Tactile Assessment for the Reversibility of Rocuronium-Induced Neuromuscular Blockade During Propofol or Sevoflurane Anesthesia

Abstract

We sought to determine whether tactile train-of-four (TOF) count can predict the efficacy of neostigmine administration for rocuronium-induced blockade during propofol or sevoflurane anesthesia, and to follow subsequent recovery until the TOF ratio reached 0.9. One-hundred-sixty patients, divided into eight equal groups, were randomly allocated to maintenance of anesthesia with propofol or sevoflurane. The tactile response of the adductor pollicis to TOF stimulation was evaluated on one arm, and the mechanomyographic response was recorded on the other. Neuromuscular block was induced with rocuronium 0.6 mg/kg and maintained with rocuronium to 15% of the control first twitch in TOF. Neostigmine 0.07 mg/kg was administered on reappearance of the first (Group I), second (Group II), third (Group III), or fourth (Group IV) tactile TOF response in each anesthesia. At this time, sevoflurane or the propofol dosage was reduced in each group (n = 20 in each group). The times from administration of neostigmine until the TOF ratio recovered to 0.7, 0.8, and 0.9 were recorded. The times [median (range)] to TOF ratio = 0.9 were 8.6 (4.7-18.9), 7.5 (3.4-9.8), 5.4 (1.6-8.6), and 4.7 (1.3-7.2) min in Groups I-IV during propofol anesthesia, respectively, and 28.6 (8.8-75.8), 22.6 (8.3-57.4), 15.6 (7.3-43.9), and 9.7 (5.1-26.4) min in corresponding groups during sevoflurane anesthesia, respectively (P < 0.0001). We recommend more than 2 TOF responses with propofol anesthesia and 4 TOF responses with sevoflurane anesthesia for adequate reversal within 10 and 15 min, respectively. The more tactile TOF responses present at the time of reversal achieved greater adequate recovery; however, tactile TOF responses are not a completely reliable predictor within a reasonable time period.

Neuromuscular monitoring: an update

“…For the moderate neuromuscular block using cisatracurium, Kirkegaard et al concluded that a dose of 0.07 mg/kg neostigmine produces block reversibility (TOF = 0.9) in 20 minutes (7-71 minutes) [45]. Kim and his team established that the average time required to reverse moderate block with rocuronium, using the same dose of neostigmine, is 23 minutes (range 8-57) [46]. The recommended sugammadex dose for reversing moderate block is 2 mg/kg [16].…”

Sugammadex: an opportunity for more thinking or more cookbook medicine?

“…This is why it is recommended to attempt reversal only when significant recovery has already taken place, that is the presence of at least two, and preferably four, twitches in response to train-of-four (TOF) stimulation is documented. 5 The second problem related to anticholinesterase agents is the cardiovascular sideeffect profile, even with the co-administration of an anticholinergic. By binding to the neuromuscular blocking agent and not to any receptor, sugammadex has the potential to solve the drawbacks of neostigmine and other anticholinesterase agents.…”

“…When four TOF responses are observed, even if fade is seen, neostigmine is considered reasonably effective, and one expects adequate neuromuscular recovery, now regarded as being a TOF ratio > 0.9, to occur within five to 15 min, with no recurarization. 5 The rules will change markedly with the introduction of sugammadex. The requirement to obtain some degree of spontaneous recovery will no longer be present.…”

“…C'est pourquoi on recommande de tenter une décurarisation pharmacologique seulement lorsqu'il y a récupération significative, soit la présence manifeste d'au moins deux, voire quatre réponses à la stimulation en train-de-quatre. 5 Un autre problème que cause l'administration d'anticholinestérasique est la survenue d'effets cardiovasculaires, même avec l'ajout d'un anticholinergique. Puisque le sugammadex se lie au curare sans interagir avec un récepteur, le sugammadex pourrait être une solution de rechange à la néostigmine et aux autres anticholinestérasiques.…”

“…On s'attend alors à une récupération satisfaisante de la fonction neuromusculaire, maintenant considérée comme étant un rapport quatrième/première réponse > 0.9, en cinq à 15 min, sans recurarisation. 5 La donne changera profondément avec l'arrivée du sugammadex, parce qu'il ne sera plus nécessaire d'attendre la venue d'une récupération spontanée.…”