Reversal agents: do we need to administer with neuromuscular monitoring – an observational study

Abstract

Background and Aims:In clinical practice, in the majority of patients, recovery from the effect of muscle relaxants is assessed using subjective methods such as head lift, eye-opening, or by sustained hand grip after giving anticholinesterases (neostigmine) at the end of surgery. We planned a prospective observational cohort study to test the hypothesis that objective neuromuscular monitoring can help us in avoiding the use of anticholinesterases for reversal.Methods:The patients posted for surgery of <2 h duration were included in the study. The cohort of patients was formed on the basis of those who were exposed to objective neuromuscular monitoring of recovery (train-of-four [TOF] ratio of 0.9 or more; exposed group) and the patients who were not exposed to objective neuromuscular monitoring (non-exposed group) acting as a control. Using objective neuromuscular monitoring, the time required for recovery from muscle relaxation when neostigmine was not given for reversal was noted and it was then compared with that of the control group.Results:A total of 190 patients were enrolled over a period of 3 years. With the use of TOF ratio of 0.9 for extubation, patients safely recovered from neuromuscular blockade, without using neostigmine, with no difference in the mean recovery time (14.48 ± 1.138 min) as compared to the control group (12.14 ± 1.067 min, P = 0.139). There was no incidence of reintubation in post-operative period.Conclusion:With objective neuromuscular monitoring, we can ensure complete recovery from the neuromuscular blockade while avoiding the use of anticholinesterases.

Reversal of neuromuscular block

“…I read with interest the recent publication by Goyal et al . [ 1 ] on the need to administer reversal agents with neuromuscular (NM) monitoring. Two groups of patients were studied – those who received objective NM monitoring and achieved a train-of-four ratio (TOFR) of ≥0.9 at recovery – and the control group, who received neostigmine and were extubated after achieving clinical signs of adequate reversal without NM monitoring.…”

Reversal agent is mandatory even with neuromuscular monitoring!

“…supporting tracheal extubation without reversing neuromuscular block made very interesting reading. [ 1 ] Earlier, some authors have been in favour of this concept using atracurium; however, with increasing evidence against this practice, use of reversal agent should be routine. [ 2 ] The authors attempted to establish that with close neuromuscular monitoring after rocuronium, adequate recovery from paralysis may be ensured without anticholinesterases.…”

“…[ 3 ] Interestingly, the incidence of POP is none according to the text and two in one group as shown in Table 3. [ 1 ] Further, authors aspired to assess adequacy of muscle relaxation for intubation and for the maintenance of intraoperative relaxation using neuromuscular monitoring, outcomes of which are not reported.…”

Comments on Published Article: A valuable resource

“…in the March 2018 issue of the IJA regarding avoidance of reversal of neuromuscular blockade in patients in whom objective neuromuscular function monitoring was carried out. [ 3 ] In that study, two cohorts of patients were studied; one cohort was exposed to objective, quantitative neuromuscular monitoring (NMM) intraoperatively and at extubation, whereas in the other, no NMM was performed. The groups were allocated based on the surgery list of that day; every alternate patient had NMM and other alternates on same day did not receive NMM.…”

“…However, Goyal et al . [ 3 7 ] and others [ 8 9 ] suggest that, if neuromuscular function is being objectively monitored, it may be safe to allow the neuromuscular function to recover to a TOF ratio >0.9 without giving neostigmine. If neuromuscular blockade is not being objectively monitored with a device that displays the TOF ratio, neuromuscular blockade should always be reversed with neostigmine, as suggested in the three letters [ 4 5 6 ] and by others.…”