Confirm recovery before extubation: train-of-four ratio ≥0.9 (quantitative monitor preferred). Inadequate reversal causes hypoxia and aspiration.
Neostigmine
- Needs at least one or two twitches on TOF
- Max dose 50 micrograms/kg (with antimuscarinic)
- Avoid if complete block (risk paradox)
Sugammadex
- Dose by depth: 2 mg/kg moderate, 4 mg/kg deep block
- 16 mg/kg for immediate rocuronium rescue (cannot intubate)
- No effect on suxamethonium or benzylisoquinoliniums
Shallow block
- 2 or more twitches on TOF
- Neostigmine 50 micrograms/kg
- With glycopyrronium or atropine
Deep block
- Neostigmine ineffective
- Sugammadex 4 mg/kg
- Rocuronium or vecuronium only
Immediate rescue (CICO)
- Sugammadex 16 mg/kg
- After rocuronium RSI
- No effect on suxamethonium
Reversal choice
1
1. Monitor
Use quantitative TOF. Document block depth at end of case.
Use quantitative TOF. Document block depth at end of case.
↓
2
2. Shallow block
Neostigmine 50 micrograms/kg + glycopyrronium or atropine per local policy.
Neostigmine 50 micrograms/kg + glycopyrronium or atropine per local policy.
↓
3
3. Deep block
Sugammadex if rocuronium/vecuronium and no contraindication (renal impairment: reduced dose per SPC).
Sugammadex if rocuronium/vecuronium and no contraindication (renal impairment: reduced dose per SPC).
↓
4
4. Extubate
Awake, following commands, strong grip, adequate tidal volume.
Awake, following commands, strong grip, adequate tidal volume.
Sugammadex cautions
- Renal impairment: reduced dosing
- Steroid interaction (reproductive hormones): short window
- Progesterone-only pill: extra contraception 7 days (check current SPC)
Pitfalls
- Neostigmine at deep block
- Extubating on visual guess without TOF
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026