Methylprednisolone vs Dexamethasone Interaction With Sugammadex in Pediatric Patients

Neuromuscular blocking agents (NMBAs) are widely used in pediatric anesthesia to facilitate tracheal intubation and optimize surgical conditions. However, residual neuromuscular block may increase the risk of postoperative respiratory complications, especially in children who have shorter safe apnea times due to their unique anatomical and physiological characteristics. Sugammadex, a modified γ-cyclodextrin, is a selective reversal agent for aminosteroid NMBAs such as rocuronium. Its mechanism of encapsulating steroidal neuromuscular blocking molecules raises concerns about potential interactions with other steroidal drugs, including perioperatively used corticosteroids.

Corticosteroids are commonly administered in the perioperative period for their antiemetic, analgesic, and anti-inflammatory effects. Dexamethasone is widely accepted for postoperative nausea and vomiting prophylaxis, while methylprednisolone is preferred for its rapid anti-inflammatory effect. Previous studies have suggested that the structural similarity of corticosteroids to rocuronium may interfere with sugammadex binding, but the available evidence is conflicting, and data on methylprednisolone remain limited. In a prior study, methylprednisolone was shown to prolong sugammadex reversal time slightly, but no direct comparison with another corticosteroid was performed.

This randomized controlled trial is designed to compare the effects of methylprednisolone and dexamethasone on sugammadex reversal time in pediatric patients undergoing adenoidectomy and/or tonsillectomy. The study will assess whether methylprednisolone has a stronger interaction with sugammadex compared with dexamethasone, leading to prolonged recovery from rocuronium block. Secondary outcomes will include postoperative pain, nausea and vomiting, extubation time, and adverse events. The results may provide clinically relevant evidence regarding the choice of corticosteroid in pediatric anesthesia when sugammadex is used for neuromuscular block reversal.

Inclusion criteria

• Children aged 5-12 years
• American Society of Anesthesiologists (ASA) physical status I-II

Exclusion criteria

• ASA physical status ≥ III
• Emergency surgery
• Known allergy or contraindication to neuromuscular blocking agents, sugammadex, or corticosteroids
• Chronic or recent systemic corticosteroid use (within the last 3 months)
• Neuromuscular disorders (e.g., muscular dystrophy, myasthenia gravis)
• Severe hepatic or renal dysfunction
• Significant respiratory or cardiac disease
• Anticipated difficult airway or history of difficult intubation
• Developmental delay or craniofacial anomalies affecting airway management
• Refusal of consent