Thinking outside the box: management of sugammadex failure in the operating room; a case series and literature review

Abstract

Ensuring complete reversal of neuromuscular blockade (NMB) is crucial for safe anesthetic care. Sugammadex, a selective binding agent, is highly effective in reversing steroidal NMB agents like rocuronium, and is often considered superior to standard reversal agents due to its ability to quickly reverse large doses of rocuronium, its increased flexibility in neuromuscular management in the operating room, and its reduced risk of residual neuromuscular blockade in the PACU when appropriately dosed. However, instances of sugammadex failing to achieve adequate reversal pose significant clinical challenges. We present here a case series of three cases in which Neuromuscular block proved resistant to the routine reversal agents.

Abbreviations: CAD: coronary artery disease, NMB: neuromuscular blockade, NASH: non-alcoholic fatty liver disease, PACU: post-anesthesia care unit, SVT: supraventricular tachycardia, TOF: train-of-four

Keywords: sugammadex, neuromuscular blockade, Neuromuscular Blocking Agents, neostigmine, Cholinesterase Inhibitors

Citation: Dhoon TQ, Shah S, Mitchell W, Field RR, Rajan G. Thinking outside the box: management of sugammadex failure in the operating room; a case series and literature review. Anaesth. pain intensive care 2025;29(8):1047-1055. DOI: 10.35975/apic.v29i8.3034

Received: May 09, 2025; Revised: October 26, 2025; Accepted: January 01, 2025