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Year : 2018  |  Volume : 62  |  Issue : 6  |  Page : 486-487  

Response to comments on “Reversal agents: Do we need to administer with neuromuscular monitoring”

1 Department of Anaesthesiology and Critical Care, AIIMS Jodhpur, Jodhpur, Rajasthan, India
2 Department of Trauma and Emergency, AIIMS Jodhpur, Jodhpur, Rajasthan, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Nikhil Kothari
Department of Anaesthesiology and Critical Care, AIIMS Jodhpur, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_237_18

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How to cite this article:
Goyal S, Kothari N, Chaudhary D, Verma S, Bihani P, Rodha MS. Response to comments on “Reversal agents: Do we need to administer with neuromuscular monitoring”. Indian J Anaesth 2018;62:486-7

How to cite this URL:
Goyal S, Kothari N, Chaudhary D, Verma S, Bihani P, Rodha MS. Response to comments on “Reversal agents: Do we need to administer with neuromuscular monitoring”. Indian J Anaesth [serial online] 2018 [cited 2021 May 12];62:486-7. Available from: https://www.ijaweb.org/text.asp?2018/62/6/486/234015


We thank the various authors for their in-depth interest in our recently published article. We also appreciate the comments and suggestions received. The reader has suggested to change the design of the study from observational to interventional. We have used the standard methods of monitoring (subjective and objective) in two groups and followed their own natural outcomes (suitable time for extubation) as per the standard protocols. Then we have compared the two groups. There is no “intervention” which is new or nonstandard and there is no “intervention” which could change the natural course in a particular patient.[1] Moreover, the anaesthesiologists were free to choose from any of the two techniques.

We agree that the data of nine patients which were excluded may have had a substantial effect on the interpretation of results. However, these patients were excluded from our study as their duration of surgery exceeded 2 hours (which was not in agreement with our approved inclusion criteria for the study). The comment that postoperative recovery of the Train of Four (TOF) ratio to 0.9 does not exclude an impairment of neuromuscular transmission is based on the study,[2] as quoted by the reader. This study was done in 13 patients who were suffering from cancer and the duration of surgery was more than 120 minutes (2 hours) in all the patients. All these factors were exclusion criteria in our study as the existing co-morbidities and duration of surgery along with the need for postoperative elective ventilation may have affected the outcome.

Recent literature suggests that monitoring of neuromuscular transmission is now the gold standard for monitoring and patients can be safely extubated once the TOF ratio >0.9.[3] According to the eminent reader our study seems to be a daring discourse as the benefits of using neostigmine to reverse a neuromuscular blockade (NMB) far outweighs its potential risks which have not been yet observed. We believe that this statement itself supports our hypothesis that objective neuromuscular monitoring (NMM) can help us in avoiding the use of anticholinesterases for reversal. Studies have shown that even after using neostigmine patients should not be extubated till the TOF ratio of 0.9 is achieved.[4] This concept is the point of research; when we have to wait for extubation till the TOF ratio >0.9 is achieved, then why should neostigmine be used for reversal of neuromuscular blockade when it causes an acetylcholine surge but does not ensure complete reversal? Moreover, we also recommend large scale randomised trials to study the risks of using neostigmine in humans and establishing NMM as a standard tool for safe reversal of patients without using neostigmine. Further, if the objective criteria were to be used instead of subjective criteria in nonexposed group as well, it would altogether be a different kind of study.

Regarding doses and frequency rocuronium, standard doses were used and repeated as per the duration of surgery and appearance of second count of TOF, so it has no effect on whether to use reversal agents or not. As suggested, there is evidence for the significant presence of residual neuromuscular weakness in the postoperative period even with the use of reversal agent; this itself justifies our conclusion that objective NMM should be a mandatory tool to avoid residual NMB effects or shortcomings of neostigmine.

As suggested, sevoflurane may affect TOF ratio, but the extubation was done when the TOF >0.9, irrespective of any other factors and the time taken for extubation between the two groups was statistically insignificant. All the suggestions are welcome and based on them, we can plan future studies with appropriate designs.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Thiese MS. Observational and interventional study design types; an overview. Biochem Med 2014;24:199-210.  Back to cited text no. 1
Eikermann M, Gerwig M, Hasselmann C, Fiedler G, Peters J. Impaired neuromuscular transmission after recovery of the train-of-four ratio. Acta Anaesthesiol Scand 2007;51:226-34.  Back to cited text no. 2
Stephan R, Thilen SR, Bhananker SM. Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade. Curr Anesthesiol Rep 2016;6:164-9.  Back to cited text no. 3
Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring: Challenges and opportunities. Anesthesiology 2017;126:173-90.  Back to cited text no. 4


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