Incomplete reversal

incomplete reversal neuromuscular blockade recovery recovery room emeregencies Aug 18, 2025

False start – Managing Incomplete Reversal in Recovery

The incomplete reversal of neuromuscular blocking agents (NMBAs) poses a significant risk to patients emerging from anaesthesia. Not only is it an extremely unpleasant and scary experience for patients and staff, residual paralysis also results in airway compromise, aspiration risk, and impaired ventilation. Early recognition and prompt management from recovery nurses is essential in preventing significant harm for patients.

So how does incomplete reversal happen, how do you spot it, and what should you do about it? Let’s break it down:

Contributing Factors ⚠️

🔸 Use of non-depolarizing muscle relaxant agents
🔸 Lack of intraoperative monitoring
🔸 Reliance on subjective testing (e.g. head lift) vs train of four count (TOFC)
🔸 Higher doses of NMBA (e.g. rapid sequence induction)
🔸 Long-acting NMBAs such as pancuronium
🔸 Prolonged/maintained deep intraoperative paralysis
🔸 Short surgical procedures requiring paralysis
🔸 Obesity
🔸 Renal and hepatic impairment
🔸 Pre-existing neuromuscular disorders

How to Spot the Problem 🔎

Signs of incomplete reversal can be subtle, and identifying the problem requires vigilance and critical thinking from recovery nurses. Look out for:
🔹 Shallow or paradoxical breathing
🔹 Weak cough
🔹 Difficulty maintaining a patent airway
🔹 Desaturation despite oxygen therapy
🔹 Inability to sustain head lift
🔹 Weak hand grip
🔹 Poor tongue control
🔹 Jerky movements and poor limb control

What to Do About It 🛠️

If you suspect incomplete reversal, escalate your concerns and notify the anaesthetist quickly. The immediate priority is airway protection and maintaining oxygen saturations. Reassure your patient that they are safe and you are addressing the problem, and keep them as calm as possible. Treatment requires administration of additional reversal agents, and in some severe cases, the patient may require re-intubation.

Recovery nurses play a pivotal role in identifying the subtle signs and symptoms of incomplete reversal, which requires vigilance, early escalation, and a solid understanding of neuromuscular blockade and its reversal. To recap on neuromuscular monitoring, check out our previous concept series article here.

Build Knowledge ✅
Improve Safety ✅

References:

Rodney, P. Raju and S. J. Brull, Neuromuscular block management: evidence-based principles and practice, BJA Education 2024 Vol. 24 Issue 1 Pages 13-22, https://doi.org/10.1016/j.bjae.2023.10.005
A. Srivastava, J. M. Hunter, Reversal of neuromuscular block, BJA: British Journal of Anaesthesia, Volume 103, Issue 1, July 2009, Pages 115–129, https://doi.org/10.1093/bja/aep093

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