What is the recommended protocol for reversing general anesthesia?

Reversal of General Anesthesia Protocol

The recommended protocol for reversing general anesthesia requires quantitative monitoring of neuromuscular blockade at the adductor pollicis and administration of reversal agents based on the degree of blockade, with sugammadex being the preferred agent for rocuronium/vecuronium and neostigmine for other non-depolarizing agents. 1

Monitoring Requirements

• Quantitative adductor pollicis monitoring of neuromuscular blockade is essential for diagnosing residual neuromuscular blockade and ensuring complete reversal (TOF ratio ≥0.9) 1
• Clinical tests alone are not sensitive enough to detect residual neuromuscular blockade, which can lead to increased postoperative morbidity and mortality 1
• Monitoring should be continued after administration of reversal agents to identify potential recurarization 1

Reversal Algorithm for Non-Depolarizing Neuromuscular Blocking Drugs

When Using Neostigmine (for atracurium, cisatracurium, or rocuronium)

1. Evaluate responses to Train of Four (TOF) stimulation at the adductor pollicis:

   • If TOF responses < 4: Wait and maintain anesthesia, then reassess TOF later 1
   • If TOF responses = 4: Administer neostigmine 0.04 mg/kg with atropine 0.02 mg/kg 1, 2
   • Efficacy (TOF ratio ≥0.9) expected in 10-20 minutes 1

2. Neostigmine dosing considerations:

   • FDA-approved dose range is 0.03-0.07 mg/kg 2
   • Use 0.03 mg/kg for reversal of shorter-acting NMBAs or when first twitch response is substantially >10% of baseline 2
   • Use 0.07 mg/kg for longer-acting NMBAs, weak first twitch response, or when rapid recovery is needed 2
   • Maximum total dose: 0.07 mg/kg or 5 mg (whichever is less) 2

When Using Sugammadex (for rocuronium or vecuronium only)

1. Dose based on depth of blockade:

   • Very moderate blockade (TOF ratio 0.5): 0.22 mg/kg 1
   • Moderate blockade (4 responses to TOF): 1.0 mg/kg 1
   • Moderate blockade (2 responses to TOF): 2.0 mg/kg 1
   • Deep blockade (PTC 1-2): 4.0 mg/kg 1
   • Very deep blockade (immediate reversal): 8.0 mg/kg 1

2. Monitoring after sugammadex:

   • Continue quantitative monitoring to detect possible recurarization 1
   • Adjust dose according to ideal body weight and intensity of blockade 1

Special Considerations

• Sugammadex provides faster and more reliable reversal than neostigmine for rocuronium and vecuronium 3, 4
• Neostigmine has a ceiling effect and is ineffective for profound blockade 3
• Sugammadex efficacy is decreased in elderly patients and those with severe renal failure (creatinine clearance <30 mL/min) 1
• Inadequate dosing of sugammadex may cause recurarization, requiring continued monitoring 1
• Residual neuromuscular blockade is associated with:
  • Higher morbidity and mortality within 24 hours postoperatively 1
  • Greater risk of critical respiratory events in recovery 1
  • Increased risk of postoperative pneumonia 1
  • Greater risk of pharyngeal muscle dysfunction 1
  • Delayed discharge from recovery room 1
  • Higher risk of postoperative delirium in older patients 5

Common Pitfalls to Avoid

• Failing to use quantitative monitoring to guide reversal agent dosing 1
• Administering neostigmine when fewer than 4 TOF responses are present 1
• Underdosing sugammadex for the depth of blockade present 1
• Discontinuing monitoring after reversal agent administration 1
• Not recognizing that anesthetic agents (particularly sevoflurane) can prolong recovery time even with reversal agents 1
• Failing to administer an anticholinergic agent (atropine or glycopyrrolate) with neostigmine to prevent bradycardia and other muscarinic side effects 2

By following this evidence-based protocol for neuromuscular blockade reversal, clinicians can minimize the risk of residual paralysis and its associated complications, ultimately improving patient safety and outcomes.