Comparison of Operating Conditions, Postoperative Pain and Recovery, and Overall Satisfaction of Surgeons with Deep vs. No Neuromuscular Blockade for Spinal Surgery under General Anesthesia: A Prospective Randomized Controlled Trial

Surgical pleth index monitoring in perioperative pain management: usefulness and limitations

Surgical pleth index (SPI) monitoring is a representative, objective nociception-monitoring device that measures nociception using photoplethysmographic signals. It is easy to apply to patients and the numerical calculation formula is intuitively easy to understand; therefore, its clinical interpretation is simple. Several studies have demonstrated its efficacy and utility. Compared with hemodynamic parameters, the SPI can detect the degree of nociception during surgery under general anesthesia with greater accuracy, and therefore can provide better guidance for the administration of various opioids, including remifentanil, fentanyl, and sufentanil. Indeed, SPI-guided analgesia is associated with lower intraoperative opioid consumption, faster patient recovery, and comparable or lower levels of postoperative pain and rates of adverse events compared with conventional analgesia. In addition, SPI monitoring allows for the degree of postoperative pain and analgesic requirements to be predicted through the SPI values immediately before patient arousal. However, because patient age, effective circulating volume, position, concomitant medication and anesthetic regimen and level of consciousness may be confounding factors in SPI monitoring, clinicians must be careful when interpreting SPI values. In addition, as SPI values can differ depending on anesthetic and analgesic regimens and the underlying disease, an awareness of the effects of these variables with an understanding of the advantages and disadvantages of SPI monitoring compared to other nociception monitoring devices is essential. Therefore, this review aimed to help clinicians perform optimal SPI-guided analgesia and to assist with the establishment of future research designs through clarifying current usefulness and limitations of SPI monitoring in perioperative pain management.

Paralysis Versus Non-Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial

OBJECTIVE

To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA).

METHODS

This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected.

RESULTS

Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0).

CONCLUSIONS

Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:2654-2664, 2023.

A study on the appropriate dose of rocuronium for intraoperative neuromonitoring in Da Vinci robot thyroid surgery: a randomized, double-blind, controlled trial

Background

This study was to explore the effect of different doses of rocuronium bromide on neuromonitoring during Da Vinci robot thyroid surgery.

Methods

This was a prospective, randomized, double-blind, controlled trial that included 189 patients who underwent Da Vinci robot thyroidectomy with intraoperative neuromonitoring(IONM). Patients were randomly divided into three groups and given three different doses of rocuronium (0.3mg/kg, 0.6mg/kg, 0.9mg/kg). Outcome measurements included IONM evoked potential, postoperative Voice Handicap Index-30(VHI-30), intraoperative body movement incidence rate, Cooper score, and hemodynamic changes during anesthesia induction.Results: The difference in IONM evoked potentials at various time points between the three groups was not statistically significant (P>0.05). The difference in Cooper scores and intraoperative body movement incidence rate between 0.6 and 0.9mg/kg groups was statistically significant compared with the 0.3mg/kg group (both P<0.001). There was no statistically significant difference in VHI-30 score and hemodynamic changes during anesthesia induction among the three groups (both P>0.05).

Conclusions

For patients undergoing Da Vinci robot thyroidectomy, a single dose of rocuronium at 0.6 and 0.9mg/kg during anesthesia induction can provide stable IONM evoked potential. Additionally, compared to 0.3 mg/kg, it can offer better tracheal intubation conditions and lower incidence of body movements during surgery. It is worth noting that the use of higher doses of rocuronium should be adjusted based on the duration of IONM and local practices.

Deep Neuromuscular Block Attenuates Chronic Postsurgical Pain and Enhances Long-Term Postoperative Recovery After Spinal Surgery: A Randomized Controlled Trial

INTRODUCTION

The effects of deep neuromuscular block (DNMB) on chronic postsurgical pain (CPSP) have not been conclusively determined. Moreover, a limited number of studies have examined the impact of DNMB on long-term recovery quality after spinal surgery. We investigated the impact of DNMB on CPSP and the quality of long-term recovery in patients who had been subjected to spinal surgery.

METHODS

This was a randomized, controlled, double-blind, single-center study performed from May 2022 to November 2022. A total of 220 patients who underwent spinal surgery under general anesthesia were randomly assigned to receive either DNMB (post-tetanic count at 1-2) (the D group) or moderate NMB (MNMB) (train-of-four at 1-3) (the M group). The primary endpoint was the incidence of CPSP. The secondary endpoints included the visual analogue scale (VAS) score in the post-anesthesia recovery unit (PACU), at 12, 24, 48 h and 3 months after surgery; postoperative opioid consumption; quality of recovery-15 (QoR-15) scores on the second postoperative day, before discharge, and 3 months after surgery.

RESULTS

The incidence of CPSP was significantly lower in the D group (30/104, 28.85%) than in the M group (45/105, 42.86%) (p = 0.035). Besides, VAS scores were significantly reduced at the third month in the D group (p = 0.016). In the PACU and 12 h after surgery, VAS scores were also significantly lower in the D group than in the M group (p < 0.001, p = 0.004, respectively). The total amount of postoperative opioid consumption (expressed in total oral morphine equivalents) was significantly less in D group than M group (p = 0.027). At 3 months after surgery, QoR-15 scores were significantly higher in D group than M group (p = 0.003).

CONCLUSIONS

Compared with MNMB, DNMB significantly reduced CPSP and postoperative opioid consumption in spinal surgery patients. Moreover, DNMB improved the long-term recovery of patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200058454).

Effects of Deep Neuromuscular Block during Robot-Assisted Transaxillary Thyroidectomy: A Randomized Controlled Trial

The occurrence of significant pain and paresthesia after robot-assisted transaxillary thyroidectomy has been reported, and some patients experience chronic symptoms even three months after surgery. This study scrutinized the effects of deep neuromuscular block during robot-assisted transaxillary thyroidectomy on postoperative pain and sensory changes. In this single-blinded, prospective, randomized, controlled trial, 88 patients who underwent robot-assisted transaxillary thyroidectomy were enrolled and randomly allocated to either the moderate or deep neuromuscular block groups. Study endpoints included postoperative pain, paresthesia, and sensory change after surgery. The linear mixed models for numeric rating scale pain scores in the chest, neck, and axilla all showed significant intergroup differences over time (p = 0.003 in chest; p = 0.001 in neck; p = 0.002 in axilla). In the post hoc analysis with Bonferroni correction, the pain scores of the chest, neck, and axilla were significantly lower in the deep neuromuscular block group on postoperative day one compared to the moderate neuromuscular block group (adjusted p < 0.001 in chest, neck, and axilla). This study demonstrated that deep neuromuscular block could reduce postoperative pain after robot-assisted transaxillary thyroidectomy. However, it could not demonstrate that deep neuromuscular block reduces paresthesia or hypoesthesia after the surgery.

The effect of dexmedetomidine on wake-up test quality when muscle relaxants are not used: A randomized control trial

Background and Aims

Stagnara wake-up test is a simple reproducible neuromonitoring method during spinal surgery which replaces the evoked potential monitoring in the absence of neuromonitoring facilities. Dexmedetomidine (DEX) effect on the intraoperative wake-up test is still unclear. The present study was conducted to evaluate the effectiveness of DEX on the quality of wake-up test during spinal correction surgery.

Methods

A randomized controlled study was carried out over 62 patients randomized into two equal groups planned for elective minimally invasive corrective spine surgery. Instead of atracurium administration in the control group, patients in the experimental group were administered titrated continuous intravenous infusion of DEX at a dose of 0.2-0.7 μg/kg/hour. Lidocaine 2% spray around the vocal cords was done in both the groups to facilitate toleration of the endotracheal tube.

Results

The DEX group showed statistically significant longer duration and better quality of the wake-up test. Statistically significant better haemodynamic state, a lower amount of intraoperative sedatives and higher amount of intraoperative analgesics were also evident in the DEX group. The postoperative Ramsay sedation scale was significantly lower in the DEX group just after extubation.

Conclusion

The DEX use has shown an improving effect on the wake-up test quality, with slightly prolonged wake-up time. The present work supports the use of DEX as an adjuvant drug alleviating the need for the neuromuscular blockade, inducing a better haemodynamic profile, exhibiting better sedation and improving the awakening condition.

Analysis of the association of sugammadex with the length of hospital stay in patients undergoing abdominal surgery: a retrospective study

BACKGROUND

Sugammadex is a newer medication used for rapid and reliable reversal of neuromuscular blockade. This study evaluated whether sugammadex could reduce the length of postoperative hospital stay in patients undergoing abdominal surgery.

METHODS

This single center retrospective cohort study included patients who underwent major abdominal surgery between January 2015 and October 2019. Patients were randomized according to reversal with sugammadex or spontaneous recovery. The primary outcome was length of postoperative hospital stay. The secondary outcomes were length of post-anesthetic care unit (PACU) stay, postoperative ambulation time, time-to-first-defecation, and incidence of pulmonary complications. After 1:1 propensity score matching, univariate and multiple linear regression analyses estimated the differences in outcomes.

RESULTS

Of the 1614 patients, 517 received sugammadex and 645 spontaneously recovered. After adjusting for potential confounders, non-linear relationship was detected between administration of sugammadex and the length of postoperative hospital stay (β = 0.29 95% confidence interval {CI}: [- 1.13, - 0.54], P = 0.4912). However, it was associated with shorter PACU stay (β = - 20.30 95% CI: [- 24.48, - 17.11], P < 0.0001), shorter time to postoperative ambulation movement (β = - 0.43 95% CI: [- 0.62, - 0.23], P < 0.0001), and reduced time-to-first-defecation (β = - 2.25 95% CI: [- 0.45, - 0.05], P = 0.0129), when compared to the spontaneously recovered group. The incidence of pneumonia in the sugammadex group was significantly lower than that in the spontaneously recovered group (18.6% [44/237] vs. 39.2% [93/237] P < 0.05).

CONCLUSIONS

Neuromuscular blockade reversal with sugammadex after abdominal surgery demonstrated an excellent recovery profile and was associated with decreased risk of pneumonia, although it did not affect the length of postoperative hospital stay.

Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials

Deep neuromuscular blockade provides better surgical workspace conditions in laparoscopic surgery, but it is still not clear whether it improves perioperative outcomes, not to mention its role in other types of surgeries. We performed this systematic review and meta-analysis of randomized controlled trials to investigate whether deep neuromuscular blockade versus other more superficial levels of neuromuscular blockade provides improved perioperative outcomes in adult patients in all types of surgeries. Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to June 25, 2022. Forty studies (3271 participants) were included. Deep neuromuscular blockade was associated with an increased rate of acceptable surgical condition (relative risk [RR]: 1.19, 95% confidence interval [CI]: [1.11, 1.27]), increased surgical condition score (MD: 0.52, 95% CI: [0.37, 0.67]), decreased rate of intraoperative movement (RR: 0.19, 95% CI: [0.10, 0.33]), fewer additional measures to improve the surgical condition (RR: 0.63, 95% CI: [0.43, 0.94]), and decreased pain score at 24 h (MD: -0.42, 95% CI: [-0.74, -0.10]). There was no significant difference in the intraoperative blood loss (MD: -22.80, 95% CI: [-48.83, 3.24]), duration of surgery (MD: -0.05, 95% CI: [-2.05, 1.95]), pain score at 48 h (MD: -0.49, 95% CI: [-1.03, 0.05]), or length of stay (MD: -0.05, 95% CI: [-0.19, 0.08]). These indicate that deep neuromuscular blockade improves surgical conditions and prevents intraoperative movement, and there is no sufficient evidence that deep neuromuscular blockade is associated with intraoperative blood loss, duration of surgery, complications, postoperative pain, and length of stay. More high-quality randomized controlled trials are needed, and more attention should be given to complications and the physiological mechanism behind deep neuromuscular blockade and postoperative outcomes.

Postoperative pain treatment after spinal fusion surgery: a systematic review with meta-analyses and trial sequential analyses

Supplemental Digital Content is Available in the Text.

Patients undergoing spinal surgery are at high risk of acute and persistent postoperative pain. Therefore, adequate pain relief is crucial. This systematic review aimed to provide answers about best-proven postoperative analgesic treatment for patients undergoing lumbar 1- or 2-level fusions for degenerative spine diseases. We performed a search in PubMed, Embase, and The Cochrane Library for randomized controlled trials. The primary outcome was opioid consumption after 24 hours postoperatively. We performed meta-analyses, trial sequential analyses, and Grading of Recommendations assessment to accommodate systematic errors. Forty-four randomized controlled trials were included with 2983 participants. Five subgroups emerged: nonsteroidal anti-inflammatory drugs (NSAIDs), epidural, ketamine, local infiltration analgesia, and intrathecal morphine. The results showed a significant reduction in opioid consumption for treatment with NSAID (P < 0.0008) and epidural (P < 0.0006) (predefined minimal clinical relevance of 10 mg). Concerning secondary outcomes, significant reductions in pain scores were detected after 6 hours at rest (NSAID [P < 0.0001] and intrathecal morphine [P < 0.0001]), 6 hours during mobilization (intrathecal morphine [P = 0.003]), 24 hours at rest (epidural [P < 0.00001] and ketamine [P < 0.00001]), and 24 hours during mobilization (intrathecal morphine [P = 0.03]). The effect of wound infiltration was nonsignificant. The quality of evidence was low to very low for most trials. The results from this systematic review showed that some analgesic interventions have the capability to reduce opioid consumption compared with control groups. However, because of the high risk of bias and low evidence, it was impossible to recommend a “gold standard” for the analgesic treatment after 1- or 2-level spinal fusion surgery.

The effects of moderate neuromuscular blockade combined with transverse abdominal plane block on surgical space conditions during laparoscopic colorectal surgery: a randomized clinical study

Background

Deep neuromuscular blockade may be beneficial on surgical space conditions during laparoscopic surgery. The effects of moderate neuromuscular blockade combined with transverse abdominal plane block (TAPB) on surgical space conditions during laparoscopic surgery have not been described. This work investigated whether the above combination is associated with similar surgical space conditions to those of deep neuromuscular blockade.

Methods

Eighty patients undergoing elective laparoscopic surgery for colorectal cancer were randomly divided into two groups. The intervention group was treated with moderate neuromuscular blockade (train-of-four (TOF) count between 1 and 3) combined with TAPB (M group), while the control group was treated with deep neuromuscular blockade (D group), with a TOF count of 0 and a post-tetanic count (PTC) ≥1. Both groups received the same anesthesia management. The distance between the sacral promontory and the umbilical skin during the operation was compared between the two groups. The surgeon scored the surgical space conditions according to a five-point ordinal scale. Patients’ pain scores were evaluated 8 h after the operation.

Results

The distance from the sacral promontory to the umbilical skin after pneumoperitoneum was similar between the D group and M group (16.03 ± 2.17 cm versus 16.37 ± 2.78 cm; P = 0.544). The 95% confidence intervals of the difference in the distance from the sacral promontory to the umbilical skin between the two groups were − 1.45–0.77 cm. According to the preset non-inferior standard of 1.5 cm, (− 1.45, ∞) completely fell within (− 1.50, ∞), and the non-inferior effect test was qualified. No significant difference was found in the surgical rating score between the two groups. The dosage of rocuronium in the group D was significantly higher than that in the group M (P < 0.01). The M group had significantly lower pain scores than the D group 8 h after the operation (P < 0.05).

Conclusions

Moderate neuromuscular blockade combined with TAPB applied to laparoscopic colorectal cancer surgery can provide surgical space conditions similar to those of deep neuromuscular blockade. In addition, it reduces the use of muscle relaxants, relieves postoperative pain within 4 h after operation, and shorten the extubation time and stay in PACU when neostigmine was used as muscle relaxant antagonist.

Trial registration

chictr.org.cn (ChiCTR2000034621), registered on July 12, 2020.

Effects of rocuronium dosage on intraoperative neurophysiological monitoring in patients undergoing spinal surgery

What is known and objective

Intraoperative neurophysiological monitoring (IONM) has been widely used in clinical practice. Therefore, the influence of neuromuscular blockers essential for spinal anaesthesia on IONM is worthy of our attention, but no randomized study has evaluated the dose‐response effect. This study investigated the effects of different doses of rocuronium bromide on the intraoperative monitoring of motor evoked potentials (MEPs).

Methods

We conducted a randomized, double‐blind trial to assess the effects of three rocuronium bromide doses (6.0, 9.0, 12 μg·kg⁻¹·min⁻¹) combined with intravenous infusion of propofol 6–8 mg·kg⁻¹·h⁻¹ and remifentanil 10 μg·kg⁻¹·h⁻¹ on the amplitudes of somatosensory evoked potentials (SEPs) and MEPs at the time of the baseline recording (T₁), before pedicle screw placement (T₂) and before spinal canal decompression (T₃). Secondary outcomes included measurement of neuromuscular function, the occurrence of unexpected intraoperative body movement and recovery of spontaneous breathing.

Results and discussion

A total of 123 patients were enrolled, and 120 patients were ultimately analysed. No differences were observed in the amplitude of SEPs among the three groups (p > 0.05). The MEP amplitude differences at T₁, T₂ and T₃ in all limbs did not differ in patients receiving rocuronium at 6.0 μg·kg⁻¹·min⁻¹ and 9.0 μg·kg⁻¹·min⁻¹ (p > 0.05). However, when rocuronium was administered at 12.0 μg·kg⁻¹·min⁻¹, MEP amplitudes at the time point T₃ were significantly attenuated compared with the time points T₁ and T₂ in both right upper limb and left lower limb (p = 0.002, p = 0.025, respectively). In patients treated with rocuronium 6.0 μg·kg⁻¹·min⁻¹, the incidence of unexpected body movement was significantly higher (p = 0.026), and the train‐of‐four count (TOF count) showed a significant increase at T₂ and T₃ (p < 0.001) compared to other doses.

What is new and conclusion

Rocuronium bromide at a rate of 9.0 μg·kg⁻¹·min⁻¹ provided suitable and adequate muscle relaxation without inhibiting IONM; thus, this dose is recommended for spinal surgery.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan

BACKGROUND

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it.

OBJECTIVES

To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex.

DESIGN

A retrospective cohort study.

SETTING

Nationwide acute in-patient care database.

PATIENTS

A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals.

MAIN OUTCOME MEASURES

The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy.

RESULTS

There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035.

CONCLUSIONS

Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Comparison between the trapezius and adductor pollicis muscles as an acceleromyography monitoring site for moderate neuromuscular blockade during lumbar surgery

Acceleromyography at the adductor pollicis located in a distal part of the body may not reflect the degree of neuromuscular blockade (NMB) at the proximally located muscles manipulated during lumbar surgery. We investigated the usefulness and characteristics of acceleromyographic monitoring at the trapezius for providing moderate NMB during lumbar surgery. Fifty patients were randomized to maintain a train-of-four count 1–3 using acceleromyography at the adductor pollicis (group A; n = 25) or the trapezius (group T; n = 25). Total rocuronium dose administered intraoperatively [mean ± SD, 106.4 ± 31.3 vs. 74.1 ± 17.6 mg; P < 0.001] and surgical satisfaction (median [IQR], 7 [5–8] vs. 5 [4–5]; P < 0.001) were significantly higher in group T than group A. Lumbar retractor pressure (88.9 ± 12.0 vs. 98.0 ± 7.8 mmHg; P = 0.003) and lumbar muscle tone in group T were significantly lower than group A. Time to maximum block with an intubating dose was significantly shorter in group T than group A (44 [37–54] vs. 60 [55–65] sec; P < 0.001). Other outcomes were comparable. Acceleromyography at the trapezius muscle during lumbar surgery required a higher rocuronium dose for moderate NMB than the adductor pollicis muscle, thereby the consequent deeper NMB provided better surgical conditions. Trapezius as proximal muscle may better reflect surgical conditions of spine muscle.

Effect of intraoperative neuromuscular blockade on postoperative sore throat and hoarseness in patients undergoing spinal surgery: a prospective observational study

Intraoperative neuromuscular blockade affects the resting tension between the vocal cords. We assessed the effect of neuromuscular blockade on postoperative sore throat and hoarseness following tracheal intubation in patients undergoing lumbar spinal surgery in the prone position. Altogether, 99 patients were included; 50 patients did not receive neuromuscular blockade, and 49 patients received moderate neuromuscular blockade during the maintenance of anesthesia. Neuromuscular blockade was performed depending on the use of intraoperative neurophysiological monitoring. The number of intubation attempts, time to achieve tracheal intubation, and duration of intubation were recorded accordingly. The incidence and severity of postoperative sore throat and hoarseness was assessed at 1, 6, and 24 h after surgery. The overall cumulative incidence of postoperative sore throat (60% vs. 59%, respectively; P = 1.000) and postoperative hoarseness (68% vs. 61%, respectively; P = 0.532) did not differ between the no neuromuscular blockade and moderate neuromuscular blockade. The incidence and severity of postoperative sore throat and hoarseness was also not different between the moderate and no neuromuscular blockade at each time point after surgery. Nevertheless, the incidences of postoperative sore throat and hoarseness were quite high. Further studies investigating strategies to alleviate them are warranted accordingly.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.