Pharmacological strategies to minimize or avoid neuromuscular blocking agents during general anesthesia: a comprehensive approach from airway management to surgical requirements

Neuromuscular blocking agents (NMBAs) are commonly used in general anesthesia and are widely applied in airway management and surgical requirements. However, the traditional use of NMBAs in anesthetic strategies has exposed potential issues, particularly residual neuromuscular blockade, which is associated with respiratory complications, delayed recovery, and prolonged hospitalization. In recent years, strategies aimed at minimizing or avoiding NMBAs have gained attention, especially in balancing airway management with surgical exposure demands during general anesthesia. This review was designed as a structured narrative review rather than a formal systematic review or meta-analysis. This review summarizes the pharmacological strategies for minimizing or avoiding NMBAs, with a focus on distinguishing between NMBA-free anesthesia, which completely avoids NMBAs, and NMBA-sparing anesthesia, which uses low doses or phased administration to minimize their use. Through the combination of other anesthetic agents and depth modulation, strategies for NMBA-free and NMBA-sparing have shown positive results in certain patients and surgeries, particularly in day surgery and fast-track recovery pathways. Nevertheless, this strategy is not suitable for all patients and surgeries, and individualized anesthetic management remains key to its successful implementation. Furthermore, with the introduction of Sugammadex, the rapid reversal of neuromuscular blockade provides assurance for minimizing or avoiding the use of NMBAs. Future research should focus on optimizing drug combinations, verifying non-inferiority, and applying these strategies to specific patient populations, further promoting their clinical adoption.