Authors: Wachtendorf LJ et al.
Journal: Anesthesiology, December 4, 2025. DOI: 10.1097/ALN.0000000000005880
Summary
This large retrospective cohort study evaluated how the introduction of sugammadex influenced intraoperative rocuronium dosing practices and whether these changes affected postoperative respiratory complications. Because sugammadex enables rapid reversal of even deep neuromuscular blockade, concerns have emerged that its availability may encourage higher neuromuscular blocking agent dosing with unintended downstream consequences.
The investigators analyzed more than 163,000 adult general anesthesia cases over a 14-year period at a single academic center, using interrupted time-series analysis to assess temporal changes in cumulative rocuronium dose. Prior to sugammadex introduction, rocuronium dosing remained stable. After sugammadex became available, cumulative rocuronium doses increased steadily, resulting in an overall increase of more than 45% by 2024.
Postoperative respiratory complications occurred in 8.4% of cases and demonstrated a clear dose–response relationship with rocuronium exposure. The risk was greatest in patients who received neither sugammadex nor neuromuscular monitoring. Administration of sugammadex significantly attenuated the association between higher rocuronium dose and respiratory complications, but did not eliminate it entirely. In contrast, the use of quantitative neuromuscular monitoring completely abolished the dose-related risk, whereas qualitative monitoring alone did not.
These findings indicate that while sugammadex mitigates some of the respiratory risks associated with higher rocuronium dosing, objective quantitative neuromuscular monitoring is essential for fully preventing dose-related postoperative respiratory complications. The study highlights an important unintended practice shift following sugammadex adoption and reinforces best practices for neuromuscular blockade management.
Key Points
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Introduction of sugammadex was followed by a 45% increase in cumulative intraoperative rocuronium dosing.
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Higher rocuronium doses were independently associated with increased postoperative respiratory complications.
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Sugammadex significantly attenuated, but did not fully eliminate, rocuronium-related respiratory risk.
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Quantitative neuromuscular monitoring abolished the dose–response association with respiratory complications.
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Qualitative monitoring alone was insufficient to prevent rocuronium-related respiratory risk.
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Findings support routine use of quantitative neuromuscular monitoring despite availability of sugammadex.
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