In this prospective dose-finding study conducted at a single center, the use of sugammadex to counteract rocuronium during sternal closure was guided by quantitative EMG neuromuscular blockade monitoring. The aim was to evaluate the efficacy of sugammadex compared to standard dosing recommendations and ensure adequate recovery (TOF >0.9) after administering 2mg/kg sugammadex with 2 or more twitches in response to train-of-four stimulation, and 4mg/kg sugammadex when there was at least 1 post-tetanic twitch but less than a 2 TOF twitch count.
Ninety-seven patients completed the study, during which a modified sugammadex dosing protocol was employed, administering 50mg sugammadex every 5 minutes. Consequently, the sugammadex administration was slower than typical clinical practice, allowing for more spontaneous recovery from rocuronium blockade.
The study revealed significant variability in the required dose to achieve recovery (TOF >0.9). Notably, 87% of patients required a smaller dose than recommended in the package insert. However, 13% of patients required a higher-than-recommended dose for effective reversal of rocuronium blockade, indicating a safety concern.
Within the study population, the dose of sugammadex needed to achieve a TOF ratio of 0.9 or greater ranged from 0.43 to 5.6 mg/kg, despite the slow dosing protocol of 50mg every 5 minutes. Additionally, two patients experienced recurrent paralysis (TOF <0.9) after initially achieving a TOF >0.9 post-sugammadex administration, both of whom responded to an additional 50mg of sugammadex.
The key takeaway is that while patients generally require less sugammadex than recommended in the package insert to reverse rocuronium blockade, approximately 13% may need a higher dose. Therefore, quantitative neuromuscular blockade monitoring is essential to confirm adequate recovery (TOF>0.9), as some patients may exhibit recurrent paralysis even after verified reversal with sugammadex.