Is the effect of sugammadex always rapid in onset?

The aim of this literature review was to compare the duration of the recovery effects of sugammadex. We therefore systematically searched Medline for relevant reports that investigated the recovery time to a train-of-four (TOF) ratio of 0.9 after sugammadex administration. Thirty-three reports were retrieved. For the recommended dose of 2 mg/kg of sugammadex, some studies noted maximum reversal times to a TOF ratio of 0.9 of up to 12 minutes. One study recorded a maximum delay of 22.3 minutes after the recommended dose of 4 mg/kg of sugammadex. Regarding the reversal of rocuronium immediately after its administration, a maximum delay of 16.6 minutes was noted after 16 mg/kg of sugammadex. Whereas reversal with sugammadex is likely within 2-3 minutes, unexpectedly long sugammadex recovery times were occasionally recognized in elderly patients, patients with slower hemodynamic circulation, patients with pulmonary disease, some obese patients, and some cases of renal failure. Additionally, variability in the onset of sugammadex effect was observed in healthier patients (up to 22.3 minutes). This review confirms the known rapid reversal by the recommended doses of sugammadex. However, due to possibility of an increased recovery time, any patient who receives sugammadex to reverse neuromuscular block should have his or her TOF checked prior to extubation.