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Anesth Pain Med > Volume 17(3); 2022 > Article
Choi and Yang: Sugammadex in pediatric patients
TO THE EDITOR: In South Korea, sugammadex has begun to be clinically used as an antagonist of nondepolarizing neuromuscular blockers since 2013 and is approved for use in pediatric patients above 2 years of age. There are many reports on the usefulness of sugammadex in pediatric patients. We read with great interest the paper titled “The use of sugammadex in an infant with prolonged neuromuscular blockade - A case report -” [1]. However, we have some concerns that we would like to discuss.
First, the authors administered neostigmine twice without anticholinergics. We assume that this was probably due to the atropine administered during the pre-induction period. However, concomitant administration of anticholinesterase and anticholinergics is not solely due to increases in the heart rate [2]. Second, the body temperature of the neuromuscular monitoring site should be well-maintained because hypothermia at the measurement site can interfere with mechanomyographic and acceleromyographic recordings. As an example, one study reported that the twitch tension of the adductor pollicis decreased by 16% per degree when the muscle temperature fell below 35.2℃ [3].
Third, when the two post-tetanic counts were measured, sugammadex 25 mg (more than 4.6 mg/kg) was administered. Sugammadex is not approved for children under 2 years of age in South Korea or in other countries, and adverse events of sugammadex such as hypersensitivity tend to be dose-proportional [4]. Although the waiting time for recovery may be longer, careful administration of small doses may be more well-tolerated [5]. Lastly, during the 90-min period of emergence, it is likely that the patient would have struggled even if he was not able to move. There would have been various symptoms and signs that the patient had regained consciousness and experienced pain. Medications for pain relief and sedation had to be administered.





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


Conceptualization: Jae Moon Choi, Hong Seuk Yang. Methodology: Hong Seuk Yang. Writing - original draft: Jae Moon Choi, Hong Seuk Yang. Writing - review & editing: Jae Moon Choi, Hong Seuk Yang. Investigation: Jae Moon Choi, Hong Seuk Yang. Supervision: Hong Seuk Yang. Validation: Jae Moon Choi, Hong Seuk Yang.


1. Kim H, Cho J, Lee S, Lim Y, Yoo B. The use of sugammadex in an infant with prolonged neuromuscular blockade - a case report. Anesth Pain Med (Seoul) 2022; 17: 52-6.
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2. Mirakhur RK, Dundee JW, Jones CJ, Coppel DL, Clarke RS. Reversal of neuromuscular blockade: dose determination studies with atropine and glycopyrrolate given before or in a mixture with neostigmine. Anesth Analg 1981; 60: 557-62.
3. Heier T, Caldwell JE, Sessler DI, Miller RD. The effect of local surface and central cooling on adductor pollicis twitch tension during nitrous oxide/isoflurane and nitrous oxide/fentanyl anesthesia in humans. Anesthesiology 1990; 72: 807-11.
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4. de Kam PJ, Nolte H, Good S, Yunan M, Williams-Herman DE, Burggraaf J, et al. Sugammadex hypersensitivity and underlying mechanisms: a randomised study of healthy non-anaesthetised volunteers. Br J Anaesth 2018; 121: 758-67.
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5. Loh PS, Miskan MM, Y Z C, Zaki RA. Staggering the dose of sugammadex lowers risks for severe emergence cough: a randomized control trial. BMC Anesthesiol 2017; 17: 137.
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