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Sugammadex associated profound bradycardia and sustained hypotension
Anesth Pain Med 2020;15(1):129
Published online January 31, 2020
© 2020 Korean Society of Anesthesiologists.

Jae Moon Choi1 , Hae Kyung Lee2 , Chan Woo Lee2 , Eung Gyun Kim2 , and Hong Seuk Yang2
Department of Anesthesiology and Pain Medicine, 1Asan Medical Center, University of Ulsan College of Medicine, Seoul, 2Daejeon Sun Medical Center, Daejeon, Korea
Correspondence to: Hong Seuk Yang, M.D., Ph.D.
Department of Anesthesiology and Pain Medicine, Daejeon Sun Medical Center, 29 Mokjung-ro, Jung-gu, Daejeon 34811, Korea Tel: 82-42-220-8921 Fax: 82-42-220-8933 E-mail:
Received September 11, 2019; Accepted November 11, 2019.
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

TO THE EDITOR: With the increasing use of sugammadex owing to its advantages, there have been increasing reports on catastrophic adverse events, such as anaphylaxis, severe bradycardia, and cardiac arrest. We read with interest the paper titled “Sugammadex associated profound bradycardia and sustained hypotension in patient with the slow recovery of neuromuscular blockade-A case report.” We have some points that we would like to discuss.

The post-tetanic count (PTC) mode of stimulation was created to evaluate the intensity of the neuromuscular blockade when no twitch response was present in the train-of-four (TOF) stimulation. After applying PTC stimulation, it takes at least 10 min to obtain a response to an accurate TOF stimulation [1]. The result showing a PTC of 10 and a TOF count (TOFc) of 0 simultaneously may indicate inaccurate monitoring of the neuromuscular function for the intensity and interval of the PTC nerve stimulation. In cases of a PTC of 10 and TOFc of 0, how much sugammadex should be administered? Is the sugammadex dose of 2.667 mg/kg (200 mg) for a body weight of 75 kg sufficient? [2,3].

As the authors described in the Discussion section, the incidence of side effects following the use of sugammadex would depend on the dose [3,4]. The patient had already developed profound bradycardia as a side effect of sugammadex. However, the authors administered a second sugammadex dose of 200 mg. What was the rationale behind this second dose? As the authors mentioned in the Discussion section, anticholinesterase is probably safer. In this case, waiting for a natural recovery of the neuromuscular function might have been safer.


No potential conflict of interest relevant to this article was reported.

  1. Hakim D, Drolet P, Donati F, and Fortier LP. Performing post-tetanic count during rocuronium blockade has limited impact on subsequent twitch height or train-of-four responses. Can J Anaesth 2016;63:828-33.
    Pubmed CrossRef
  2. Naguib M, Brull SJ, and Johnson KB. Conceptual and technical insights into the basis of neuromuscular monitoring. Anaesthesia 2017;72 Suppl 1:16-37.
    Pubmed CrossRef
  3. Brull SJ, and Kopman AF. Current status of neuromuscular reversal and monitoring: challenges and opportunities. Anesthesiology 2017;126:173-90.
    Pubmed CrossRef
  4. Hunter JM, and Naguib M. Sugammadex-induced bradycardia and asystole: how great is the risk?. Br J Anaesth 2018;121:8-12.
    Pubmed CrossRef

January 2020, 15 (1)
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