Neostigmine: how much is necessary for patients who receive a nondepolarizing neuromuscular blocking agent?

摘要

Forty-five years after Beecher and Todd first described an increase in mortality associated with the use of D-tubocurarine, anesthesiologists are still learning how best to use neuromuscular blocking agents (NMBAs) and their antagonists. Practices regarding antagonism of residual neuromuscular block vary based on the country of practice, type of anesthetic practice, and individual clinician preference. These disparate practices developed in part because of concern of adverse effects, such as arrhythmias, nausea, and vomiting, resulting from anticholinesterase administration as well as an inability to reliably detect the presence of residual neuromuscular block. Although a patient with four equal responses to train-of-four (TOF) stimulation, on either visual or tactile assessment, might be completely recovered from neuromuscular blockade, the TOF ratio (TOFR) could be as low as 0.4. Subjective detection of fade is improved by monitoring the response to double-burst stimulation that allows detection of 40% fade in the response.