Sugammadex Versus Neostigmine for Reversal of Rocuronium Neuromuscular

Incomplete recovery from neuromuscular blocking agents (NMBAs) residual block after anesthesia and surgery continues to be a common problem in the postanesthesia care (PACU).

Neostigmine remains the most common acetylcholinesterase inhibitor in the United States. However, administration of the drug significantly impairs genioglossus muscle activity when administered after full recovery from neuromuscular block. Moreover, doses of neostigmine exceeding 0.06 mg/kg increase the risk of respiratory complications independent of NMBAs effects.

Sugammadex is a modified γ-cyclodextrin that rapidly reverses that effect of the steroidal nondepolarizing NMBAs rocuronium and vecuronium. Sugammadex forms a stable, inactive 1:1 complex with rocuronium or vecuronium, reducing the amount of free NMBA available to bind to nicotinic acetylcholine receptors at the neuromuscular junction. Unlike neostigmine, sugammadex completely reverses even dense neuromuscular blocks.

Patients having catheter-based neurointerventional procedures are kept deeply anesthetized. It is common to find patients nearly completely paralyzed at the end of neurointerventional procedures and have a markedly delayed emergence while waiting for muscle function to recover sufficiently to safely antagonize with neostigmine.

Inclusion criteria

• Age ≥ 18 years;
• American Society of Anesthesiologists (ASA) physical status 1-3;
• Scheduled for catheter-based neurointerventional procedures including coiling and stent insertion;
• General anesthesia.

Exclusion criteria

• Suspected difficult intubation;
• Neuromuscular disorder;
• Renal impairment creatinine ≥ 2 mg /dl;
• Hepatic dysfunction;
• History of malignant hyperthermia;
• Allergy to neuromuscular blocking drugs, Sugammadex, neostigmine or glycopyrrolate;
• Perioperative respiratory infections and/or pneumonia;
• Intubated or unresponsive;
• Pregnancy or breastfeeding.