Sudden, Severe, Refractory Hypotension Following Sugammadex Administration During Low-Risk Orthopedic Surgery in a Healthy Young Adult: A Case Report.

Sugammadex is widely used for rapid and predictable reversal of aminosteroid neuromuscular blockade and has a favorable safety profile. However, rare cardiovascular adverse events, including severe hypotension, bradycardia, and asystole, have been reported. We describe a case of a 39-year-old healthy male who developed profound hypotension without bradycardia approximately six minutes after receiving sugammadex for reversal of moderate neuromuscular blockade following uncomplicated orthopedic surgery. His blood pressure decreased from 95/51 mmHg at baseline to 68/33 mmHg six minutes after sugammadex administration, reaching a nadir of 50/29 mmHg at 17 min, with a heart rate of 117 beats/min. The patient had stable intraoperative hemodynamics and no evidence of bronchospasm, cutaneous manifestations, or airway compromise at the time of the event. Hypotension was refractory to repeated boluses of phenylephrine and ephedrine, with subsequent improvement following norepinephrine administration. The patient recovered without further complications and was discharged the same day. Although causality cannot be definitively established, the temporal relationship raises concern for sugammadex-associated hypotension without bradycardia, possibly related to an atypical hypersensitivity reaction. This case highlights that severe hypotension may occur even in low-risk patients in the absence of bradycardia or other classic features of anaphylaxis, requiring prompt recognition and early potent vasopressor support.