Open Journal of Anesthesiology, 2013, 3, 393-395
Published Online November 2013 (
Open Access OJAnes
Effective Use of Sugammadex for Incomplete
Pyridostigmine Reversal of Muscle Relaxation by
Rocuronium: A Case Report
Hee Jong Lee, Kyo Sang Kim*, Ji Seon Jeong, Sung Hwan Choi, Kyu Nam Kim
Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, South Korea.
Email: *
Received September 3rd, 2013; revised September 28th, 2013; accepted October 11th, 2013
Copyright © 2013 Hee Jong Lee et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Anticholinesterase does not allow adequate reversal of the deep neuromuscular blockade (NMB) achieved using high
doses of relaxants. A 71-year-old female patient (weight 70 kg, height 169 cm) was scheduled for a transurethral re-
section of a bladder tumor under general anesthesia. We administered rocuronium 30 mg (0.43 mg/kg) for tracheal in-
tubation due to an estimated short surgical time. During the operation, an additional rocuronium 10 mg was injected.
The surgical procedure ended abruptly 10 minutes after receiving the last dose of rocuronium. At the end of surgery, the
patient received pyridostigmine as a reversal. However, residual NMB persisted, and neuromuscular monitoring did not
show the expected degree of recovery. Sugammadex 2 mg/kg was used, and the patient experienced complete reversal
from NMB in just 2 min.
Keywords: Pyridostigmine; Residual Block; Rocuronium; Sugammadex
1. Introduction
Neostigmine is widely used in many countries, but a high
frequency (32%) of residual block (train-of-four (TOF)
ratios < 0.9) was noted after the use of intermediateac-
ting neuromuscular blockade (NMB) drugs in a post-
anesthesia care unit [1]. Pyridostigmine is frequently
used as reversal agent for rocuronium-induced NMB
only in Korea [2]. Pyridostigmine is preferred for its
longer duration of action compared with neostigmine or
edrophonium, although the onset of pyridostigmine is
slower [3]. However, there is a high risk of significant
residual neuromuscular block after rocuronium even with
reversal using a large dose of pyridostigmine in the re-
covery room [4]. Recent reports indicate that sugam-
madex, a modified γ-cyclodextrin, is highly effective for
reversal of deep or moderate NMB induced by steroidal
agents [5]. We report a case of successful reverse by su-
gammadex after previous administration of pyridostig-
mine that resulted in incomplete reversal of deep rocuro-
nium-induced NMB.
2. Case Report
A female patient, 71 years old, 70 kg, 169 cm, ASA II,
was scheduled for transurethral resection under general
anesthesia of a malignant bladder tumor located on the
dome of the bladder. She had a history of bladder cancer
five years before her presentation and which was treated
with subtotal bladder resection, and a cerebral hemor-
rhage 25 years ago for which surgery was performed.
She suffered from systemic hypertension and had been
receiving antihypertensive medication for 25 years. Preo-
perative laboratory investigations (normal range) showed
a hemoglobin level of 14.8 g/dL (11.3 - 16.1), alanine
aminotransferase (ALT) 65 U/L (5 - 45), aspartate ami-
notransferase (AST) 45 U/L (5 - 40), alkaline phospha-
tase 61 U/L (30 - 110), total bilirubin 0.68 mg/dL (0.2 -
1.2), high density lipoprotein (HDL) 46 mg/dL (32 - 71),
low density lipoprotein (LDL) 142 mg/dL (0 - 137), and
creatinine 0.92 mg/dL (0.6 - 1.4).
On the day of the surgery, the patient received atropine
0.5 mg and midazolam 1.5 mg as premedication. Moni-
tors included ECG, heart rate (HR), non-invasive blood
pressure (BP), blood oxygen saturation (SpO2), and end-
*Corresponding author.
Effective Use of Sugammadex for Incomplete Pyridostigmine Reversal
of Muscle Relaxation by Rocuronium: A Case Report
tidal CO2. Her pre-anesthetic vital signs were BP 130/82
mmHg, HR 73 bpm, and SpO2 96%. General anesthesia
was induced with remifentanil 0.5 μg/kg/min and propo-
fol 80 mg IV. After the loss of eyelash reflex was con-
firmed, neuromuscular monitoring began immediately.
For the calibration of acceleromyography (TOF-Watch
SX®, Organon Ltd., Dublin, Ireland), a 5-s 50-Hz supra-
maximal tetanic stimulus was administered over both
ulnar nerves [6]. A supramaximal current was obtained
after the initial single twitch calibration. After stabiliza-
tion of control responses, rocuronium 30 mg (0.43 mg/kg)
was administered due to an estimated short surgical time,
and tracheal intubation was performed at the disappear-
ance of the TOF response. Anesthesia was maintained
with desflurane 6% by volume in 50% oxygen-enriched
air and remifentanil 0.2 μg/kg/min, and this mixture was
titrated to maintain a bispectral index (BIS) of approxi-
mately 40. At 45 minutes after induction of anesthesia,
the patient bucked in response to surgical traction, so ro-
curonium 10 mg was injected. At that time, the TOF re-
sponse showed three twitches. The surgical procedure
ended 10 minutes after receiving the last dose of rocuro-
nium. The neuromuscular block was antagonized with
glycopyrrolate 0.4 mg and pyridostigmine 10 mg IV,
when one twitch was shown at TOF stimulation. Fifteen
minutes passed after the reversal with no indication that
the patient was recovering from the rocuronium-induced
NMB. Only one twitch was not changed at TOF stimula-
tion. At that point, a bolus of IV sugammadex 140 mg (2
mg/kg) was injected to remove the residual NMB. A TOF
ratio of 1.0 was confirmed by acceleromyography within
2 minutes. Tracheal extubation was performed unevent-
fully in the operating room. The patient’s postoperative
recovery course was unremarkable.
3. Discussion
The recovery time from rocuronium may be increased in
elderly and female patients [7]. Due to this fact and an
estimated short surgical time, low-dose rocuronium 30
mg (0.43 mg/kg) was injected initially for this patient.
However, an additional dose of rocuronium 10 mg was
required once the surgical time was prolonged, and the
patient began bucking in response to surgical traction.
The surgical procedure ended abruptly 10 minutes after
receiving the last dose of rocuronium. Initially, we de-
cided to use glycopyrrolate 0.4 mg and pyridostigmine
10 mg IV after the confirmation of one twitch at TOF
stimulation, which have an onset of 2 - 5 minutes, a peak
activity occurring at about 10 - 20 minutes, and a 2 - 4
hour duration [8]. After fifteen minutes from the reversal,
the TOF response of one twitch was not changed. Pyri-
dostigmine does not achieve complete reversal of muscle
blockade compared to neostigmine at 10% of initial first
twitch height during pancuronium-induced NMB [9].
The incidence of residual block (TOF ratio < 0.7) after
reversal using pyridostigmine 10 mg is 21.5% in the re-
covery room [4]. Moreover, the time to obtain a TOF
ratio of 0.9 is extended greatly [10]. Only in Korea
pyridostigmine is still used as a reversal agent in clinical
practice (more than 80%) [11]. We think that the stan-
dard of care for reversal of rocuronium-induced NMB in
Korea should be changed from pyridostigmine, with its
lower potency and slower onset, to neostigmine. The rea-
son of prolonged paralysis after reversal of neuromuscu-
lar blockade was not known, but we suspect that the con-
comitant drugs (local anesthetics, antibiotics, and cal-
cium channel blockers, etc) have also been affected.
Sugammadex is a modified γ-cyclodextrin that forms
tight one-to-one complexes with rocuronium and, to a
slightly lesser extent, vecuronium, resulting in rapid ter-
mination of NMB [12]. Sugammadex is a fast and predi-
ctable dose-dependent reversing agent of any degree of
block induced by rocuronium, a property that cannot be
replicated with neostigmine/glycopyrrolate [13]. In mod-
erate degrees of neuromuscular block (reappearance of
two twitches), significantly faster recovery (1.5 min) to a
TOF ratio of 0.9 occurred after administration of sugam-
madex 2 mg/kg compared to neostigmine 50 µg/kg (18.6
min) [14]. Sugammadex (4.0 and 8.0 mg/kg) reversed
profound NMB (post-tetanic count 1 or 2) induced by ro-
curonium in a mean time of 1.7 minutes [13]. Sugam-
madex has the potential to be cost-effective compared
with neostigmine/glycopyrrolate for the reversal of ro-
curonium-induced moderate or profound NMB and po-
tentially provides increased patient safety due to the in-
creased predictability of recovery from NMB [15]. In this
case, moderate rocuronium-induced NMB was success-
sfully reversed within 2 minutes with sugammadex at
doses of 2 mg/kg. Sugammadex made it possible that the
predictable effectiveness of a reversal agent, and which
fully prevents residual block, is therefore highly desir-
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