Reversal of Atracurium-induced Neuromuscular Blockade in Daycare Pediatric Cases – Is it Always Necessary

Abstract

Context: The reversal of the neuromuscular blocking drugs (NMBDs) by neostigmine is an integral component of general anesthesia. The requirement of NMBD is minimal in pediatric superficial surgeries supplemented with regional analgesia techniques. The pediatric age group has a rapid metabolism of atracurium, allowing rapid spontaneous recovery. The use of the combination of neostigmine and glycopyrrolate does not come without side effects. Aims: The aim of this prospective randomized controlled trial was to evaluate the incidence of residual neuromuscular blockade (RNMB) detected by train-of-four ratio (TOFR) of <0.9 following a single dose of atracurium administration in children undergoing infraumbilical daycare procedures with or without neostigmine for pharmacological reversal of neuromuscular blockade. Subjects and Methods: One hundred American Society of Anesthesiologists 1–2 patients of age group 1–12 years undergoing infraumbilical daycare surgery of ≤120 min with ProSeal laryngeal mask airway as airway device were included in the study. The study population was randomized into two groups to receive either neostigmine or normal saline (Group N – neostigmine; Group S – normal saline). Neuromuscular blockade was monitored by acceleromyography (TOF-Watch® SX, Organon). The primary outcome variable was to assess the incidence of RNMB in both the groups. The secondary outcomes observed were to assess any critical respiratory event, hypoxemia (SpO2 < 95%), flushing, nausea, and vomiting in postanesthesia care unit (PACU) for 6 h. Statistical Analysis Used: Statistical testing was conducted with the Statistical Package for the Social Sciences system version SPSS 17.0 (SPSS Inc., Chicago, IL, USA). Continuous variables are presented as mean ± SD with a mean difference and 95% confidence interval for the comparison between two groups using Student's t-test. Nominal categorical data between the groups were compared using the Chi-squared test or Fisher's exact test as appropriate. P <0.05 was considered statistically significant. Results: The demographic parameters, type, and duration of surgery were comparable. No statistically significant difference in TOFR was found between the two groups. None of the participants in either group had RNMB while shifting to PACU. Thirty-four percent in Group N experienced flushing with raised temperature and 2% had nausea with vomiting, whereas none of these was noticed in Group S. Conclusion: Our study suggests that omission of routine neostigmine reversal of atracurium in pediatric daycare surgery may be considered without compromising patient safety by using a combination of sound clinical judgment and quantitative neuromuscular monitoring documenting complete spontaneous neuromuscular recovery.