Reversal of Neuromuscular Blockade Based on Train of Four Response: a Prospective Randomized Controlled Trial

Background and aims : Use of neostigmine to reverse the non-depoloarizing neuromuscular block is a standard practice. Reversal with neostigmine based on body weight is still commonly followed. However, neostigmine may affect adversely if used empirically in the absence of residual blockade. This study compares the empirical technique of reversal based on body weight with reversal using neostigmine dose adjusted to train-of-four (TOF) response. Methods: This prospective, double-blinded, randomized controlled trial included 126 patients undergoing surgery under general anaesthesia, lasting for >1 hour. They were randomized into group control receiving weight-based reversal (0.05 mg/kg neostigmine) and group study receiving dose determined by TOF response. Signs of residual paralysis after extubation were observed. TOF ratios/count, reversal to extubation time, dose and side-effects of reversal agent were also noted. Results: Patient characteristics were comparable in both groups. Number of patients with signs of residual weakness was less in group study (26/63), but comparable to group control (40/63, p=0.094). Number of patients with TOF≥0.9 at reversal and extubation was significantly high in group study (40/63) than group control (22/63), and number of patients with TOF count <4 were significantly high in group control than group study (17/63 vs 8/63). Overall TOF ratio at reversal and extubation, reversal-extubation time, time taken to reach TOF 0.9 and side-effects were comparable. Conclusion : Reversal of neuromuscular block with neostigmine dose based on TOF ratio is comparable to weight-based reversal with respect to postoperative residual weakness, reversal-extubation time and side effects of reversal