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In the recent guidelines from the Difficult Airway Society [1], the authors state that neuromuscular block should be fully reversed in order to maximise the likelihood of adequate ventilation and restore protective reflexes and the ability to clear upper airway secretions. Subjective assessment, either clinically or using a peripheral nerve stimulator to measure return of the train-of-four (TOF) ratio to 0.9, the current gold standard for safe extubation, is unreliable. Volunteer studies at TOF ratios of 0.7 to 0.9 show incomplete function of upper airway reflexes [2]. Conventional reversal with cholinesterase inhibitors, even when deemed adequate, can still theoretically mean that 70% of neuromuscular receptors are occupied by a neuromuscular blocking drug (NBD). When administering rocuronium, using the correct dose of sugammadex ensures that the NBD is removed completely from the neuromuscular junction, ensuring no element of residual block [3].

In patients in whom the smallest degree of residual block might compromise the upper airway or airway reflexes at extubation, I would suggest that rather than suggesting that sugammadex provides more ‘reliable’ antagonism of neuromuscular blockade, its administration should be considered mandatory.

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