Episode 77: Reversal of Neuromuscular Blockade

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 77: Reversal of Neuromuscular Blockade

In this episode, episode 77, I discuss reversal of neuromuscular blockade.  This is a follow up to episode 66 in which I covered neuromuscular blockade.

CME: https://earnc.me/An714h

Outline by Brian Park: NMB Reversal Outline


Miller’s Anesthesia 8th Edition. Reversal (Antagonism) of Neuromuscular Blockade. Murphy GS, de Boer HD, Eriksson LI and Miller RD. Chapter 35, 995-1027.e5.

Appiah-Ankam J, Hunter J.  Pharmacology of neuromuscular blocking drugs.  Cont Educ Anaesthesia Critical Care & Pain.  2004;4(1):2-7.

Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017 Aug 14;8:CD012763.

Keating GM. Sugammadex: A Review of Neuromuscular Blockade Reversal. Drugs. 2016 Jul;76(10):1041-52.

McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications. Anesthesiology. 2015 Jun;122(6):1201-13.

Schaller S, Fink H.  Sugammadex as a reversal agent for neuromuscular block: an evidence-based review.  Core Evidence.  2013;8:57-67.

15 thoughts on “Episode 77: Reversal of Neuromuscular Blockade”

  1. Great podcast as always!
    3 questions:
    -is there an increased incidence of ponv if you use neostigmine?
    -can you use lesser doses of sugammadex and just wait longer (since its quite expensive)?
    -roc is dosed according to ideal bodyweight-why do you dose sugammadex according to actual bodyweight

    Thank you very much,

    1. Hi Flo,

      1. There is mixed evidence, but for the most part studies have shown that if you use neostigmine and glycopyrrolate together there is not an increased risk of PONV.

      2. Yes, you can, but since there aren’t clear guidelines of HOW long to wait if you give less than the recommended dose, you would need to use AMG monitoring to be sure you had complete reversal.

      3. Remember, roc is dosed based on studies showing that X amount will lead to X affect. Sugammedex is dosed based on studies showing that X amount will have X affect GIVEN A CERTAIN AMOUNT OF RECOVERY. So they are based on different standards, so to speak.

      I hope that helps!

  2. Hi Dr. Wolpow,

    I have a couple of questions based on my (limited) experience rotating cardiac surgery and cardiac ICU. I’ve seen patients sent to cardiac ICU from various bypass procedures and when the time comes to wake up the patient, no one checks for AMG monitoring or gives reversal of any sort. The main points would be to see how well the patient is ventilating along with their metabolic and hemodynamic stability.
    If the patient is doing great, sometimes they can get “expedited wake up” where the ICU team tries to extubate within 3 hours of getting the patient, but I don’t recall the patient getting reversal even then. Later when I worked in the OR side of those procedures, I noticed that the anesthesia team doesn’t give any reversal before dropping off the patient either. Does the bypass machine act similar to a dialysis filter where the rocuronium is no longer there? Or is this just based on the assumption that there is no more paralytic on board?

    At a different hospital, I learned of a completely different method of waking up from bypass procedures where anesthesia will actually reverse the patient with suggamedex (lots of local at incision sites), extubate in the OR, and drop them off at ICU spontaneously breathing. Since you work at the cardiac ICU, do you think this method might be better?

    Thanks for the great podcast!

    1. I’ve never used it, so can’t speak from personal experience but I would say the literature supports reversing unless you have AMG evidence of tof ratio of 0.9 or greater.

  3. Dr. Wolpaw,

    Excellent podcast, I really do appreciate you making this content.

    In regards to deciding which anti-cholinergic to match with which anti-cholinesterase to reverse neuromuscular blocking drugs, you specifically mention onset of action -atropine with edrophonium / glycopyrrolate with neostigmine. Wouldn’t considering the duration of action be more important in making this decision? For example, if using neostigmine (4-6 h) and glycopyrrolate (2-4 h), once the patient is out of close observation in the OR or PACU they have the unbalanced effect of the anti-cholinesterase. Wouldn’t it be more rationale to use drugs with equal duration of action like glycopyrrolate (2-4 h) pyridostigmine (4 h)?

    1. Hi Jordan,

      What you’re saying makes a ton of sense, but it doesn’t play out that way clinically. Patients who get neostigmine and glycopyrrolate don’t have unopposed cholinergic activity after 4 hours. These matchups have been used too many times to count and they seem to be safe for patients.

  4. I’m curious if other people have the same experience . My experience with accelerometers is not that great as the ones we use often don’t work (not counting: ie tof 1 with three clear contractions , let alone measuring fade).

    1. We had good ones that worked well where I did residency but I am definitely curious to hear about others’ experiences.

  5. HI Dr. Wolpaw

    I would like first and foremost to acknowledge that your podcasts is a saving grace for me. Thank you.

    OK….here is my question as a student I was questioned by my clinical preceptor why I choose Roc over Vec. In my mind both drugs had the same DOA, but in order to answer my preceptor I stated that the difference between the two drugs is the onset was different, that was the only Rational I could come up with. If you have a better answer, I am a SRNA trying to learn the ropes.

    Thank you again

    Deanna Essa

    1. Hi Deanna,

      Traditionally Roc was more expensive, so that was one reason people would sometimes choose vec. I’m not sure if that’s true anymore but others should feel free to comment if they know.

      Roc has a slightly shorter onset time, and can be reversed a bit more quickly with Sugammadex than Vec, so those might be reasons to choose it.

      I hope that’s helpful.

      All the best in your ongoing training.


  6. Dr. Wolpaw,

    Your podcast was helpful in differentiating when and how to you post tetanic counts. Do you foresee a podcast on TOF, AMG, etc., in the future?

    1. Hi Sabrena,

      I think I touched on those in this and the NMB episode. Check those out and let me know if you have any specific questions. Thanks!

  7. hello ,
    I am a new fan of your podcast , great work !
    I want to mention a less kown medication for reversal ,which was descovered long ago in Bulgaria and we use it there with sucess .
    it is calle Nivaline and I was wondering if you have heard of it 🙂
    thanks for all the hardwork you are doing

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