Aim
To reduce avoidable anaphylaxis risk and postoperative respiratory complications by ensuring neuromuscular blockade reversal is only used when indicated and is guided by quantitative neuromuscular monitoring.
Background
The Anaesthetic Subcommittee (ASC) of the Victorian Perioperative Consultative Council (VPCC) has become aware of cases of sugammadex anaphylaxis where the indication for reversal of neuromuscular blockade was unclear.
Adequate reversal of neuromuscular blockade prior to extubation is important to avoid residual paralysis and respiratory complications. Quantitative neuromuscular function monitoring must be available and should be used whenever the anaesthetist considers extubation following the use of non-depolarising neuromuscular blockade (PG18 Anaesthesia Monitoring, ANZCA, 2025).
Drugs used to reverse non-depolarising neuromuscular blocking agents have different side effect profiles. The risk of anaphylaxis differs significantly between the currently available reversal agents; sugammadex and neostigmine. Anaphylaxis is thought to be possible either to sugammadex alone, or the sugammadex-rocuronium complex, with an estimated incidence varying between 1 in 2500 and 1in 24,000 patients. Case reports of neostigmine anaphylaxis exist, however, the incidence is generally considered lower than sugammadex. The results of the SNaPP multi centre randomised control trial will help determine if there are differences in other complications such as post-operative pulmonary complications, death and other secondary endpoints (Leslie K., Braat S., Darvall J., et al, BJA Open, 2026).
Recommendations
The Anaesthetic Subcommittee recommends that clinicians:
- Recognise the different risk profiles of agents used to reverse non-depolarising neuromuscular blockade and consider these risks when selecting the most appropriate reversal agent.
- Use quantitative neuromuscular function monitoring in accordance with ANZCA PG18.
- Avoid use of reversal agents where quantitative neuromuscular function monitoring has demonstrated adequate return of neuromuscular function, as indicated by Train-Of-Four Ratio > 0.9.