title: Cisatracurium- and rocuronium-associated residual neuromuscular dysfunction under intraoperative neuromuscular monitoring and postoperative neostigmine reversal: a single-blind randomized trial.
abstract: BACKGROUND
  Postoperative residual neuromuscular blockade (RNMB) is a common complication in the postanesthesia care unit (PACU), but also one of the most controversial issues. Many studies and trials demonstrated that some methods and techniques can reduce the incidence and the extent of the phenomenon.
  
  
  OBJECTIVE
  To determine the incidence of RNMB in the PACU at standardized times after extubation with the implementation of a protocol of careful neuromuscular blockade management.
  
  
  METHODS
  Randomized, single-blinded controlled clinical trial.
  
  
  METHODS
  Operating room and PACU.
  
  
  METHODS
  A total of 120 patients of either sex with American Society of Anesthesiologists grades 1, 2, and 3, aged 18 to 80 years were scheduled to undergo elective abdominal surgical procedures lasting for at least 60 minutes.
  
  
  METHODS
  Patients were randomized to receive either cisatracurium (n=60) or rocuronium (n=60) at the time of intubation and during surgery. Every patient received quantitative neuromuscular monitoring during general anesthesia. On completion of surgery, patients were given neostigmine 0.05 mg kg-1. Patients were extubated at a train-of-four (TOF) ratio≥0.9.
  
  
  METHODS
  TOF measurements were performed 15, 30, and 60 minutes after extubation. Tolerability of neuromuscular monitoring was evaluated with a scale from 1 to 10 (with 1 meaning no discomfort at all and 10 meaning maximal discomfort or pain).
  
  
  RESULTS
  Six, 11, and 14 patients (5.0%, 9.2%, and 11.7%) exhibited a TOF ratio <0.9 at 15, 30, and 60 minutes after extubation, respectively. No statistically significant difference in the postoperative RNMB between cisatracurium and rocuronium was found. The median tolerability score for neuromuscular monitoring was 3.
  
  
  CONCLUSIONS
  Careful conduction, monitoring, and subsequent reversal of neuromuscular block may allow for obtaining considerably low incidence of residual neuromuscular block. However, our trial shows that some mid- and long-term cases of TOF ratios <0.9 can still occur, possibly jeopardizing the patients' postoperative recovery.
authors.affiliation: Section of Anaesthesia and Intensive Care Medicine, Department of Medicine, Padua University Hospital, Via Battisti, 267, 35121 Padua, Italy. Electronic address: paolofeltracco@inwind.it.
authors.forename: Paolo
authors.initials: P
authors.lastname: Feltracco
authors.affiliation: Section of Anaesthesia and Intensive Care Medicine, Department of Medicine, Padua University Hospital, Via Battisti, 267, 35121 Padua, Italy.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Tonetti
authors.affiliation: Section of Anaesthesia and Intensive Care Medicine, Department of Medicine, Padua University Hospital, Via Battisti, 267, 35121 Padua, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Barbieri
authors.affiliation: Section of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Via Loredan, 18, 35131 Padua, Italy.
authors.forename: Anna Chiara
authors.initials: AC
authors.lastname: Frigo
authors.affiliation: Section of Anaesthesia and Intensive Care Medicine, Department of Medicine, Padua University Hospital, Via Battisti, 267, 35121 Padua, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Ori
mesh_terms: D000328:Adult; D000368:Aged; D060666:Airway Extubation; D000732:Androstanols / Q000008:administration & dosage / Q000009:adverse effects*; D000762:Anesthesia Recovery Period; D001279:Atracurium / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D002800:Cholinesterase Inhibitors / Q000008:administration & dosage*; D055191:Delayed Emergence from Anesthesia / Q000139:chemically induced / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000009:adverse effects; D009388:Neostigmine / Q000008:administration & dosage*; D019148:Neuromuscular Blockade / Q000009:adverse effects*; D061886:Neuromuscular Monitoring / Q000009:adverse effects; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage / Q000009:adverse effects*; D000077123:Rocuronium; D016037:Single-Blind Method; D055815:Young Adult
chemical_list: D000732:Androstanols; D002800:Cholinesterase Inhibitors; D003473:Neuromuscular Nondepolarizing Agents; D001279:Atracurium; D009388:Neostigmine; C101584:cisatracurium; D000077123:Rocuronium
keywords: Anesthesia recovery period; Muscle relaxation; Neuromuscular block