OPTIMIZED REVERSAL WITHOUT TRAIN-OF-FOUR MONITORING VERSUS REVERSAL USING QUANTITATIVE TRAIN-OF-FOUR MONITORING: AN EQUIVALENCE STUDY

Abstract

Background:

Neuromuscular blocking agents (NMBAs) such as atracurium and vecuronium are frequently used to facilitate intubation during general anesthesia, with residual paralysis posing potential morbidity risks postoperatively. Quantitative train-of-four (TOF) monitoring has shown promise in reducing residual paralysis, but its availability is limited. This study compares optimized reversal without TOF monitoring to reversal using quantitative TOF monitoring.

Methods:

We conducted a prospective randomized observational study in the Department of Anesthesiology at Saveetha Medical College & Hospital, enrolling 100 patients scheduled for elective surgeries under general anesthesia with NMBAs. Patients were stratified by surgery type and randomized into Group A (TOF monitoring-guided reversal) and Group B (optimized clinical reversal without TOF monitoring). The primary outcome was the incidence of residual paralysis (TOF ratio <0.90) in the recovery room.

Results:

Both groups were demographically comparable. Residual paralysis occurred in 4% of Group A and 10% of Group B. Other adverse events, including hypoxemia, reintubation, and nausea/vomiting, were infrequent and did not differ significantly between groups. Statistical analysis indicated that optimized reversal without TOF monitoring was not equivalent to TOF monitoring-guided reversal (p<0.05).

Conclusion:

Optimized clinical reversal without quantitative TOF monitoring does not provide equivalent protection against residual paralysis compared to TOF-based strategies. TOF monitoring should be preferred where available to reduce postoperative neuromuscular complications.