Abstract
Background and objective
Residual neuromuscular blockade (rNMB) is associated with perioperative pulmonary complications. Effective neuromuscular monitoring and the use of reversal agents can help reduce rNMB. We surveyed the current practices of neuromuscular reversal and neuromuscular monitoring among anesthesiologists in China.
Methods
We released a questionnaire containing 25 questions via the New Youth Anesthesia Forum and promoted it through WeChat. We allowed one submission from each IP address. The survey was available online for 30 days. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression analysis.
Results
We analyzed 3,168 valid questionnaires. Rocuronium (41.76%) and cisatracurium (38.83%) were the most frequently used neuromuscular blocking agents. Only 40.09% of respondents routinely administered pharmacological reversal agents, with neostigmine being the predominant choice (61.11% of total respondents) and sugammadex used by merely 19.03%. The adoption of quantitative neuromuscular monitoring was low, with only 1.61% (n = 51) reported routinely utilizing quantitative monitoring (TOF ratio measurement), while 98.01% relied solely on subjective clinical signs. Logistic regression identified that advanced education (master’s or higher) and senior academic rank (associate chief or chief physician) independently predicted greater adoption of neuromuscular monitoring. Anesthesiologists in primary and secondary hospitals demonstrated significantly lower adherence to both antagonist administration and objective monitoring compared to those in tertiary centers.
Conclusions
Our findings reveal substantial gaps in adherence to evidence-based practices for managing rNMB in China, particularly concerning the underutilization of quantitative monitoring and sugammadex. Systemic interventions to improve equipment accessibility, drug availability, and targeted education are crucial to enhance patient safety. Policy-driven resource allocation and standardized training programs are recommended to bridge the gap between evidence and practice.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12871-026-03913-w.
Keywords: Neuromuscular blocking agents, Neuromuscular monitoring, Antagonism, Sugammadex, Surveys and Questionnaires
Introduction
Neuromuscular blocking agents (NMBAs) are essential for facilitating tracheal intubation and optimizing surgical conditions during general anesthesia [1]. However, the use of NMBAs may be associated with severe postoperative complications, including airway obstruction, hypoxemia, postoperative pulmonary complications, aspiration, re-intubation, delayed tracheal extubation, prolonged stay in the post-anesthesia care unit (PACU), and symptoms of unease, such as muscle weakness [2–4]. These complications are related to the persistence or incomplete post-surgical reversal of neuromuscular blockade, which is referred to as residual neuromuscular blockade (rNMB). A multicenter study in China showed that the incidence of rNMB at tracheal extubation was as high as 57.8% [5]. Multicenter studies conducted in the United States and Canada have also reported that 64.7% and 63.5% of patients, respectively, exhibited rNMB at tracheal extubation [6, 7].
Quantitative neuromuscular monitoring, specifically measuring the train-of-four (TOF) ratio, is the gold standard for assessing recovery and is demonstrably superior to qualitative or clinical assessments [2, 8–11]. Current guidelines mandate a TOF ratio of ≥ 0.9 before extubation. In the absence of such monitoring, routine administration of reversal agents is recommended [8–10, 12]. Despite these clear recommendations, prior surveys in China have indicated suboptimal adoption of both monitoring and reversal strategies, though these studies were limited by small sample sizes and narrow geographic scope [1, 8, 9, 13–17]. In clinical practice, the use of NMBAs, reversal agents, and neuromuscular monitoring varies among regions, hospitals, and anesthesiologists and across different surgical procedures. To provide a comprehensive national perspective, we conducted this large-scale cross-sectional survey to evaluate the current landscape of NMBA use, reversal practices, and monitoring attitudes among Chinese anesthesia providers.
Methods
Study design and participants
This cross-sectional study was approved by the Ethics Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine (Approval No.: 2024 − 0759) and was conducted in accordance with the Declaration of Helsinki. The questionnaire consisted of two parts and had 25 questions. We asked respondents to specify if they were an anesthesiologist or nurse (resuscitation room or anesthesia nurse) at the beginning of the questionnaire. If the respondents were not anesthesiologists or nurses, they were instructed to not proceed with the questionnaire. The first part of the questionnaire primarily focused on the general characteristics of the respondents, including their gender, academic background, professional title, city of work, years of professional experience, and hospital level. The second part primarily included questions on the use of NMBAs and reversal, neuromuscular monitoring, and adverse reactions. The inclusion criteria were as follows: engagement in perioperative clinical anesthesia-related work (including anesthesiologists, anesthesia nurses, and resuscitation room nurses). The exclusion criteria were as follows: lack of consent to the use of survey data for the study and incomplete responses provided in the questionnaire.
Context of anesthesia workforce in china
Unlike systems where anesthesia is exclusively administered by specialist physician anesthesiologists, the current clinical landscape in China utilizes a mixed care team model to address regional resource disparities. This survey encompasses all perioperative anesthesia providers, including both physician anesthesiologists and anesthesia nurses. Physician anesthesiologists in China enter practice after completing a minimum of a 5-year Bachelor of Medicine degree followed by standardized residency training. Anesthesia nurses typically hold 3-year Associate degrees or 4-year Bachelor degrees in nursing. While anesthesia nurses participate in perioperative care, physician anesthesiologists retain primary authority over pharmacological interventions and monitoring decisions. To ensure the robustness of our findings regarding clinical decision-making, a sensitivity analysis was conducted excluding nursing staff. Professional titles (Resident, Attending, Associate Chief, and Chief Physician) are awarded based on a combination of years of clinical service, national licensing examinations, and academic contributions, rather than solely on fellowship completion. This hierarchical structure influences decision-making patterns regarding monitoring protocols and pharmacological interventions, particularly in secondary and primary care hospitals where less specialized staff may predominate.
Sample size estimation
In accordance with the recommendations of Bartlett et al. [18]. we considered the formula n = Z2*p*(1-p)/d2 to be suitable for sample size calculation in cross-sectional surveys. Given the limited research on NMBAs in the perioperative stage, we set the expected proportion (p) at 0.5, with a confidence level of 95% (corresponding Z value of 1.96) and an acceptable error margin of 5%. The calculated required sample size was 384. Based on published survey research [13]. we assumed a response rate of 40% and calculated the minimum required sample size to be 960.
Validity test of the questionnaire
The questionnaire was developed based on relevant literature and data from clinical practice on NMBAs. After the initial questionnaire was completed, we invited six experts (four anesthesiologists and two nursing specialists) with over 10 years of clinical work experience to analyze and evaluate each item of the questionnaire and assess content validity. As this instrument is a survey questionnaire designed to capture current practices rather than a standardized psychometric scale measuring latent constructs, formal psychometric validation metrics such as internal consistency (Cronbach’s alpha) or test-retest reliability were not applicable and thus not performed.
Data collection
We prepared the questionnaire using the WJC platform (Changsha Ranxing IT Ltd., Changsha, China). We primarily released the questionnaire via the New Youth Anesthesia Forum (http://www.xqnmz.com) and additionally distributed and promoted it through WeChat, a multifunctional instant messaging and social media application. Respondents could respond to the questions by clicking on the link or scanning the QR code provided. They could complete the questionnaire using either a computer or a mobile device. The questionnaire was designed to be completed within 5 min. We obtained informed consent from the respondents before we administered the questionnaire. We allowed a single response from each IP address. The data collected were managed anonymously. The online survey was available for 30 days, from June 30, 2024, to July 29, 2024. The questionnaire structure is presented in Appendix 1 and the full questionnaire is presented in Appendix 2.
Statistical analysis
Categorical data are presented as frequencies (percentages). Chi-square or Fisher’s exact tests were used for group comparisons, and logistic regression models identified factors associated with the use of reversal agents and monitoring. A p-value < 0.05 was considered statistically significant. All statistical analyses was performed using version R 4.2.0 and version SPSS 23.0, graphs were generated using GraphPad Prism 9.0.
Results
Respondents’ general information
We received 3,196 valid questionnaires, with 8,312 visits, resulting in a response rate of 38.45%. Among the 3,196 questionnaires, 28 questionnaires from non-anesthesiologists or non-nurses (PACU nurses or anesthesia nurses) were excluded. Eventually, we included 3,168 questionnaires in the data analysis, comprising responses from 3,098 anesthesiologists and 70 nurses. The respondents were from 32 provinces of China (excluding Hong Kong and Macao). Figure 1 shows the geographic distribution and the proportions of provinces. In Table 1, we have summarized the demographic characteristics of the respondents. Of the respondents, 73.93% had a bachelor’s degree, 52.11% were attending physicians, more than 50.00% had over 10 years of work experience, and 61.65% worked at tertiary hospitals.
Fig. 1.
Geographic distribution of respondents and proportion of provinces
Table 1.
Respondent’s demographic data
| Variables | n (%) |
|---|---|
| Gender | |
| Man | 1689 (53.31) |
| Female | 1479 (46.69) |
| Education Background | |
| Associate’s degree | 120 (3.79) |
| Bachelor’s degree | 2342 (73.93) |
| Master’s degree | 654 (20.64) |
| Doctoral degree | 52 (1.64) |
| Physician title | |
| Resident physician | 482 (15.21) |
| Attending physician | 1651 (52.11) |
| Associate chief physician | 792 (25.00) |
| Chief physician | 243 (7.67) |
| Working years | |
| < 5 years | 330 (10.42) |
| 5–10 years | 893 (28.19) |
| 11–15 years | 766 (24.18) |
| > 15 years | 1179 (37.22) |
| Hospital grade | |
| Tertiary hospital | 1953 (61.65) |
| Secondary hospital | 1158 (36.55) |
| Primary hospital | 57 (1.80) |
n number of respondents
Definitions:
Education Background: Reflects the diverse entry pathways into the Chinese anesthesia workforce:
• Associate’s degree: 3-year vocational training, primarily qualifying individuals as anesthesia technicians or nurses with limited independent prescribing rights
• Bachelor’s degree: 5-year undergraduate medical education, the mandatory minimum for licensed physician status and entry into anesthesia residency
• Master’s degree: 3-year postgraduate training integrating advanced clinical rotations with research methodology; often a prerequisite for promotion in tertiary hospitals
• Doctoral degree: 3-4 years of specialized research-focused training post-master’s, typically held by senior academic clinicians
Physician Title: Professional ranks determined by tenure, examination performance, and academic output:
• Resident physician: Junior clinicians (<5 years of experience) undergoing standardized residency training
• Attending physician: Mid-level practitioners (5–10+ years) authorized for independent practice and resident supervision
• Associate chief physician: Senior experts (>10–15 years) holding leadership roles in clinical management and academia
• Chief physician: The highest clinical rank, reserved for department heads and nationally recognized specialists
The inclusion of anesthesia nursing staff in the survey cohort accounts for the presence of Associate’s degrees within the demographic data
Use of NMBAs
As shown in Table 2, rocuronium (n = 1323, 41.76%) and cisatracurium (n = 1230, 38.83%) were the dominant NMBAs. Anesthesiologists with less than 5 years of work experience preferred rocuronium, whereas anesthesiologists with over 15 years of work experience used cisatracurium and vecuronium more commonly. Respondents from tertiary hospitals reported using rocuronium, cisatracurium, succinylcholine, and atracurium at higher rates than respondents from secondary and primary hospitals, whereas respondents from secondary hospitals reported using vecuronium more frequently. We found significant differences in the use of NMBAs among anesthesiologists with different years of experience and those working in different hospital grades (P < 0.05), as shown in Table 3.
Table 2.
Usage of neuromuscular blocking agents (Overall)
| Neuromuscular Blocking Agent | n (%) |
|---|---|
| Rocuronium | 1323 (41.76%) |
| Cisatracurium | 1230 (38.83%) |
| Vecuronium | 495 (15.62%) |
| Succinylcholine | 27 (0.85%) |
| Atracurium | 62 (1.96%) |
| Others | 31 (0.98%) |
| Total | 3168 (100%) |
n number of respondents
Table 3.
Comparison of different neuromuscular blocking agents Use by Respondent Characteristics
| Variables | Rocuronium n (%) |
Cisatracurium n (%) |
Vecuronium n (%) |
Atracurium n (%) |
Succinylcholine n (%) |
P-value |
|---|---|---|---|---|---|---|
| Physician title | 0.215 | |||||
| Resident physician | 214 (16.18) | 164 (13.33) | 83 (16.77) | 10 (16.13) | 5 (18.52) | |
| Attending physician | 684 (51.70) | 659 (53.58) | 240 (48.48) | 34 (54.84) | 15 (55.56) | |
| Associate chief physician | 319 (24.11) | 326 (26.50) | 127 (25.66) | 11 (17.74) | 4 (14.81) | |
| Chief physician | 106 (8.01) | 81 (6.59) | 45 (9.09) | 7 (11.29) | 3 (11.11) | |
| Working years | < 0.001 | |||||
| < 5 years | 168 (12.70) | 117 (9.51) | 31 (6.26) | 4 (6.45) | 6 (22.22) | |
| 5–10 years | 390 (29.48) | 334 (27.15) | 130 (26.26) | 16 (25.81) | 7 (25.93) | |
| 11–15 years | 292 (22.07) | 325 (26.42) | 122 (24.65) | 16 (25.81) | 5 (18.52) | |
| > 15 years | 473 (35.75) | 454 (36.91) | 212 (42.83) | 26 (41.94) | 9 (33.33) | |
| Hospital grade | < 0.001 | |||||
| Tertiary hospital | 860 (65.00) | 824 (66.99) | 193 (38.99) | 38 (61.29) | 17 (62.96) | |
| Secondary hospital | 448 (33.86) | 389 (31.63) | 281 (56.77) | 21 (33.87) | 9 (33.33) | |
| Primary hospital | 15 (1.13) | 17 (1.38) | 21 (4.24) | 3 (4.84) | 1 (3.70) |
n number of respondents
Clinical application and correlation analysis of neuromuscular reversal agents and neuromuscular monitoring
Among all respondents (n = 3168), only 40.09% (n = 1270) reported routinely using pharmacological antagonists to reverse residual neuromuscular blockade (rNMB); Notably, this percentages represents the choice of agent among those who do use a reversal agent; a substantial minority (59.91%, n = 1898) reported not using any reversal agent routinely, relying instead on spontaneous recovery.
Regarding the most commonly used assessment methods for rNMB, 98.01% (n = 3105) relied on subjective clinical signs. Only 0.28% (n = 9) employed qualitative peripheral nerve stimulation, and a mere 1.61% (n = 51) reported routinely utilizing quantitative monitoring (TOF ratio measurement). Notably, while 73.61% (n = 2332) of clinicians reported never using peripheral nerve stimulators, 25.13% (n = 796) indicated they had used quantitative monitoring at least once. Among this subgroup of users, 84.67% confirmed a TOF ratio of ≥ 0.9 before extubation. The low utilization was primarily due to equipment unavailability in their department (81.05%, n = 1890).
Among those who did use reversal agents, neostigmine was the predominant choice (61.11% of total respondents, n = 1936), whereas sugammadex was used by only 19.03% (n = 603). The low adoption of sugammadex was largely attributed to its limited availability in departments (73.06%, n = 1874) and high cost (41.40%, n = 1062). When administering neostigmine, 83.43% (n = 2643) co-administered atropine to counteract bradycardia. Timing of antagonist administration was predominantly guided by clinical cues: 62.78% (n = 1989) gave reversal agents when patients exhibited voluntary movement or resumed spontaneous breathing. With respect to the monitoring site, the adductor pollicis muscle was overwhelmingly preferred (78.83%, n = 659) among users of neuromuscular monitors. Among the 3168 respondents, 25.13% (n = 796) had used quantitative monitoring to assess rNMB. Among this group of respondents, 84.67% (n = 674) confirmed a TOF ratio of ≥ 0.9 before tracheal extubation, while 15.33% (n = 122) did not.
Univariate logistic regression analysis showed that female sex (OR: 0.79, 95% CI: 0.68–0.91), holding a master’s degree (OR: 1.76, 95% CI: 1.17–2.64), being an attending physician (OR: 0.77, 95% CI: 0.63–0.95), and working in a secondary hospital (OR: 0.71, 95% CI: 0.61–0.82) were significantly associated with lower likelihood of using neuromuscular reversal agents (P < 0.05). Regarding neuromuscular monitoring, female sex (OR: 0.85, 95% CI: 0.73–0.99), higher educational attainment (master’s degree: OR: 2.67, 95% CI: 1.68–4.23; doctoral degree: OR: 2.81, 95% CI: 1.42–5.56), senior professional titles (associate chief physician: OR: 1.63, 95% CI: 1.25–2.13; chief physician: OR: 2.69, 95% CI: 1.93–3.77), and employment in lower-tier hospitals (secondary hospital: OR: 0.46, 95% CI: 0.39–0.55; primary hospital: OR: 0.31, 95% CI: 0.14–0.68) were significantly associated with the use of neuromuscular monitoring (P < 0.05). Multivariate analysis identified an association between female gender and a lower likelihood of using reversal agents or quantitative monitoring. In contrast, advanced education (master’s or higher) and senior academic rank (associate chief or chief physician) independently predicted greater adoption of neuromuscular monitoring. Anesthesiologists in primary and secondary hospitals demonstrated significantly lower adherence to both antagonist administration and objective monitoring compared to those in tertiary centers. (Tables 4 and 5)
Table 4.
Logistic regression analysis of whether to perform neuromuscular reversal
| Variables | Univariate logistic regression | Multivariate logistic regression | ||||
|---|---|---|---|---|---|---|
| β | P | OR (95% CI) | β | P | OR (95% CI) | |
| Gender | ||||||
| Man | 1.00 (Reference) | 1.00 (Reference) | ||||
| Female | -0.24 | 0.001 | 0.79 (0.68 ~ 0.91) | -0.31 | < 0.001 | 0.74 (0.63 ~ 0.85) |
| Education background | ||||||
| Associate’s degree | 1.00 (Reference) | 1.00 (Reference) | ||||
| Bachelor’s degree | 0.17 | 0.393 | 1.18 (0.80 ~ 1.74) | 0.08 | 0.689 | 1.09 (0.73 ~ 1.63) |
| Master’s degree | 0.56 | 0.007 | 1.76 (1.17 ~ 2.64) | 0.39 | 0.083 | 1.48 (0.95 ~ 2.31) |
| Doctoral degree | 0.66 | 0.052 | 1.93 (0.99 ~ 3.73) | 0.38 | 0.279 | 1.47 (0.73 ~ 2.93) |
| Professional title | ||||||
| Resident physician | 1.00 (Reference) | 1.00 (Reference) | ||||
| Attending physician | -0.26 | 0.013 | 0.77 (0.63 ~ 0.95) | -0.24 | 0.082 | 0.79 (0.60 ~ 1.03) |
| Associate chief physician | -0.05 | 0.668 | 0.95 (0.76 ~ 1.20) | 0.06 | 0.754 | 1.06 (0.74 ~ 1.50) |
| Chief physician | -0.06 | 0.722 | 0.94 (0.69 ~ 1.29) | 0.04 | 0.856 | 1.04 (0.68 ~ 1.60) |
| Working years | ||||||
| < 5 years | 1.00 (Reference) | 1.00 (Reference) | ||||
| 5–10 years | -0.21 | 0.111 | 0.81 (0.63 ~ 1.05) | -0.01 | 0.929 | 0.99 (0.72 ~ 1.34) |
| 11–15 years | -0.25 | 0.059 | 0.78 (0.60 ~ 1.01) | -0.05 | 0.772 | 0.95 (0.67 ~ 1.35) |
| > 15 years | -0.24 | 0.058 | 0.79 (0.62 ~ 1.01) | -0.20 | 0.301 | 0.82 (0.56 ~ 1.20) |
| Hospital grade | ||||||
| Tertiary hospital | 1.00 (Reference) | 1.00 (Reference) | ||||
| Secondary hospital | -0.34 | < 0.001 | 0.71 (0.61 ~ 0.82) | -0.25 | 0.002 | 0.78 (0.66 ~ 0.91) |
| Primary hospital | -0.11 | 0.678 | 0.89 (0.52 ~ 1.53) | 0.04 | 0.887 | 1.04 (0.60 ~ 1.81) |
OR Odds Ratio, CI Confidence Interval
Table 5.
Logistic regression analysis of whether to perform neuromuscular monitoring
| Variables | Univariate logistic regression | Multivariate logistic regression | ||||
|---|---|---|---|---|---|---|
| β | P | OR (95% CI) | β | P | OR (95% CI) | |
| Gender | ||||||
| Man | 1.00 (Reference) | 1.00 (Reference) | ||||
| Female | -0.16 | 0.044 | 0.85 (0.73 ~ 0.99) | -0.27 | 0.002 | 0.77 (0.65 ~ 0.91) |
| Education background | ||||||
| Associate’s degree | 1.00 (Reference) | 1.00 (Reference) | ||||
| Bachelor’s degree | -0.07 | 0.756 | 0.93 (0.60 ~ 1.46) | -0.36 | 0.131 | 0.70 (0.44 ~ 1.11) |
| Master’s degree | 0.98 | < 0.001 | 2.67 (1.68 ~ 4.23) | 0.55 | 0.033 | 1.74 (1.05 ~ 2.88) |
| Doctoral degree | 1.03 | 0.003 | 2.81 (1.42 ~ 5.56) | 0.37 | 0.313 | 1.45 (0.70 ~ 3.01) |
| Professional title | ||||||
| Resident physician | 1.00 (Reference) | 1.00 (Reference) | ||||
| Attending physician | 0.21 | 0.099 | 1.23 (0.96 ~ 1.58) | 0.30 | 0.077 | 1.34 (0.97 ~ 1.86) |
| Associate chief physician | 0.49 | < 0.001 | 1.63 (1.25 ~ 2.13) | 0.66 | 0.002 | 1.94 (1.28 ~ 2.94) |
| Chief physician | 0.99 | < 0.001 | 2.69 (1.93 ~ 3.77) | 1.13 | < 0.001 | 3.08 (1.90 ~ 5.01) |
| Working years | ||||||
| < 5 years | 1.00 (Reference) | 1.00 (Reference) | ||||
| 5–10 years | -0.02 | 0.917 | 0.98 (0.74 ~ 1.31) | 0.06 | 0.748 | 1.06 (0.74 ~ 1.52) |
| 11–15 years | -0.16 | 0.296 | 0.85 (0.64 ~ 1.15) | -0.13 | 0.528 | 0.88 (0.59 ~ 1.32) |
| > 15 years | 0.13 | 0.348 | 1.14 (0.87 ~ 1.50) | -0.13 | 0.567 | 0.88 (0.56 ~ 1.37) |
| Hospital grade | ||||||
| Tertiary hospital | 1.00 (Reference) | 1.00 (Reference) | ||||
| Secondary hospital | -0.77 | < 0.001 | 0.46 (0.39 ~ 0.55) | -0.51 | < 0.001 | 0.60 (0.49 ~ 0.73) |
| Primary hospital | -1.18 | 0.004 | 0.31 (0.14 ~ 0.68) | -0.84 | 0.043 | 0.43 (0.19 ~ 0.97) |
OR Odds Ratio, CI Confidence Interval
A sensitivity analysis excluding the 70 nursing respondents (analyzing only 3,098 physician anesthesiologists) yielded similar results: advanced education and senior professional titles remained significant predictors for the use of quantitative monitoring and reversal agents, and hospital grade remained a significant barrier. This suggests that the inclusion of nurses did not substantially bias the primary associations observed. (Appendix 3)
Postoperative resuscitation
Of the respondents, 39.93% (n = 1265) indicated that they removed the patient’s endotracheal tube in the operating room after surgery and returned the patient to the ward after the patient regained consciousness; 63.00% (n = 797) of these respondents were from secondary hospitals. Additionally, 31.25% (n = 990) reported transferring patients to the PACU after extubation in the operating room; 73.33% (n = 726) of these respondents were from tertiary hospitals. Of the respondents, 27.90% (n = 884) reported transferring patients to the PACU with the endotracheal tube after surgery and extubating them in the PACU; 88.91% (n = 786) of these respondents were from tertiary hospitals. In primary hospitals, patients were mostly extubated in the operating room and returned to the ward after recovery.
When it came to measures for improving neuromuscular monitoring, 88.23% of respondents were hopeful about improvements in equipment allocation in their department, 77.11% expected the department to organize training, and 70.64% and 72.92% opined that department leaders and anesthesiologists should pay sufficient attention to the improvement of neuromuscular monitoring. Reading guidelines or literature (93.18%) and attending academic conferences (74.81%) were the primary methods most respondents reported using to obtain relevant updates on the techniques used in this field.
Discussion
Here, we surveyed the use of NMBAs and reversal agents as well as the application of neuromuscular monitoring among Chinese anesthesia practitioners. We received 3168 complete questionnaires in this survey, with respondents belonging to 32 provinces in China. This was the largest survey on NMBA use in China based on the number of respondents and geographical coverage. Our survey results showed that rocuronium and cisatracurium are the NMBAs most commonly used by anesthesiologists in China. Currently, there is no ideal NMBA available in clinical practice. Among the NMBAs used currently, rocuronium and cisatracurium are considered the closest to ideal, which explains their widespread clinical application [19, 20]. In this survey, the usage rate of rocuronium was higher than that of cisatracurium (41.76% vs. 38.83%), which is different from the results reported in a survey of Chinese anesthesiologists in 2022 (rocuronium: 35.48%, cisatracurium: 45.68%) [13]. This difference may be associated with the increased use of sugammadex.
Sugammadex is a modified γ-cyclodextrin that reverses the effects of the non-depolarizing NMBAs rocuronium and vecuronium, enabling rapid recovery from moderate to deep neuromuscular blockade in surgical patients [21]. Neostigmine, the most commonly used antagonist, antagonizes both the aminosteroidal and curariform types of non-depolarizing NMBAs by inhibiting acetylcholine breakdown at the neuromuscular junction. Several studies have shown that, compared to neostigmine, sugammadex facilitates superior reversal of rNMB with fewer side effects [22–26]. In this survey, when respondents identified rNMB in patients, 80% opted for a reversal agent, with sugammadex and neostigmine being used by 19.03% and 61.11% of respondents, respectively. Although sugammadex is a superior antagonist, only 19.03% of respondents in our survey used it, which is significantly lower than the percentage reported in South Korea (89.1%) [16]. However, this value has increased markedly from values reported in previous surveys in China [13]. According to our survey results, the low use rate of sugammadex is related to its high cost and unavailability in departments. Although sugammadex is expensive, other factors, such as recovery time, operating room expenses, nursing expenses, rNMB, and expenses associated with adverse events caused by rNMB, should also be considered when selecting the most appropriate drug [27–29].
Our survey findings highlight a critical reality within the Chinese healthcare system: a substantial proportion of respondents (39.93%) reported extubating patients in the operating room and transferring them directly to the general ward once they exhibited initial signs of awakening, thereby bypassing the PACU for structured recovery. This practice was primarily observed in secondary and primary hospitals. This may be related to the lack of PACU establishment, insufficient beds, and a shortage of nursing staff in these hospitals in China [30].
This survey highlights critical gaps in perioperative neuromuscular management across China. Only 40.09% of respondents routinely administered reversal agents for rNMB - a rate higher than in Korea (22.4%) but slightly below that in Europe (45.8%) [16, 17]. Notably, attending physicians, and those in secondary hospitals were less likely to use reversal agents, suggesting potential influences from hierarchical constraints, or resource limitations in non-tertiary settings. Our multivariate analysis identified an association between female gender and lower likelihood of using reversal agents or quantitative monitoring. It is crucial to interpret this finding as an association rather than a causal effect of gender on clinical practice. This disparity may reflect underlying structural or organizational factors, such as differences in professional seniority, access to decision-making roles, or resource allocation within departments, rather than individual behavioral preferences. Further qualitative research is needed to elucidate the systemic barriers that may disproportionately affect different demographic groups in adopting new technologies and protocols.
More concerning is the extremely low adoption of routine quantitative neuromuscular monitoring: only 1.61% of respondents used objective methods regularly. Although 25.13% reported having used quantitative devices at some point, the vast majority (98.01%) rely on subjective clinical tests such as head-lift or handgrip. The discrepancy between ‘ever used’ (25.13%) and ‘routinely used’ (1.61%) highlights a gap between equipment availability/access and consistent clinical application. Although many administered reversal agents once spontaneous breathing or movement returned, these signs lack sensitivity and cannot reliably exclude clinically significant rNMB (TOF < 0.9) [8, 31, 32]. Current evidence mandates quantitative confirmation of TOF ≥ 0.9 before tracheal extubation to reduce postoperative pulmonary complications [8]. Yet, merely 2.97% of respondents based antagonist use on monitoring data, and over two-thirds had never used quantitative devices-primarily due to equipment unavailability, insufficient institutional support, and inadequate training. A positive trend is evident: the overall monitoring utilization rate (26.39%) has improved compared to prior Chinese surveys [13], reflecting growing awareness. Moreover, advanced education and senior academic rank strongly correlate with guideline-concordant practice, underscoring the role of expertise in driving quality care. To bridge the gap between evidence and practice-especially in primary and secondary hospitals-concerted efforts are needed: policy-driven equipment deployment, structured educational programs, and integration of quantitative monitoring into institutional quality metrics. Only through such systemic interventions can patient safety in the context of neuromuscular blockade be consistently assured. Our data reveal a significant correlation between provider qualification levels and adherence to safety protocols. In settings dominated by providers with lower-tier educational backgrounds or junior titles, we observed a reduced frequency of quantitative neuromuscular monitoring and a higher reliance on empirical reversal strategies. This phenomenon likely stems from variations in pathophysiological understanding of residual neuromuscular blockade and differing thresholds for recognizing subtle signs of respiratory compromise. These findings underscore that the low adoption of monitoring and reversal agents in non-tertiary hospitals is partly driven by the presence of less-specialized staff, reinforcing the need for targeted policy interventions.
Our findings indicated that the adductor pollicis muscle is the most commonly used site for neuromuscular monitoring. Research has confirmed that patients monitored at the adductor pollicis muscle is used for monitoring have a lower probability of rNMB than patients monitored at other muscles, as it takes longer to reach a TOF ratio of 0.9 in the former case. The prolonged recovery duration of the adductor pollicis muscle provides a more reliable indicator for ensuring the complete reversal of neuromuscular blockade [33–35].
Urban-rural and hospital-tier disparities: Our data show that physicians in tertiary hospitals are more likely to use rocuronium and sugammadex and transfer patients to the post-anesthesia care unit (PACU) for recovery, whereas primary and secondary hospitals more commonly extubate patients directly in the operating room and return them to general wards. This clearly reflects the current inequity in healthcare resource distribution across China. Primary, secondary, and grassroots hospitals may be constrained by limited equipment (e.g., neuromuscular monitoring devices, PACU beds), drug availability (e.g., shortages of sugammadex or glycopyrronium), and staffing, resulting in a significant gap between their clinical practice and guideline recommendations. This systemic disparity constitutes a critical contextual factor in our findings and underscores the urgent need to promote standardized neuromuscular blockade management in grassroots healthcare settings.
This study had several limitations. The response rate of this survey was slightly below 40%, which is the minimum response rate strongly recommended by Story DA and Tait AR for survey research [36]. While we invited experts to evaluate the validity of the questionnaire, we did not conduct statistical analyses for reliability and validity tests because our questionnaire was not a typical Likert-scale questionnaire. We cannot rule out recall bias or confirm the accuracy and reliability of the responses. Although this survey covered the entire country, the sample may have overly represented the group of anesthesiologists who are proficient in using the internet and actively participate in academic forums. It may not have adequately captured the true situation of colleagues in remote areas or non-teaching hospitals. The sample is not necessarily representative of all practicing anesthesiologists in China, particularly those in rural or less-resourced settings. Nevertheless, the responding hospitals covered all provinces of mainland China, and the sample size was large. Additionally, we conducted careful data cleaning and inspection to ensure data accuracy. Therefore, our results may represent the current status of NMBAs, reversal agents, and neuromuscular monitoring in mainland China.
Conclusion
Our findings indicate that Chinese anesthesiologists have insufficient awareness of the importance of neuromuscular monitoring, which is particularly evident in primary and secondary hospitals. The usage rate of neuromuscular reversal agents, especially sugammadex, is relatively low. Addressing this requires concerted efforts to democratize access to essential monitoring technology, ensure the availability of effective reversal drugs, and implement nationwide educational initiatives to standardize care and prioritize patient safety across all levels of the healthcare system.
Supplementary Information
Acknowledgements
We are thankful to those who took the time to complete our survey.
Abbreviations
- rNMB
Residual neuromuscular blockade
- NMBAs
Neuromuscular blocking agents
- PACU
Post-anesthesia care unit
- TOF
Train-of-four
Authors’ contributions
JCT, XYZ and TTW: Writing-original draft preparation and conceptualization, TJC was a major contributor in writing the manuscript. TTW and QG: Data curation, methodology and visualization. YYY: Supervision, writing, reviewing, and editing. All authors read and approved the final manuscript.
Funding
The author declare that no financial support was received for the research, authorship, and/or publication of this article.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine, and obtain informed consent from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jia-chun Tao, Xiang-yong Zhou and Ting-ting Wang contributed equally to this work.
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Associated Data
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Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.