Pharmacological Reversal of Neuromuscular Blockade in Critically Ill Patients

Patients who agree to participate in the study will be randomized to the sugammadex group, neostigmine group, or control group.

Randomization will be performed by an independent investigator. Patient, medical staff performing patient evaluation are masked for the assignment otherwise the medical staff administering medications to patient is not blinded.

An independent investigator, who is not included in this study, will provide the assignment result to the medical staff administering medications to patient.

1. Neurologic assessment

The point at which first available neurologic assessment is defined as the point at which the patient is able to move on command (Motor score of 6 on the GCS), and the GCS will be assessed until that point.

Regardless of randomization outcome, all patients will be monitored for GCS and monitored for processed EEG and cerebral regional oxygen saturation prior to intubation.

Assessment of GCS before administration of sedatives for endotracheal intubation, every 10 minutes after intubation, before administration of study medications, every 5 minutes until 30 minutes after administration of study medications, and every 10 minutes after 30 minutes, with additional assessments at that time if spontaneous eye opening occurs. The GCS will be assessed until directed movement is possible (Motor score of 6 on the GCS).

Eye opening response: If there is no response after 2 repetitions of 'OOO, please open your eyes', the response is evaluated with 2 repetitions of the stimulus of pressing the thumb nail. If the subject opens his/her eyes spontaneously, skip this assessment.

Motor response: 'Please make a fist' and 'Please open your fist' are performed twice, and if there is no response, the stimulus of pressing the thumb nail is performed twice to assess the response. 2. Processed EEG and cerebral regional oxygen saturation

Processed EEG using Masimo's Next Generation SedLine® Brain Function Monitoring, and cerebral regional oxygen saturation using Masimo's O3® Regional Oximetry is monitored and recorded.

Processed EEG and cerebral regional oxygen saturation will be recorded at 10 minute intervals from before sedation for intubation until neurological function can be assessed. 3. Neuromuscular function monitoring

Utilized by the Philips Intellivue NMT(neuromuscular transmission) monitor. Monitor every 5 minutes beginning 30 minutes after Rocuronium dosing and discontinue monitoring if eyes open spontaneously (Eye score of 4 on GCS). 4. Endotracheal intubation 100% oxygen is delivered via a facial fitting mask. Patients who have been maintained on oxygen via a high-flow nasal cannula are given 100% oxygen with a flow rate of 60 L/min.

Sedation is administered with etomidate 0.1-0.2 mg/kg, and endotracheal intubation is performed with rocuronium 1 mg/kg once the patient's loss of consciousness is confirmed. 5. Drug Administration

Sugammadex treatment group

Neuromuscular function monitoring is performed every 5 minutes starting 30 minutes after rocuronium administration.

Sugammadex 0.2 mg/kg 30 minutes after rocuronium is administered, after GCS assessment and neuromuscular function monitoring.

Processed EEG and cerebral regional oxygen saturation levels at the time of sugammadex administration is recorded.

Neostigmine group Neuromuscular function monitoring is performed every 5 minutes starting 30 minutes after rocuronium administration.

Administer neostigmine 0.05 mg/kg + glycopyrrolate 0.01 mg/kg after rocuronium is administered, after GCS assessment and neuromuscular function monitoring.

Processed EEG and cerebral regional oxygen saturation levels at the time of sugammadex administration is recorded.

Control group Processed EEG and cerebral regional oxygen saturation levels at the time of sugammadex administration is recorded. 6. GCS assessment and neuromuscular function monitoring is performed 30 minutes after rocuronium administration, and processed EEG and cerebral regional oxygen saturation levels is recorded.

• Time from administration of neuromuscular blocker to first available spontaneous eye opening (in minutes) [Time frame: Time from administration of neuromuscular blocker to first time the patient is able to open eyes spontaneously (Eye score 4 on GCS, in minutes), assessed up to 48 hours.]
• Changes of Patient State index (PSi) values [Time frame: Before intubation (Time 0), Time 10/20/30/35/40/45/50/55/60/70/80/90 minutes]
• Changes of regional cerebral oxygen saturation (O3) values [Time frame: Before intubation (Time 0), Time 10/20/30/35/40/45/50/55/60/70/80/90 minutes]
• Time from intubation to extubation [Time frame: Date of the patient extubated, up to 1 month]
• Total length of hospital stay [Time frame: Date of discharge from the hospital, up to 1 month]
• Total length of intensive care unit(ICU) stay [Time frame: Date of discharge from the ICU, up to 1 month]
• In-ICU mortality [Time frame: Date of death from any cause in ICU, up to 1 month]
• In-hospital mortality [Time frame: Date of death from any cause in hospital, up to 1 month]