Despite these limitations and limited evidence, TOF testing has achieved broad acceptance because of expert recommendation, its relative simplicity and low cost, its low risk, and its incorporation into successful strategies for managing neuromuscular blockade.1–3,6,16–17 The simple numerical score enhances clarity and improves communication among caregivers. Thus, the removal of TOF testing from the box of ICU-monitoring tools, even for selected cases as suggested by Baumann and colleagues, requires careful consideration. Given the unreliable recovery profile of vecuronium,21 the use of TOF testing, in concert with clinical assessment, should improve dosing, shorten the recovery time, and reduce the likelihood of complications in this setting,9and is thus recommended. In contrast, the added value of TOF testing to clinical assessment during atracurium or cisatracurium blockade is unproven for preventing delayed recovery or AQMS, or even for reducing the dosage of drug administered.10 It is likely, however, that TOF testing would allow more precise dosing, even for atracurium and cisatracurium, when deep neuromuscular blockade (ie, for apnea or complete paralysis) is performed and clinical assessment is less reliable.,22 Reliance on clinical assessment alone would highlight some practical issues. As noted above, there is considerable variability and subjectivity in performing, interpreting, and documenting a periodic clinical assessment, and thus standardization of the evaluation among caregivers would be important. Simplicity and clarity of documentation, similar to that for TOF testing, also would be useful. Finally, it would be important to confirm that the elimination of TOF testing, as an additional safety measure, did not inadvertently reduce the vigilance with which these critically ill and complex patients are monitored. Recommendations for the administration of NMBAs to ICU patients are offered in Table 1
, recognizing that many are based primarily on expert opinion or limited data.,1–2 Baumann and colleagues are to be commended for challenging the status quo with their well-done prospective study. Further research is needed to optimize our use of these valuable but potentially hazardous drugs, and to develop strategies to prevent AQMS and/or recognize it an early stage.