Unexpected Delayed Neuromuscular Recovery Despite Sequential Neostigmine-Sugammadex Reversal in a Difficult Airway: A Case Report

Sugammadex is a selective relaxant-binding agent that allows for quick and predictable reversal of aminosteroid-induced neuromuscular blockade, increasing perioperative safety and recovery results. Its usage in orthopaedic procedures, particularly fracture fixation surgeries, allows for earlier extubation, improves postoperative respiratory function, and shortens recovery room stays as compared to standard reversal agents. Furthermore, sugammadex allows for successful reversal even at deep levels of neuromuscular blockade, reducing the likelihood of persistent paralysis and related consequences. We present a case of intertrochanteric femur fracture repair that demonstrates the anaesthetic implications and therapeutic usefulness of sugammadex. The patient had a narrow mouth opening (one finger breadth), needing fiberoptic-guided intubation with adequate airway nerve blocks. After general anaesthesia was administered, acceleromyography was used to measure neuromuscular activity at the ulnar nerve-adductor pollicis complex. Induction was accomplished using intravenous propofol, fentanyl, and vecuronium, and anaesthesia was maintained with sevoflurane in a combination with 50% oxygen and 50% nitrous oxide. Additional fentanyl dosages were provided intraoperatively at regular intervals to provide analgesia. Neuromuscular blockage was maintained at a Train-Of-Four (TOF) count of 0 to 2. This case emphasises the necessity of continual neuromuscular monitoring and the efficacy of sugammadex in achieving dependable reversal, especially in patients with restricted airways. Its usage improves recovery profiles, lowers the likelihood of persistent neuromuscular blockade, and helps to prevent unexpected postoperative critical care stays.