Relationship between first-twitch depression and train-of-four ratio during sugammadex reversal of rocuronium-induced neuromuscular blockade

Abstract

BackgroundThe primary outcome of sugammadex reversal for rocuronium-induced neuromuscular block (NMB) is a train-of-four ratio (TOFR) of 0.9, not first twitch (T1) height. We investigated whether the recovery of TOFR or T1 differs based on the reversal of NMB with neostigmine or sugammadex.MethodsThe acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in 80 patients after induction of anesthesia. The TOFR and T1 height were recorded, and saved in a personal computer using TOF-Watch SX Monitor software in all patients. Patients were randomly assigned to 2 groups to receive either neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg (neostigmine group, n = 40) or sugammadex 2.0 mg/kg (sugammadex group, n = 40). The primary objective was to determine the difference of recovery time between TOFR to 0.9 and T1 to 0.9 after sugammadex or neostigmine administration during moderate rocuronium-induced NMB.ResultsThe recovery pattern of the TOFR 2 min after sugammadex administration was 1.0 or more, but that of T1 was less than 90% (T1 / control value) up to 6 min after drug was injected. The recovery pattern of TOFR and T1 was similar during the 20 min after reversal with neostigmine.ConclusionsIf you have not performed the T1 monitoring, both TOFR and T1 should be considered to confirm suitable recovery during the 6 min after reversal with sugammadex during rocuronium-induced moderate NMB.

Train‐of‐four recovery precedes twitch recovery during reversal with sugammadex in pediatric patients: A retrospective analysis

“…Moreover, objective neuromuscular monitoring can prevent residual neuromuscular blockade and related morbidity and mortality . Regarding neuromuscular monitoring modes, single twitch (ST) and first twitch (T1) of train‐of‐four (TOF) forces do not differ when employing a stimulus interval of 10 seconds or more . As the TOF ratio reflects the effects of the neuromuscular‐blocking drugs at the presynaptic membrane of the neuromuscular junction, ST and T1 response reflect the events at the postjunctional membrane and is directly related to the force generated …”

“…However, after reversal of a rocuronium‐induced neuromuscular blockade with an optimal dose of sugammadex, the recovery of TOF ratio to 0.9 is faster than recovery of T1 to 90% (of final T1 height) in adults. The TOF ratio value of 0.9, by itself, may not provide adequate neuromuscular recovery if the T1 recovery is not back to baseline …”

“…[6][7][8] Regarding neuromuscular monitoring modes, single twitch (ST) and first twitch (T1) of train-of-four (TOF) forces do not differ when employing a stimulus interval of 10 seconds or more. 9 As the TOF ratio reflects the effects of the neuromuscular-blocking drugs at the presynaptic membrane of the neuromuscular junction, ST and T1 response reflect the events at the postjunctional membrane and is directly related to the force generated. 10 During spontaneous recovery from nondepolarizing neuromuscular-blocking drugs, the T1 response of the TOF normally recovers to baseline (a stable T1 response should be 80%-120% of the control value) first, while at this point, TOF ratio may still be no more than 0.7.…”

“…The TOF ratio value of 0.9, by itself, may not provide adequate neuromuscular recovery if the T1 recovery is not back to baseline. 9,10 The aim of this retrospective analysis was to investigate the relationship of the recovery of T1 height and TOF ratio after reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric patients. We hypothesized that T1 and TOF ratio behavior in pediatric patients is the same as observed in adults during reversal with sugammadex.…”

Response to neuromuscular blockade with rocuronium during general anesthesia in a patient with dermatomyositis - A case report -

“…We are not aware of the complete recov- www.anesth-pain-med.org KNRS um causes a rapid decrease in free rocuronium concentration in plasma and provides faster reversal in the absence of TOF response to neuromuscular blockade. In previous reports [11,12], the authors noted that administration of 2 mg/ kg sugammadex could completely reverse neuromuscular blockade within a few minutes. This is similar to the normal recovery pattern in patients with DM.…”