Titrating Sugammadex to Reverse Neuromuscular Blockade to ≥90% Train-of-Four-Ratio

Abstract

Introduction: In January 2023, the American Society of Anesthesiologists (ASA) published its first practice guideline on monitoring and antagonism of neuromuscular blockade, recommending quantitative monitoring and a Train-Of-Four Ratio (TOFR) of 90% or greater before extubation. The ASA called for further investigation into the appropriate dosing of Sugammadex. Methods: This was a prospective, single-arm (non-randomized) dose-finding/titration study conducted from August 2023 to February 2024. Neuromuscular blockade was measured with a TwitchView Electromyographic (EMG) monitor. Patients with TOFR below 40% at reversal received Sugammadex in 20-mg increments every three minutes until TOFR reached 90% or greater; those with TOFR 40%-89% received Neostigmine and were excluded. Of the 130 patients who consented, 105 completed the protocol. Sugammadex dose was correlated with Rocuronium dose using Pearson correlation and linear regression.Results: Of 105 patients, 102 (97%) required less than the FDA-recommended dose of 2, 4, or 16 mg/kg; 2 patients required the recommended dose, and 1 patient required more. Seventy patients (67%) required 100 mg or less, and 19 patients (18%) required 40 mg or less. Sugammadex dose correlated significantly with Rocuronium dose (r=0.423, r²=0.179, P<.001) but not with weight or depth of block.Conclusions: The Sugammadex dose required to achieve a TOFR of 90% or greater was determined by the total Rocuronium dose, not by weight or block depth. It was substantially lower than the FDArecommended dose in most patients. These findings support a Rocuronium-based dosing methodology and reinforce the need for quantitative monitoring, rather than fixed weight-based dosing, to individualize reversal.