TOF-Guided Rocuronium Administration Shortens Spontaneous Breathing Recovery and Reduces Consumption Compared to Time-Based Dosing: A Prospective Comparative Study

Lozan Sagvan  Ramadhan; Dr. Haider Nasser Mohammed

doi:10.51168/sjhrafrica.v7i3.2436

Authors

Lozan Sagvan Ramadhan MSc Department of Anesthesia and Intensive Care College of Health Sciences, University of Duhok Duhok
Dr. Haider Nasser Mohammed, MD Assistant Professor and Consultant Department of Anesthesia and Intensive Care M.B.Ch.B., C.A.B.M.S.

DOI:

https://doi.org/10.51168/sjhrafrica.v7i3.2436

Keywords:

Rocuronium, Train-of-Four monitoring, Neuromuscular blockade , General anesthesia, Postoperative recovery

Abstract

Background: Muscle and nerve relaxants, such as rocuronium, are essential in general anesthesia to facilitate endotracheal intubation and achieve optimal relaxation during surgery. However, time-based dosing without objective monitoring often leads to cumulative overdoses, residual neuromuscular blockade, and delayed postoperative respiratory recovery. Quantitative four-pulse response monitoring enables precise dosing but remains underutilized, particularly in resource-constrained settings. This study evaluated the effect of four-pulse response-guided rocuronium administration versus conventional time-based dosing on spontaneous respiratory recovery and total muscle and nerve relaxant consumption during elective surgical procedures.

Methods: A prospective, non-randomized comparative clinical study included 150 American Society of Anesthesiologists (ASA) Class I and II adults (aged 16–66 years) undergoing elective surgery at Al-Badari Hospital (Zakho) and Azadi Teaching Hospital (Duhok) between November 2024 and April 2025. Participants were sequentially divided into two groups: Group T (n=75, time-measured doses) and Group S (n=75, ulnar nerve stimulation-measured doses). Ideal body weight (0.6–1.2 mg/kg) was used to initiate rocuronium anesthesia; maintenance doses were either time-measured (Group T) or titrated according to response (Group S). Primary outcome: time from last dose to spontaneous breathing (minutes). Secondary outcome: total rocuronium maintenance dose (mg). Outliers were analyzed using the Mann-Whitney U test and the chi-squared test (SPSS version 23; p-value ≤ 0.05 is statistically significant).

Results: The baseline parameters were similar, with small changes in age and height (p=0.021, 0.004). The TOF group's recovery time was shorter (median (IQR): 20 (10) min vs. 25 (12) min; U=2051.5, p=0.004) and their dosages were lower (6 (7) mg vs. 15 (10) mg; p<0.001). The TOF group had a lower rate of delayed recovery (≥22 minutes) than the other group (35.1% vs. 64.9%; OR=1.875, p<0.001).

References

Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: A report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023 Jan 1;138(1):13-41. https://doi.org/10.1097/aln.0000000000004379

Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, De Boer HD. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology| EJA. 2023 Feb 1;40(2):82-94. https://doi.org/10.1097/EJA.0000000000001769

Rosenberg J, Fuchs-Buder T. Deep Neuromuscular Blockade During General Anesthesia: Advantages, Challenges, and Future Directions. Anesthesia Research. 2025 Mar 26;2(2):8. https://doi.org/10.3390/anesthres2020008

Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann MW, et al. POPULAR Study Group. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med. 2019;7:129–140. http://dx.doi.org/10.1016/

Martini CH, Honing GM, Bash LD, Olofsen E, Niesters M, van Velzen M, et al. The use of muscle relaxants and reversal agents in a setting without cost restrictions: experience from a tertiary academic hospital in the Netherlands. Ther Clin Risk Manag. 2022;18:379–390. https://doi.org/10.2147/TCRM.S350314

Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate-acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: a prospective propensity score-matched cohort study. BMJ. 2012;345:e6329. https://doi.org/10.1136/bmj.e6329

Blum LV, Steeger E, Iken S, Lotz G, Zinn S, Piekarski F, et al. Effect of quantitative versus qualitative neuromuscular blockade monitoring on rocuronium consumption in abdominal and gynecological surgery. J Clin Monit Comput. 2023;37(2):509–516. https://doi.org/10.1007/s10877-022-00909-y

Murphy GS. Neuromuscular monitoring in the perioperative period. Anesth Analg. 2018;126(2):464–468. https://doi.org/10.1213/ANE.0000000000002387

Errando CL, Garutti I, Mazzinari G, Diaz-Cambronero O, Bebawy JF, et al. Residual neuromuscular blockade in the postanesthesia care unit: an observational cross-sectional study of a multicenter cohort. Minerva Anestesiol. 2016;82(12):1267–1277.

Cammu G. Residual neuromuscular blockade and postoperative pulmonary complications: what does the recent evidence demonstrate? Curr Anesthesiol Rep. 2020;10:131–136. https://doi.org/10.1007/s40140-020-00388-4

Thilen SR, Bhananker SM. Qualitative neuromuscular monitoring: how to optimize the use of a peripheral nerve stimulator to reduce the risk of residual neuromuscular blockade. Curr Anesthesiol Rep. 2016;6:164–169. https://doi.org/10.1007/s40140-016-0155-8

Kosciuczuk U, Dardzinska A, Kasperczuk A, Dzienis P, Tomaszuk A, Tarnowska K, et al. Practice guidelines for monitoring neuromuscular blockade: improving the quality of anesthesiological procedures. J Clin Med. 2024;13(7):1976. https://doi.org/10.3390/jcm13071976

Fabregat Lopez J, Candia Arana CA, Castillo Monzon CG. Neuromuscular monitoring and its importance in neuromuscular blockade. Colomb J Anesthesiol. 2012;40(4):293–303.

Sessler CN. Train-of-four to monitor neuromuscular blockade? Chest. 2004;126(4):1018–1022.

Saager L, Maiese EM, Bash LD, Meyer TA, Minkowitz HS, Groudine SB, et al. Incidence, risk factors, and consequences of residual neuromuscular block in the United States: the prospective, observational, multicenter RECITE-US study. J Clin Anesth. 2019;55:33–41.

Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111(1):120–128. https://doi.org/10.1213/ANE.0b013e3181da832d

Zafirova Z, Dalton A. Neuromuscular blockers, reversal agents, and monitoring. Best Pract Res Clin Anaesthesiol. 2018;32(2):203–211. https://doi.org/10.1016/j.bpa.2018.06.004

Murray MJ, DeBlock H, Erstad B, Gray A, Jacobi J, Jordan C, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079–2103. https://doi.org/10.1097/CCM.0000000000002027

McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent association between intermediate-acting neuromuscular blocking agents and postoperative respiratory complications. Anesthesiology. 2015;122(6):1201–1213.

Brull SJ, Longrois D, Plaud B, Fuchs-Buder T, Afshari A, Kranke P, et al. Why a guideline on peri-operative management of neuromuscular blockade? Eur J Anaesthesiol. 2023;40:75–77. https://doi.org/10.1097/EJA.0000000000001785