Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2016 Jun;69(3):239-43.
doi: 10.4097/kjae.2016.69.3.239. Epub 2016 Jun 1.

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

Kyo Sang Kim  1 , You Na Oh  1 , Tae Yeon Kim  1 , Song Yee Oh  1 , Yeong Hun Sin  1
Affiliations

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

Kyo Sang Kim et al. Korean J Anesthesiol. 2016 Jun.

Abstract

Background: The 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.

Methods: The 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.

Results: The 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.

Conclusions: If 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.

Keywords: Neostigmine; Neuromuscular monitoring; Rocuronium; Sugammadex.

PubMed Disclaimer

Figures

Fig. 1
Fig. 1. Patient flow through the study. T2: second twitch reappeared in TOF stimulation.
Fig. 2
Fig. 2. Progress of the first twitch and the train-of-four ratio after administration of neostigmine during rocuronium-induced neuromuscular block. Neostigmine is administered at time 0 when the second twitch reappears in TOF stimulation.
Fig. 3
Fig. 3. Progress of the first twitch and the train-of-four ratio after administration of sugammadex during rocuronium-induced neuromuscular block. Sugammadex is administered at time 0 when the second twitch reappears in TOF stimulation. *P < 0.001 versus first twitch. †P < 0.01 versus first twitch.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology. 2008;109:389–398. - PubMed
    1. van Santen G, Fidler V, Houwertjes MC, Top WM, Wierda JM. The effect of single twitch and train-of-four stimulation on twitch forces during stable neuromuscular block. J Clin Monit Comput. 2000;16:529–533. - PubMed
    1. Fuchs-Buder T, Claudius C, Skovgaard LT, Eriksson LI, Mirakhur RK, Viby-Mogensen J. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand. 2007;51:789–808. - PubMed
    1. Suzuki T. A train-of-four ratio of 0.9 may not certify adequate recovery after sugammadex. Acta Anaesthesiol Scand. 2011;55:368–369. - PubMed
    1. Staals LM, Driessen JJ, Van Egmond J, De Boer HD, Klimek M, Flockton EA, et al. Train-of-four ratio recovery often precedes twitch recovery when neuromuscular block is reversed by sugammadex. Acta Anaesthesiol Scand. 2011;55:700–707. - PubMed

LinkOut - more resources