The Train-of-Four Ratio in Patients Fulfilling Clinical Criteria for Extubation
Abstract
Objective: Neuromuscular blocking agents are commonly used in patients undergoing general anesthesia with an endotracheal tube. This can result in residual neuromuscular blockade and respiratory complications. The decision to extubate is usually based on clinical criteria assessment. This study aimed to investigate the train-of-four (TOF) ratio in patients having fulfilled the clinical criteria before extubation.
Material and Methods: This prospective observational study recruited 294 elective adult patients, with American Society of Anesthesiologists classification I-III, having undergone general anesthesia using muscle relaxants. The baseline TOF ratio was measured before surgery. Once the surgery was finished, the endotracheal tube would be removed if the patient fulfilled the clinical criteria for extubation. The TOF was immediately measured before extubation, and upon postanesthesia care unit (PACU) arrival. The TOF ratio was normalized by dividing it with the baseline TOF ratio.
Results: The overall median interquartile range (IQR) for the normalized TOF (nTOF) outcomes before extubation was 0.87 (0.74, 0.98). Of the 294 patients, 162 (55%) and 132 (45%) had a nTOF ratio of <0.9 and ≥0.9, respectively. On PACU arrival, the overall median IQR TOF ratio was 0.9 (0.8, 0.98), with 51% and 49% of them having had an nTOF ratio of <0.9 or ≥0.9, respectively.
Conclusion: In patients fulfilling the clinical criteria for extubation, approximately half of them demonstrated residual neuromuscular blockade (nTOF <0.9) immediately before extubation and upon PACU arrival. Close observation and monitoring of patients receiving muscle relaxants should be warranted.
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