A Comment About Methodological Limitations on the Study by An et al.

The study by An et al. provides valuable insights into rocuronium pharmacodynamics in patients with high body fat percentages (PBF). However, the lack of normalisation for acceleromyographic train-of-four (TOF) ratios raises concerns about the validity of endpoints. Due to the acceleromygraph's inherent "inverse fade" artefact, non-normalised TOF ratios may mask clinically significant residual paralysis. For example, a reported TOF of 0.9 could correspond to a true ratio of 0.75 (assuming a baseline of 1.2), overestimating recovery. This methodological gap weakens the study's conclusion on fat-free mass-based dosing advantages in high-PBF patients. Future studies should adopt TOF normalisation or electromyography (EMG)-based monitoring to improve accuracy and patient safety. Addressing this limitation would strengthen the clinical applicability of individualised neuromuscular blocking strategies.