Comparison of Sugammadex and Neostigmine for Reversal of Vecuronium-Induced Neuromuscular Blockade in Pediatric Patients: A Prospective Randomized Study
TL;DR
Sugammadex provided significantly faster and more reliable reversal of vecuronium-induced neuromuscular blockade in children aged two to 12 years, compared to neostigmine (as shown by neuromuscular monitoring), with less tachycardia following reversal.
Abstract
Background and objective Neuromuscular blocking agents (NMBAs) used during general anesthesia require effective reversal to prevent residual paralysis. Neostigmine, the conventional reversal agent, is associated with slower recovery and muscarinic side effects. Sugammadex selectively encapsulates amino-steroidal NMBAs, providing rapid and predictable reversal. This study compared the efficacy, safety, and recovery profile of sugammadex and neostigmine for reversal of vecuronium-induced neuromuscular blockade in children. Methods In this prospective, randomized, double-blind trial, 100 children aged two to 12 years (American Society of Anesthesiologists (ASA) I-III) undergoing elective surgery requiring general anesthesia were randomized to receive sugammadex (2 mg/kg) or neostigmine (50 mcg/kg) with glycopyrrolate (10 mcg/kg). Neuromuscular function was monitored using train-of-four (TOF) stimulation. The primary outcome was time to achieve TOF ratios of ≥0.9 and 1.0 after reversal. Secondary outcomes included residual neuromuscular blockade, functional respiratory recovery assessed by tidal volume, hemodynamic adverse events, and respiratory complications. Results Demographic and intraoperative characteristics were comparable between groups. The median time (±IQR) to achieve TOF ≥0.9 and 1.0 was significantly shorter with Sugammadex than with Neostigmine [70(65-108) vs 252(240-280) and 85.5(75-142) vs 272(255-304) seconds, respectively, p = 0.001]. Heart rate was significantly higher following reversal with neostigmine and glycopyrrolate than with sugammadex, with the difference peaking at five minutes and progressively narrowing thereafter, but remaining significant for up to 1.5 hours after arrival in the post-anesthesia care unit. Tidal volume increased more rapidly with sugammadex than neostigmine after reversal, although this exploratory secondary outcome does not establish a causal relationship. Conclusions Sugammadex provided significantly faster and more reliable reversal of vecuronium-induced neuromuscular blockade in children aged two to 12 years, compared to neostigmine (as shown by neuromuscular monitoring), with less tachycardia following reversal.