# Neuromuscular Blockade Antagonism for Thyroid Surgery During Intraoperative Neural Monitoring—An Anesthesia Perspective

## TL;DR

This review compares two drugs used to reverse muscle relaxation during thyroid surgery, focusing on their effects on nerve monitoring and surgical outcomes.

## Contribution

The paper provides a comparative analysis of sugammadex and neostigmine for neuromuscular blockade reversal in thyroid surgery with IONM.

## Key findings

- Sugammadex provides rapid and reliable neuromuscular function recovery, preserving EMG signal quality.
- Neostigmine is a cost-effective alternative that can support IONM signal integrity when carefully dosed.
- Both drugs require precise dosing to avoid compromising surgical conditions or monitoring quality.

## Abstract

Background and Objectives: Thyroid surgery with intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve (RLN) requires precise anesthetic management. This narrative review compares non-selective (neostigmine) and selective (sugammadex) reversal agents for neuromuscular blockade (NMB), discussing their mechanisms of action and the challenges of achieving optimal NMB reversal without compromising surgical conditions or IONM quality. Materials and Methods: A literature search was conducted using PubMed, MEDLINE, and Google Scholar for studies published up to November 2023. Relevant case studies, clinical trials, systematic reviews, and guidelines focusing on NMB reversal in thyroid surgery with IONM were included, prioritizing investigations involving sugammadex and neostigmine. Results: Clinical evidence indicates that sugammadex (0.5–1 mg/kg) provides the rapid and reliable return of neuromuscular function, benefiting electromyography (EMG) signal quality preservation. However, overshooting the reversal can precipitate patient movement, compromising surgical precision. Neostigmine (0.03–0.04 mg/kg), while less selective, remains a cost-effective alternative, with recent studies suggesting adequate support for IONM signal integrity when carefully dosed and timed. Conclusions: This review underscores the need for balanced NMB reversal strategies tailored to intraoperative monitoring requirements in thyroidectomy. Further randomized trials and large-scale studies are needed to refine and standardize NMB reversal strategies in thyroid surgery with IONM.