TO THE EDITOR: With the increasing use of sugammadex owing to its advantages, there have been increasing reports on catastrophic adverse events, such as anaphylaxis, severe bradycardia, and cardiac arrest. We read with interest the paper titled “Sugammadex associated profound bradycardia and sustained hypotension in patient with the slow recovery of neuromuscular blockade-A case report.” We have some points that we would like to discuss.

The post-tetanic count (PTC) mode of stimulation was created to evaluate the intensity of the neuromuscular blockade when no twitch response was present in the train-of-four (TOF) stimulation. After applying PTC stimulation, it takes at least 10 min to obtain a response to an accurate TOF stimulation [1]. The result showing a PTC of 10 and a TOF count (TOFc) of 0 simultaneously may indicate inaccurate monitoring of the neuromuscular function for the intensity and interval of the PTC nerve stimulation. In cases of a PTC of 10 and TOFc of 0, how much sugammadex should be administered? Is the sugammadex dose of 2.667 mg/kg (200 mg) for a body weight of 75 kg sufficient? [2,3].

As the authors described in the Discussion section, the incidence of side effects following the use of sugammadex would depend on the dose [3,4]. The patient had already developed profound bradycardia as a side effect of sugammadex. However, the authors administered a second sugammadex dose of 200 mg. What was the rationale behind this second dose? As the authors mentioned in the Discussion section, anticholinesterase is probably safer. In this case, waiting for a natural recovery of the neuromuscular function might have been safer.