Timing of reversal with respect to three nerve stimulator end‐points from cisatracurium‐induced neuromuscular block

Summary After elective ear surgery with cisatracurium neuromuscular blockade, 48 adults were randomly assigned to receive neostigmine: (a) at appearance of the fourth twitch of a ‘train‐of‐four’; (b) at loss of fade to train‐of‐four; or (c) at loss of fade to double‐burst stimulation, all monitored using a TOF‐Watch SX® on one arm. For each of these conditions, the recovery from train‐of‐four (TOF) ratio was measured in parallel objectively using a TOF‐Watch SX placed on the contralateral arm. The median (IQR [range]) time from administration of reversal to a train‐of‐four ratio ≥ 0.9 was 11 (9–15.5 [2–28]) min, 8 (4–13.5 [1–25]) min and 7 (4–10 [2–15]) min in the three groups, respectively. This recovery time was significantly shorter when reversal was given at loss of fade to double‐burst stimulation (c), than when given at the appearance of the fourth twitch (a), p = 0.046. However, the total time to extubation may be unaffected as it takes longer for fade to be lost after double‐burst stimulation than for four twitches subjectively to appear.