, and accuracy! In this matter, Dr. Kempen partly refers to a study when accelography was not yet in routine clinical use. He also states that recovery includes recovery from all anesthetic agents, not only the neuromuscular blocking drugs. Currently, most commercially available neuromuscular monitoring principles are easy to use and have a simple and rapid setup procedure. Of course, objective neuromuscular monitoring, as mentioned in the editorial, 1only detects muscular function rather than recovery from anesthesia within other organ systems (e.g. , central nervous system, spinal cord). As such, neuromuscular monitoring provides important pieces of information that cannot be derived from other monitoring principles, such as capnography, spirometry, or end-tidal gas analysis. More important, it is not justified to accept a nonmonitoring attitude merely because one thinks the evidence is insufficient and without having studied the recent literature.

Dr. Pinsker touches on issues related to morbidity and mortality caused by residual block. In this context, he also states that he has not seen a clinical problem with a patient cared for in his practice, which he declares routinely lacks neuromuscular monitoring and reversal agents. He further thinks that more outcome studies are needed before a change in practice can be recommended. As a clinical anesthesiologist who routinely reads our anesthesia journals, I am surprised at this statement. Even without knowing the quality of the data and the protocols that Dr. Pinsker uses, I strongly suggest that he publish his clinical observations about the lack of any problems in his practice, because such findings are in deep contrast to several reports in the anesthesia literature. 2–6Moreover, the existence of e few outcome studies 5,6of the kind Dr. Pinsker wants to see must have escaped his attention. As written in the editorial, investigations of that kind 5,6and many more clearly demonstrate that such practices result in residual paralysis in many patients, that residual block is a risk factor for the development of postoperative pulmonary complications, and, finally, that such block can be avoided by objective neuromuscular monitoring. To my opinion, this sends a clear message to all of us who frequently read anesthesia journals.

Finally, Dr. Rizzi would like to see better outcome studies. Each publication can (and should) be evaluated in this context, which improves the discussion. The editorial 1tried to do this by putting neuromuscular monitoring in perspective with intraoperative and postoperative studies, thus providing key information, even if further studies are yet to be done. In this light, there is far more scientific evidence that residual neuromuscular block affects outcome in a way that may be hazardous for some patients, with increased risk for pulmonary adverse events occurring late in the postoperative period, when most anesthesiologists are back in the operating room. Solid information 1,7,8currently supports the view that failure to introduce objective neuromuscular monitoring into routine anesthetic practice represents substandard care.

Once again, explore the references and join the club! It is time for action and to provide neuromuscular monitoring in our operating theaters.

Eriksson LI: Evidence-based practice and neuromuscular monitoring: It’s time for routine quantitative assessment. A nesthesiology 2003; 98: 1037–9
Lunn JN, Hunter AR, Scott DB: Anaesthesia-related surgical mortality. Anaesthesia 1983; 38: 1090–6
Cooper AL, Leigh JM, Tring IC: Admissions to the intensive care unit after complications of anesthestic techniques over 10 years. Anaesthesia 1989; 44: 953–8
Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourch G: Complications related to anaesthesia in infants and children: A prospective survey in 40,240 anaesthetics. Br J Anaesth 1988; 61: 263–9
Gätke MR, Viby-Mogensen J, Rosenstock C, Jensen FS, Skovgaard LT: Postoperative muscle paralysis after rocuronium: Less residual block when acceleromyography is used. Acta Anaesthesiol Scand 2002; 46: 207–13
Berg H, Viby-Mogensen J, Roed Mortensen CR, Engbaek J, Skovgaard LT: Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomized and blinded study of postoperative complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997; 41: 1095–103
Kopman AA: Atracurium associated with postoperative residual curarization (letter). Br J Anaesth 2003; 90: 523–4
Viby Mogensen J: Postoperative residual curarization and evidence-based anaesthesia. Br J Anaesth 2000; 84: 301–3