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Difficult Airway Society guidelines for extubation

Last post 13 Mar 2012, 10:02 PM by MICHAEL COPP. 0 replies.
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  •  13 Mar 2012, 10:02 PM 1089

    Difficult Airway Society guidelines for extubation

    In the recent guidelines from the Difficult Airway Society [1] the authors state that neuromuscular block should be fully reversed in order to maximise the likelihood of adequate ventilation, restore protective reflexes and the ability to clear upper airway secretions. Subjective assessment either clinically or using a peripheral nerve stimulator to measure return of the train-of-four (TOF) ratio to 0.9, the current gold standard for safe extubation, is unreliable. Volunteer studies at TOF ratios of 0.7 to 0.9 show incomplete function of upper airway reflexes [2]. Conventional reversal with cholinesterase inhibitors, even when deemed adequate, can still theoretically mean that 70% of neuromuscular receptors are occupied by a neuromuscular blocking drug (NMB). When administering rocuronium, using the correct dose of sugammadex ensures that the NMB is removed completely from the neuromuscular junction ensuring no element of residual block. In patients where the smallest degree of residual block may play a part in upper airway compromise and protection of airway reflexes at extubation I would suggest that rather than consider sugammadex as providing more "reliable antagonism" it should be deemed essential in patients who have received rocuronium and are a concern at extubation.

    M. Copp

    Cheltenham General Hospital

    Cheltenham, U.K.

    Email: michael.copp@glos.nhs.uk

    Declaration of interest - I have received honoraria payments to lecture on sugammadex and neuromuscular monitoring. No other external funding or competing interests declared.


    1. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67: 318–40.
    2. Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology 1997; 86: 765-71.
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