Changes in intraoperative rocuronium dosing following the introduction of sugammadex and association with postoperative respiratory complications: A retrospective cohort study.

Summary

After sugammadex introduction, cumulative intraoperative rocuronium dosing increased from 0.83 to 1.20 mg/kg (≈45%). Respiratory complications rose dose-dependently, but the risk was attenuated with sugammadex and abolished when quantitative neuromuscular monitoring (train-of-four ratio) was used, unlike qualitative monitoring.

Key Findings

• Rocuronium dosing increased by 0.05 mg/kg per year after September 2016 (0.83 to 1.20 mg/kg by 2024).
• 8.4% experienced postoperative respiratory complications; risk increased per 1 mg/kg additional rocuronium.
• Dose–risk association was strongest without sugammadex or neuromuscular monitoring (ORadj 1.99).
• Risk attenuated with sugammadex (ORadj 1.08) and was abolished with quantitative monitoring (ORadj 0.94), but not with qualitative monitoring.

Clinical Implications

Adopt routine quantitative neuromuscular monitoring to prevent residual blockade-related respiratory complications, especially when using higher cumulative rocuronium dosing enabled by sugammadex.

Limitations

• Single-center retrospective design; residual confounding and practice pattern bias possible
• No direct causality; outcomes limited to early postoperative respiratory events

Future Directions

Prospective, multicenter studies testing dosing strategies aligned with quantitative monitoring thresholds; implementation science on universal quantitative monitoring and NMBA stewardship.