Document Type


Publication Date

Winter 1-26-2021



Inadequate neuromuscular blockade contributes to postoperative respiratory complications such as hypoventilation, hypoxia, reintubation, and a prolonged hospital stay.1-5 Anesthetists commonly use neostigmine to reverse neuromuscular blockade. However, neostigmine can cause bronchospasm, nausea, vomiting, hypotension, and bradycardia.6 Sugammadex, a novel reversal of neuromuscular blockade agent, belongs to a new category of drugs called “selective relaxant binding agents.” Sugammadex selectively binds rocuronium in a one-to-one fashion and reverses any depth of neuromuscular blockade and has been used in patients with severe renal impairment.7-11

Studies proved sugammadex’s safety in patients with a history of severe renal impairment.8-11 Cisatracurium, the current standard of care for patients with severe renal impairment, undergoes a process independent of the renal function called Hofmann elimination. Neostigmine reverses cisatracurium’s neuromuscular blockade. A recent systematic review showed that not only does sugammadex reverse neuromuscular blockade more quickly than neostigmine, but also has less adverse outcomes.12 A study also showed that sugammadex is safe and effective in adult patients with end-stage renal disease receiving preoperative renal replacement.13 However, no specific studies of patients with severe renal impairment compare the return of neuromuscular function after reversal of cisatracurium with neostigmine versus reversal of rocuronium with sugammadex. Patients with severe renal impairment often have comorbidities that put them at high risk for postoperative cardiac and pulmonary complications. A recent cohort study showed that sugammadex caused a lower incidence of pneumonia, respiratory failure, and other major pulmonary complications.14 No study has simultaneously evaluated clinical outcomes and quality of postoperative recovery.

In patients with severe renal impairment, the duration of rocuronium’s effects is prolonged and unpredictable. Since cisatracurium is eliminated independent of a patient’s renal function and, therefore, provides more predictability in patients with severe renal impairment, it is the preferred agent. The combination of rocuronium and sugammadex achieved successful neuromuscular blockade and reversal in patients with severe renal impairment. Dialysis through a high-flux filter removes sugammadex and the sugammadex-rocuronium compound from a patient’s circulation.15

Anecdotal evidence suggests that patients treated with sugammadex have better subjective measures of recovery than patients treated with neostigmine, but few studies systematically evaluated this. Some studies show that patients with sugammadex have less postoperative nausea, vomiting, and pain than patients with cholinesterase inhibitors.16-17 In an observational study of 101 patients, sugammadex improved psychological and nociceptive postoperative recovery and increased overall satisfaction compared to patients treated with neostigmine.18 Patient-reported outcomes become increasingly important for hospitals. Researchers continue to study treatments that have the potential to increase patient satisfaction.19 The postoperative quality recovery scale (PQRS) assesses recovery of different domains over time and compares them to baseline values.20 PQRS is validated, takes less than five minutes to administer, has a low patient refusal rate, and is acceptable to patients across a wide range of ages.21

Academic Level

medical student

Previous Versions

Jan 26 2021



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