We thank Drs. Kempen and Pinsker for their remarks on our article. 1The main criticism of these two letters is that because outcome of partially paralyzed patients in the postoperative setting was not extensively evaluated, there is not enough evidence to recommend a quantitative evaluation of neuromuscular blockade or to promote universal reversal in presence of a partial paralysis at the end of the procedure. We agree with the first part of the comment. Indeed, our study was not designed to assess adverse events induced by partial paralysis. Our aim was limited to the determination of the incidence of partial paralysis at arrival in the PACU following the administration of a single dose of nondepolarizing muscle relaxant with an intermediate duration of action. This was done only to alert physicians that a time interval longer than 2 h after tracheal intubation to the end of the surgical procedure does not guarantee full recovery. Numerous studies have already demonstrated that moderate degree of paralysis (train-of-four ratio between 0.7 to 0.9) impedes physiologic pathways during early recovery. These alterations particularly affect respiratory response to hypoxemia, 2,3and the ability to swallow, a mechanism involved in the upper airway protection from inhalation after extubation. 4–6In our study, we tried to demonstrate that quantitative monitoring (i.e. , train-of-four ratio measurement) is a valuable tool to detect a low degree of residual paralysis with a good accuracy while qualitative instrumental tests and clinical test (head-lift) are not sensitive enough. To resume, there is enough scientific evidence to think that residual paralysis is not advantageous to the patient, even if it is not necessarily deleterious. Thereafter, anesthesiologists can detect quantitatively moderate residual paralysis levels and have long known how to accelerate recovery using different reversal agents (neostigmine or edrophonium). Therefore, and as mentioned in the editorial view accompanying our article, 7why not use all of these facts to improve our patient’s safety?

1.
Debaene B, Plaud B, Dilly M-P, Donati F: Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. A nesthesiology 2003; 98: 1042–8
2.
Eriksson LI, Lenmarken C, Wyon N, Johnson A: Attenuated ventilatory response to hypoxaemie at vecuronium-induced partial neuromuscular bloc. Acta Anaesthesiol Scand 1992; 36: 710–5
3.
Eriksson LI, Sato M, Severinghaus JW: Effects of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. A nesthesiology 1993; 78: 693–9
4.
Eriksson LI, Sundman E, Olsson R, Nilson L, Witt H, Ekberg O, Kuylenstierna R: Functional assessment of the pharynx at rest and during swallowing in partially paralysed humans: Simultaneous videomanometry of awake human volunteers. A nesthesiology 1997; 87: 1035–43
5.
Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI: The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralysed humans: Pharyngeal videoradiography and simultaneous manometry after atracurium. A nesthesiology 2000; 92: 977–84
6.
Isono I, Ide T, Kochi T, Mizuguchi T, Nishino T: Effects of paralysis on the swallowing reflex in conscious humans. A nesthesiology 1991; 75: 980–4
7.
Eriksson LI: Evidence-based practice and neuromuscular monitoring: It’s time for routine quantitative assessment. A nesthesiology 2003; 98: 1037–9