DOI

10.21007/con.dnp.2026.0135

Faculty Advisor

Margaret Harvey, PhD, APRN, ACNP-BC, CHFN, FHRS

Subject Matter Expert

Dwayne Accardo, DNP, CRNA, FAANA

Clinical Site

University of Tennessee Health Science Center

Document Type

Poster

Publication Date

Spring 5-1-2026

Disciplines

Health and Medical Administration | Investigative Techniques | Medicine and Health Sciences | Nursing | Nursing Administration | Other Nursing | Perioperative, Operating Room and Surgical Nursing

Abstract

Purpose/Background

Neuromuscular blockade (NMB) reversal is a critical component of anesthesia care, particularly in infants under two years of age who have immature autonomic regulation and heightened vagal tone, predisposing them to bradycardia. Neostigmine, the traditional reversal agent, is associated with parasympathomimetic effects such as bradycardia, requiring anticholinergic co- administration. Sugammadex, a selective relaxant binding agent, offers rapid and predictable reversal of aminosteroidal neuromuscular blocking agents with less cholinergic side effects. Although the safety profile of sugammadex is well established in older pediatric populations, limited evidence exists regarding its cardiovascular effects in infants under two years of age.

Methods

A scoping review was conducted using the databases CINAHL, PubMed, Cochrane Library, Scopus, and Google Scholar. Studies published between 2009 and 2025 evaluating intraoperative heart rate outcomes following NMB reversal with sugammadex or neostigmine in pediatric patients aged 0–24 months were included. Eligible study designs comprised randomized controlled trials, retrospective cohort studies, observational studies, and meta-analyses. The primary outcomes of this review included intraoperative heart rate trends, incidence of bradycardia, and need for anticholinergic rescue medications. Secondary outcomes included time to achieve a train-of-four (TOF) ratio of 0.9 and overall recovery characteristics.

Results

Seven studies met inclusion criteria. Across all study designs, sugammadex demonstrated superior intraoperative hemodynamic stability compared to neostigmine. Sugammadex wasconsistently associated with a lower incidence of bradycardia, reduced need for anticholinergic rescue agents, and faster recovery to a TOF ratio of 0.9. No clinically significant arrhythmias or adverse cardiovascular events were attributed to sugammadex. In contrast, neostigmine use was frequently associated with transient bradycardia related to its cholinergic effects. Findings were consistent in demonstrating a significant decreased risk of bradycardia with sugammadex.

Implications for Nursing and Nurse Anesthesia Practice

The findings of this scoping review support sugammadex as a safer and more hemodynamically stable alternative to neostigmine for neuromuscular blockade reversal in infants under two years of age. For nurse anesthetists, preferential use of sugammadex may reduce the risk of intraoperative bradycardia, decrease reliance on anticholinergic rescue medications, and promote safer emergence from anesthesia. Incorporating sugammadex into standardized pediatric anesthesia protocols can enhance cardiovascular safety and optimize perioperative outcomes in this pediatric popula

Download

Share

COinS