2026 Southeastern Residency Conference

Unmasking the Neurologic Exam: Sugammadex for Neuromuscular Blockade Reversal in Neurocritical Care 
 
Authors: Autumn Locke McClung1; Gianna Marie Antinone2; Michael L. Behal1; Mary W. Massaro; Thomas J. Christianson1,4; Paige Ledlow1; Bryn E. Ferguson3; Sarah J. Kugler,3; Robert E. Heidel4; Leslie A. Hamilton1,3 
 
1University of Tennessee Medical Center, Knoxville, TN  
2Inova Fairfax Hospital, Falls Church, VA  
3University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN  
4University of Tennessee Health Science Center College of Medicine, Knoxville, TN 
  
Background 
Evidence supporting sugammadex for neuromuscular blockade reversal is largely derived from perioperative and traumatic populations, with limited data in nontraumatic neurocritical care patients. Residual blockade following emergent intubation may delay neurologic assessment and impact time-sensitive decisions. This study evaluated the safety and effectiveness of sugammadex in facilitating neurologic assessment and informing clinical decision-making in this population. 

Methods 
This retrospective, observational cohort study was conducted at a large academic medical center in Knoxville, Tennessee. Adult patients with nontraumatic neurologic injury who received sugammadex for NMB reversal between April 2016 through December 2024 were included. Patients were excluded if they were pediatric, pregnant, had traumatic neurologic injury, or received sugammadex for routine postoperative anesthesia reversal. The primary outcome was the impact of sugammadex on neurologic decision-making, defined as escalation or de-escalation of care following reversal. Secondary outcomes included adverse events, train-of-four monitoring when available, and successful NMB reversal defined as improvement in neurologic examination using Glasgow Coma Scale scores. Four a priori subgroup analyses were conducted, including comparisons of sugammadex dosing strategies relative to neurologic injury severity, neurologic injury type and the incidence of escalation or de-escalation of care, and patients intubated at an outside hospital or by Emergency Medical Services (EMS) versus the study institution. Statistical analyses were performed using SPSS (Version 31). Descriptive statistics summarized variables, and subgroup comparisons were conducted using chi-square tests, with significance defined as p<0.05. 

Results 
A total of 153 patients were included. Patients had severe neurologic injury, with a median presenting Glasgow Coma Scale (GCS) of 5 (IQR 3–8) and pre-intubation GCS of 4 (IQR 3–8). Intracranial hemorrhage syndromes were most common (57.5%), followed by ischemic stroke (22.9%) and status epilepticus (22.9%). Intubation occurred prior to arrival in 39.9% of patients and at the study institution in 60.1%. Rocuronium was the predominant paralytic (92.2%) at a median dose of 1.2 mg/kg (IQR 1.04–1.33). Most patients received sugammadex 2–4 mg/kg (64.1%), with fewer receiving <2 mg/kg (7.8%) or >4 mg/kg (15%). Following sugammadex administration, 23.5% of patients underwent escalation of care, most commonly neurosurgical intervention, while 24.8% experienced de-escalation, including 19% of patients who transitioned to comfort-based management. No neurologic deterioration was attributed to sugammadex. Adverse events were infrequent, including hypotension (13.7%) and bradycardia (11.1%). Subgroup analyses demonstrated no significant differences in outcomes across dosing strategies or neurologic injury subtypes. 

Conclusions 
Sugammadex demonstrated a favorable safety profile in nontraumatic neurocritical care patients and was not associated with neurologic deterioration. Nearly half of patients underwent escalation or de-escalation of care following sugammadex administration, supporting its role in expediting neurologic assessment and facilitating timely, clinically meaningful management decisions.