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Year : 2018  |  Volume : 62  |  Issue : 6  |  Page : 482-483  

Reversal agent is mandatory even with neuromuscular monitoring!

Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte (Deemed To Be) University, Mangaluru, Karnataka, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Sripada Gopalakrishna Mehandale
Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte (Deemed To Be) University, Deralakatte, Mangaluru - 575 018, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_280_18

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How to cite this article:
Mehandale SG, Bangera A, Thiyath SV. Reversal agent is mandatory even with neuromuscular monitoring!. Indian J Anaesth 2018;62:482-3

How to cite this URL:
Mehandale SG, Bangera A, Thiyath SV. Reversal agent is mandatory even with neuromuscular monitoring!. Indian J Anaesth [serial online] 2018 [cited 2021 May 12];62:482-3. Available from: https://www.ijaweb.org/text.asp?2018/62/6/482/234018


An original article by Goyal et al. 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. However, the evidence was not strong enough to state so, as the authors have not specified average duration of surgery (though procedures were supposed to last <2 h), total amount of rocuronium used, as well as time elapsed since the last dose. They solely relied upon clinical tests to assess recovery from paralysis before extubation in group which received reversal agent. It would have been better if the adequacy of recovery was verified by objective criteria in non-exposed group and compared with the other. Furthermore, in neuromuscular transmission (NMT) group, time to extubation was defined differently, that is, time from end of the surgery to reach a train-of-four ratio of 0.9 and not actual time to extubation, as patients were sedated with sevoflurane. Nine patients received reversal agent among NMT group, and they were excluded from analysis without reason! If reversal agent was used due to inadequate recovery, then it simply justifies use of the same for hastening or completion of recovery.

Of the surrogate measures used, postoperative pneumonia (POP) is rare and may appear later than observation period of 2 days employed here.[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.{Table 3}

Finally, the current work is only pertaining to rocuronium, which already has a well-established reversal agent devoid of side effects attributable to neostigmine; hence, there should not be any hesitation in using the same. In the light of evidence for the significant presence of residual neuromuscular weakness in the postoperative period even with the use of reversal agent, how far we are justified in drawing conclusions with this kind of work?[4]

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There are no conflicts of interest.

   References Top

Goyal S, Kothari N, Chaudhary D, Verma S, Bihani P, Rodha MS, et al. Reversal agents: Do we need to administer with neuromuscular monitoring – An observational study. Indian J Anaesth 2018;62:219-24.  Back to cited text no. 1
[PUBMED]  [Full text]  
Murphy GS, Kopman AF. “To reverse or not to reverse?”: The answer is clear! Anesthesiology 2016;125:611-4.  Back to cited text no. 2
Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997;41:1095-103.  Back to cited text no. 3
Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology 2003;98:1042-8.  Back to cited text no. 4


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