Myth busters: The role of quantitative monitoring in the era of sugammadex

The introduction of sugammadex revolutionized neuromuscular block (NMB) management, but it hasn’t eliminated the need for monitoring. Despite the powerful reversal capabilities of sugammadex, residual neuromuscular block (rNMB) remains a significant clinical concern. 

In this blog, we'll tackle common myths surrounding NMB management and highlight why quantitative monitoring is still critical to ensuring full recovery, optimal dosing, and patient safety.

Myth: “We have sugammadex—we don’t need quantitative monitoring.”

Truth: Even with sugammadex, residual neuromuscular block (rNMB) is not eliminated. In one study, 16% of patients required more than the standard 2 mg/kg dose of sugammadex to reach a train-of-four (TOF) ratio of ≥0.9. Some even required doses exceeding 4 mg/kg (Koo, 2024).

Another study found that 47.1% of patients had TOF ratios below 1.0 in the PACU, despite receiving sugammadex—highlighting the gap between drug administration and actual recovery (Todd, 2023).

Myth: “We use qualitative measures and that’s adequate for our patients.”

Truth: Clinical signs like head lift or tidal volume are poor indicators of neuromuscular recovery. Research has shown that patients can perform these tasks while still experiencing significant residual paralysis, especially when quantitative monitoring isn’t used (Naguib, 2017; Murphy, 2008).

Murphy’s study showed that 37% of patients had rNMB despite appearing clinically recovered.
 

Myth: “We don’t have residual block in our PACU—we only use sugammadex.”

Truth: A cohort study found a 4.8% incidence of rNMB even with sugammadex, compared to 25.9% with neostigmine.

Notably, when quantitative monitoring was used, no rNMB was detected—even with lower reversal doses (Ozbey, 2022). Our internal PACU audits consistently show 10–20% rNMB rates, regardless of the reversal agent.

Myth: “Quantitative monitoring won’t save us much money.”

Truth: Accurate monitoring helps tailor sugammadex dosing, reducing waste and cost. One study estimated nearly $370,000 in annual savings by using aliquots and avoiding unnecessary reversal when spontaneous recovery was sufficient (Haberkorn, 2024).

Another study found that 60% of sugammadex doses resulted in wastage due to partial vial use, equating to an estimated $14 million in avoidable costs across 400,000 administrations (Mpody, 2023).

Myth: “Quantitative monitoring takes too long and slows me down.”

Truth: A study evaluating device setup time found:
• Peripheral Nerve Stimulator (PNS): Median 29 seconds
• IntelliVue NMT: Median 46 seconds
• TetraGraph (EMG): Median 63 seconds

While quantitative monitors took ~19 seconds longer, this marginal increase does not materially delay workflow (Renew, 2021).

To summarize, here are eight reasons why quantitative TOF monitoring remains essential, even when using sugammadex:

1. Reduces the risk of residual paralysis
2. Optimizes intraoperative NMBA management
3. Enables early, accurate reversal assessment
4. Prevents over- and underdosing of NMBAs
5. Improves postoperative recovery
6. Supports better monitoring in ICU settings
7. Enhances patient safety and satisfaction
8. Provides educational value for clinicians

Sugammadex has undoubtedly transformed the way we manage neuromuscular block, but it's not a substitute for clinical vigilance. The myth that monitoring is optional in the era of sugammadex can lead to complacency and potential harm. Quantitative TOF monitoring based on electromyography (EMG) remains the gold standard for detecting residual block, optimizing reversal dosing, and ensuring safe extubation. 

By combining the power of sugammadex with the precision of EMG-based quantitative TOF monitoring, we can deliver the highest standard of care and improve outcomes for every patient.

• Haberkorn, S., Twite, M., Klockau, K., Whitney, G., & Faulk, D. J. (2024). Quantitative Monitoring Maximizes Cost-Saving Strategies When Antagonizing Neuromuscular Block With Sugammadex. Cureus, 16(9), e68551. https://doi.org/10.7759/cureus.68551
   
• Koo, C. H., Lee, S., Yim, S., Bae, Y. K., Park, I., & Oh, A. Y. (2024). Is quantitative neuromuscular monitoring mandatory after administration of the recommended dose of sugammadex? Anaesthesia, Critical Care & Pain Medicine, 43(6), 101445. https://doi.org/10.1016/j.accpm.2024.101445
   
• Mpody, C., Beltran, R., Hayes, S., Nafiu, O. O., & Tobias, J. D. (2023). Sugammadex Vial Wastage: Implications for the Cost of Anesthesia Care in Children. Anesthesiology, 139(1), 108–109. https://doi.org/10.1097/ALN.0000000000004551
   
• Murphy GS, Szokol JW, Marymont JH, et al. Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Neuromuscular Blockade and Adverse Respiratory Events in the Postanesthesia Care Unit. Anesthesiology. 2008;109(3):389–398.
   
• Naguib M, Brull SJ, Kopman AF, et al. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesthesia & Analgesia. 2017;124(1):82–95.
   
• Özbey, N. B., Abdullah, T., & Deligöz, Ö. (2022). Residual neuromuscular block in the postanesthesia care unit: Incidence, risk factors, and effect of neuromuscular monitoring and reversal agents. Turkish Journal of Medical Sciences, 52(5), 1656–1664. https://doi.org/10.55730/1300-0144.5507
   
• Todd, M. M., & Kopman, A. F. (2023). Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal. Anesthesiology, 139(1), 1–3. https://doi.org/10.1097/ALN.0000000000004587
   
• Renew, J. R., Hex, K., Johnson, P., Lovett, P., & Pence, R. (2021). Ease of Application of Various Neuromuscular Devices for Routine Monitoring. Anesthesia & Analgesia, 132(5), 1421–1428. https://doi.org/10.1213/ANE.0000000000005213