Restoration of Train-of-Four Ratio with Neostigmine After Insufficient Recovery with Sugammadex in a Patient with Myasthenia Gravis.

We present a patient with myasthenia gravis in whom sugammadex failed to restore the train-of-four ratio (TOFR) sufficiently. When the patient's TOFR count had recovered to 2, we administered 2 mg/kg of sugammadex. However, the TOFR did not recover to the preoperative value. An additional 2 mg/kg of sugammadex also had no effect. We then administered 30 μg/kg of neostigmine which restored the TOFR to more than the preoperative value. We speculate that exacerbation of myasthenia symptoms during surgery interfered with recovery of TOFR after sugammadex administration.