Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents. Response to Br J Anaesth 2024; 132: 461–5

Editor—We read with interest the recent editorial by Hunter and Blobner 1 Hunter J.M. Blobner M. Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents: beware of the risks. Br J Anaesth. 2024; 132: 461-465 Google Scholar regarding risks related to under-dosing and over-dosing neuromuscular blocking drugs and reversal agents, an issue of ongoing importance in anaesthesiology. We agree with the authors that more research on recurrent paralysis after rocuronium and sugammadex reversal is necessary as the mechanism of recurrent paralysis is not understood. We are unaware of any evidence to date that recurrent paralysis is caused by neuromuscular blocking drug redistribution from the extravascular space to the plasma, as suggested by Hunter and Blobner, 1 Hunter J.M. Blobner M. Under-dosing and over-dosing of neuromuscular blocking drugs and reversal agents: beware of the risks. Br J Anaesth. 2024; 132: 461-465 Google Scholar although this is a possible explanation. Confirmation of this hypothesis would require pharmacokinetic evidence, such as demonstration of an increase in unbound rocuronium plasma concentration after reversal with sugammadex, that corresponds to recurrent paralysis.