Low-dose neostigmine to antagonise shallow atracurium neuromuscular block during inhalational anaesthesia A randomised controlled trial

BACKGROUNDEven shallow residual neuromuscular block [i.e. train-of-four (TOF) ratio around 0.6] is harmful. It can be effectively antagonised by small doses of neostigmine, but reports are limited to intravenous anaesthesia. Inhalational anaesthesia may enhance neuromuscular block and delay recovery. It is not known whether low doses of neostigmine are still effective in the context of inhalational anaesthesia.OBJECTIVETo assess the effectiveness of low doses of neostigmine to antagonise shallow atracurium block during desflurane anaesthesia.DESIGNRandomised controlled trial, four groups.SETTINGSingle centre, University Hospital, May 2010 to March 2011.PARTICIPANTSForty-eight American Society of Anesthesiologists I-III patients undergoing desflurane anaesthesia.INTERVENTIONAt TOF ratio 0.6, patients were randomised to one of four treatments (physiological saline, 10, 20 or 30gkg(-1) neostigmine, n=12 for each).MAIN OUTCOME MEASUREPrimary efficacy endpoint: time interval between study drug injection and a TOF ratio more than 0.9 using acceleromyography. Secondary efficacy endpoint: neuromuscular recovery after 5 and 10min.RESULTSAfter physiological saline, the time interval [median (range)] between a TOF ratio of 0.6 and 0.9 was 14 (7 to 18)min. After 10, 20 and 30gkg(-1) neostigmine, it was reduced to 5 (3 to 8)min, 5 (3 to 10) and 4 (2 to 6)min, respectively (P<0.001 compared to physiological saline). At 5min after physiological saline, the TOF ratio [mean (SD)] was 0.73 (0.05) and 0.91 (0.06), 0.90 (0.10), 0.96 (0.02) after neostigmine 10, 20 or 30gkg(-1), respectively (P<0.01 compared to physiological saline). At 10min after physiological saline, the TOF ratio was 0.86 (0.08) and 1.0 (0), 0.98 (0.03), 1.0 (0) after neostigmine 10, 20 or 30gkg(-1), respectively (P<0.01 compared to physiological saline).CONCLUSIONUnder desflurane anaesthesia, neostigmine 10gkg(-1) is effective in antagonising shallow atracurium block. Compared to no neostigmine, the time to a TOF ratio more than 0.9 was shortened and neuromuscular recovery at 5 and 10min was more advanced.TRIAL REGISTRATIONEudraCT Nr. is 2009 - 018214-19.