Vital Times 2017 - 69

Table 2. Neostigmine Dosing12
Qualitative Monitoring

Quantitative Monitoring

Neostigmine Dose

4	twitches	without	fade

TOF	(0.4-	0.9)

15-30	μg/kg

4	twitches	with	fade	

TOF<0.4

40-50	μg/kg

2-3	twitches

2-3	twitches

50-70	μg/kg

1	twitch

1	twitch

Delay

acceleromyograph are not user friendly and are difficult
to use. To avoid residual NMB, post-reversal TOF should
exceed 0.9 as determined by quantitative monitoring. If
the TOF is 0.8, forced vital capacity is impaired. TOF
<0.7 is associated with adverse outcomes.

Reversal of Neuromuscular Blockade
After rocuronium 0.6 mg/kg, train of four (TOF)
recovers to 0.7 in 73+- 24.2 min.10 If TOF > 0.9 has not
been confirmed by quantitative monitoring, rocuronium
blockade should be reversed, even after several hours.
Neostigmine up to 70 mcg/kg & glycopyrrolate 14
mcg/kg can be utilized for reversing moderate block.
Neostigmine & glycopyrrolate are not suitable for
reversing deep block. Higher than recommended
doses of neostigmine can lead to a depolarizing block
and inadequate doses can lead to residual weakness or
recurarization. A smaller dose of neostigmine <60 mcg/
kg, as guided by monitoring, may reduce respiratory
complications, even in patients who appear to be
strong.11
The dose of sugammadex to reverse moderate block
is 2 mg/kg total body weight. To reverse deep block,
sugammadex 4 mg/kg is recommended. To reverse deep
block to TOF> 0.9, sugammadex required a mean of
2.9 min, whereas neostigmine required a mean of 50.4
min.13 Thus, neostigmine is not suitable for reversing
deep block caused by rocuronium.14 There has been one
case report of sugammadex not reversing rocuronium
blockade.15

Sugammadex can be utilized to reverse residual block
after neostigmine & glycopyrrolate have already
been administered. In institutions where the cost of
neostigmine & glycopyrrolate is lower than the cost
of sugammadex, neostigmine & glycopyrrolate can be
utilized as the primary reversal agents and sugammadex
can be utilized for patients whose reversal is inadequate.
Sugammadex is preferable over neostigmine &
glycopyrrolate for patients in whom residual NMB is
particularly detrimental. These include patients with
neuromuscular disorders such as myasthenia gravis,
muscular dystrophy or ALS.16 Sugammadex is also
preferable in patients with impaired respiratory reserve or
obstructive sleep apnea.
After a rapid sequence induction dose of rocuronium
1.2 mg/kg, if sugammadex 16 mg/kg is administered
3 min later, the T1 of 10% of baseline, i.e., TOF 1, is
achieved in 4.4+-0.7 min after the start of rocuronium.17
When succinylcholine 1 mg/kg is administered for rapid
sequence intubation, T1 of 10% of baseline is achieved
in 7.1 +-1.6 min. Thus, recovery from succinylcholine is
slower, increasing the risk of hypoxia in the setting of a
failed intubation.
Occasionally, it may become necessary to re-administer a
relaxant after sugammadex has been administered. In this
setting, the onset of rocuronium will be delayed and its
duration of action will be shortened. Five minutes after
(continued)

Annual	Publication	2017	|	 	69



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