A 70 kg man undergoes emergency laparotomy with rocuronium-based relaxation and receives neostigmine 2.5 mg with glycopyrrolate at closure. In the PACU he cannot lift his head or generate a sustained hand grip. Train-of-four monitoring shows a ratio of 0.4. The MOST appropriate next step is:

• A Administer a further dose of neostigmine
• B Administer edrophonium 10 mg
• C Give calcium gluconate intravenously
• D Give sugammadex 2 to 4 mg/kg intravenously ✓

Explanation

A train-of-four ratio below 0.9 confirms clinically significant residual neuromuscular blockade. Sugammadex encapsulates rocuronium and reverses even deep blockade rapidly and reliably. Repeating neostigmine is poor practice because acetylcholinesterase inhibitors have a ceiling effect, and giving them late or repeatedly can paradoxically impair transmission through channel blockade. Calcium and edrophonium have no defined role here.

Reference: Miller's Anesthesia, 9th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.