Authors: Wachtendorf LJ et al.
Anesthesiology. December 2025.
Summary
This large retrospective cohort study examined how the introduction of sugammadex influenced intraoperative rocuronium dosing practices and whether changes in dosing were associated with postoperative respiratory complications. While sugammadex enables rapid and reliable reversal of even deep neuromuscular blockade, concerns have emerged that its availability may encourage more liberal neuromuscular blocker dosing, potentially increasing perioperative risk.
The investigators analyzed 163,402 adult general anesthesia cases at a single academic center between 2010 and 2024 in which rocuronium was the sole neuromuscular blocking agent used. An interrupted time-series analysis assessed changes in cumulative intraoperative rocuronium dose before and after the introduction of sugammadex in September 2016. Postoperative respiratory complications were defined as post-extubation desaturation below 90%, reintubation within seven days, or emergency noninvasive ventilation.
Rocuronium dosing remained stable before sugammadex introduction but increased steadily thereafter, rising by approximately 45% over the subsequent years. Overall, 8.4% of patients experienced postoperative respiratory complications. Higher cumulative rocuronium doses were associated with increased risk of respiratory complications, particularly in patients who received neither sugammadex nor neuromuscular monitoring. The risk was attenuated in patients who received sugammadex and was completely abolished when quantitative neuromuscular monitoring (train-of-four ratio) was used. In contrast, qualitative monitoring based on twitch count did not eliminate the dose-dependent risk.
These findings suggest that while sugammadex mitigates the respiratory risks associated with higher neuromuscular blocker dosing, it does not fully substitute for best practices in neuromuscular management. Quantitative neuromuscular monitoring appears essential to eliminate dose-related postoperative respiratory risk, even in the era of routine sugammadex availability.
Key Points
Introduction of sugammadex was associated with a substantial increase in intraoperative rocuronium dosing.
Higher rocuronium doses were dose-dependently associated with postoperative respiratory complications.
Sugammadex attenuated, but did not fully eliminate, respiratory risk associated with higher rocuronium doses.
Quantitative neuromuscular monitoring abolished the dose-dependent risk of respiratory complications.
Optimal neuromuscular safety requires both appropriate reversal and objective monitoring.
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