Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal

In the current issue of Anesthesiology, Bowdle et al.¹  report the results of an observational study examining the dose of sugammadex required to achieve adequate reversal of a rocuronium neuromuscular block in a group of elective cardiac surgical patients. At the end of surgery, the authors gave 97 patients small (50 mg), repeated (every 5 min) incremental doses of sugammadex until a train-of-four ratio of 0.90 or greater was achieved and then continued to monitor the train-of-four ratio for up to 7 h postoperatively. This work contains a number of findings that deserve attention from our entire profession. Most importantly, it contradicts the widespread belief that simply giving the recommended 2- or 4-mg/kg dose of sugammadex, based solely on an observed twitch count (or post-tetanic count) ensures adequate reversal. While we have no objections to these recommended (and Food and Drug Administration–approved) doses, the Bowdle et al.^1...