Quantitative neuromuscular monitoring during general anesthesia: a prospective clinical audit of adherence to international guidelines

Quantitative neuromuscular (qNM) monitoring is recommended whenever neuromuscular blocking agents (NMBAs) are administered, but adherence in routine clinical practice remains inconsistent. This audit evaluated adherence to recommended qNM monitoring standards in adult patients undergoing general anesthesia at a Portuguese tertiary hospital. This prospective clinical audit evaluated adherence to recommended qNM monitoring standards in adult patients undergoing general anesthesia at a major Portuguese tertiary hospital. Over five predefined weekdays between March and May 2025, all adult patients receiving general anesthesia across six operating or procedural areas were assessed. Of 329 patients included, 308 (93.6%) received NMBAs. Quantitative neuromuscular monitoring was omitted in 13.0% despite universal device availability. Utilization was lower in ambulatory and obstetrical settings and in procedures lasting less than one hour. Increasing anesthesia duration was associated with greater monitoring use in univariable analysis, but this association was not independent of clinical location. Equipment-related limitations accounted for a small proportion of omissions. This audit demonstrates high but incomplete adherence to qNM monitoring standards. Non-adherence is clustered primarily in procedures lasting less than one hour and in ambulatory and obstetrical settings. Although equipment was universally available, factors beyond equipment availability appear to contribute to incomplete implementation. Additional research is required to better understand the reasons underlying monitoring omission. In the meantime, targeted educational strategies and reinforcement of evidence-based neuromuscular monitoring practices may further enhance perioperative patient safety.