Postoperative recurarization undetected by neuromuscular monitoring

Background: Muscle relaxants and reversal agents, including sugammadex, should be administered according to the neuromuscular monitoring guidelines to prevent recurarization. However, recurarization may still occur with adequate neuromuscular monitoring. This case describes recurarization that occurred in the post-anesthesia care unit (PACU) where the patient’s acceleromyography (AMG) train-of-four (TOF) ratio was 1.0 despite the use of sugammadex. Case: A 66-year-old woman completely recovered from general anesthesia using sugammadex but suddenly became unresponsive in the PACU. Her TOF ratio was 1.0, that we first suspected residual effects of benzodiazepines or opioids. However, there was no response to flumazenil or naloxone. Based on her symptoms, we suspected muscle relaxant recurarization with possibility of overestimation of uncalibrated TOF monitoring device and administered additional sugammadex, which immediately caused her to become responsive. Her symptoms were relieved completely after two additional doses of sugammadex. Conclusions: Despite the use of sugammadex, recurarization can occur without appropriate TOF monitoring.

Neuromuscular blockade; Sugammadex; Benzodiazepine; Anesthesia

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