Neuromuscular blockade management in neuromuscular diseases: toward a safety-oriented approach

Perioperative management of neuromuscular blockade in patients with neuromuscular diseases (NMDs) is complicated by disease-specific alterations in neuromuscular transmission and acetylcholine receptor regulation.These changes lead to highly variable responses to neuromuscular blocking agents (NMBAs) and reversal drugs and contribute to serious perioperative complications.Major NMDs are reviewed and classified into pre-junctional, junctional, and post-junctional categories based on the predominant site of dysfunction.This framework clarifies differential responses to NMBAs, identifies conditions in which succinylcholine is contraindicated or blockade and reversal are unreliable, and highlights key perioperative risks such as hyperkalemia, anesthesia-induced rhabdomyolysis, myotonia, and delayed respiratory failure.Common perioperative considerations are summarized, including preoperative assessment, quantitative neuromuscular monitoring, cautious NMBA dosing, reversal strategies, and postoperative surveillance.The role of sugammadex in improving the predictability of neuromuscular recovery in selected neuromuscular diseases is outlined within a pathophysiology-based management framework.