A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion, what is the most important adverse effect to monitor?

• A. Nausea
• B. Confusion
• C. Bronchospasm
• D. Weak chest-wall movement

Answer: (D)

The key concept is that neuromuscular blocking agents paralyze skeletal muscles, including the diaphragm and chest wall. After surgery, the most critical issue is whether these respiratory muscles have recovered enough to ventilate the patient effectively. If chest-wall movement is weak or absent, the patient may not achieve adequate tidal volumes, leading to hypoventilation, hypercapnia, hypoxemia, and potential airway compromise. This is why monitoring for restoration of neuromuscular function and ensuring adequate ventilation is paramount, often using methods like train-of-four monitoring and watching for visible chest wall movement and respiratory effort. Reversal agents are given to restore muscle function, but ongoing assessment of the patient’s ability to breathe adequately remains the priority. Nausea, confusion, and even bronchospasm can occur, but they do not pose as immediate a threat to life as the inability to ventilate due to impaired chest-wall movement.