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Anesth Analg. 2011 Jan;112(1):63-8. doi: 10.1213/ANE.0b013e3181fdf889. Epub 2010 Oct 26.

The duration of residual neuromuscular block after administration of neostigmine or sugammadex at two visible twitches during train-of-four monitoring.

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  • 1Department of Anesthesiology, Intensive Care, Emergency Care and Pain Medicine, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, PO Box 52, FI-20521 Turku, Finland.



Adequate recovery from neuromuscular block (NMB) is imperative for the patient to have full control of pharyngeal and respiratory muscles. The train-of-4 (TOF) ratio should return to at least 0.90 to exclude potentially clinically significant postoperative residual block. Fade cannot be detected reliably with a peripheral nerve stimulator (PNS) at a TOF ratio >0.4. The time gap between loss of visual fade by using a PNS until objective TOF ratio has returned to >0.90 can be considered "the potentially unsafe period of recovery." According to our hypothesis the duration of this period would be significantly shorter with sugammadex than with neostigmine.


Fifty patients received volatile anesthetics, opioids, and a rocuronium-induced NMB. TOF-Watch without a preload was used, but the anesthesiologist relied on visual evaluation of the TOF responses only. At end of operation, patients were randomized to receive either neostigmine 50 μg/kg or sugammadex 2 mg/kg, when 2 twitch responses were detected after the last dose of rocuronium. Timing of tracheal extubation was based on PNS and clinical data. Duration of the potentially unsafe period of recovery after reversal by either neostigmine or sugammadex was analyzed. Mann-Whitney U test and Pearson χ(2) test were used for statistical analysis.


The times [mean ± sd (range)] from loss of visual fade to TOF ratio >0.90 were 10.3 ± 5.5 (1.3 to 26.0) minutes and 0.3 ± 0.3 (0.0 to 1.0) minutes in the neostigmine and sugammadex groups, respectively (P < 0.001). The times from reversal by neostigmine or sugammadex to TOF ratio >0.90 were 13.3 ± 5.7 (3.5 to 28.9) and 1.7 ± 0.7 (0.7 to 3.5) minutes, respectively (P < 0.001). The values of TOF ratios at the time of loss of visual fade were 0.34 ± 0.14 (0.00 to 0.56) in patients given neostigmine and 0.86 ± 0.11 (0.64 to 1.04) in patients given sugammadex (P < 0.001).


There is a significant time gap between visual loss of fade and return of TOF ratio >0.90 after reversal of a rocuronium block by neostigmine. Sugammadex in comparison with neostigmine allows a safer reversal of a moderate NMB when relying on visual evaluation of the TOF response.

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