Effect of sugammadex titration versus manufacturer's recommendation for reversal of rocuronium-induced neuromuscular block: a prospective, randomized, controlled trial.

Background: Both under-dosing and over-dosing of sugammadex for reversing neuromuscular block pose risks to patients, yet the optimal dosage for different degrees of neuromuscular block remains undefined. This study compared titration with single bolus of sugammadex recommended by manufacturer to determine the optimal dose for achieving a train-of-four ratio (TOFR) of 0.9 or greater while minimizing residual paralysis.

Methods: Patients were randomly assigned to titrated group or manufacturer-recommended group. In titrated group, sugammadex was given in 50-mg increments every 5 min until a TOFR of 0.9 or greater was reached. In recommended group, a single dose (2 mg/kg or 4 mg/kg) was given based on train-of-four count (TOFC). Neuromuscular block was monitored continuously, and residual paralysis was assessed in the post-anesthesia care unit (PACU).

Results: Of 210 enrolled patients, 205 were evaluated. The median dose of sugammadex for reversing different depths of neuromuscular block induced by rocuronium was ascertained via the titration method in this study. Titrated group required significantly less sugammadex to achieve a TOFR of at least 0.9 compared to recommended group (P < 0.001). Residual paralysis incidence was similar between groups (5.4% in titrated group vs. 4.9% in recommended group; P = 0.564). Although recovery time was longer in titrated group, extubation time and length of stay in the PACU were comparable.

Conclusions: Titrated sugammadex administration significantly reduces required dosage without increasing residual paralysis risk. Continuous neuromuscular monitoring postoperatively is strongly recommended due to individual variability in dosage needs.

Trial registration: The study was registered in the Chinese Clinical Trial Registry on March 4, 2024(ChiCTR2400081540).