Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function

Neostigmine injected 5 minutes after low-dose rocuronium accelerates the recovery of neuromuscular function

“…The varying duration of equipotent doses of rocuronium in different patients advocates routine perioperative neuromuscular blockade monitoring. This is in agreement with the findings of Kopman et al [15].…”

Residual Neuromuscular Blockade: A Persistent Clinical Problem

“…In the PACU, 40% of the patients who had received pancuronium had TOF ratios <0.7 compared with 5.9% of the rocuronium patients. In this study, and most of the other studies employing rocuronium, [18][19][20][21][22][23][24][25] the doses used were in the lower range, comparable to the effects of vecuronium, rather than in the higher range used for rapid sequence inductions. 26 In our hands (unpublished observations), rocuronium at 0.9 and 1.2 mg/kg has a recovery that is similar to pancuronium but with a higher degree of variability.…”

“…The goal of a TOF ratio of 0.9 was not attained in all patients even at 20 to 30 minutes. In a similar study, 25 20 minutes after reversal from a twitch height of 5%, only 11 of 40 patients recovered to a TOF ratio of 0.9.…”

“…In another study, 40 subjects were administered cisatracurium or rocuronium. 25 Five exhibited TOF ratios <0.7 20 minutes after reversal and only 11 patients recovered to TOF ratios >0.9. …”

In Reply:

“…Rather, the explanation is more likely to be that the sufficient spontaneous recovery was not achieved before administration of neostigmine. When discussing about earlier administration of reversal, at deep levels of block and using qualitative monitoring, Kopman et al 6 stated that this practice "places the patient at risk and the anesthetist in the dark". Early administration of neostigmine will prolong the postreversal amount of time with a TOF-ratio in the range 0.4-0.9 and a TOF-count of 4 without fade (referred to as the "zone of blind paralysis" by Plaud et al 4 ) and will not shorten the time to full reversal.…”