Titrating Sugammadex to Reverse Neuromuscular Blockade to≥90% Train-of-Four-Ratio

Authors

  • Blakeley F Ward Associate Chief Nurse Anesthetist, Quality and Education Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA. Author
  • Austin G Conn Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA Author
  • Zachary A Conn Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA Author
  • Yasmeen M Elewa Clinical Pharmacy Specialist Department of Pharmacy University of Mississippi Medical Center, Jackson, MS, USA Author
  • Michelle A Tucci Professor Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA Author
  • Jonathan W Vaughn Assistant Professor School of Nursing Nurse Anesthesia Program University of Mississippi Medical Center, Jackson, MS, USA Author

DOI:

https://doi.org/10.47363/JSAR/2026(7)275

Keywords:

Neuromuscular, Sugammadex, Electromyography

Abstract

Introduction: In January 2023, the American Society of Anesthesiologists (ASA) published its first practice guideline on monitoring and antagonism of neuromuscular blockade, recommending quantitative monitoring and a Train-Of-Four Ratio (TOFR) of 90% or greater before extubation. The ASA called for further investigation into the appropriate dosing of Sugammadex.

Methods: This was a prospective, single-arm (non-randomized) dose-finding/titration study conducted from August 2023 to February 2024. Neuromuscular blockade was measured with a TwitchView Electromyographic (EMG) monitor. Patients with TOFR below 40% at reversal received Sugammadex in 20- mg increments every three minutes until TOFR reached 90% or greater; those with TOFR 40%-89% received Neostigmine and were excluded. Of the 130 patients who consented, 105 completed the protocol. Sugammadex dose was correlated with Rocuronium dose using Pearson correlation and linear regression.

Results: Of 105 patients, 102 (97%) required less than the FDA-recommended dose of 2, 4, or 16 mg/kg; 2 patients required the recommended dose, and 1 patient required more. Seventy patients (67%) required 100 mg or less, and 19 patients (18%) required 40 mg or less. Sugammadex dose correlated significantly with Rocuronium dose (r=0.423, r²=0.179, P<.001) but not with weight or depth of block.

Conclusions: The Sugammadex dose required to achieve a TOFR of 90% or greater was determined by the total Rocuronium dose, not by weight or block depth. It was substantially lower than the FDArecommended dose in most patients. These findings support a Rocuronium-based dosing methodology and reinforce the need for quantitative monitoring, rather than fixed weight-based dosing, to individualize reversal.

Author Biographies

  • Blakeley F Ward, Associate Chief Nurse Anesthetist, Quality and Education Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA.

    Blakeley F Ward, Associate Chief Nurse Anesthetist, Quality and Education Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA.

  • Austin G Conn, Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

    Austin G Conn, Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

  • Zachary A Conn, Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

    Zachary A Conn, Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

  • Yasmeen M Elewa, Clinical Pharmacy Specialist Department of Pharmacy University of Mississippi Medical Center, Jackson, MS, USA

    Yasmeen M Elewa, Clinical Pharmacy Specialist Department of Pharmacy University of Mississippi Medical Center, Jackson, MS, USA

  • Michelle A Tucci, Professor Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

    Michelle A Tucci, Professor Department of Anesthesiology University of Mississippi Medical Center, Jackson, MS, USA

  • Jonathan W Vaughn, Assistant Professor School of Nursing Nurse Anesthesia Program University of Mississippi Medical Center, Jackson, MS, USA

    Jonathan W Vaughn, Assistant Professor School of Nursing Nurse Anesthesia Program University of Mississippi Medical Center, Jackson, MS, USA

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Published

2026-10-14

Issue

Vol. 7 No. 10 (2026): Volume 7 issue 10

Section

Articles