Sugammadex is not enough: quantitative neuromuscular monitoring remains essential for postoperative respiratory safety

Neuromuscular blocking agents are key components of modern anesthesia, yet their use has long been accompanied by the persistent problem of incomplete neuromuscular recovery in the postoperative period (1-3). Residual neuromuscular blockade is not merely a physiological curiosity; it may impair upper airway patency, compromise ventilatory function, weaken airway protective reflexes, and contribute to clinically important postoperative respiratory events (1,2). Over the last decade, the introduction of sugammadex has fundamentally changed the pharmacologic reversal of aminosteroidal neuromuscular blockade (4). Because sugammadex can rapidly and effectively reverse even rocuronium-induced deep blockade, it has reshaped clinician expectations and intraoperative practice.

In the study by Wachtendorf et al. (5), the authors addressed an important and timely question: whether the introduction of sugammadex was associated with changes in intraoperative rocuronium dosing, and whether such changes carried implications for postoperative respiratory complications.

Following the introduction of sugammadex, cumulative intraoperative rocuronium dosing increased from 0.83±0.49 mg/kg in August 2016 to 1.20±0.65 mg/kg in January 2024, corresponding to a 45.1% increase. This increase in rocuronium dosing was observed across procedural groups, including surgeries that do not necessarily require deep neuromuscular blockade. Among 108,317 cases included in the coprimary analysis, 9,101 patients (8.4%) experienced postoperative respiratory complications. Greater rocuronium exposure was associated with a higher risk of postoperative respiratory complications, and although sugammadex attenuated this association, it did not abolish it completely. Only quantitative neuromuscular monitoring consistently eliminated the excess risk associated with higher rocuronium dosing, regardless of administration of sugammadex.

The key message of this study is not simply that rocuronium use increased after sugammadex became available, but that this pharmacologic advance changed clinician behavior without fully eliminating risk. This may be regarded as the paradox of the sugammadex era. As anesthesiologists become more confident that even profound neuromuscular blockade can be rapidly reversed, they may become more willing to administer larger cumulative doses of rocuronium, maintain deeper blockade until later in the procedure, or rely less on objective evidence of recovery before extubation. In such a setting, some of the safety gains offered by a highly effective reversal agent may be offset by more liberal exposure to neuromuscular blocking drugs.

This interpretation is clinically plausible and consistent with broader literature. Residual neuromuscular blockade remains common and clinically meaningful, even in the era of intermediate-acting neuromuscular blocking agents and modern reversal strategies (1,2,6-8). Importantly, reversal and monitoring are not interchangeable. Sugammadex is a treatment, whereas quantitative neuromuscular monitoring is a measurement strategy. The former reverses blockade; the latter confirms whether recovery is sufficient at the bedside. Because bedside clinical signs are unreliable for excluding residual weakness, and qualitative assessment alone may miss clinically relevant incomplete recovery, objective monitoring remains essential (1,2,9).

The findings of Wachtendorf et al. make one point difficult to ignore: pharmacologic reversal cannot substitute for objective confirmation of recovery. In their analysis, the dose-related risk of postoperative respiratory complications was greatest when neither sugammadex nor neuromuscular monitoring was used, with an adjusted odds ratio of 1.99 per 1 mg/kg increase in rocuronium. Sugammadex reduced that signal, but the association remained statistically significant even when sugammadex was administered. By contrast, when quantitative neuromuscular monitoring was documented, the association was no longer significant. This observation directly challenges a common but potentially hazardous assumption in routine practice: that the availability of sugammadex allows clinicians to be less rigorous about monitoring. The present data suggest the opposite. Sugammadex appears most effective when incorporated into a broader strategy of objective neuromuscular monitoring, not when treated as a substitute for it.

This conclusion is well aligned with previous evidence. Large observational data suggest that sugammadex is associated with fewer postoperative pulmonary complications than neostigmine in adult surgical populations (10). At the same time, narrative reviews, consensus statements, and practice guidelines have repeatedly emphasized that quantitative monitoring reduces unrecognized residual paralysis and improves the quality of perioperative neuromuscular management (8,11,12). Thus, this study adds an important and practical layer to existing knowledge: even if sugammadex is superior to older reversal paradigms in many settings, its benefit may be diluted if clinicians respond by increasing rocuronium exposure without verifying recovery quantitatively.

This study has several notable strengths. Its sample size is substantial, the study period spans more than a decade, and the interrupted time-series approach is well suited to evaluating practice changes after the introduction of a new drug. In addition, the authors adjusted for a broad range of patient-, procedure-, and intraoperative-level confounders, and their findings remained robust in sensitivity analyses. Particularly noteworthy is the observation that rocuronium dosing increased across different procedural groups, including surgeries that do not necessarily require deep neuromuscular blockade. This suggests that the observed effect was not merely a function of shifting case mix, but instead reflects a broader behavioral change in anesthetic practice after sugammadex became available.

The limitations are also clear and deserve acknowledgment. This was a single-center retrospective observational study and therefore cannot establish causality. Residual neuromuscular blockade itself was not directly measured; instead, postoperative respiratory complications were used as a clinically relevant downstream outcome. Documentation of neuromuscular monitoring may not fully capture the quality of monitor use, calibration, timing, or adherence to extubation thresholds. Residual confounding remains possible despite extensive adjustment. These limitations should temper causal interpretation, but they do not diminish the practical relevance of the findings. Rather, they underscore how neuromuscular management is often conducted outside idealized study conditions (1,6).

The practical implication is straightforward. Adoption of sugammadex should not mark the endpoint of neuromuscular safety improvement. Instead, it should be accompanied by systematic implementation of quantitative neuromuscular monitoring, consistent documentation of train-of-four ratio recovery, and extubation workflows grounded in objective evidence rather than clinical impression alone (9,11,12). The modern standard should not be framed as sugammadex instead of monitoring, but rather sugammadex together with monitoring.

In summary, Wachtendorf et al. provide an important corrective to therapeutic overconfidence. Their findings suggest that the introduction of sugammadex has been accompanied by more liberal intraoperative rocuronium use and that sugammadex alone does not completely abolish the respiratory risks associated with greater rocuronium exposure. The broader lesson is that postoperative respiratory safety still depends on verification, not assumption. Sugammadex is an important advance, but it is not a substitute for measurement.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1102/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1102/coif). The authors have no conflicts of interest to declare.

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