Risk factors for administration of additional reversal following neuromuscular blockade with rocuronium in children: A retrospective case-control study.


This is a retrospective case control study of electronic records in <18-year-olds from one institution between 2017-2020. Of 6373 patients who received neostigmine after rocuronium paralysis, 101 patients received a second dose of reversal (1.58%), 36 with sugammadex and 65 with an additional neostigmine dose.

Risk factors associated with the administration of additional reversal included time <28 min from the last dose of rocuronium to initial dose of neostigmine (OR 1.52 (95% CI, 1.08–2.35)), cumulative dose of rocuronium >0.45 mg/kg/hr (OR 1.71 (95% CI, 1.10–2.67), and initial neostigmine dose <0.05 mg/kg (OR 4.98 (95% CI, 2.84–6.49)).


From previous studies, inadequate reversal following administration of neostigmine remains relatively common and contributes to postoperative pulmonary complications. However, definitions of clinically significant residual neuromuscular blockade in children are not well defined.
In this study, use of additional reversal was used as a measure to evaluate the prevalence of residual neuromuscular blockade. The main limitation is the lack of documentation or clinical reasoning for administration of additional reversal (i.e., TOF<0.9, response to delayed emergence, low tidal volumes or a lack of movement) and thus may or may not have represented actual residual neuromuscular blockade.

Take home message

Use of a second additional dose of reversal after rocuronium and neostigmine is uncommon. The risk factors are timing and cumulative dose of rocuronium, as well as initial neostigmine dose.
Manufacturer labelling identifies the usual dose of neostigmine for NMJ reversal as 0.03-0.07mg/kg. Awareness of potential risk factors could encourage the higher dose (>0.05mg/kg) of initial neostigmine.
This study does not address which reversal agent to use for additional reversal (neostigmine or sugammadex) though the benefits and risks of each is worth considering.

Reviewed by Dr Graham Knottenbelt