Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file

Eur J Anaesthesiol. 2018 Nov;35(11):883-892. doi: 10.1097/EJA.0000000000000861.


Background: Residual neuromuscular block (rNMB) after surgery is not difficult to identify if proper neuromuscular monitoring is used, but many clinicians do not use quantitative neuromuscular monitoring.

Objective: The aim of this study was to develop a REsidual neuromuscular block Prediction Score (REPS) to predict postoperative rNMB and compare the predictive accuracy of the prediction score with train-of-four count (TOFC) measurement at the end of a surgical case.

Design: Retrospective cohort study of data on file.

Data source: Electronic patient data and peri-operative data on vital signs, administered medications, and train-of-four ratio (TOFR) obtained in the postoperative recovery rooms [postanaesthesia care unit (PACU)] at Massachusetts General Hospital in Boston, Massachusetts, USA.

Patients: Quantitative TOFR measurements obtained on admission to the PACU were available from 2144 adult noncardiac surgical patients.

Main outcome measure: Presence of rNMB at PACU admission, defined as a TOFR of less than 0.9.

Results: In the score development cohort (n=2144), rNMB occurred in 432 cases (20.2%). Ten independent predictors for residual paralysis were identified and used for the score development. The final model included: hepatic failure, neurological disease, high-neostigmine dose, metastatic tumour, female sex, short time between neuromuscular blocking agent administration and extubation, aminosteroidal neuromuscular blocking agent, BMI more than 35, absence of nurse anaesthetist and having an experienced surgeon. The model discrimination by C statistics was 0.63, 95% confidence interval (0.60 to 0.66), and risk categories derived from the REPS had a higher accuracy than the last documented intra-operative TOFC for predicting rNMB (net reclassification improvement score 0.26, standard error 0.03, P < 0.001).

Conclusion: The REPS can be used to identify patients at greater risk of rNMB. This tool may inform anaesthetists better than an intra-operative TOFC and thus enable peri-operative anaesthetic practices to be tailored to the patient and minimise the undesirable effects of rNMB.

Trial registry number: Approved by Partners Human Research Committee (protocol number 2016P000940) at MGH in Boston, Massachusetts, USA on 25 April 2016.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Delayed Emergence from Anesthesia / diagnosis*
  • Delayed Emergence from Anesthesia / etiology
  • Electronic Health Records / statistics & numerical data
  • Feasibility Studies
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neuromuscular Blockade / adverse effects*
  • Neuromuscular Blockade / methods
  • Neuromuscular Blocking Agents / administration & dosage
  • Neuromuscular Blocking Agents / adverse effects*
  • Neuromuscular Monitoring / methods*
  • Predictive Value of Tests
  • Prognosis
  • Recovery Room / statistics & numerical data
  • Retrospective Studies
  • Time Factors


  • Neuromuscular Blocking Agents