Preparing for the Unexpected: Special Considerations and Complications After Sugammadex Administration

Hajime Iwasaki; J. Ross Renew; Takayuki Kunisawa; Sorin J. Brull


BMC Anesthesiol. 2017;17(140) 

In This Article


Sugammadex, a modified gamma-cyclodextrin, has made neuromuscular reversal faster[1] and safer[2] when compared to traditional acetylcholinesterase inhibitors. However, simply administering sugammadex based on clinical signs or time since the last administration of neuromuscular blocking agents (NMBAs) (without using objective neuromuscular monitoring to guide appropriate dosing) cannot ensure full and reliable recovery and patient safety. Residual neuromuscular paralysis is a remaining complication even with the use of sugammadex.[3] Appropriate dosing [4 mg/kg at post tetanic count (PTC) of 1–2; 2 mg/kg at reappearance of two twitches to train of four (TOF) stimulation; 1 mg/kg[4] at reappearance of four twitches to TOF stimulation; 0.49 mg/kg[5] at TOF ratio (TOFR) of ≥0.2; and 0.22 mg/kg[6] at TOFR of ≥0.5] is necessary; excessive doses of sugammadex may prevent residual neuromuscular paralysis, but may also result in excessive costs and pose an entirely new set of challenges when re-establishment of neuromuscular blockade is needed.[7] Moreover, aspects of the clinical use of sugammadex are controversial or may require special attention in some clinical situations. For example, hypersensitivity reaction to sugammadex is a life-threatening problem for which immediate detection and treatment are imperative. Anesthesiologists must familiarize themselves with these specific issues. This review will address several clinical scenarios to which attention should be focused following sugammadex administration.