Changes in Intraoperative Rocuronium Dosing after the Introduction of Sugammadex and Association with Postoperative...

Neuromuscular blocking agents dose-dependently precipitate residual neuromuscular blockade and postoperative respiratory complications. The introduction of sugammadex allowed for reversal of even deep neuromuscular blockade and might have provoked more liberal use of neuromuscular blocking agents. The authors investigated whether the introduction of sugammadex led to higher intraoperative rocuronium doses and whether this impacted postoperative respiratory complications.

A total of 163,402 adult patient cases who underwent general anesthesia and received exclusively rocuronium at an academic medical center between 2010 and 2024 were included. Interrupted time series analysis adjusted for patient and procedural characteristics was applied to assess changes in cumulative intraoperative rocuronium doses (milligrams per kilogram body weight) after sugammadex introduction in September 2016. Rocuronium-associated risks of postoperative respiratory complications (postextubation desaturation less than 90%, 7-day reintubation or emergency noninvasive ventilation) and effect modification by use of sugammadex and qualitative (twitch count) versus quantitative (train-of-four ratio) neuromuscular monitoring were evaluated. Reported odds ratios represent the dose-response association (per 1 mg/kg rocuronium increase) within the respective subgroup of patient cases.

After a stable baseline (-0.01 mg/kg per year between January 2010 and August 2016; 95% CI, -0.05 to 0.03 mg/kg; P = 0.58), rocuronium doses increased by 0.05 mg/kg annually after introduction of sugammadex (95% CI, 0.03 to 0.07 mg/kg; P < 0.001) from (mean ± SD) 0.83 ± 0.49 mg/kg in August 2016 to 1.20 ± 0.65 mg/kg in January 2024. A total of 9,101 of 108,317 patient cases (8.4%) experienced postoperative respiratory complications. Rocuronium was dose-dependently associated with higher postoperative respiratory complication risks, which was most pronounced among patient cases receiving neither sugammadex nor neuromuscular monitoring (adjusted odds ratio [OR adj ], 1.99 per 1 mg/kg; 95% CI, 1.82 to 2.18; P < 0.001). This association was attenuated when sugammadex was administered (n = 42,141; median dose, 200 mg; interquartile range, 200 to 300 mg; OR adj , 1.08 per 1 mg/kg; 95% CI, 1.01 to 1.16; P = 0.023; P for interaction < 0.001) and abolished with quantitative (n = 25,564; OR adj , 10.94 per 1 mg/kg; 95% CI, 0.85 to 1.03; P = 0.19; P for interaction < 0.001) but not qualitative neuromuscular monitoring (n = 49,045; OR adj , 1.10 per 1 mg/kg; 95% CI, 1.02 to 1.18; P = 0.017; P for interaction < 0.001).

Sugammadex introduction was followed by a 45.1% increase in rocuronium doses. While sugammadex attenuated the risk of postoperative respiratory complications, it was completely abolished only with quantitative neuromuscular monitoring.