Neuromuscular management and guidelines for the safe practice of total intravenous anaesthesia

We congratulate Nimmo et al. for producing the first guidelines for the safe practice of total intravenous anaesthesia (TIVA), but disagree with their statement that the “use of a processed EEG (pEEG) monitor is recommended when a neuromuscular blocking drug is used with TIVA” 1. Additionally, we strongly suggest that neuromuscular monitoring is used when neuromuscular blocking agents (NMBA) are administered, which provides the anaesthetist with useful information about the degree of neuromuscular blockade and may reduce the incidence of accidental awareness cases during general anaesthesia when TIVA is used. The use of NMBAs occurred in 93% of cases of accidental awareness under general anaesthesia reported in the 5th National Audit Project (NAP5), 20% of which occurred due to residual blockade after emergence. Block reversal was administered in only 48% of these cases, and neuromuscular monitoring used in only 9% 2, values that are similar to those reported previously 3. Correct management of neuromuscular blockade, involving quantitative neuromuscular monitoring and appropriate reversal, would therefore seem essential in addition to pEEG in reducing the prevalence of emergence accidental awareness under general anaesthesia.