Literature Review for Office-Based Anesthesia

When muscle relaxants are used to facilitate intubation, a significant amount of residual neuromuscular blockade remains when reversal drugs are not administered; however, routine reversal is not a universal practice. While most anesthesiologists routinely reverse neuromuscular blockade if muscular weakness is suspected at the time of extubation, others caution against the routine use of anticholinesterase reversal agents, which have been associated with impaired upper airway and breathing function with increased risk of adverse postoperative respiratory events. Neostigmine has neuromuscular blocking properties when given in the absence of neuromuscular blockade and can induce paradoxical reduction in the train-of-four ratio (TOF ratio). This study tested the hypothesis that TOF ratios in patients receiving neostigmine at the time of postanesthesia care unit admission would not be less than TOF ratios in patients randomly assigned to receive a saline placebo. The authors also tested the hypothesis that the incidence of postextubation adverse respiratory symptoms and muscle weakness would not be increased in the neostigmine group. One hundred twenty patients undergoing general anesthesia received a small dose of rocuronium to facilitate intubation. Ninety patients achieved a TOF ratio of 0.9 to 1.0 and received either neostigmine or saline. Patients were subsequently monitored for muscle strength and postextubation respiratory adverse events. No significant difference in these parameters was noted between the 2 groups, leading the authors to conclude that administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness