Intended for healthcare professionals


Antagonising neuromuscular block at the end of surgery

BMJ 2012; 345 doi: (Published 16 October 2012) Cite this as: BMJ 2012;345:e6666
  1. Jennifer M Hunter, emeritus professor of anaesthesia
  1. 1Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool L69 3GA, UK
  1. bja{at}

To reverse or not to reverse? That is the question

The introduction of neuromuscular blocking drugs (muscle relaxants) into anaesthetic practice 70 years ago revolutionised acute clinical care. It led to the development of major cardiac surgery, paediatric surgery, and neurosurgery, as well as the specialty of critical care. In the presence of muscle relaxants, anaesthesia could be lightened and postoperative recovery was faster. This allowed patients to protect their airway more rapidly on recovery, thereby preventing pulmonary aspiration of stomach contents. In a linked study (doi:10.1136/bmj.e6329), Grosse-Sundrup and colleagues used a prospective propensity score matched cohort analysis to compare outcomes in 18 579 patients who received intermediate acting muscle relaxants and 18 579 who did not.1

In the United Kingdom, the development of anaesthesia using neuromuscular blockade was led by T Cecil Gray in Liverpool. In 1946, he described a series of more than 1000 cases of what became known as the Liverpool anaesthetic technique, which consisted of sleep induced with a barbiturate and maintained with nitrous oxide in oxygen, analgesia with morphine, and profound muscle relaxation with D-tubocurarine.2 He insisted on the need for good oxygenation throughout anaesthesia—in itself a new concept at the time—and diligent clinical monitoring of the …

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