Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function.
OBJECTIVE
The purpose of this study is to determine the incidence of significant (train-of-four [TOF] ratio <0.70), but clinically undetectable (TOF ratio >0.40), residual neuromuscular block after neostigmine antagonism of profound cisatracurium (CIS) or rocuronium (ROC) block.


METHODS
Prospective, randomized, open-label study.


METHODS
University hospital.


METHODS
Forty ASA physical status I and II undergoing elective surgical procedures.


METHODS
Anesthesia was induced with propofol 1.5 to 2.5 mg/kg IV plus fentanyl 2 to 4 mug/kg and maintained with N(2)O/desflurane plus narcotic supplementation. The electromyographic response of the adductor pollicis was recorded. Train-of-four stimulation was given every 20 seconds. Twitch height (T1) and TOF fade ratio were continuously recorded. In group 1 (n = 20), neuromuscular block was induced with CIS 0.10 mg/kg, and T1 was maintained at 5% of control by a constant infusion of CIS until the end of surgery. One minute after the termination of the infusion, neostigmine 0.05 mg/kg was administered. T1 and TOF values were monitored continuously for the next 20 minutes. Group 2 (n = 20) is identical to group 1 except that the initial drug was ROC 0.60 mg/kg, and paralysis was maintained with an infusion of ROC.


RESULTS
There were no significant differences in the recovery patterns of CIS vs ROC. The duration (bolus to end of infusion) in both groups averaged 2.7 hours, and the mean cumulative dose of relaxant approximated 4 x the ED(95). T1 at the time of reversal was 6% (4%-10%) of control. Mean TOF ratios at 10, 15, and 20 minutes were 0.55, 0.71, and 0.0.81, respectively. Return to a TOF ratio >0.40 was always achieved in 15 minutes or less. However, at 20 minutes postreversal, 5 of 40 subjects had TOF ratios <0.70 and only 11 individuals had recovered to a TOF ratio of 0.90 or greater.


CONCLUSIONS
Most clinicians cannot detect tactile fade once the TOF ratio exceeds 0.40. When reversing profound block, an objective monitor of neuromuscular function is required if the extent of residual block is to be assessed with any confidence.
Kopman
Aaron F
AF
Department of Anesthesiology, New York Medical College, Valhalla, NY, USA. akopman@svcmcny.org
Kopman
David J
DJ
Ng
Jennifer
J
Zank
Lee M
LM
D000328:Adult; D000368:Aged; D000732:Androstanols / Q000037:antagonists & inhibitors*; D000762:Anesthesia Recovery Period; D000768:Anesthesia, General; D001279:Atracurium / Q000037:antagonists & inhibitors*; D004558:Electric Stimulation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009388:Neostigmine / Q000627:therapeutic use*; D009407:Nerve Block; D003473:Neuromuscular Nondepolarizing Agents / Q000037:antagonists & inhibitors*; D010277:Parasympathomimetics / Q000627:therapeutic use*; D011446:Prospective Studies; D000077123:Rocuronium
D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D010277:Parasympathomimetics; D001279:Atracurium; D009388:Neostigmine; D000077123:Rocuronium