PACU Recurarization: The Challenges of Reversing Rocuronium with Sugammadex

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Authors

• Peter van der Eb, Michigan State University College of Human Medicine Medical Student
• Sydney Musick, Michigan State University College of Human Medicine Medical Student
• Nicholas Watson, Corewell Health West

Description

Rocuronium, a competitive antagonist at nicotinic acetylcholine receptors, produces skeletal muscle paralysis and is routinely used during general anesthesia to facilitate tracheal intubation and optimize surgical conditions.  Sugammadex, a modified γ-cyclodextrin that encapsulates plasma rocuronium, rapidly reverses neuromuscular blockade.  Recurarization is the phenomenon of the return of neuromuscular weakness after paralytic agent reversal. The mechanisms underlying recurarization following sugammadex administration remain incompletely understood.  This report explores a case of recurarization and examines potential causes and preventive interventions.

A 72 yo woman presented for CT-guided kidney ablation for renal cell carcinoma.  PMH was significant for morbid obesity (111.1 kg), asthma, and chronic renal insufficiency.  The procedure and general anesthetic were unremarkable.  The patient received rocuronium 80 mg which was reversed with sugammadex 200 mg 85 minutes later.  She was stable in the post-anesthesia care unit (PACU) for 15 minutes until she complained of shortness of breath followed by acute oxygen desaturation and poor respiratory effort.  Bag-valve-mask ventilation improved oxygenation.  She appeared "floppy" and was unable to raise arms or legs to command.  Train-of-four monitoring at the ulnar nerve demonstrated four twitches without tetany. Sugammadex 200 mg was administered followed by immediate resolution of muscle weakness.  When she was interviewed after stabilization, she described the anxiety of being unable to speak, breath, or move despite being awake and alert throughout.

This case highlights the risk factors for recurarization: renal insufficiency, advanced age, and obesity.  Best practices for avoiding recurarization include dosing rocuronium by ideal body weight, dosing sugammadex by actual body weight, quantitative neuromuscular monitoring, and dose adjustments for renal insufficiency and age.

Publication Date

5-8-2026

Recommended Citation

van der Eb P, Musick S, Watson N. PACU recurarization: The challenges of reversing rocuronium with sugammadex. Presented at: Research Day Corewell Health West; 2026 May 8; Grand Rapids, MI.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2029